Ryan White HIV/AIDS Program Parts C and D Stakeholders Call April 19, 2018

Mahyar Mofidi, DMD, PhDDirector, Division of Community HIV/AIDS Programs (DCHAP)HIV/AIDS Bureau (HAB)Health Resources and Services Administration (HRSA)

Agenda

• HRSA/HAB/DCHAP Overview

• Division Updates• 2018 National Ryan White Conference on HIV Care and

Treatment

• RWHAP Part C Recipient Program Income Presentations

2

Health Resources and Services Administration (HRSA)Overview

Supports more than 90 programs that provide health care to people who are geographically isolated, economically, or medically challenged

HRSA does this through grants and cooperative agreements to more than 3,000 awardees, including community and faith-based organizations, colleges and universities, hospitals, state, local, and tribal governments, and private entities

Every year, HRSA programs serve tens of millions of people, including people living with HIV/AIDS, pregnant women, mothers and their families, and those otherwise unable to access quality health care

3

HIV/AIDS Bureau Vision and Mission

VisionOptimal HIV/AIDS care and treatment for all.

MissionProvide leadership and resources to assure access to and retention in

high quality, integrated care, and treatment services for vulnerable people living with HIV/AIDS and their families.

4

Purpose of Ryan White HIV/AIDS Program

• Public health approach to provide a comprehensive patient-centered system of HIV care

• Ensure low-income people living with HIV (PLWH) receive optimal care and treatment

5

DCHAP Mission and Core Values

MissionProvide leadership and resources to assure access to and retention in

high quality, comprehensive HIV care and treatment services for vulnerable people living with HIV/AIDS, their families and providers

within our nation’s communities.

Core Values Communication ∙ Integrity ∙ Professionalism Accountability ∙

Consistency ∙ Respect.

6

Ryan White HIV/AIDS Program by the Numbers: 2016

7Source: HRSA. Ryan White HIV/AIDS Program Data Report (RSR) 2015. Does not include AIDS Drug Assistance Program data.

Viral Suppression among RWHAP Clients, by State, 2010 and 2016—United States and 2 Territoriesa

8

Viral suppression: ≥1 OAHS visit during the calendar year and ≥1 viral load reported, with the last viral load result <200 copies/mL.a Puerto Rico and the U.S. Virgin Islands.

Viral Suppression among Key Populations Served by the Ryan White HIV/AIDS Program, 2010 and 2016—United States and 3 Territoriesa

9

RWHAP overall, 2016 (84.9%)

RWHAP overall, 2010 (69.5%)

Hispanics/Latinos can be of any race.Viral suppression: ≥1 OAHS visit during the calendar year and ≥1 viral load reported, with the last viral load result <200 copies/mL.a Guam, Puerto Rico, and the U.S. Virgin Islands.

HAB Data Slides and Reports

• Clients Served by the Ryan White HIV/AIDS Program, 2016

• HIV Care Outcomes: Viral Suppression, 2016

• Annual Client-Level Data Reports

• https://hab.hrsa.gov/data/data-reports

10

DCHAP Updates

11

2018 National Ryan White Conference on HIV Care and Treatment

12

National Ryan White Conference on HIV Care & Treatment

• Theme

Catalyzing Success: Advancing Innovation. Leveraging Data. Ending the HIV Epidemic.

• Dates2018 National Ryan White Conference on HIV Care and Treatment (NRWC)

December 11 – 14, 2018

DCHAP Business Meeting

Tuesday, December 11, 2018

2018 Clinical Conference (to precede NRWC)

December 9 – 11, 2018

13

Gaylord National Harbor Hotel and Convention Center

(Oxon Hill, Maryland)

Registration now open!https://ryanwhite2018.hrsa.gov/

DCHAP Business Meeting

December 11th from 8:30 to 2:30pm

• For Part C, D, and F Dental recipients only

• Similar format as the 2016 DCHAP Business Meeting• Plenary Session• Concurrent Breakout Sessions

• Technical assistance presentations • Panel presentations • Roundtable discussions

• Discuss “State of the DCHAP Programs” • Technical assistance• Best practices

• DCHAP will follow up with recipients to get YOUR input on topics that interest YOU

• Additional information will be forwarded to you from your Project Officer

14

NRWC Conference Tracks

15

Increasing Access, Engagement, and Retention in HIV Care and Treatment

This track will focus on best practices and models for access to, engagement, retention, and re-engagement in HIV

care and treatment that result in improved health outcomes for PLWH.

