2. Title I and Title II Coordination
Title I and Title II Coordination
Although they operate fairly independently, Title I and Title II planning bodies work together in pursuit of CARE Act goals to strengthen the service continuum for people living with HIV (PLWH) and ensure that funds are used to fill gaps in care. More practical benefits can include reduced administrative and planning costs and lessened duplication of effort.
Coordination efforts are driven by both grantee initiative and such CARE Act requirements as cross-title membership in planning groups, and consistency across State and local comprehensive plans, and the joint work on the Statewide Coordinated Statement of Need (SCSN). Among the more visible areas of coordination is determining use of Title II AIDS Drug Assistance Program (ADAP) dollars in Title I areas. Other areas for coordination with Title II include State programs like Medicaid and substance abuse block grants. Tools to streamline planning and enhance services might be jointly developed, thus benefiting providers who are funded under both titles.
Coordination across Title I and Title II can occur on multiple levels, from less formal information sharing to more structured efforts such as:
Making such collaboration work requires attention to differing legislative mandates for each title. Among these are the Title I focus of responsibility on local needs and the Title II focus on the consortium area or State. Key decision makers also vary, with Title I centered on the chief elected official in the eligible metropolitan area (EMA) and Title II on the State. In addition, the specific planning task of resource allocation has significant legislative distinctions, with Title I planning council involvement being much more restricted in this area.
CARE Act requirements for coordination between Title I and Title II cover planning body membership, participation in the SCSN, consistency of Title II services with the SCSN, and coordination with other Federal grantees providing HIV prevention and care services.
Planning body requirements for States are outlined in Section 2617(b)(6) require them 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 (e.g., PLWH, health and social service providers, other payers).
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 (e.g., PLWH, health and social service providers, other payers).
Section 2617(B)(4)(c) requires States to “develop a comprehensive plan for the organization and delivery of health and support services” to be funded under Title II that, in part—
“(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); (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….”
Section 2612(c) of the CARE Act states that Title II funds may be used to provide early intervention services to facilitate access to HIV-related health services. Entities that may deliver EIS include, for example, public health departments, emergency rooms, and substance abuse and mental health treatment programs. However, entities that propose to delivery EIS must demonstrate to the State that “Federal, State, or local funds are otherwise inadequate for the early intervention services the entity proposes to provide; and the entity will expend funds pursuant to such paragraph to supplement and not supplant other funds available to the entity for the provision of early intervention services for the fiscal year involved.”
HAB/DSS expectations for Title I and Title II coordination relate to legislative requirements on planning body membership, the SCSN and comprehensive plans, and service delivery coordination.
Planning Body Membership
Title II areas are expected to include in their planning body representatives from of local and State level agencies, such as representatives from other CARE Act titles and membership similar to that of Title I planning councils (e.g., HIV prevention providers, the State Medicaid program).
Requirements for the SCSN (outlined in the SCSN chapter in this Manual) address the focus of the SCSN and required involvement, which includes Title II, both the Title I grantee and planning council, other CARE Act entities, and other programs. In particular, HAB/DSS generally expects Title II programs to describe, in their annual application, how they participated in developing the SCSN and how their implementation plan relates to and is consistent with the SCSN.
HAB/DSS expects and encourages Title I and Title II coordination on a broad range of activities, even beyond those specifically mandated in law. This is especially true in those geographic areas where planning council and consortium service areas overlap. In overlapping service areas, the following types of cooperation should be pursued:
Differences in Planning Body Authority and Autonomy
In exploring ways to work together, Title I and Title II planning bodies must consider the following differences in their respective authority and autonomy.
These variations have implications for what structures can be used and responsibilities undertaken, particularly with regard to allocations and contracting.
Benefits of Coordination
Experience with collaborative and merged planning bodies shows that many types of cooperative activities can be implemented. *
Challenges of Coordination and Lessons Learned
HRSA/HAB has identified the following challenges faced by planning bodies seeking to enhance collaboration. Many have been successfully addressed.
