Ryan White HIV/AIDS Program Part A Manual

Although they usually operate fairly independently, Part A and B planning bodies can work together in pursuit of common Ryan White goals to strengthen the service continuum for people living with HIV/AIDS (PLWHA) 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 grantee initiative and such Ryan White requirements as cross-Part membership in planning groups, consistency across State and local comprehensive plans, and joint work on the Statewide Coordinated Statement of Need (SCSN). Among the more visible areas of coordination is determining use of Part B AIDS Drug Assistance Program (ADAP) dollars in Part A areas. Other areas for coordination with Part B include State programs like Medicaid and substance abuse block grants. Tools to streamline planning and enhance services might be jointly developed, thus benefi ting providers who are funded under both Parts.

Coordination across Parts A and B can occur on multiple levels, from less formal information sharing to more structured efforts like:

• Cooperation on planning-related tasks (e.g., needs assessment, comprehensive plans)
  
• Joint service-related tasks (e.g., design of data collection processes, standards of care, quality management, evaluation), and
  
• Consolidation or even merger of planning bodies.

Making such collaboration work requires attention to differing legislative mandates for each Part. In addition, the specific planning task of resource allocation has significant legislative distinctions, with Part A planning council involvement being much more defined in this area.

Ryan White requirements for coordination between Parts A and B cover planning council membership, participation in the SCSN, consistency of Part A services with both the SCSN and State comprehensive plan, and coordination with other Federal grantees providing HIV prevention and care services.

Section 2602(b)(2)(I) states that “the [Part A] HIV health services planning council shall include representatives of State government (including the State Medicaid agency and the agency administering the program under Part B).”

Section 2602 (b)(4)(D)(iii) directs the planning council to “develop a comprehensive plan for the organization and delivery of health and support services… that is compatible with any State or local plan for the provision of services to individuals with HIV/AIDS.”

Section 2602(b)(4)(F) directs the planning council 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 2603(b)(1)(G) requires Part A funding applicants to demonstrate that proposed services are consistent with the statewide coordinated statement of need.

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

HAB/DSS expectations for Part A and B coordination relate to legislative requirements on planning body membership, the SCSN and comprehensive plans, and service delivery coordination. Each is described below.

Planning Body Membership

Part A areas are expected to document their overall planning council membership, which must include State-level representatives (i.e., Part B agency and the State Medicaid program).

SCSN

Requirements for the SCSN (outlined in the SCSN chapter in this manual) address the focus of the SCSN and required involvement, which includes both the Part A grantee and planning council, Part B, other Ryan White entities, and other programs. In particular, HAB/DSS generally expects Part A programs to describe, in their annual application, how the planning council and grantee participated in developing the SCSN and how the Part A implementation plan relates to and is consistent with the SCSN.

Planning Activities

HAB/DSS expects and encourages Part A and B 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 Part B planning body service areas overlap. In overlapping service areas, the following types of cooperation should be pursued:

• Inclusion of a representative of the other Part on each planning body. This might include joint committees. Notably, HAB/DSS does not specifically promote consolidation of Part A and B planning groups into a single entity. Rather than prescribe a particular model of coordination, HAB/DSS encourages planning bodies to determine the model that works best in their community.
  
• Information-sharing procedures to ensure effective communication between the two planning bodies.
  
• Coordinated needs assessment activities, where possible, particularly the epidemiologic profile and other specific needs assessment activities such as development of a joint resource inventory, and perhaps use of the same PLWHA survey instrument.
  
• Coordinated comprehensive plans.
  
• Consideration of joint priority setting.
  
• Collaborative contracts with providers that are funded by both Parts.
  
• Coordination of capacity development, outreach, and early intervention services (EIS), expectations for which are outlined in greater detail in both Ryan White and HRSA/HAB policies.
  
• Consideration of uniform data collection and reporting systems and collaborative approaches to evaluation and quality measurement.
  
• Mutual understanding of both how Part B funding is used in the EMA/TGA and what, if any, contribution Part A might make to State-administered programs (e.g., ADAP, health insurance continuity).
  
• Collaboration on planning body member training, which might include technical training on topics such as needs assessment, comprehensive planning, resource allocation, and understanding HIV treatments. Joint training for PLWHA members should also be considered.

Differences in Planning Body Authority and Autonomy

In exploring ways to work together, Part A and B planning bodies must consider the following differences in their respective authority and autonomy.

• Planning councils are public bodies established by the EMA’s/TGA's chief elected official (CEO). Legislation defines their key responsibilities, such as determining service priorities, allocating resources to priority service categories, and assessing the administrative agent’s timeliness in disbursing funds. The procurement process and monitoring of funded service providers are grantee responsibilities. Legislation forbids planning council participation in the procurement process.
  
