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The Northern Virginia HIV Service and Financing System

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Title: The Northern Virginia HIV Service and Financing System


1
The Northern Virginia HIV Service and Financing
System
Assessing Resources to Address an Era of
Constrained Funding
2
  • NOVAM submitted a proposal to the Washington AIDS
    Partnership on behalf of Northern Virginia (NOVA)
    HIV programs
  • The Partnership funded NOVAM in July 2005
  • NOVAM partnered with Positive Outcomes, Inc. and
    VORA to undertake the assessment
  • The assessment was designed to assist funders and
    HIV programs to achieve optimal HIV funding by
    maximizing insurance payments and other funds and
    to inform region-wide HIV planning and care
    coordination

3
Acknowledgements
  • Andrew Oatman, Barbara Lawrence, Brenda Hicks,
    Brett Minor, Brian Jennings, Dr. Charles
    Konigsberg, Jr., Chris Delcher, Christine Ingle,
    Cindi Jones, Reverend Daniel Brown, Dave Chandra,
    Dr. David Wheeler, Debbie Dimon, Debra Rowe, Dena
    Ellison, Dent Farr, Diana Jordan, Evelyn Poppell,
    Faye Bates, Gary Race, Geraldine Stile-Killian,
    Harry Miles, Honorable Jay Fisette, Jan Gordon,
    Jim Harvey, Joan Wright-Andoh, Johanne Messore,
    John Ruthinoski, Joseph Santone, Kathleen
    McEnerny, Lawrence Frison, Leo Rouse, Luau
    Temprosa, Mari Parr, Dr. Marsha Martin, David
    Shippee, Dr. Gary Simon, Nancy Sinback, Peggy
    Beckman, Robert Kenney, Robert Moon, Roberto
    Nolte, Ron Wilder, Ronnie Parker, Dr. Reuben
    Varghese, Shannon Glatz, Sue Rowland, Tae Lee,
    Tanya Ehrmann, Terry Smith, and Toni Howard
  • We also acknowledge the considerable contribution
    of NVRC staff Michelle Simmons, Nicolette
    Sheridan, and Stacy Balderston

4
What questions did we try to answer?
  • What is the likely impact of population changes
    in NOVA on future demand for HIV-related
    services?
  • What are the trends in per capita HIV funding in
    NOVA? How do these trends compare with other
    jurisdictions in VA and DC?
  • How do the priorities reflected in NOVA Title I
    spending compare with other jurisdictions in the
    metropolitan Washington EMA?
  • What is the distribution between core and
    non-core services, as defined by the HRSA
    HIV/AIDS Bureau?
  • How do these priorities compare with other Title
    I EMAs?
  • What is the impact of reduced or flattened
    funding on the HIV care system in NOVA, including
    the impact on HIV consumers, HIV clinics, and
    other HIV programs?
  • How effective are efforts by NOVA HIV programs in
    obtaining third party payment, reducing
    duplication of services, and easing insufficient
    HIV clinic and other service capacity?
  • Can other health and social support systems help
    to support NOVA HIV services?
  • Can greater efficiencies or other systematic
    changes be adopted to optimize future HIV funding
    in NOVA?

5
What else did we do?
  • POI provided TA to NOVA funders, clinics, and HIV
    service program
  • We worked with them to identify and address
    immediate barriers to the effective funding,
    organization, and management of HIV services
  • Offered examples of best practices used in
    other EMAs
  • We attempted, but were unable, to measure the
    utilization patterns of HIV Northern Virginians
    in CARE Act-funded programs
  • Deficiencies in XPRES data precluded us from
    conducting these analyses
  • We focused on HIV outreach, counseling and
    testing, clinical, housing, case management, and
    other psychosocial support services
  • We did not address NOVA HIV prevention activities
  • We did not assess the quality of services
    provided by NOVA HIV service organizations or the
    extent that HIV clients are satisfied with their
    HIV care

