1. Planning Body Duties
Planning Body Duties
Title II funds are awarded to the State agency designated by the Governor to administer Title II, usually the State health department. States provide Title II services directly as well as through consortia, which are groups comprised of providers, consumers, and others who perform a planning and advisory function to regions, or the entire State, in determining needs and delivering essential health and support services. Regardless of the mechanism used, planning and other duties are part of determining how to use limited Title II funds to ensure the CARE Act is the payer of last resort and to manage their use.
Both the State (as the Title II grantee) and consortia have designated responsibilities in the areas of planning and delivery of CARE Act services. Duties can occur through Title II planning bodies, Statewide or regional, as well as through consortia or other planning groups established by the State. Regardless of the set-up, planning requires broad membership involvement in order to bring diverse experience and input into such tasks as needs assessment and developing a comprehensive plan. Ensuring smooth operation of planning bodies also requires them to have in place conflict of interest and grievance procedures to guide their decision making
Beyond their planning duties, consortia have duties that are prescribed in the legislation. Others are delegated by the State, and still others are assumed by the consortium in response to needs in its service area. In some cases, they actually deliver services, while other consortia do so through funding agreements.
Section 2617(a) requires States to submit Title II applications that contain requirements outlined in the legislation and the annual program guidance. Section 2617(b) requires applications to contain:
“(1) a detailed description of the HIV-related services provided in the State to individuals and families with HIV disease during the year preceding the year for which the grant is requested, and the number of individuals and families receiving such services, that shall include—
(A) a description of the types of programs operated or funded by the State for the provision of HIV-related services during the year preceding the year for which the grant is requested and the methods utilized by the State to finance such programs;
(B) an accounting of the amount of funds that the State has expended for such services and programs during the year preceding the year for which the grant is requested; and
(C) information concerning—
(i) the number of individuals to be served with assistance provided under the grant;
(ii) demographic data on the population of the individuals to be served;
(iii) the average cost of providing each category of HIV-related health services and the extent to which such cost is paid by third-party payors; and
(iv) the aggregate amounts expended for each such category of services;
(2) a determination of the size and demographics of the population of individuals with HIV disease in the State;
(3) a determination of the needs of such population, with particular attention to—
(A) individuals with HIV disease who know their HIV status and are not receiving HIV-related services; and
(B) disparities in access and services among affected subpopulations and historically underserved communities;
(4) a comprehensive plan that describes the organization and delivery of HIV health care and support services to be funded with assistance received under this part that shall include a description of the purposes for which the State intends to use such assistance, and that—
(A) establishes priorities for the allocation of funds within the State based on—
(i) size and demographics of the population of individuals with HIV disease (as determined under paragraph (2)) and the needs of such population (as determined under paragraph (3));
(ii) availability of other governmental and non-governmental resources, including the State medicaid plan under title XIX of the Social Security Act and the State Children’s Health Insurance Program under title XXI of such Act to cover health care costs of eligible individuals and families with HIV disease;
(iii) capacity development needs resulting from disparities in the availability of HIV-related services in historically underserved communities and rural communities; and
(iv) the efficiency of the administrative mechanism of the State for rapidly allocating funds to the areas of greatest need within the State;
(B) includes a strategy for identifying individuals who know their HIV status and are not receiving such services and for informing the individuals of and enabling the individuals to utilize the services, giving particular attention to eliminating disparities in access and services among affected subpopulations and historically underserved communities, and including discrete goals, a timetable, and an appropriate allocation of funds;
(C) includes a strategy to coordinate the provision of such services with programs for HIV prevention (including outreach and early intervention) and for the prevention and treatment of substance abuse (including programs that provide comprehensive treatment services for such abuse);
(D) describes the services and activities to be provided and an explanation of the manner in which the elements of the program to be implemented by the State with such assistance will maximize the quality of health and support services available to individuals with HIV disease throughout the State;
(E) provides a description of the manner in which services funded with assistance provided under this part will be coordinated with other available related services for individuals with HIV disease; and