• Since Part B planning bodies are not as defined in the legislation, they have a more varied structure and membership than planning councils. Part B bodies are shaped primarily by the Part B grantee. They may be incorporated bodies with responsibility not only for needs assessment and planning, but—unlike planning councils—also for procurement and contract management. In some areas, a separate local lead agency fulfills those roles or the State may serve as lead agency.

Benefits of Coordination

Experience with collaborative and merged planning bodies shows that many types of cooperative activities can be implemented. *

• Joint needs assessments. Variations include use of a single needs assessment to cover both Parts A and B; EMA/TGA and State collaboration in conducting a joint needs assessment, with EMA/TGA responses separated out for use in planning; use of State-developed needs assessment methodologies or tools by Part A planning councils; or coordinated review of past needs assessments. Planning bodies need not merge to make this happen and can remain separate but use a single committee to conduct the needs assessment.
  
• Allocation of funds across Parts and funding streams. A coordinated allocations system to disseminate funds can occur through a shared system or a combined planning body.
  
• Uniform State and local reporting systems and unified management information systems. Uniform reporting requirements can be developed for use by all Ryan White providers, or the State can support common data collection and management systems that better support use of CAREWare and preparation of the Ryan White Data Report, whose use is required by all Ryan White grantees.
  
• Reduced duplication of provider contracts. A single request for proposals (RFP) process can be used for the two Parts so that a provider has just one contract for any type of service.
  
• Joint service models or Standards of Care (e.g., case management guidelines) and provider training. Such efforts are especially beneficial for providers funded under both Parts.
  
• Equity in access to services across areas. A funding formula can adjust for award of Part B funds to counties outside the EMA/TGA, or a parity formula can seek to equalize per capita spending from Part A and B streams. Some EMAs/TGAs contribute Part A funds to the State ADAP, increasing the number of drugs in the formulary and the number of clients served.
  
• Coordination of Services. For example, clients in an EMA/TGA might be served by State-supported providers, such as a statewide case management system that also does eligibility determination for both Parts.

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.

• Differences in service boundaries complicate joint planning activities. Mergers often change and sometimes increase the size of the service area. This can complicate planning tasks like needs assessment and priority setting.
  
• Multi-State EMAs/TGAs complicate coordination. A merged planning body comprising a Part B planning body and multi-state EMAs/TGAs requires Part B representatives to become familiar with issues faced by interstate EMAs/TGAs. Procedures may be needed to ensure geographic membership representation, develop intergovernmental agreements, and in some cases arrange for more than one administrative agency as a way to disburse funds efficiently throughout multiple jurisdictions. Specific arrangements may be needed to address such issues as contributions to the State ADAP and differing State licensing and regulatory requirements for services such as home care and ambulatory care. Perhaps the greatest challenge is to ensure that needs assessment and planning consider differences in health care delivery and Medicaid programs. Multi-State EMAs/TGAs may want to collaborate with planning bodies located in each State because they bring valuable expertise in State-specific issues, which can be fed back into a larger planning body effort.
  
• Allowable uses of funds may vary. Members of combined planning bodies need to know what services can be funded from which streams. For example, the legislation requires that core medical services be contracted by the State, not by regional Part B consortia.
  
• A merged planning body might focus on the strictest requirements. This can include such areas as priority setting, resource allocation, and quality management programs. Part B consortia are often advisory, while Part A planning councils are decision makers about service priorities and allocations.
  
• Financial resources carry influence. The planning body that brings the most money to the merger is likely to expect to exert considerable influence in decision making. Usually, planning councils allocate more funds than Part B planning groups, although some control significant State funding for HIV/AIDS services. Planning can ensure that major activities reflect the perspectives of both Parts, such as needs assessments and priority-setting processes that account for both Parts.
  
• Mergers may affect planning body membership representativeness and reflectiveness.
  The membership of a consolidated body must maintain/enhance its diversity and PLWHA involvement. If the bodies are fully merged, then the combined planning body’s membership must be at least 33 percent unaligned PLWHA and include individuals from all the categories specified in the Part A legislation. Ensuring rural representation is also a challenge. The planning body needs to be large enough to represent the membership of both Part A and Part B programs but small enough to be manageable. In order to minimize membership issues, different committees within the planning body may need to serve as the official planning council or Part B planning body so that the membership is not fully merged.
  
• Maintaining provider involvement and minimizing potential conflict of interest. A combined planning body may have a smaller proportion of providers than separate groups. In several sites, provider caucuses have been established, including sub-caucuses of specific providers like case managers. They can meet regularly, provide recommendations to the planning body, and in some locations elect representatives to serve on the consolidated planning body.
  
• New protocols may need to define relationships among the planning body, State, and HAB/DSS. For example, HAB/DSS generally communicates with Part B planning groups only through grantees and would not visit them without first informing the State. However, a merged planning body is also a planning council, and HAB/DSS regularly communicates directly with planning council co-chairs or staff.