6
How was the assessment conducted?
  • Received orientation to the NOVA HIV system from
    NVRC staff
  • Reviewed reports, articles, data, and other
    materials
  • Conducted a services inventory to identify
    agencies that provide
  • HIV counseling and testing, clinical, housing,
    and psychosocial services, the services they
    provide, their service areas, and funders
  • Used a previously field-tested HIV clinic
    assessment tool to conduct on-site assessments
    and TA at four HIV clinics
  • Conducted a semi-structured field-tested key
    informant tool to guide interviews conducted with
    funders, government officials, NVRC staff, HIV
    service organization staff, clinicians, and
    consumers

7
How was the assessment conducted?
  • Gathered MORE information to document anecdotal
    information gathered during site visits and
    interviews
  • Analyzed HAB funding allocation data to compare
    Title I and II actual and proposed funding
    allocations by service categories for
  • NOVA, other jurisdictions in the Washington
    Metropolitan EMA, and other EMAs
  • Made a presentation at the Executive Committee to
    get feedback from the Northern Virginia HIV
    Consortium
  • Met with NOVA local public health officials and
    legislators
  • Consulted extensively with HAB project officers,
    NVRC, and DC AHPP (HAA) staff to
  • Clarify policies and gain feedback on the
    findings and proposed recommendations

8
What did we not assess?
  • We attempted to gain an understanding of the
    distribution of HOPWA funds awarded to NOVA via
    DC, assess services purchased, and estimate per
    capita HOPWA funding for NOVA and DC
  • We were unable to obtain AHPP data reported to
    HUD
  • We attempted to estimate per capita HIV services
    funding for NOVA, the Norfolk EMA, other VA
    jurisdictions, and DC
  • County and city jurisdictional allocations to HIV
    were difficult to ascertain and DC data were not
    available
  • We attempted to assess the impact of the recent
    HIV clinic crisis on out-migration of HIV
    Northern Virginians to other NOVA HIV programs or
    to DC for care
  • XPRES data could not be used to assess the actual
    number of unduplicated clients served due to
  • Unique identifiers assigned to more than one
    client and
  • Significant amounts of missing data
  • These data limitations also prevented analysis of
    HIV program-specific service volume or
    productivity analyses

9
How is the Northern VA Region defined?
  • For this project, Northern Virginia includes
  • Arlington, Clarke, Culpeper, Fairfax, Fauquier,
    Loudoun, Prince William, Spotsylvania, Stafford,
    and Warren Counties
  • Cities of Alexandria, Fairfax, Falls Church,
    Fredericksburg, Manassas, and Manassas Park.
  • This geographic area is consistent with the
    federal Metropolitan Statistical Area (MSA) used
    by the federal government to award Title I funds

10
Which agencies participated in the assessment?
  • AIDS Response Effort, Inc.
  • Alexandria Health Department
  • Arlington County Department of Human Services
    Public Health Division
  • Chase Brexton Medical Services
  • City of Alexandria Health Department
  • DC Administration for HIV Policy and Programs
  • DC Primary Care Association
  • Fairfax County Health Department
  • Fairfax-Falls Church Community Services Board,
    Mental Health
  • Food and Friends
  • Fredericksburg Area HIV/ AIDS Support Services
  • George Washington University Medical Center
  • HRSA HIV/AIDS Bureau
  • INOVA Juniper Program
  • Korean Community Services Center
  • Loudoun County Health Department
  • MediCorp Health System
  • NOVAM
  • Northern Virginia AHEC
  • NVRC
  • Positive Livin', Inc.
  • Prince William County Health Department
  • Prince William Interfaith Volunteer Caregivers
  • VA Department of Health, Division of HIV, STD
    Pharmacy Services
  • VA Department of Housing Community Development
  • VA Department of Medical Assistance Services
  • VORA
  • Whitman Walker of NOVA
  • Wholistic Family Agape Ministries Institute

11
Why is this report so long?
  • We were asked to address a large, complex set of
    questions
  • Attempted to address not only regional, but
    county and city-specific issues
  • Particular effort was made to substantiate
    anecdotal reports from key respondents with
    supporting documentation
  • We outlined specific recommendations related to
    future planning, policy, programmatic
    requirements, TA, and training activities
  • Developed recommendations based on POIs
    knowledge of what has worked and not worked in
    other EMAs, states, and nationally
  • To the extent feasible, we specified the groups
    that might take responsibility for addressing the
    recommendations
  • Effort was made to create a road map for short
    and long-term action