Data Utilization

This track will examine data integration, data analysis, and data utilization with a focus on how these activities

improve engagement/re-engagement, service delivery, and public health approaches to ending the HIV epidemic

and curing Hepatitis C in the RWHAP.

Leveraging Innovative Practices to Improve Outcomes and Address Emerging Priorities

This track will highlight new and innovative models for PLWH engagement, HIV workforce development and

deployment, service integration, and service delivery that lead to improvements in health outcomes along the HIV

care continuum as well as addressing emerging priorities such as curing Hepatitis C in the RWHAP, behavioral health

integration, and the opioid epidemic.

NRWC Conference Tracks

16

Clinical Quality Management and Clinical Improvement

This track will examine the fundamentals and best practices for clinical quality management programs to measure and improve HIV service delivery and health outcomes with the ultimate goal of reducing health disparities.

Ryan White HIV/AIDS Program Planning and Resource Allocation: Collaborative Partnerships and Community

Engagement

This track will focus on requirements and best practices for integrated planning, program implementation,

workforce development, and resource allocation and utilization, including examples of collaborative partnerships

and community engagement initiatives that result in a quality, comprehensive system of HIV prevention, care,

and treatment that is responsive to the evolving HIV epidemic.

Ryan White HIV/AIDS Program Fiscal and Grant Management Boot Camp

This track is a technical assistance track focusing on training RWHAP recipients and subrecipients on fiscal and

grant management requirements and best practices.

NRWC Conference Logistics

• Registration decisions (confirm/deny) are made by Project Officers

• Hotel reservations can be made after registration has been confirmed by Project Officer

• Cap per RWHAP:

• Part C: 4

• Part D: 4

• Part F: 2

• Staff attending the Clinical Conference ONLY will not count towards cap

• Additional registration slots are available for consumers and subrecipients- first come, first served

17

NRWC- Call for Abstracts

• Call for Abstracts: Deadline: April 30, 2018https://ryanwhite2018.hrsa.gov

• Session types • Breakout sessions 90 minute workshop (Multi-speaker session with time for attendee

participation or interaction)• 30 minute oral presentation• Poster presentations- visual information presentations sharing best practices, lessons

learned, unique strategies or tools and research findings

Plenary sessions• Tuesday, December 11, 2018 – Opening Plenary (approximately 3 pm EST)• Wednesday, December 12, 2018• Thursday, December 13, 2018• Friday, December 14, 2018 – Closing Plenary

18

Program Updates

19

Notice of Award (NoA)

Starts FY 18 Partial awards Reporting Requirements

January

5 months Ryan White HIV/AIDS Program Services Report (RSR),

Federal Financial Report (FFR), Expenditure Report

Allocation report will be added on balance of award NoA

April3 months RSR, FFR, Expenditure Report

Allocation report will be added on balance of award NoA

May3 months RSR, FFR, Expenditure Report

Allocation report will be added on balance of award NoA

• No Conditions of Awards (COAs) and Minority AIDS Initiative (MAI) designation on initial NoA• Balance of award NoA will have COAs and MAI designation

20

HRSA-18-092

• This competition was open to current RWHAP Part C Early Intervention Services (EIS) recipients and new organizations proposing to provide RWHAP Part C EIS funded services in new geographic service areas as described by the applicant.

• NOAs will be released in this month for a May 1st start date.

21

2018 Stakeholder Call ScheduleUpcoming Dates

Date Time

Thursday, July 19, 2018 2 pm – 4 pm ET

Thursday, October 25, 2018 2 pm – 4 pm ET

22

EHB Updates and Helpful Links

• Site Visit Action Plan (Corrective Action Plan)• The EHB now allows HRSA staff to collaboratively plan a Corrective Action Plan with

grantees/recipients

• All information related to the Corrective Action Plan will be entered through the EHB

• HRSA staff (PO) will enter the initial information in the EHB and send the Corrective Action Plan to the recipient to enter “resolve action plan” tasks

• The Corrective Action Plan must be sent back to the HRSA staff (PO) for review and approval before the recipient can begin working on resolving the issues

• Only after all site visit findings, included in the plan, have been resolved can the Corrective Action Plan be closed by the PO

23

The Site Visit Action Plan EHB Help Page: https://help.hrsa.gov/x/jYCZAwTier 2 Support: 301-443-2112

Questions

24

Program Income

25

Program Income

Background

• Since 2016 DCHAP has provided focused technical assistance on recipients’ use of program income (tracking, allocating, and spending)

• Technical assistance provided through PCNs; FAQs; webinars; 2016 NRWC; TARGET Center; monitoring calls; site visits; and linking recipients for collaborative learning.

