Ryan White HIV/AIDS Program Part A Manual

Use of Part A Ryan White funds is guided by planning, which takes place through the planning council established by the chief elected official (CEO) of each eligible metropolitan area/transitional grant area (EMA/TGA). (Note: The five TGAs first funded in 2007 have the option of creating a planning council or another mechanism for securing community input, especially from people living with HIV and AIDS.) The planning council is not advisory. It has legislative authority to carry out its assigned tasks, along with roles recommended by HRSA's HIV/AIDS Bureau (HAB), Division of Service Systems (DSS).

The planning council takes the lead in conducting many of its legislated responsibilities and shares duties with the grantee in some areas. To guarantee that a broad range of ideas are heard, the planning council membership must reflect specific areas of expertise as well as disproportionately affected and historically underserved populations.

Each planning council's responsibilities include the following:

• Establish operations to make planning tasks function smoothly. Examples include procedures for membership (e.g., nominations procedures to secure new members), decision making (e.g., open meeting processes, grievance procedures related to funding decisions, conflict of interest), and other tasks.
  

• Assess the EMA's/TGA's HIV/AIDS service needs and gaps. This includes determining the needs of those who know their HIV status but are not receiving HIV-related primary medical care, as well as disparities in access to care across affected groups. This assessment must include a public process to obtain community input on needs and priorities.
  

• Establish priorities for the allocation of funds. Decisions are to be data-based, including consideration of needs assessment results; the cost effectiveness and outcome effectiveness of funded services; priorities in HIV-infected communities within the EMA/TGA; and the availability of other governmental and nongovernmental resources.
  

• Develop a comprehensive plan for the organization and delivery of HIV services that is compatible with existing State and local plans. As part of the plan, the EMA/TGA must coordinate use of Ryan White dollars with other programs, including prevention and substance abuse services. Part of this is done through participation in the development of a Statewide Coordinated Statement of Need (SCSN), which is a mechanism Ryan White programs use to address HIV/AIDS care issues and enhance coordination.

Ryan White legislation specifies the following mandated activities that planning councils must accomplish and other requirements and prohibitions related to its operations.

Planning Body Operations

Section 2602(b)(5)(A) prohibits the planning council from being "directly involved in the administration of a grant" under and does not permit it to "designate (or otherwise be involved in the selection of) particular entities as [sub]recipients" of Part A funds.

Section 2602(b)(6) requires the planning council to "develop procedures for addressing grievances with respect to funding [allocation of funds]," and to describe these procedures in its bylaws.

Section 2602(b)(7)(A) prohibits the planning council from being "chaired solely by an employee of the grantee."

Section 2602(b)(7)(B) states that:

1. "The meetings of the council shall be open to the public and shall be held only after adequate notice to the public.

2. The records, reports, transcripts, minutes, agenda, or other documents which were made available to or prepared for or by the council shall be available for public inspection and copying at a single location.

3. Detailed minutes of each meeting of the council shall be kept. The accuracy of all minutes shall be certified to by the chair of the council.

4. This subparagraph does not apply to any disclosure of information of a personal nature that would constitute a clearly unwarranted invasion of personal privacy, including any disclosure of medical information or personnel matters."

Needs Assessment

Section 2602(b)(4) requires the planning council to:

1. "determine the size and demographics of the population of individuals with HIV/AIDS;

2. "determine the needs of such population, with particular attention to:

   1. individuals with HIV/AIDS who know their HIV status and are not receiving HIV-related services; and

   2. disparities in access and services among affected subpopulations and historically underserved communities."

2602(b)(4)(G) requires planning councils to "establish methods for obtaining input on community needs and priorities which may include public meetings, conducting focus groups, and convening ad-hoc panels."