(F) provides a description of how the allocation and utilization of resources are consistent with the statewide coordinated statement of need (including traditionally underserved populations and subpopulations) developed in partnership with other grantees in the State that receive funding under this title; and
(5) an assurance that the public health agency administering the grant for the State will periodically convene a meeting of individuals with HIV disease, representatives of grantees under each part under this title, providers, and public agency representatives for the purpose of developing a statewide coordinated statement of need; and
(6) an assurance by the State that—
(A) the public health agency that is administering the grant for the State engages in a public advisory planning process, including public hearings, that includes the participants under paragraph (5), and the types of entities described in section 2602(b)(2), in developing the comprehensive plan under paragraph (4) and commenting on the implementation of such plan;
(B) the State will—
(i) to the maximum extent practicable, ensure that HIV-related health care and support services delivered pursuant to a program established with assistance provided under this part will be provided without regard to the ability of the individual to pay for such services and without regard to the current or past health condition of the individual with HIV disease;
(ii) ensure that such services will be provided in a setting that is accessible to low-income individuals with HIV disease;
(iii) provide outreach to low-income individuals with HIV disease to inform such individuals of the services available under this part; and
(iv) in the case of a State that intends to use amounts provided under the grant for purposes described in 26151, submit a plan to the Secretary that demonstrates that the State has established a program that assures that—
(I) such amounts will be targeted to individuals who would not otherwise be able to afford health insurance coverage; and
(II) income, asset, and medical expense criteria will be established and applied by the State to identify those individuals who qualify for assistance under such program, and information concerning such criteria shall be made available to the public;
(C) the State will provide for periodic independent peer review to assess the quality and appropriateness of health and support services provided by entities that receive funds from the State under this part;
(D) the State will permit and cooperate with any Federal investigations undertaken regarding programs conducted under this part;
(E) the State will maintain HIV-related activities at a level that is equal to not less than the level of such expenditures by the State for the 1-year period preceding the fiscal year for which the State is applying to receive a grant under this part;
(F) the State will ensure that grant funds are not utilized to make payments for any item or service to the extent that payment has been made, or can reasonably be expected to be made, with respect to that item or service—
(i) under any State compensation program, under an insurance policy, or under any Federal or State health benefits program; or
(ii) by an entity that provides health services on a prepaid basis; and
(G) entities within areas in which activities under the grant are carried out will maintain appropriate relationships with entities in the area served that constitute key points of access to the health care system for individuals with HIV disease (including emergency rooms, substance abuse treatment programs, detoxification centers, adult and juvenile detention facilities, sexually transmitted disease clinics, HIV counseling and testing sites, mental health programs, and homeless shelters), and other entities under section 2612(c) and 2652(a), for the purposes of facilitating early intervention for individuals newly diagnosed with HIV disease and individuals knowledgeable of their HIV status but not in care.”
Section 2613(a)(1) of the CARE Act defines a consortium as “an association of one or more public, and one or more nonprofit private, (or private for-profit providers or organizations if such entities are the only available providers of quality HIV care in the area) health care and support service providers and community based organizations operating within areas determined by the State to be most affected by HIV disease;”
Section 2613(a)(2) states that consortia must agree “to use such assistance for the planning, development and delivery, through the direct provision of services or through entering into agreements with other entities for the provision of such services, of comprehensive outpatient health and support services for individuals with HIV disease;”
Section 2613(b)(1) states that consortia, in order to receive Title II funding from the State, must provide the State with assurances stating, [in part] that:
“(A) within any locality in which such consortium is to operate, the populations and subpopulations of individuals and families with HIV disease have been identified by the consortium, particularly those experiencing disparities in access and services and those who reside in historically underserved communities;
(B) the service plan established under subsection (c)(2) by such consortium is consistent with the comprehensive plan under section 2617(b)(4) and addresses the special care and service needs of the populations and subpopulations identified under subparagraph (A); and
(C) except as provided in paragraph (2), the consortium will be a single coordinating entity that will integrate the delivery of services among the populations and subpopulations identified under subparagraph (A).
