Chapter 3
Consortia  TOP

Introduction

Local autonomy in determining the use of available funds is a core principle of the CARE Act, including for State-level activities as funded through Title II. In a number of Title II States and Territories, one or more HIV care consortia serve as local Title II planning bodies. Consortia 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. Consortia identify service needs, plan how they can be met, and in some cases actually deliver services and in others do so through funding agreements.

Regional and Statewide Title II consortia exist nationwide. The size and composition of regions served vary greatly. For example, the service area may include a single county, a metropolitan area, or a large multi-county area.

In making these consortia work effectively, the CARE Act establishes basic duties of Title II grantees and consortia, as well as lead agencies that administer consortia. Many States have developed their Title II consortia structures and relationships based on experience gained since the CARE Act was enacted in 1990. There is no single structure or division of responsibilities that all consortia must use. Rather, they are guided by the legislation, State policies and guidelines, HAB/DSS guidance, the unique characteristics of a State, the epidemic as it affects a State or region, and sound practice (e.g., efficient and effective service delivery, program management, flexibility, regular oversight, and open communication within and across States).

Legislative Background  TOP

Section 2613 of the CARE Act specifies responsibilities of Title II consortia in terms of services, consortia duties, and composition of consortia, under the following provisions:

Establishment of Consortia

Section 2613(a) allows States to establish consortia to provide HIV-related services, where consortia are defined 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;"

Consortia Services

Consortia are established to provide services as follows:

(2) [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; that may include:

(A) essential health services such as case management services, medical, nursing, substance abuse treatment, mental health treatment, and dental care, diagnostics, monitoring, prophylactic treatment for opportunistic infections, treatment education to take place in the context of health care delivery, and medical follow-up services, mental health, developmental, and rehabilitation services, home health and hospice care; and

(B) essential support services such as transportation services, attendant care, homemaker services, day or respite care, benefits advocacy, advocacy services provided through public and nonprofit private entities, and services that are incidental to the provision of health care services for individuals with HIV disease including nutrition services, housing referral services, and child welfare and family services (including foster care and adoption services).

An entity or entities of the type described in this subsection shall hereinafter be referred to in this title as a "consortium or "consortia."

Consortia Duties

(b) Assurances.

(1) Requirement-To receive assistance from a State under subsection (a), an applicant consortium shall provide the State with assurances 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.

(c) Application.

(1) In General.-To receive assistance from the State under subsection (a), a consortium shall prepare and submit to the State, an application that-

(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.

(d) Definition.-As used in this part, the term "family centered care" means the system of services described in this section that is targeted specifically to the special needs of infants, children, women, and families. Family centered care shall be based on a partnership between parents, professionals, and the community designed to ensure an integrated, coordinated, culturally sensitive, and community-based continuum of care for children, women, and families with HIV disease.

(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

(1) to any other existing HIV care consortia.

Establishment of HIV CARE Consortia  TOP

The CARE Act enables-but no longer requires-States to use Title II funds to support HIV care consortia within areas most affected by HIV disease and to provide a comprehensive continuum of care to individuals and families with HIV disease. (Prior to the 1996 CARE Act Amendments , States with more than one percent of total national AIDS cases were required to use at least 50 percent of their award to fund consortia.) Under the amended Act, the grantee may do the following:

• Fund consortia to provide comprehensive outpatient health and support services within areas determined by the State to be most affected by HIV disease, or
• When justified, use Title II funds to directly plan, develop, and deliver such services.

Section 2613 of the CARE Act specifies the following categories of services, which may be provided through consortia or directly by the grantee:

• Essential health services such as case management services, medical nursing, substance abuse treatment, mental health treatment, dental care diagnostics, monitoring, prophylactic treatment for opportunistic infections, treatment education to take place in the context of health care delivery, medical follow-up services, mental health, developmental and rehabilitation services, and home health and hospice care.
• Essential support services such as transportation services, attendant care, homemaker services, day or respite care, benefits advocacy, and advocacy services provided through public and nonprofit private entities, and services that are incidental to the provision of health care services for individuals with HIV disease including nutrition services, housing referral services, and child welfare and family services (including foster care and adoption services).

In States with established consortia, the consortia usually contract for or deliver these services, but the State may provide services directly if it can demonstrate that other delivery mechanisms would be more effective. In making such a determination, the State is required to consult with representatives of service providers and with service recipients who would be affected by such a decision, and to report the findings of this consultation to HAB/DSS, as stated in the CARE Act, Section 2612.

Legislative Requirements and "Sound Practices" for Consortia  TOP

Consortium Composition and Service Area

The legislation describes a consortium as an association of one or more public and one or more private nonprofit health care and support service providers (or private for-profit providers of quality HIV care in the area) and community-based organizations.

A consortium serves a specified geographic area within a State, generally determined by the grantee. While usually a single consortium serves each area, it is possible for a State to determine, or a consortium to demonstrate, that specific populations within a community or locality have unique service requirements that cannot be adequately and efficiently addressed by a single consortium serving the entire community or locality. In such situations, more than one consortium may serve different population groups within the same geographic area, or a State may provide services directly to a specific population.

Consortia Legislated Responsibilities

According to Section 2613 of the CARE Act, a Title II consortium is required to carry out the following responsibilities:

• Conduct a needs assessment within the geographic area served. The assessment is to be done in collaboration with public health and community-based providers of HIV-related services and with the participation of PLWH.
• Develop a plan to meet identified service needs, with the participation of PLWH. In establishing service plans, consortia must demonstrate that they have consulted with the public health agency or other entity(ies) providing HIV-related health care in the area, at least one community-based AIDS service provider, and Title IV grantees or organizations with a history of serving children, youth, women, and families with HIV disease.
• Promote coordination and integration of community resources and services and address the needs of all affected populations. The consortium is required to address service needs through the coordination and expansion of existing resources before new programs are created, and to ensure access to a continuum of care through case management services.
• Assure the provision of comprehensive outpatient health and support services, either by entering into agreements with existing agencies or by providing services directly.
• Periodically assess its own success and cost-effectiveness in responding to service needs.

To obtain Title II funding from the grantee, a consortium must do the following:

• Submit an application that demonstrates that it has carried out the required needs assessment and service planning with the required consultation and community involvement.
• Demonstrate its capacity to coordinate services.
• Show that it has mechanisms in place to evaluate program success.
• Demonstrate that adequate planning occurred to address disparities in access to services and historically underserved communities.

Other Consortium Roles and Responsibilities

A Title II consortium typically fulfills both the responsibilities specified in the legislation and additional roles that may be specified by the State or may be agreed upon by the consortium membership based on its stated purposes and priorities. The roles and activities required of a consortium depend upon the responsibilities delegated to it by the State, its structure and service area characteristics, and its funding level. Effective and efficient operations-"sound practice"-may require roles additional to those specified in the legislation or required by a grantee. Some functions may not be feasible in a very rural State or an area with a very limited network of service providers. A consortium should carefully consider roles and responsibilities such as the following:

Planning and Decision Making Procedures

• Develop and consistently enforce effective and clearly explained policies and procedures for managing conflicts of interest. Members must especially be aware of the potential for conflict of interest when consortia are responsible for procurement, and when a large proportion of consortium members are funded Title II providers.
• Establish grievance procedures.

Priority Setting

• Complete an annual priority-setting process that weighs needs against available resources and informs the resource allocation process.

Other Planning-Related Tasks

• Establish mechanisms for collaboration among all HIV care and prevention agencies.
• Sometimes, serve as an umbrella for HIV/AIDS planning in the community.
• Develop resources to obtain additional sources of funding, both public and private.
• Develop initiatives to educate the community about treatment for HIV disease, and advocate for enhanced HIV-related health care and support.
• Take a leadership role in assessment and evaluation of service quality, unit costs, effectiveness, and administrative efficiency, in cooperation with providers, the lead agency, and the grantee.
• Provide management and support services to service providers. Consortia may choose to assume responsibility for providing or coordinating capacity-building assistance in organizational management and service delivery.
• Provide advisory services to local government agencies, to encourage attention to HIV/AIDS issues and coordination and collaboration with Title II services.

Service Delivery

• Establish service standards. Consortia may develop service or quality of care standards for their providers, and may choose to use-or have their lead agencies use-these standards as criteria for selecting providers/contractors.
• Where a continuum of care does not exist, directly provide essential services to PLWH and their families.

Lead Agency Duties

Lead agency roles relate to managing Title II funds, not only for the consortium's own planning and administration but also for the provision of primary care and support services for PLWH.

The CARE Act does not require the existence of a separate lead agency or fiscal agent for a consortium. All the roles and responsibilities carried out by lead agencies may be carried out directly by consortia.

In addition, because providers that receive-or would like to obtain-Title II funding are often a major segment of the consortium membership, the potential for conflict of interest is especially great when consortia are directly involved in procurement. (The CARE Act does not directly address this issue with regard to consortia unless they are merged with Title I planning councils, which are not permitted to do procurement.) Consortia are expected to have policies that address conflict of interest, and many consortium service areas have a separate lead agency to fulfill the procurement function; sometimes the grantee requires a separate lead agency.

The lead agency may be a public agency, service provider, or some other kind of nonprofit organization. A for-profit entity may serve as lead agency only where a service area includes no nonprofit organization capable of serving as lead agency.

In some States, the consortium contracts with the lead agency through a written agreement or contract to carry out specific duties on its behalf. In other States, the grantee designates the responsibilities of the lead agencies and contracts directly with them.

The following duties are often assigned to the lead agency:

• Procurement. This includes developing and implementing a competitive and/or sole source bidding process for selecting subcontractors, developing subcontract agreements, and signing subcontracts with providers and consultants.
• Staff support to the consortium. This may include employing, supervising, and providing office space for consortium staff, or assigning lead agency staff to support consortium functions. It may also include administrative tasks such as maintaining consortium files, organizing consortium mailings, and arranging consortium meetings.
• Fiscal management. This includes such tasks as establishing a bank account; receiving, checking, and paying invoices from subcontractors; invoicing the State and other funders; reimbursing subcontractors; and, submitting financial reports to the consortium and the State.
• Subcontract management. This includes such tasks as developing program and fiscal report formats for subcontractors, ensuring that subcontractors collect and report CARE Act Data Report (CADR) data, monitoring and evaluating the work of providers and other subcontractors, modifying and terminating contracts based on approved standards and requirements, and ensuring that subcontractors have client grievance procedures.
• Establishment and implementation of conflict of interest and grievance procedures. This includes preventing conflict of interest in procurement and providing grievance procedures that address the procurement and contract management process.
• Reporting. This includes preparation and submission of regular programmatic and financial reports to the consortium, the State, and other funders.
• Resource development. This may include a major role in preparing the consortium's Title II funding application to the State and the preparation of other funding proposals to public or private funding sources. Such resource development may be independent of Title II activities.

Some lead agencies are also HIV disease service providers. Lead agencies may also provide direct Title II services. However, some grantees and consortia require that lead agencies not receive Title II funds for direct service provision, to avoid the potential for conflict of interest in the procurement process. If a lead agency is also a Title II-funded provider, the grantee and consortium should require that procedures be established and implemented to manage conflict of interest in the procurement and contract management process.

Whether the grantee or the consortium is the decision maker, the determination of which duties should be contracted to a lead agency requires careful consideration. Factors to consider include:

• State procurement regulations
• Legal status of the consortium
• Whether the consortium has sufficient funds to hire full-time staff
• Composition of the consortium's membership
• Frequency with which the consortium meets
• Consortium's capacity to maintain active committees to share the workload
• Consortium's ability to address issues such as conflict of interest and grievances.

Generally, the more limited the financial and human resources available to the consortium, the greater the need for a staffed lead agency. Selection of a lead agency separate from the consortium also depends on the availability of a credible, appropriate, and willing entity, with strong fiscal and administrative management capacity and an ability to manage and minimize conflict of interest, particularly in the procurement process.

Relationships  TOP

The Grantee and its Consortia

Consortia are responsible to the State Title II grantee. The grantee typically determines whether there will be consortia, and if so, specifies their geographic boundaries and responsibilities. The State decisions regarding consortia may include the following:

• The State may decide whether consortia should operate independently or be merged with Title I-eligible metropolitan areas (EMAs) in States that have Title I EMAs, or with HIV Prevention Community Planning Groups. For example, in 1997, California decided that Title I planning councils and Title II consortia serving overlapping geographic areas must merge into a single combined planning body. The State also encourages them to serve as HIV Prevention Community Planning Groups. Florida has combined all three entities.
• The State may decide what funds consortia are to plan for and allocate: only Title II funds or other State or Federal funds, such as Housing Opportunities for People with AIDS (HOPWA) funds or State HIV/AIDS funds.
• The State may decide whether consortia will serve as decision makers with respect to the allocation of Title II funds in their geographic area, or serve as planning and advisory entities, perhaps setting service priorities and recommending them to the grantee, which makes final decisions regarding the allocation of Title II funds and serves as the fiscal agent, responsible for procurement and subcontract management. For example, Massachusetts does all contracting with providers.
• The State may decide whether a consortium is permitted to serve as its own lead agency. For example, Wisconsin does not permit consortia to serve as their own lead agencies because they are not incorporated. Michigan serves as lead or fiscal agent for two of its eight consortia, while the other six have separate lead agencies. Where consortia are not permitted to serve as lead agencies, the grantee may specify what kind of entity may serve as a lead agency. There may be a requirement that the lead agency not be an agency that seeks CARE Act funding, or that it must be a public health agency. For example, Florida now has regional offices of the State health department serve as lead agencies.
• The State may establish any requirements regarding consortium leadership or operating procedures. For example, Wisconsin does not allow a consortium to be chaired by an individual who represents a funded Title II provider. Many grantees require consortia to develop conflict of interest policies.
• The State may define proper lines of communication. When a consortium has employees, it is important to clarify lines of communication among staff, chair, or co-chairs, and the grantee. The grantee often considers staff the first point of contact. For example, in New Jersey, where consortia have paid staff, the grantee works through staff and sometimes chairs or co-chairs, and discourages direct contact with individual consortium members and subcontractors.

The Consortium and its Lead Agency

Where the Title II structure includes a consortium and a separate lead agency, the success of program planning and implementation at the local level depends to a considerable degree upon the relationship between these two entities. Experience demonstrates the importance of clearly defined and regularly monitored relationships. The different roles and shared responsibilities of consortia and lead agencies are charted in the Attachment at the end of this chapter.

Some consortia feel that they can obtain the most benefit from a lead agency if they share office space and tasks. However, to avoid overlap, perceived or actual conflict of interest, and inefficiencies due to role confusion, it is important to ensure careful definition and deliberate separation of at least certain key functions, such as financial decision making and fiscal management. To ensure appropriate separation, some grantees and/or consortia may bar lead agency staff from serving as voting members, board members, officers, or members of certain committees.

The consortium and the lead agency need a written memorandum of understanding that defines their working relationship. The following should be included in the memorandum of understanding:

• Clear written specification of responsibilities and tasks assigned to each entity, with special clarity regarding shared responsibilities
• Applicable State procurement policies
• An ongoing system of checks and balances using mutual reviews and discussion
• Appropriate oversight (and in some States, periodic evaluation) of the lead agency by the consortium, including whether the lead agency adheres to priorities established by the consortium
• Clarity regarding the relationship of each entity to the grantee.

The grantee should provide oversight of lead agency policies, procedures, and performance, with emphasis on procurement, subcontract management, grievance policies and procedures, and conflict of interest management, as well as periodic evaluation of the lead agency. See "Contract Monitoring" in this Manual for more information on evaluation of the lead agency by the consortium, as well as lead agency responsibility for contract monitoring and evaluation.

The Grantee, Consortia, and Lead Agencies

States differ in their formal and informal relationships with consortia and lead agencies, and in their points of contact within the consortia. These relationships are determined by factors including the State's consortium and lead agency structure, the level of resources at the grantee and consortium levels, whether consortia have paid staff, and the number of consortia in the State.

In many States, the grantee emphasizes the importance of frequent and direct communication between consortia, lead agencies, and grantee. However, the demands on staff created by frequent direct contact with many consortia can lead some States to seek ways to reduce or manage direct contacts. Grantees may expect to receive reports and to address administrative and fiscal matters directly with the lead agency. For example, California has contracts with its lead agencies, but no direct agreements with consortia. In Wisconsin, the State holds meetings and conference calls with consortia chairs, but deals directly with the lead agencies on contract issues. Michigan and Wisconsin try to keep lines of communication open with both consortia and lead agencies.

It is important for grantees, consortia, and lead agencies to share a common understanding of expected lines of communication and reporting. For example, there should be explicit agreement on the following:

• Desired lines of communication between the grantee and its consortia and lead agencies, including whether the grantee expects to deal directly with both entities and on what issues
• Reporting requirements, including what kinds of written information will be provided directly to the grantee from the lead agency, and what information must be submitted to or through the consortium
• Points of communication-chairs versus staff of consortia, and when and under what conditions the State will talk to individual consortium members other than chairs or co-chairs and/or to funded providers.

REFERENCES  TOP

Title II structures and models. See the "Title I and Title II Coordination" chapter in this Manual.

Evaluation of the lead agency by the consortium; Lead agency responsibility for contract monitoring and evaluation. See the "Contract Monitoring" chapter in this Manual.

ATTACHMENT  TOP

Lead Agency and Consortium Roles