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

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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

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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

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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

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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

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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

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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

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Key Findings
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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

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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

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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

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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
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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

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Recommendations
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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

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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

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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

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Next Steps
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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

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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

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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
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Questions and Discussion