(2) Exception.—Subparagraph (C) of paragraph (1) shall not apply to any applicant consortium that the State determines will operate in a community or locality in which it has been demonstrated by the applicant consortium that—
(A) subpopulations exist within the community to be served that have unique service requirements; and
(B) such unique service requirements cannot be adequately and efficiently addressed by a single consortium serving the entire community or locality.”
Section 2613(c) requires a consortium to submit an application to the State that [in part]:
“(A) demonstrates that the consortium includes agencies and community-based organizations—
(i) with a record of service to populations and subpopulations with HIV disease requiring care within the community to be served; and
(ii) that are representative of populations and subpopulations reflecting the local incidence of HIV and that are located in areas in which such populations reside;
(B) demonstrates that the consortium has carried out an assessment of service needs within the geographic area to be served and, after consultation with the entities described in paragraph (2), has established a plan to ensure the delivery of services to meet such identified needs that shall include—
(i) assurances that service needs will be addressed through the coordination and expansion of existing programs before new programs are created;
(ii) assurances that, in metropolitan areas, the geographic area to be served by the consortium corresponds to the geographic boundaries of local health and support services delivery systems to the extent practicable;
(iii) assurances that, in the case of services for individuals residing in rural areas, the applicant consortium shall deliver case management services that link available community support services to appropriate specialized medical services; and
(iv) assurances that the assessment of service needs and the planning of the delivery of services will include participation by individuals with HIV disease;
(C) demonstrates that adequate planning has occurred to meet the special needs of families with HIV disease, including family centered and youth centered care;
(D) demonstrates that the consortium has created a mechanism to evaluate periodically—
(i) the success of the consortium in responding to identified needs; and
(ii) the cost-effectiveness of the mechanisms employed by the consortium to deliver comprehensive care;
(E) demonstrates that the consortium will report to the State the results of the evaluations described in subparagraph (D) and shall make available to the State or the Secretary, on request, such data and information on the program methodology that may be required to perform an independent evaluation; and
(F) demonstrates that adequate planning occurred to address disparities in access and services and historically underserved communities.”
“(2) Consultation.—In establishing the plan required under paragraph (1)(B), the consortium shall consult with—
(A)(i) the public health agency that provides or supports ambulatory and outpatient HIV-related health care services within the geographic area to be served; or
(ii) in the case of a public health agency that does not directly provide such HIV-related health care services such agency shall consult with an entity or entities that directly provide ambulatory and outpatient HIV-related health care services within the geographic area to be served;
(B) not less than one community-based organization that is organized solely for the purpose of providing HIV-related support services to individuals with HIV disease;
(C) grantees under section 2671, or, if none are operating in the area, representatives in the area of organizations with a history of serving children, youth, women, and families living with HIV; and
(D) the types of entities described in section 2602(b)(2).
The organization to be consulted under subparagraph (B) shall be at the discretion of the applicant consortium.”
“(e) Priority.—In providing assistance under subsection (a), the State shall, among applicants that meet the requirements of this section, give priority—
(1) first to consortia that are receiving assistance from the Health Resources and Services Administration for adult and pediatric HIV-related care demonstration projects; and then
(2) to any other existing HIV care consortia.”
Consortia and State Planning and Service Delivery Activities
The CARE Act contains planning and related duties for both consortia and States.
Consortia. Section 2613 of the CARE Act requires each Title II consortium to complete various planning and other tasks and submit an application to the State assuring that it has carried out required activities. Duties are also often required by the State in its annual consortium application process or even in the consortium’s mission statement.
Consortia responsibilities require efficient and effective operations that help the consortium fulfill its duties. They may require a consortium to take on roles beyond what is required by CARE Act legislation or by the State/grantee. While additional roles may be agreed upon by a consortium membership in response to factors such as consortium structure, service area, and/or funding level, other consortia in very rural areas or areas with very limited service provider networks may be unable to take on additional functions.