12
Key Findings
13
Demand For HIV Services is Growing in NOVA
  • In recent years, the NOVAs HIV care system of
    clinical, supportive, and housing services has
    experienced increased service demand
  • The number of new clients and frequency of their
    units of service are increasing
  • Existing clients are not moving into other
    systems, creating further demand for resources
  • Funding levels have not kept pace with the demand
    for services
  • Funds have been shifted from supportive services
    to medical care to address the need to sustain
    clinical capacity
  • While these facts are in play in other EMAs,
    NOVAs unbalanced demand, capacity, and funding
    is particularly unusual for a US metropolitan
    region
  • NOVA has a much smaller network of HIV care
    providers than other metropolitan regions
  • Unusual mix of independent county and city
    jurisdictions
  • Reliance on other governments to gather and
    allocate funds

14
Historical Funding HIV Funding Levels Have
Constrained Growth of the NOVA HIV Service System
  • NOVAs HIV system has experienced a long period
    of inadequate funding- a phenomenon that is usual
    for a U.S. urban region
  • Due to the relatively small number of HIV
    programs, any crisis in one program has a
    disrupting effect throughout the HIV system
  • This situation has unfolded in HIV clinical
    services, as well as in case management services
    in the EMAs outlying counties
  • The cascading impact of single-agency crises has
    been experienced elsewhere in the U.S., but
    usually sufficient capacity is available to move
    patients to other providers
  • Due to the recent HIV clinic crisis, Title I
    funds were shifted to primary care
  • DC allocated no additional Title I funds to
    address this issue, despite the availability of
    unspent funds
  • While local (county and city) funds were
    allocated to HIV clinics, it is unclear if
    clinical capacity has been sustained or expanded
    sufficiently to meet demand
  • The impact of the NOVA HIV clinic crisis
    continues to be felt throughout the HIV care
    system, one year after the precipitating events

15
Historical Funding HIV Funding Levels Have
Constrained Growth of the NOVA HIV Service System
  • There is heavy reliance on CARE Act funds to
    support HIV services
  • In some local jurisdictions, other systems of
    care are unable to absorb additional clients
  • Examples mental health, drug treatment,
    subsidized housing, homeless shelters
  • Available resources from these systems often
    cannot be accessed if a client does not reside in
    the right jurisdiction

16
How do these findings compare to other EMAs?
  • It has been difficult to gain access to resources
    in other systems due to significant cuts in local
    and state funds in the early part of the decade
  • Cuts particularly impacted drug treatment, mental
    health, subsidized housing, and public health
    services
  • Elsewhere, EMAs have been slow to shift funds
    from psychosocial service to clinical core
    services, except where required by HAB core
    service policies
  • Diverse funding streams found in other U.S. urban
    EMAs are not present in NOVA
  • The types of organizations commonly participating
    in HIV care elsewhere in the U.S. are not present
    in NOVA
  • Teaching hospitals participating in clinical
    trials, hospital HIV outpatient departments,
    community, dental school HIV clinics,
    minority-focused CBOs, HIV experienced
    sub-specialists, primary and secondary prevention
    programs
  • Community health centers tend to be more widely
    available than in NOVA

17
Impact of Financing on the Organization of HIV
Services
  • The VA Medicaid impacts significantly the NOVA
    HIV system
  • VA Medicaid is a program lagging historically
    behind other states in its eligibility and
    payment policies
  • CARE Act programs pay for services that would
    otherwise be covered by Medicaid in other states
  • Northern Virginia is heavily dependent on DC and
    VA government officials to allocate funds through
    Title I and Title II of the CARE and HOPWA
  • The flat funding of VA Title II has limited NOVA
    support
  • Title I was just cut 2.5 million for the grant
    year beginning on March 1
  • Unclear what the impact will be on the NOVA Title
    I allocation
  • The level of NOVA local government funds varies
    between jurisdictions, creating disparities in
    available services
  • Several jurisdictions have lost some local
    government support for HIV services with many
    competing demands reported in the local
    jurisdictions
  • Limited efforts by HIV programs to seek federal
    or other funding
  • Sources of potential funding hampered by
    impression that single provider-grants meet the
    needs of the region
  • HIV programs report that any further funding cuts
    will undermine patients ability to sustain their
    HIV clinical regimens