One Approach to Coordination: Merger and Consolidation
While HAB/DSS expects Title I and II planning bodies with common service areas to collaborate, there is no preferred or best model. Planning bodies with overlapping geographic areas are encouraged to explore the feasibility of consolidation among other options for effective enhancing coordination. Merged planning bodies have been an effective means of integrating HIV activities in some communities but have been less successful in others.
Austin: A Merged Consortium and Planning Council
When Austin became an EMA in 1994, the community had an HIV consortium and an HIV commission. These two bodies met with representatives from the Mayor’s office (the CEO) to discuss establishment of the new planning council and decided that the efficient path would be to combine responsibilities with their existing bodies. The Austin Area Comprehensive HIV Planning Council was created as a single body that fulfills three roles: the Title I planning council, the Title II consortium, and the city/county HIV commission.
Benefits of this combined group relate to overlapping duties in needs assessment, priority setting, and organization and delivery of services. Having one set of priorities and one comprehensive plan that applies to all funding streams—CARE Act Title I and Title II, HOPWA, State, city and county—results in better coordination of funds and reduced duplication of effort.
In addition to joint planning bodies, Austin has one administrative agency. The Austin-Travis County Health and Human Services Department administers Title I, Title II, and seven other Federal and State HIV-related grants. With a single administrative agency, the procurement process is simplified. The planning council identifies needs and allocates funds from the various funding streams by service category. The administrative agency issues a single RFP for Title I and Title II, as well as the State health and social services grant. A single RFP minimizes the workload of the administrative agency and of community providers, who have more time to provide services because they need not respond to multiple RFPs. One external grant review panel evaluates proposals from numerous agencies for all the service categories. Once that process is completed, the administrative agency decides which funding sources are best used for each award. Where possible, providers are supported by a single funding stream, so they prepare only one quarterly report. A single database for all services enhances data reporting and provider and contract monitoring, while reducing the administrative workload.
An Alternative Approach: Collaborative but Separate Bodies
Merger or consolidation of Title I and Title II planning bodies may not always work, but other approaches exist for coordinating activities. They include: one planning body functions as a subgroup of the other; separate groups collaborate on specific activities; and separate bodies exist and share information and communicate.
San Diego: Cooperation between a Consortium and a Planning Council
San Diego’s collaboration developed through a gradual process of building trust and developing opportunities for collaboration, beginning in 1991. Consumer involvement was the catalyst. The Title I planning council, created under the auspices of the county, was perceived as exclusive and not reflective of the HIV community. The Title II consortium was formed as a community- and consumer-based group. Events forced both groups to share responsibility for funding several programs, which was solidified in a memorandum of understanding that laid the foundation for a successful partnership.
The agreement spelled out a philosophy for working together and encouraging community and consumer input to provide the best possible continuum of HIV services, prevent duplication, and maximize resources. During the next year, the two groups began combining needs assessment, planning activities, and decision making for prioritization of services and resource allocations. Title I and Title II funds were also pooled for joint decision making. San Diego now has a joint planning and allocations process. Decisions to fund a service category are made and then a process occurs to decide which services will be funded from which title.
The planning council and consortium share two important committees. The planning committee, which has co-chairs from each group and is responsible for joint needs assessment and planning. The consumer committee coordinates consumer representation and involvement. In addition to joint activities through these two committees, multiple opportunities are provided for consumer and community involvement at combined meetings of Title I and Title II groups every year.
Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB). “Effective Integration of Consortium and Planning Council Activities.” CARE Act National Technical Assistance Call Report. Rockville, MD: U.S. Department of Health and Human Services, 1996.
HRSA, HAB. Addressing Major Title I/II Coordination Issues in Newly Developing Eligible Metropolitan Areas. Rockville, MD: U.S. Department of Health and Human Services, 1996.
* The findings presented are from a HRSA/HAB Office of Science and Epidemiology (OSE) study on the challenges of coordination and ways to overcome them. The study included three sites with a merged, single planing body (Austin, TX; Kansas City, MO and KS; and Sonoma County, California) and three sites with separate but coordinated planning bodies (New Haven, CT; San Diego, CA; and San Atonio, TX). Portland, OR was examined as a site with emerging coordination.