States. For States, planning requirements are outlined in Section 2617 and include submission of an application for Title II funding describing current services, PLWH being served, and information about services to be provided. These duties imply planning responsibilities, which are in fact explicitly outlined in Section 2617 to include needs assessment, priority setting for the allocation of funds, development of a comprehensive plan, and service delivery and coordination. These tasks are in addition to Title II grantee responsibility to manage the funds.
Following are planning body and service duties. Those required by the legislation are so noted. Those that represent sound practices and HAB/DSS expectations are also presented. More information about a number of these requirements are covered in greater detail in other chapters in this manual (e.g., needs assessment, comprehensive plan, priority setting and resource allocation, coordination).
Planning Body Membership
States. Planning body requirements for States are outlined in Section 2617(b)(6). States are required to engage in “a public advisory planning process” to secure broad input in the development and implementation of the comprehensive plan from PLWH, providers, other CARE Act entities, and other agencies, similar to those outlined for Title I planning councils.
Consortia. Title II planning body requirements are also outlined for consortia. Section 2613 requires the consortium membership to be inclusive in terms of (1) agencies with experience in HIV/AIDS service delivery and (2) populations and subpopulations of persons living with HIV disease (PLWH), who are reflective of the local incidence of HIV. Such consortia are also to be located in areas where such populations reside.
Section 2613(c)(2) also provides for additional involvement by diverse perspectives by requiring consortia, in establishing their service plans, to demonstrate that they have consulted with PLWH, the public health agency or other entity(ies) providing HIV-related health care in the area, at least one community-based AIDS service provider, Title II grantee, Title IV grantees or organizations with a history of serving children, youth, women, and families with HIV, and entities such as those required to be represented on Title I planning councils.
Consortia are expected to actively recruit and develop programs to retain the membership of persons living with HIV disease (PLWH). PLWH bring the perspective of those most important to the CARE Act planning process—the people who need the services. PLWH can help to orient, train, and mentor other PLWH and monitor the consortium’s activities to assure its responsiveness to PLWH needs. Consortium activities should include PLWH input, and PLWH should be mentored and developed to undertake leadership positions. For more information on meeting this requirement, see “PLWH Participation” in this manual.
Planning Body Operations
States and Consortia. Implementing membership and planning body functioning requires organizational development activities to create a planning group that can perform the tasks mandated by the CARE Act, the State, and the consortium’s mission. This includes development of policies and procedures, meeting rules, rules of interaction, committee structure, and leadership/membership duties.
The potential for conflict of interest is one area that requires specific attention in running planning bodies that engage in decisions about how to use funds. Conflicts of interest increase when consortia have responsibilities for procuring services. Because the CARE Act requires that providers be part of consortia, decision makers within consortia are frequently employees, board members, or clients of the agencies seeking resources to provide services. Close attention must be paid to conflict of interest in all phases of resource allocation. Policies and procedures must be in place to minimize this problem.
Both States and their consortia have needs assessment requirements. Specific requirements for needs assessment are outlined in the needs assessment chapter of this manual.
States. Section 2617(b) outlines State Title II requirements, which entail determining the size and demographics of the population of PLWH in the State and determining their needs, with particular attention to PLWH who know their status and not are receiving HIV-related services and disparities in access and services among affected subpopulations and historically underserved communities.
Consortia. Section 2613(c)(1)(B) requires consortia to conduct a needs assessment within the geographic area served. The assessment must be done in collaboration with public health and community-based providers of HIV-related services and with the participation of people living with HIV disease (PLWH).
Needs assessment activities happen throughout the annual cycle of planning and help capture information about met and unmet needs. A comprehensive, formal needs assessment does not need to be completed every year. Consortia should undertake periodic needs assessment updating activities (e.g., a client survey or an update of the resource inventory) to stay informed about changing needs. Epidemiologic data should be updated each year.