18
HIV Financing in NOVA Led to Disparities in the
Availability of HIV Services
  • While HIV Northern Virginians are offered a
    minimal set of core services, as defined by HAB
  • HIV DC residents may chose from a relatively
    wide array of HIV services
  • DC HIV indigent residents have significantly
    greater access to health insurance programs not
    available in NOVA
  • Important HIV services are available to only a
    small portion of Northern Virginians
  • Funds are limited for outreach, case finding,
    substance abuse treatment, mental health
    services, medication education, and adherence
    counseling and support
  • Geographic disparities exist in NOVA related to
    the availability of these services
  • Since most HIV clinics are at or near capacity,
    outreach and case finding might actually further
    stressing the HIV clinical system

19
NOVAs Housing Crisis is Impacting Availability
and Access to HIV Services
  • NOVAs affordable housing crisis has had a
    significant on HIV Northern Virginians and other
    indigent populations
  • Some HIV Northern Virginians are reported to be
    unable to find affordable housing, leading them
    seek affordable housing in outlying counties in
    the region far from their HIV clinics or support
    programs
  • Lack of geographic accessibility of HIV programs
    is a growing problem, as many HIV programs are
    centralized in the inner-Beltway area
  • Some HIV Northern Virginians that move to
    outlying counties must change their HIV clinical
    providers, resulting in delayed intake and the
    need to establish a new clinical relationship
  • Due to the migratory patterns of HIV
    individuals, health departments in outlying
    Northern Virginia counties are hard-pressed to
    meet demand for HIV services
  • The regions highly variable public
    transportation system compounds the negative
    impact of centralized services for HIV Northern
    Virginians
  • Particularly for clients without cars

20
Doing More For Less Reality Among NOVA HIV
Programs
  • We identified the need to attain greater
    efficiency and fiscal solvency among Northern
    Virginia HIV service organizations
  • Eligibility determination screening is not
    addressed adequately by many HIV programs
  • Poor screening methods, inadequate staff
    training, staff turnover, conflicting
    understanding of eligibility criteria, Medicaid
    denial requirements, and inadequate funding for
    legal services
  • Applicants allowed to opt out of disclosure of
    income and insurance coverage
  • Third party reimbursement billing practices must
    be addressed better
  • Adherence to HAB payer of last resort policies
    must be improved

21
Doing More For Less Reality Among NOVA HIV
Programs
  • Organizational processes and policies could be
    improved among some HIV programs
  • Some issues were addressed by POI through TA,
    with additional intervention needed by some HIV
    programs
  • Further capacity development is hampered by lack
    of funds
  • A systematic approach is not used by HIV clinics
    and case managers to remind patients about
    appointments or to locate patients that have
    dropped out of care
  • Once enrolled in care, efforts are needed to
    ensure patients are retained in care
  • These findings are NOT unique to NOVA, except for
    opting out of disclosing disclosure of income and
    insurance coverage

22
Doing More For Less Reality Among NOVA HIV
Programs
  • Stakeholders are unified in their desire to
    achieve parity in funding throughout the
    Washington metropolitan area to ensure that all
    HIV Northern Virginians are assured equitable
    access to high quality HIV care

23
NOVA Lacks a Coordinated HIV Care Continuum That
Effectively Links HIV Programs
  • NOVA HIV programs tend to have a low degree of
    integration across agencies
  • Limited joint strategic planning, seeking and
    sharing of resources, communication about shared
    clients
  • Some agencies however, have demonstrated greater
    degrees of integration
  • Limited efforts to seek joint funding, with
    equitable distribution of funds among partnering
    programs
  • Hoarding behavior is indicative of insufficient
    funding and growing competition for the same
    limited funds

Current System
24
NOVA is an HIV System Under Construction
  • Current NOVA HIV planning processes were
    acknowledged by most respondents to be
    ineffective in achieving a coordinated HIV care
    continuum
  • These processes included the Title I Planning
    Council and the Consortium
  • A need to create a process that focuses on HIV
    care planning was identified by almost all
    individuals interviewed
  • Significant interest was expressed in better
    integrating services across funding streams and
    HIV care providers
  • Positively, local jurisdictions have demonstrated
    significant willingness to work together to
    address the need to increase HIV primary care
    capacity

25
Recommendations
26
Recommendations
  • The report outlines almost 90 detailed, targeted
    recommendations
  • Recommendations focus on
  • Establishing an effective HIV systems planning
    process
  • Building an HIV care continuum that
    systematically transitions HIV at-risk Northern
    Virginians from community and institution-based
    outreach to counseling and testing and to
    engagement in HIV treatment
  • Expanding the capacity of HIV clinical, case
    management, housing, and psychosocial support
    services to address the needs of HIV Northern
    Virginians, including emerging populations
  • Maximizing Medicaid and other sources of revenue
  • Activities designed to foster independence among
    HIV Northern Virginians

27
Recommendations
  • Adoption of these recommendations can help
    achieve effective planning, resource allocation,
    and care coordination in NOVA
  • Improved efficiency and adoption of better
    business models can help to optimize the
    limited funds available to HIV programs
  • Recommendations are based on HAB policy, best
    practices achieved by other EMAs, and activities
    undertaken by other HIV programs to create
    integrated HIV care networks
  • Adoption of the recommendations outlined in the
    report cannot substitute for additional funds to
    address NOVAs insufficient capacity to meet
    current and future demand for HIV services among
    its neediest HIV NOVA residents

28
To this end, the report recommends
  • A task force to develop a new funding formula for
    distributing federal HIV care funds, including
    Title I and HOPWA, to NOVA, Suburban MD, and W VA
  • Setting a minimum standard of core services
    available to all eligible HIV residents in the
    Washington EMA to ensure equity and reduce
    disparities in availability and accessibility of
    HIV services
  • Developing an alternative approach to identify
    and appoint NOVA representatives to the Planning
    Council to ensure adequate representation of NOVA
    consumers and HIV care providers
  • Appointing NOVA representatives to a regional
    HOPWA planning and resource allocation body that
    will ensure accountability in HOPWA program
    management and funding allocations
  • Identifying additional local funds to support HIV
    services
  • Advocating effectively for additional State and
    local funds earmarked for HIV surveillance,
    prevention, and care

29
Next Steps
30
Building an Action Plan
  • Due to the dominance of regional funding for HIV
    care and housing, it is critical that other
    jurisdictions in the EMA also identify and adopt
    measures to achieve a more efficient HIV system
    of care
  • Efforts to ensure that CARE Act funds are the
    payer of last resort must be undertaken
    region-wide to free CARE Act funds to support
    HIV individuals with no other source of funds or
    services not covered by Medicaid or other payers
  • Consistent with federal policies, CARE Act and
    HOPWA funds should be used to address short-term,
    transitional needs to the full extent possible
  • Isolated efforts in NOVA to accomplish these
    changes will only result in further disparities
    and put their HIV service organizations in
    further financial peril

31
Building an Action Plan
  • An action plan is needed to address the
    recommendations and sustain the positive momentum
    achieved by stakeholders
  • NOVAM is seeking WAP funds to help develop and
    implement the action plan
  • Developing an action plan will require consensus
    building among stakeholders to identify and
    implement system-wide short and long-term
    activities
  • HIV service programs should undertake their own
    planning efforts to address recommendations
    directed at them
  • A system-wide timetable should be developed for
    implementation of the action plan
  • Evaluation strategies should be used to ensure
    that the timely implementation of the
    recommendations
  • Facilitated processes may be needed to ensure
    that group efforts are goal-oriented, focused,
    and that turf issues and competing interests are
    addressed
  • The action plan must be specific, identify
    stakeholders responsible for implementation, and
    address geopolitical, financing, and
    organizational barriers to implementation

32
The (HIV) diagnosis is changing and our care
model has to change too. We need to reexamine
things and develop another model. Time is passing
us by. We have an enormous intellectual
undertaking ahead of us. County health department
staff person
33
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