The Northern Virginia HIV Service and

Financing System

Assessing Resources to

Address an Era of Constrained Funding

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

AcknowledgementsAndrew 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

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?

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

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

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

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 DCCounty 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 andSignificant amounts of missing data

These data limitations also prevented analysis of HIV program-specific service volume or productivity analyses

How is the Northern VA Region defined?

For this project, Northern Virginia includesArlington, 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

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

Why is this report so long? We were asked to address a large, complex set of

questionsAttempted 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 POI’s knowledge of what has worked and not worked in other EMAs, states, and nationallyTo 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

Key Findings

Demand For HIV Services is Growing in NOVA

In recent years, the NOVA’s 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 increasingExisting 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, NOVA’s 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 regionsUnusual mix of independent county and city jurisdictionsReliance on other governments to gather and allocate funds

NOVA’s 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 EMA’s 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 fundsWhile “local” (county and city) funds were allocated to HIV clinics, it is unclear if clinical capacity has been sustained or expanded sufficiently to meet demandThe impact of the NOVA HIV clinic crisis continues to be felt throughout the HIV care system, one year after the precipitating events

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”

Historical Funding HIV Funding Levels Have Constrained Growth of the NOVA HIV Service System

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 programsCommunity health centers tend to be more widely available than in NOVA

How do these findings compare to other EMAs?

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 policiesCARE 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 servicesSeveral 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 fundingSources 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

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 HABHIV+ 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 supportGeographic 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

NOVA’s Housing Crisis is Impacting Availability and Access to HIV Services

NOVA’s 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 relationshipDue to the migratory patterns of HIV+ individuals, health departments in outlying Northern Virginia counties are hard-pressed to meet demand for HIV services

The region’s highly variable public transportation system compounds the negative impact of centralized services for HIV+ Northern Virginians

Particularly for clients without cars

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 servicesApplicants 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

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 programsFurther 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

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

Doing More For Less: Reality Among NOVA HIV Programs

NOVA Lacks a Coordinated HIV Care Continuum That Effectively Links HIV Programs

Current System

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

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

Recommendations

RecommendationsThe report outlines almost 90 detailed, targeted

recommendationsRecommendations focus on

Establishing an effective HIV systems planning processBuilding 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 treatmentExpanding the capacity of HIV clinical, case management, housing, and psychosocial support services to address the needs of HIV+ Northern Virginians, including emerging populationsMaximizing Medicaid and other sources of revenueActivities designed to foster independence among HIV+ Northern Virginians

RecommendationsAdoption 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 NOVA’s insufficient capacity to meet current and future demand for HIV services among its neediest HIV+ NOVA residents

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

To this end, the report recommends

Next Steps

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

Building an Action Plan

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

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

Questions and Discussion