• Major challenges identified: Correctly tracking, allocating, and spending program income in accordance with the parameters of the RWHAP statute and the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards (45 CFR Part 75).

26

Program Income

Per 45 CFR §75.2, Program Income: Program income means gross income earned by the non-Federal entity that is directly generated by a supported activity or earned as a result of the Federal award during the period of performance except as provided on 45 CFR §75.307(f). Program income includes but is not limited to income from fees for services performed, the use or rental of [sic.] real or personal property acquired under Federal awards, the sale of commodities or items fabricated under a Federal award, license fees and royalties on patents and copyrights, and principal and interest on loans made with Federal award funds. Interest earned on advances of Federal funds is not program income. Except as otherwise provided in Federal statutes, regulation, or the terms and conditions of the Federal award, program income does not include rebates, credits, discounts, and interest earned on any of them.

27

Program Income

Use of Program Income – RHWAP Part C

To support comprehensive primary health care and support services in an outpatient setting for low income, uninsured, and underserved people living with HIV (PLWH).

Early Intervention Services

Core Medical Services

Support Services

Administrative expenses

Clinical quality management activities

Not subject to statutory distribution requirements (i.e., 10% administration)

28

Program Income

Use of Program Income – RWHAP Part D

To support a comprehensive system of family-centered care for low-income women, infants, children, and youth affected by or living with HIV.

Core Medical Services

Support Services

Administrative expenses

Clinical quality management activities

Not subject to statutory distribution requirements (i.e., 10% admin)

29

Program Income

Expenditure of Program Income

• To the extent available, recipients and sub-recipients must disburse funds available from program income, rebates, refunds, contract settlements, audit recoveries and interest earned on such funds before requesting additional cash payments (45 CFR §75.305(b)(5)).

• Estimate accrued program income and determine RWHAP funds that will be needed during current performance period.

30

HAB/OFAM Program Income Initiative

• Program Income Initiative

• Collaboration between HRSA HAB/DCHAP and the HRSA Office of Federal Assistance Management (OFAM)

• Goals:

1. Identify recipients who have established appropriate processes and procedures related to program income (allocation, spending, tracking, and reporting)

2. Disseminate information about these processes and procedures

• During June and July 2017, HAB and OFAM staff interviewed nine Part C recipients.

• Recipient presentations

• Presenting examples of internal control and allocation practices

31

Recipient Program Income Presentations: Internal Controls and Allocation

32

Rock Hill, South Carolina

BackgroundCare Setting

• Mission, Vision, Values• Opened as HIV service organization – 2000• Transitioned to FQHC – 2015• Four service sites – York County, SC

• 2 Rural, 2 suburban

• 1.5 Physicians, 3 Nurse Practitioners, 0.2 Certified Nurse Midwife• 4,367 patients served in 2017

• Approx. 600 HIV+• 66% living below poverty• 61% uninsured

34

Background

Model of Care• Integrated Services

• Primary care, HIV specialty care, Hepatitis C Virus (HCV) treatment, Pre-exposure Prophylaxis (PrEP) & Post-exposure Prophylaxis (PEP), dental care, behavioral health, medical case management

• Other HIV Services• Housing, peer support, emergency financial assistance,

medication/insurance assistance, outreach/specialized case management, HIV/HCV/STD screening, linkage to care, 3MV

• Level 3 Patient Centered Medical Home – National Committee for Quality Assurance (NCQA)