States. Section 2617(b) requires States to establish “priorities for the allocation of funds within the State.” Factors to consider in setting priorities include: size and demographics of the population of individuals with HIV disease and the needs of such population (with a focus on PLWH who know their status and are not in care and on disparities in access and services among affected subpopulations and historically underserved communities); availability of other governmental and non-governmental resources, including the State Medicaid plan and the State Children’s Health Insurance Program to cover health care costs of eligible individuals and families with HIV disease; capacity development needs resulting from disparities in the availability of HIV-related services in historically underserved communities and rural communities; and efficiency of the administrative mechanism of the State for rapidly allocating funds to the areas of greatest need within the State. Completing an annual priority setting process weighs needs against available resources and uses results to inform the resource allocation process.
Consortia. For consortia, the legislation does not explicitly outline priority setting but does imply its importance in language requiring consortia to ensure that services address identified needs. Clearly, this indicates that needs assessment results must be used in determining service priorities.
States and Consortia. Both the State and their consortia are required to develop a plan to meet identified service needs. Specific requirements are outlined in greater detail in the comprehensive planning chapter in this manual.
The comprehensive plan must demonstrate that adequate planning occurred to address multiple areas. They include: disparities in access and services to historically underserved communities; the needs of those who know their HIV status and are not in care and the needs of those who are currently in the care system; and coordination of services with other services, including HIV prevention programs (including outreach and early intervention services) and substance abuse prevention and treatment programs
A comprehensive plan should include data from local needs assessments and/or statewide needs assessments to meet legislative requirements. Many Title II areas have conducted an assessment process, enabling them to update their Statewide Coordinated Statement of Need. This information may play a valuable part in the development of a comprehensive plan. Those needs identified should be an impetus in the development of the comprehensive plan that includes goals and measurable objectives for use in guiding resource allocation decisions.
Consortia. In establishing service plans, consortia must demonstrate that they have consulted with PLWH, the public health agency or other entity(ies) providing HIV-related health care in the area, at least one community-based AIDS service provider, Title II grantee, Title IV grantees or organizations with a history of serving children, youth, women, and families with HIV, and entities such as those required to be represented on Title I planning councils.
DEVELOP A BALANCED WORKPLAN
Some consortia spend the bulk of their meeting time dealing only with organizational issues and concerns and then find they have just a couple of months before they apply to the State for funding to complete planning activities such as needs assessment, prioritization, the comprehensive plan, and evaluation. A balance must be established. During some times of the year, the consortium will focus on planning tasks and on organizational activities. At other junctures the consortium can revisit its mission and annual workplan or develop and implement a new membership recruitment plan. A key is to develop an annual workplan that specifies who is responsible for what activities by when, on a month-by-month basis. The workplan should include the following, with timelines:
Coordination requirements exist for both States and their consortia. Some are outlined above under comprehensive planning, wherein the plan must coordinate services with HIV prevention programs (including outreach and early intervention services) and substance abuse prevention and treatment programs. Coordination is also discussed in the early intervention chapter and coordination chapters in this manual, with the latter covering working with other payers, programs, and planning bodies.
States. In Section 2617, States are required to coordinate use of Title II funds with other payers and to coordinate with HIV prevention and substance abuse services. Section 2617(b) also requires States to assure that funded entities maintain appropriate relationships with key points of access to facilitate early intervention. This requires grantees and planning bodies to define such relationships and establish them with key points of access, as defined in Section 2612(c) (e.g., public health departments, emergency rooms, and sexually transmitted disease clinics).
Consortia. Section 2613(c) contains provisions for consortia to develop plans to promote coordination and integration of community resources. They require consortia to address service needs through the coordination and expansion of existing resources before new programs are created. In the case of services for individuals in rural areas, consortia must assure access to a continuum of care through case management services.
Coordination of services is an important and necessary outgrowth of bringing together a wide variety of provider organizations and community representatives into a planning body. An institutional memory develops of the services being provided by members. Meetings are frequently used to learn more about those services. Face-to-face relationships often facilitate referrals between service providers who have not previously worked together.