Priority Setting and Resource Allocation

2602(b)(4)(C) requires planning councils to "establish priorities for the allocation of funds within the eligible area, including how best to meet each such priority and additional factors that a grantee should consider in allocating funds [procuring services] under a grant based on the:

1. size and demographics of the population of individuals with HIV/AIDS (as determined under subparagraph (A)) and the needs of such population (as determined under subparagraph (B));

2. demonstrated (or probable) cost effectiveness and outcome effectiveness of proposed strategies and interventions, to the extent that data are reasonably available;

3. priorities of the communities with HIV/AIDS for whom the services are intended;

4. coordination in the provision of services to such individuals with programs for HIV prevention and for the prevention and treatment of substance abuse, including programs that provide comprehensive treatment for such abuse;

5. availability of other governmental and nongovernmental 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/AIDS; and

6. capacity development needs resulting from disparities in the availability of HIV-related services in historically underserved communities…"

Required Funding for Core Medical Services

Section 2604(c)(1) requires that at least 75 percent of funds be spent on "core medical services:"

"With respect to a grant under section 2601 for an eligible area for a grant year, the chief elected official of the area shall, of the portion of the grant remaining after reserving amounts for purposes of paragraphs (1) and (5)(B)(i) of subsection (h), use not less than 75 percent to provide core medical services that are needed in the eligible area for individuals with HIV/AIDS who are identified and eligible under this title (including services regarding the co- occurring conditions of the individuals)."

Section 2604(c)(2)(A) states that the Secretary of HHS may grant a waiver for a grant year:

"if the Secretary determines that, within the eligible area involved-

1. there are no waiting lists for AIDS Drug Assistance Program services under section 2616; and
2. core medical services are available to all individuals with HIV/AIDS identified and eligible under this title."

Core medical services include the following, as stated in Section 2604(c)(3):

1. Outpatient and ambulatory health services.
2. AIDS Drug Assistance Program treatments in accordance with section 2616.
3. AIDS pharmaceutical assistance.
4. Oral health care.
5. Early intervention services described in subsection (e).
6. Health insurance premium and cost sharing assistance for low-income individuals in accordance with section 2615.
7. Home health care.
8. Medical nutrition therapy.
9. Hospice services.
10. Home and community-based health services as defined under section 2614(c).
11. Mental health services.
12. Substance abuse outpatient care.
13. Medical case management, including treatment adherence services.

Allocation of Funds to Services for Infants, Children, Youth, and Women

Section 2604(f) specifies that "[f]or the purpose of providing health and support services to infants, children, youth, and women with HIV/AIDS, including treatment measures to prevent the perinatal transmission of HIV, the chief elected official of an eligible area, in accordance with the established priorities of the planning council, shall for each of such populations in the eligible area use, from the grants made for the area under section 2601(a) for a fiscal year, not less than the percentage constituted by the ratio of the population involved (infants, children, youth, or women in such area) with HIV/AIDS to the general population in such area of individuals with HIV/AIDS."

This provision does not require planning councils to create a special priority for services to these populations. A waiver to this provision can be granted when EMAs/TGAs can demonstrate that the needs of each population or combination of these populations is being met through other programs such as Medicaid, the Children's Health Insurance Program (CHIP), or other Federal or State programs.

Comprehensive Planning

2602(b)(4)(D) requires the planning council to "develop a comprehensive plan for the organization and delivery of health and support services described in section 2604 that:

1. "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;

2. 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); and

3. is compatible with any State or local plan for the provision of services to individuals with HIV/AIDS."

Coordination

Section 2602(b)(4)(F) calls for the planning council and grantee to "participate in the development of the statewide coordinated statement of need initiated by the State public health agency responsible for administering grants under Part B."

Section 2602(b)(4)(H) requires the planning council to "coordinate with Federal grantees that provide HIV-related services within the eligible area."

Assessment of the Administrative Mechanism and Effectiveness of Services

2602(b)(4)(E) requires planning councils to "assess the efficiency of the administrative mechanism in rapidly allocating funds to the areas of greatest need within the eligible area, and at the discretion of the planning council, assess the effectiveness, either directly or through contractual arrangements, of the services offered in meeting the identified needs."

Planning Councils in Transitional Grant Areas

Section 2609(d)(1) specifies that

• The chief elected official of a new TGA "may elect not to comply with the provisions of section 2602(b) if the official provides documentation to the Secretary that details the process used to obtain community input (particularly from those with HIV) in the transitional area for formulating the overall plan for priority setting and allocating funds from the grant" and
• Through fiscal year 2009, this exception "does not apply if the transitional area involved received funding [under Part A] for fiscal year 2006."

Planning councils must set up planning council operations to help the planning council to operate smoothly and fairly. This includes such features as bylaws, open meetings, grievance procedures, and conflict of interest standards. (See below and chapters on Grievance Procedures and conflict of Interest.

Planning Council Operations

Planning councils must set up planning council operations to help the planning council to operate smoothly and fairly. This includes such features as bylaws, open meetings, grievance procedures, and conflict of interest standards. (See below and chapters on Grievance Procedures and conflict of Interest.)

• Open Meetings. Section 2602(b)(7)(B) of Ryan White states that "meetings of the council shall be open to the public and shall be held only after adequate notice to the public." This includes planning council committees and task forces as well as full planning council meetings.
• Council Chair. The legislation specifies that an employee of the Part A grantee may not be the only chair of a planning council. An employee of the grantee may serve as a co-chair, provided the bylaws of the planning council permit or specify that arrangement.
• Meetings and Minutes. To comply with legislative requirements around open meetings and public access to minutes and other planning council documents, planning councils must:
  • Ensure that meetings are open to all members of the general public and maintain a system that provides for public written notice of all council meetings. This includes publication of the meeting notices in local print media and through other forums accessible to the disabled (i.e., the hearing- or speech-impaired).
     
  • Have a summary of the minutes certified by the chair of the planning council available for public inspection. The complete transcript of minutes should be available within six weeks after the meeting date.
     
  • Have a publicly accessible location where minutes and other legislatively required information can be inspected and copied if requested.
     
  • Take appropriate steps to guard against disclosure of personal information that would constitute an invasion of privacy.
     
  • Make available for public inspection records of the recommendations made by committees or other subgroups to the planning council, as well as the subsequent actions taken by the planning council. A sound practice to implement this requirements is to post approved minutes on the planning council Web site.
     
  • Where local, county, or State regulations, ordinances, or statutes are more stringent than Ryan White requirements, follow these more stringent requirements.

Needs Assessment

One of the main planning tasks for the planning council is to conduct a needs assessment to find out what services are needed, what populations need care, and what are the gaps in the current system of care. (See Needs Assessment chapter.)

Priority Setting and Resource Allocation

Based upon the results of the needs assessment, and other information, the planning council sets priorities for the allocation of funds. (See Priority Setting and Resource Allocation chapter.)

Comprehensive Planning

The planning council develops a comprehensive plan on how to provide these services. (See Comprehensive Planning chapter.)

Coordination

The planning council also looks for ways that Part A services work to fill gaps in care with other Ryan White programs through the Statewide Coordinated Statement of Need (SCSN); special attention to early intervention services, HIV prevention, and substance abuse prevention and treatment; and ongoing coordination with other services like Medicaid. (See chapters on Coordination, Care/Prevention Collaborative Planning, SCSN, and Managed Care and HIV/AIDS.)

Assessment of Administrative Mechanism

The planning council assesses the efficiency of the administrative mechanism, which entails evaluation of how rapidly funds are allocated.

The purpose is to assure that funds are being contracted for quickly and through an open process, and that providers are being paid in a timely manner.  The planning council should not be involved in how the administrative agency monitors providers.

Generally, assessments are based on time-framed observations of procurement, expenditure, and reimbursement processes. For example, an evaluation could identify the percent of funds obligated within a certain time period (e.g., 90 days) from the date of grant award. Similarly, reimbursement processes can be tracked from date of service delivery through invoicing to payment, with documentation of any adverse impact on clients or providers related to delayed payments. HAB/DSS will occasionally request information about the assessment or require EMAs/TGAs to submit a copy of the most recent administrative assessment as part of progress reports or grant applications.

In evaluating the administrative mechanism, communication between the grantee and planning council is essential so that information can be efficiently shared. The planning council and grantee should establish, before the procurement process begins, a memorandum of understanding outlining a process and timeline for sharing data necessary to evaluate the administrative mechanism. The grantee must communicate back to the planning council the results of its procurement process. The planning council may then assess the consistency of the procurement process with its stated service priorities and allocations.

If the council finds that the existing mechanism is not working effectively, it is responsible for making formal recommendations for improvement and change.

The planning council can also assess whether the services that have been procured by the grantee are consistent with stated planning council priorities, resource allocations, and instructions as to how to meet these priorities. However, assessing the administrative mechanism is not an evaluation of the grantee or individual service providers, which is a grantee responsibility. (See outcomes evaluation and cost-effectiveness chapters in this section of the manual.)

Evaluation of Service Effectiveness

The planning council and grantee should determine what impact services are having on client health outcomes (outcomes evaluation) and also examine the cost-effectiveness of the services being delivered. As discussed in the chapter on outcomes evaluation, the planning council has the option of evaluating the "effectiveness of the services offered in meeting identified needs."

In order for planning councils to function in the most efficient manner possible, it is important to understand the relationships between and among grantees, planning councils, PLWHA, and planning council support staff (including consultants and shared staff of the council and grantee).

Planning Council and the Grantee

The planning council is a legislatively constituted body with clearly defined responsibilities in Ryan White planning and decision making.

Separation of Planning Council and Grantee Roles

While the CEO may designate a specific department within local government to administer the program, it is not appropriate for the grantee to perform duties related to the planning council's legislative responsibilities. A separation of grantee and planning council roles is necessary to avoid conflicts of interest. For example, Section 2602(b)(7)(A) prohibits the planning council from being "chaired solely by an employee of the grantee." However, a grantee employee may be a co-chair.

Planning Council Support funds are now part of the 10 percent administrative funds available to the grantee for managing the Part A program. The grantee and planning council must work together to agree on the planning council budget.

Memorandum of Understanding

To clarify the roles of the planning council and the grantee, and to encourage a collaborative working relationship, HAB/DSS recommends that these two entities develop a written agreement (a Memorandum of Understanding) that identifies the individual and shared responsibilities of both parties and specifies communication mechanisms. The role of planning council staff can also be included. The planning council should establish bylaws and operating procedures that codify this relationship.

A clear delineation of roles and responsibilities will help ensure timely and efficient disbursement of Part A funds and facilitate the development of a continuum of care that addresses the needs of PLWHA.

Persons Living with HIV/AIDS (PLWHA)

In fulfilling its roles and responsibilities, a planning council must include PLWHA in all its activities. The Ryan White legislation requires that at least 33% of the planning council be consumers of Ryan White Part A services who are not officers, employees, or consultants to any entity that receives Part A funds. The individuals who meet the 33% unaligned definition must (like the planning council as a whole) reflect the demographics of the population of individuals with HIV/AIDS in the EMA/TGA.

Inclusion of PLWHA brings unique benefits, including a consumer perspective to all decision making and a link between the planning council and the community served. It also presents challenges, such as the need for:

• Training and mentoring to make new members familiar with the legislation and the roles and responsibilities of a Part A planning council

• Flexibility to address changing health status

• Methods to help PLWHA become comfortable with the planning council's processes, which often involve difficult decision making, challenges related to relationships, and frustrations due to the time required to accomplish needed improvements in the system of care, and

• Especially for representatives with limited incomes, resources to address transportation, child care, and other direct financial costs of planning council membership

HAB/DSS strongly recommends that planning councils adopt a variety of strategies to strengthen the effective participation of PLWHA. Two HAB/DSS manuals, the Planning Council Primer and the Training Guide: Preparing Planning Body Members , provide materials to help address the challenges of recruiting and maintaining the active participation of people living with HIV disease in planning council processes.

Planning Council Support

The planning council needs funding to carry out its responsibilities. HAB/DSS refers to these funds as "planning council support." Administrative funds under Part A formula and supplemental grants can be used as a source of planning council support. The planning council must negotiate the size of the planning council support budget with the grantee and is then responsible for developing and managing that budget within the grantee's grants management structure. . Planning council support funds may be used for such purposes as hiring staff, developing and carrying out needs assessments and estimating unmet need, identifying barriers to access and care, conducting planning activities and assuring PLWHA participation.

Procedures for Selecting Support Staff and Consultants

The procedures to be used in hiring planning council support staff or contracting with consultants need to be agreed upon ahead of time with the grantee. Planning council staff may be employed through the grantee's payroll system, but measures must be taken to ensure that the planning council, not the grantee, directs the work of the planning council's staff.

A planning council is not permitted to be directly involved in selecting particular entities to receive Ryan White funding for services, but it can be involved with selecting entities and people to carry out activities directly related to planning council functioning and responsibilities. It should be keenly attuned to potential conflicts of interest (real or perceived) in these hiring decisions. The planning council must use an open, public process to contract for planning council support services-such as a competitive request for proposals (RFP) process under the direction of the grantee. If a planning council's procedures allow planning council members or the agencies they represent to compete in this process, the planning council must define specific parameters and processes to manage real or perceived conflicts of interest.

Shared Staff of Grantee and Planning Council

HAB/DSS discourages the practice of having the same staff person perform administrative work for the grantee and provide support to the planning council. However, sometimes-because of limited funds-this situation is unavoidable. The challenge presented in such situations is to balance that dual role with the legislative intent of Ryan White legislation to provide the planning council with full authority and autonomy to carry out its mandated responsibilities. Having a single staff member perform dual roles could compromise objectivity. A special complication is the planning council's responsibility to assess the grantee's administrative mechanism for distributing and managing Ryan White Part A funds. A single staff member who performs both grantee and planning council support roles may be in the conflicted position of evaluating his/her own work.

To address this challenge, a planning council and grantee sharing a staff member should:

• Define in writing the functions/activities of planning council and grantee staff

• Clarify assignments and responsibilities

• Cost out time and ensure that resource needs are reflected in the budget justifications for grantee administrative expenses (which include planning council support), and

• Clearly specify lines of communication and reporting for the staff member so that work performed for the grantee is reported to the grantee contact and planning council support work is reported to the planning council chair, a committee, or the full council

Program and fiscal monitoring are grantee responsibilities as part of Part A grant administration. Program and fiscal monitoring are related functions.

• Program monitoring involves assessing the quality and quantity of the services being provided by a particular contractor in such terms, as whether services are being provided, how well they are being provided, and whether goals of the contract are being met. Such monitoring might include reviewing program reports, making site visits, and/or reviewing client data and utilization rates.

• Fiscal monitoring involves assessing how quickly, efficiently, and appropriately contractors use Ryan White funds. This type of monitoring includes review and assessment of monthly expenditure patterns for groups of service providers, as well as processes to ensure adherence to Federal, State, and local rules and guidelines on the uses of Ryan White funds.

Planning councils should request that the grantee or administrative agency provide them with aggregate summary reports of the information collected during these site visits. Grantees should not provide and planning councils should not have access to individual provider information, but should receive data by service category and/or across service categories. Planning councils can greatly benefit from knowing, for example, the percentage of agencies within a particular service category that have been able to meet established goals for serving specified numbers of clients with regard to race/ethnicity and gender, documenting client health outcomes, implementing clinical quality management programs and documenting system changes associated with those programs, etc.

Data provided by the grantee can also help planning councils evaluate the expenditure patterns of the EMA/TGA as a whole as well as service categories. If money is not being spent in an efficient manner, planning councils can know early on and reallocate funds to another service category.  Note: Grantees may, without planning council approval, redirect funds within a service category.

The planning council must be informed of the changes to service priority allocations that result from any redistribution of program funds by the grantee. As with the initial disbursement of funds, the outcome of the redistribution must be consistent with the priorities and resource allocations of the planning council. Any redistribution of funds by the grantee that is not consistent may lead to a grievance by the planning council.