• Care Team Model

35

Background

Federal Awards

• Ryan White HIV/AIDS Program (RWHAP) Part B since 2000

• Housing Opportunities for Persons with HIV (HOPWA) since

2000

• RWHAP Part C since 2001

• RWHAP Part A since 2008

• HRSA Section 330 since 2015

36

Background

Types of Program Income

• Third Party Insurance Payers

• Medicaid, Medicare, Private Insurance

• Patient Services Revenue

• Self-pay

• Sliding fee

• 340B Drug Pricing Program

• Contract, mail order pharmacy

37

Background

38

16%

8%

16%

60%

11%

23%

39%

27%

-5%

5%

15%

25%

35%

45%

55%

65%

Medicaid Medicare Private Insurance Uninsured

Affinity Health CenterThird Party Payer

Breakdown

All Patients RWHAP Patients

Background

Organizational Structure

• 501(c)(3) tax-exempt non-profit

• Board of Directors

• Currently 13 members

• 61.5% consumer directors

• 6 member Leadership Team

• Fund Accounting

39

Challenges Tracking Program Income (PI)

• Tracking/Internal Control for Earned PI

• Transactional versus Allocation Accounting

• Accounting for revenue by encounter

• Tracking/Internal Control for Expenditure of PI

• Transactional versus Allocation Accounting

• Spending versus Encumbering PI

40

Overcoming Challenges

• Use of information technology

• Staff education & training

• Internal control methods

• Trend & reporting analysis

41

Overcoming ChallengesUse of Information Technology

• Fund accounting software

• Use of Abila MIP

• Robust chart of accounts

• GL Acct / Grant / Program / Location

• Built-in reporting

• Use of add-on modules

• Allocations

• Advanced Reporting

42

Overcoming ChallengesStaff Education & Training

• 45 CFR 75

• HRSA resources

• Policy clarification notices

• Webinars

• TARGET Center

• In-person trainings

• Internal policies & procedures

• Organizational specific IT

43

Overcoming ChallengesInternal Control Methods

• Segregation of Duties

• Purchase authorization procedures

• Line level coding

• Review and approval of coding (pre-posting)

• Post disbursement review & approval

44

Overcoming ChallengesTrend & Reporting Analysis

• Organizational financial statements

• Prepared and reviewed monthly (Accounting Department)

• Reviewed and analyzed by organizational leadership

• Summarized and presented to Board

• Grant & fund reporting

• Prepared and reviewed monthly (Accounting Department)

• Reviewed and analyzed by organizational leadership

45

East Carolina UniversityGreenville, North Carolina

Numbers on map correspond to numbers in location column Table 7. Area includes East of I-95 & North of I-40

Entity Location Counties Covered# of HIV Patients

Main Source of Funding

ECU-BSOMHIVP Greenville, NC1

RWPC/D - Beaufort, Bertie, Chowan, Craven, Gates, Hertford, Hyde, Martin, Pamlico, Pasquotank, Perquimans, Pitt, Tyrell, WashingtonRWPB - Beaufort, Carteret, Craven, Greene, Jones, Lenoir, Martin, Pamlico, Pitt, Washington, Wayne

1,500 Part B, C, D

Hertford Co Public Health Ahoskie, NC2

RWPB - Bertie, Camden, Chowan, Dare, Gates, Hertford, Hyde, Pasquotank, Perquimans, Tyrrell

≈130 Part B

Carolina Family Health Centers Wilson, NC3

RWPC - Edgecombe, Nash, WilsonRWPB - Edgecombe, Halifax, Nash, Northampton, Wilson

≈350 Part B,C

Warren-Vance Community Health Center, Inc. Infectious Diseases

Henderson, NC 4

RWPC - Franklin, Granville, Person, Vance, Warren. ≈100 Part C

3 1

4 2

• Primary Provider for HIV Care in Eastern North Carolina (ENC)

• Catchment area - 30 Counties

ECU HIV Program

47

1500+ active patients/PLWH.