Many consortia have created resource directories of available services to increase awareness of and access to services. Consortia have worked on approaches to service coordination goals such as the following:
States. States are allowed to provide services under five program categories. (See chapters on these for additional information.)
Consortia. The CARE Act requires that consortia provide for the delivery of a broad range of health and support services either by entering into agreements with existing agencies or by providing services directly. Most consortia provide services through contracts with existing service providers. Assuring the provision of health and support services requires the development and maintenance of a comprehensive service delivery network and the implementation of a case management system to ensure that clients have appropriate access to those services.
Enhancing service delivery can take on other forms, such as:
States and Consortia. As part of their needs assessment, priority setting and resource allocation duties, States and consortia must consider capacity development needs resulting from disparities in the availability of HIV-related services in historically underserved communities and rural communities. In particular is examining needs of PLWH who know their status and are not in care. If the needs assessment identifies gaps in the ability of the area to reach and address the HIV service needs of underserved populations or communities, capacity development activities must be prioritized. Where there are no other sources of funding, Title II funds must be allocated for this activity. Capacity development should be targeted to service providers located in or with a history of serving communities where these access or service disparities exist.
The State and planning bodies can actively participate in recruiting and assisting with development of increased service provider capacity in a community. Capacity building can also extend to the provision of technical assistance to service providers as long as such assistance contributes to specific capacity development needs that have been identified.
States and planning bodies may choose to assume responsibility for providing or coordinating technical assistance to service contractors in organizational development areas. Examples of eligible areas include training, equipment, system design, help with planning, and other consultations. Inappropriate activities include staffing, major construction, and planning grants.
Consortia. Consortia with procurement authority may provide technical assistance on grant application processes to assure applications from a diverse number of providers. This is particularly important when a consortium has prioritized services provided by smaller, minority, or rural organizations lacking experience in applying for and managing Federally funded programs.
Efficiency of the Administrative Mechanism
States. Section 2617 requires States to assess the efficiency of the administrative mechanism for rapidly allocating funds to areas of greatest need in the State.
States. (See outcomes evaluation and cost effectiveness chapters in this Manual.)
Consortia. Section 2613 requires consortia to have a mechanism to evaluate periodically their success in responding to identified needs and the cost-effectiveness of the mechanisms employed by the consortium in delivering comprehensive care.
Consortia can build evaluation of the costs and effectiveness of different service delivery approaches into the competitive funding award process. For example, the cost of providing a service can be considered when awarding contracts to providers.
A consortium should evaluate how satisfied its members are with consortium processes and outcomes. Consortia should assess periodically their own administrative structures and procedures to ensure that they are operating effectively.
A consortium should check with its State grantee about any restrictions and specifications on the administrative cap requirements. An administrative budget should be developed, either as part of the lead agency’s budget or separately.
Most lead agencies make ”in-kind” donations to the consortium process (e.g., allocating staff time and resources such as copying and postage beyond the funding available for administration). Additionally, members contribute large amounts of time and resources to the success of the consortium process. It should never be assumed that the lead agency or members will automatically donate everything. Consortia need to develop annual budgets that include an estimation not only of anticipated costs but also anticipated time and “in-kind” donations.
Some consortia combine resources for more efficient use of their administrative allocation. For example, a community could “pool” its Title II and Centers for Disease Control and Prevention (CDC) Community Planning Group dollars for a joint needs assessment and evaluation. Other communities share resources across consortium boundaries by doing a multi-consortia needs assessment or sharing one staff person among multiple consortia and splitting that cost. Another solution to a lack of administrative support is to use other local resources such as interns from a local university. Many consortia find that combining planning resources helps financially and enhances community wide HIV/AIDS planning.
Establishment of consortia by the State is outlined in the CARE Act legislation. Various consortium models have emerged in the States, including the following:
In some States, the consortia select the service providers who will be providing the services required by the consortium’s comprehensive plan. Several different processes may be used for allocating funds, including the following: