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CARE
Act Title II Manual - 2003 Version |
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Chapter
2
Title I and Title II Coordination
TOP
Introduction
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:
- 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 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.
Legislative
Background
TOP
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
TOP
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).
SCSN
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.
Planning
Activities
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:
- Inclusion
of the other title as a representative on the planning body. This
might include joint committees. Notably, HAB/DSS does not specifically
promote consolidation of a Title II planning body and Title I
planning council 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.
- Coordinated
or combined comprehensive plans.
- Consideration
of joint priority setting.
- Collaborative
contracts with providers that are funded by both titles.
- Coordination
of capacity development, outreach, and early intervention services
(EIS), expectations for which are outlined in greater detail in
both the CARE Act 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 Title II funding is used in EMAs and what, if any,
contribution Title I 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 PLWH members should also be considered.
Title
I and II Working Together
TOP
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.
- Planning
councils are public bodies established by the EMA’s chief
elected official (CEO). Legislation defines their key responsibilities,
such as determining service priorities, allocating resources across
priorities, 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 Title
II planning bodies are not as defined in the legislation, their
setup is more diverse than planning councils. Title II bodies
are shaped primarily by the Title II 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.
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. *
- Joint
needs assessments. Variations include use of a single needs
assessment to cover both Title I and Title II; EMA and State collaboration
in conducting a joint needs assessment, with EMA responses separated
out for use in planning; use of State-developed needs assessment
methodologies; 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 titles 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 CARE Act providers, or the State can support common
data collection and management systems that better support use
of CAREWare and preparation of the CARE Act Data Report (CADR),
whose use is required by all CARE Act grantees.
- Reduced
duplication of provider contracts.
A single request for proposals (RFP) process can be used for the
two titles so that a provider has just one contract for any type
of service.
- Joint
service guidelines (e.g., case management guidelines) and provider
training. Such efforts are especially beneficial for providers
funded under both titles.
- Equity
in access to services across areas.
A funding formula can adjust for award of Title II funds to counties
outside the EMAs, or a parity formula can seek to equalize per
capita spending from Title I and Title II streams. Some EMAs contribute
Title I 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 might be served by State-supported
providers, such as a statewide case management system.
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.
- Variations
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 planning body coordination.
A merged planning body comprising a Title II planning body and
multi-state EMA requires Title II representatives to become familiar
with issues faced by interstate EMAs. 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
may want to collaborate with consortia 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.
- A merged
planning body might focus on the strictest requirements. This
can include such areas as priority setting, resource allocation,
fundable services, and quality management programs. If Title I
is stricter about allowable services to be funded, those criteria
need to be followed when allocations start. Conversely, if a State
has implemented more stringent case management standards of care,
an EMA may need to adopt those.
- 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 Title II planning groups, although some control
significant State funding for HIV/AIDS services. Planning can
ensure that major activities reflect the perspectives of both
titles, such as needs assessments and priority-setting processes
that account for both titles.
- Mergers
may affect planning body membership representativeness and reflectiveness.
The membership of a consolidated body must maintain/enhance its
diversity and PLWH involvement. If the bodies are fully merged,
then the combined planning body’s membership must be at least
33 percent unaligned PLWH and include individuals from all the
categories specified in the Title I legislation. Ensuring rural
representation is also a challenge. The planning body needs to
be large enough to represent the membership of both Title I and
Title II 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 Title II 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
Title II planning bodies 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—and visits—planning council co-chairs.
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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.
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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.
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References
TOP
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. < Return
to Text >
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