200 new and 100 reengaging clients per year (no HIV care > 9 months)

Nutritional Screening and Treatment

Medical Case Management/Linkage Retention Coordinators

Transportation Assistance & Medication Assistance/ADAP

Oral Health Services (School of Dental Medicine) and Vision program

Specialty and Primary Care Referral program

Active Clinical trials program: 6 Active, 1 actively enrolling

48

ECU HIV Program Client Demographics

2017 ECU Client Level Data N (%)

Number of people living with HIV 1563 (100%)

African Americans 1191 (76%)

Females 552 (35%)

Men >24 960 (60%)

FPL <100 960 (61%)

49

ECU HIV Program Insurance Breakdown

Insurance 2017 Total %

Medicaid 355 23%

Medicare 377 24%

No Insurance 511 33%

Private/Other/VA 320 20%

Total 1563 100%

50

RWHAP at ECU

• RWHAP Parts B, C, and D

• Support core medical and support services for PLWH who have no other payer source

• RWHAP Part B: $546,094: covers gaps in services; 11 counties

• RHWAP Part C: $490,977: covers men >24 year of age; covers 14 counties in Eastern North Carolina

• RWHAP Part D: $591,280: covers women, infants, children and youth (WICY); and men <25; and 28 counties

51

Sources of RWHAP Income

• Patient Charges: Record the collections from insurance (third party reimbursement) or client self-payment for the services provided for RWHAP clients.

• Pharmacy: Record all revenue from the 340B program generated by RWHAP client pharmacy transactions.

• Percentages for sources of program income: 75% from 340B revenue and 25% from patient charges.

52

Annual Budgeting Process

• Annual Budget Plan for RWHAP Parts C and D Income

• Monthly variance report

53

Allocation of Program Income

• Personnel: • Developed a methodology of how to allocate different personnel between grant

and program income

• Rent and utilities:• Allocation based on space occupied by RWHAP funded staff and clinic utilization

data

• Specialty Referrals:• We established referral systems where uninsured RWHAP eligible patients can

receive primary and specialty medical services from other clinics within ECU

54

Tracking Expenditures

The Grant Fiscal Coordinator:

1. Runs monthly expenditures report for each fund, RWHAP Part C/ RWHAP Part D/ RWHAP Part C Program Income/ RWHAP Part D Program Income

2. Compares the expenditures with approved budget for each line item (expenditures data)• Find out how much variance is for each line item

3. Generates variance analysis report based on the expenditures data• Analyze to determine reason(s) for the variance(s)

4. Reports to Principal Investigator to assist in decision-making for daily operations

55

Internal Controls

• Principal investigator approval is required when charging any expenditures to program income.

• All transactions require a minimum of two reviewer/approvers at the departmental and institutional level.

• Institutional offices review/approve/process all transactions (Accounts Payable, Travel Office, Payroll, Materials Management).

• No program income payments/transactions can be processed at the local/project level.

5656

Research Administration and Oversight

• The Office of Grants and Contracts (OGC) provides:• Expertise in Federal compliance rules and regulations

• Dedicated oversight for certain expenditures, including financial adjustments and corrections

• Project monitoring

• Award review and setup

• Establishing a dedicated fund specific to the project in Banner

• Support for grant closeout and timely reporting

5757

Internal Controls through OGC

• Dedicated financial reporting• Unique fund dedicated to project expenses and revenues

• Accounts within each code to identify type of expenditure (supplies, etc.)

• Layered/Tiered Approvals• ECU specific routing to ensure appropriate review (Purchasing/

Materials Management, etc.)

• OGC has final approval authority on questionable expenditures

5858

Challenges and Solutions – Spending Program Income

• Challenge: Multiple internal steps are required to document a client’s RWHAP eligibility (RWE) to pay referral invoices from program income.

• Solution: We hired a billing specialist who is familiar with the billing system and has access to different databases to confirm lack of other payors and clients have completed RWE.

59 59

Challenges and Solutions - Spending Program Income

• Challenge: Determining eligibility to use RWHAP income for clients who have made independent referrals

• Solution: We met with ECU Physicians billing department and developed a process to receive overdue requests for payment before clients go into collection.

6060

Next DCHAP Stakeholder Webinar

Date: Thursday, July 19, 2018, 2:00 p.m. to 4:00 p.m. EST

Topic: Program Income Spending and Strategic Planning

61

Questions

62

Contact Information

Mahyar Mofidi, DMD, PhD

Director, Division of Community HIV/AIDS Programs

HIV/AIDS Bureau (HAB)

Health Resources and Services Administration (HRSA)

Email: Mmofidi@HRSA.gov

Phone: 301-443-2075

Web: hab.hrsa.gov

63

Connect with HRSA

64

To learn more about our agency, visit

www.HRSA.gov

Sign up for the HRSA eNews

FOLLOW US: