Thursday, December 10, 2021, 2:05-3:35pm
By Zoom Videoconference
Members Present: Graham Harriman (Governmental Co-chair), Dorella Walters (Community Co-chair), Paul Carr (Finance Officer), Saqib Altaf, Billy Fields, Ronnie Fortunato, Marya Gilborn, Charmaine Graham, Matthew Lesieur, David Martin, Jeff Natt, Julian Palmer, Guadalupe Dominguez Plummer, Donald Powell, Finn Schubert, Claire Simon
Members Absent: Leo Ruiz, Marcy Thompson
Staff Present: NYC DOHMH: David Klotz, Melanie Lawrence, Scott Spiegler, Johnell Lawrence, Jose Colon-Berdecia, Kimbirly Mack, Giovanna Navoa; Public Health Solutions: Barbara Silver, Arya Shahi; HRSA/HAB: S. Morgan, Mae Rupert; J. Corbisiero (Parliamentarian)
Agenda Item #1: Welcome/Introductions/Minutes/Public Comment
Ms. Walters and Mr. Harriman opened the meeting followed by introductions and a moment of silence. The minutes from the October 21, 2021 meeting were approved with no changes.
Agenda Item #2: Project Officer Update
Ms. Morgan reported that HRSA’s HIV/AIDS Bureau’s (HAB) announced the release of the 2020 Ryan White HIV/AIDS Program Annual Client-Level Data Report. Abstracts are due on December 17th for the 2022 National Ryan White conference (theme: The Time Is Now: Harnessing the Power of Innovation, Health Equity, and Community to End the HIV Epidemic). The conference, which will take place August 23-26, 2022, will use both limited in-person attendance and virtual participation. A new HRSA HAB white paper, Innovation and Resilience: How Ryan White HIV/AIDS Program Recipients Leverage Telehealth During the COVID-19 Pandemic, focuses on telehealth and HIV care delivery best practices and lessons learned.
Ms. Morgan reported that Deborah Medina will serve as acting project officer until a permanent replacement is appointed. Ms. Medina has worked as a sub-recipient in Puerto Rico and has been at HRSA/HAV for two years. Mr. Harriman, Ms. Plummer and others thanked Ms. Morgan for her incredible support and partnership as the NY EMA’s project officer. She was praised for her collaborative efforts, open door and advocacy for the consumers and providers of the EMA. The Committee wished her the best for her retirement.
Agenda Item #3: Revised Framing Directive
Mr. Harriman introduced the Framing Directive by noting that it is past time to address the persistent inequities in health outcomes and address issues of equity and social justice in Ryan White Part A (RWPA) services. After the first version of the Directive was voted down (mostly through abstentions), the Integration of Care Committee reviewed the Directive, reworking it to address the concerns that were expressed. This is a trailblazing approach that can be a model for Ryan White programs across the country.
Ms. Fortunato and Mr. Powell presented the revised Framing Directive, approved by the Integration of Care Committee (IOC) on December 3rd. Formerly known as the Master Directive, this document guides all services in the RWPA portfolio. The Directive utilizes an implementation science framework to clearly establish the context of the portfolio and align implementation strategies with that context. In this directive, the entire RWPA portfolio is considered as the intervention.
The first sections of the directive, Determinants, Intervention Characteristics, and Inner Setting, Outer Setting, Characteristics of Individuals Implementing the Intervention and Process establish the context in which the RWPA portfolio operates. The Implementation Strategies and Mechanisms are evidence-based responses to this context that seek to achieve optimal service delivery and health outcomes for PWH. The Outcomes (Implementation and Clinical/Patient) are the identified metrics to track the portfolio’s progress (or lack thereof) in improving health outcomes. Two relevant inner settings (Care and Treatment Program (CTP)/Department of Health & Mental Hygiene (DOHMH), and RWPA Funded Organizations) describe expertise, organizational structure and bureaucracy and the stigma and equity characteristics of both. Outer Setting Characteristics are drawn from the DOHMH EHE Situational Analysis (e.g., generally high but inequitable achievement of outcomes along the HIV care continuum).
The Directive describes implementation strategies to be initiated over time. To prevent redundancy, organizations may substitute other work, with CTP approval, for the following strategies: 1) pay equity & racial equity analysis; 2) organizational stigma assessment and plan that must be conducted by all contracted & monitoring bodies; 3) prepare consumers to be active participants in the implementation of client centered care; 4) facilitate the development of client crisis plans grounded in research; 5) train staff to deploy non-police alternatives, where police are called as a last resort; and 6) develop mechanisms to enhance or modify programs mid-contract to reflect emerging evaluation.
Quality Management-related strategies include: 1) recruit, identify, train, and prepare organizational champions to ensure participation in quality improvement processes; 2) collect new and updated client assistance resources to create a searchable live site/resource map that facilitates the completion of comprehensive and appropriate referrals and linkages; 3) provide technical assistance to enhance uptake of current and emerging technologies that reduce client and staff burden train staff to deploy non-police alternatives, where police are called as a last resort; and 4) support tools and activities (technical assistance on organizational development, grant writing, development of mutually beneficial collaborative funding opportunities) that support the development of a multi-organizational initiative that facilitates leveraging supplemental public/private funding sources to build economies of scale.
The Directive requires training and education of stakeholders (e.g., hard reduction, trauma-informed care, outreach protocols, health equity, anti-racism/anti-oppression, gender affirmation). Training calendars and resources should be coordinated throughout DOHMH, DOHMH will incentivize inclusion of disproportionately impacted populations of PWH, and DOHMH will support modifications to existing spaces, resources, and materials to ensure reasonable accommodations to persons with any type of disability. DOHMH will also modernize and streamline data collection to minimize data burden and improve identification of unmet needs, set up an anonymous suggestion box to field questions/comments from program staff, and funded sites will set up mechanisms for clients to provide each other with social support to reduce stigma and isolation.
The Recipient (CTP) will report on the outcome measures to the Planning Council to be reviewed by a workgroup, made up of the recipient, the Council and agency representatives who have the authority to examine and amend the outcomes, and determine the methods and a timeline of outcome data collection that is feasible to RWPA providers, the Council and the Recipient. Outcomes include: increase of PWH aware of their status, viral suppression, declines in reports of stigma and racism, etc.
Members commended the work that went into this ambitious initiative.
A summary of the ensuing discussion follows:
- The Directive is ambitious and addresses vital issues, but brings up concerns around practicality and implementation if certain mandates are enforced through the RFP or contracting process. Mandates around pay equity can be particularly problematic for large institutions such as hospitals, where pay scales are determined by the larger institution that the specific RWPA program would not be able to adapt. Pay can be tied to performance and other factors that a blanket pay equity mandate does not account for.
- The Directive does not mandate parity in pay and there is no discussion of a floor or ceiling for salaries in the Directive. It asks for providers to perform a self-analysis within the constraints of their institutional structure. (DOHMH has done this and found that some Black staff in equivalent positions to white staff are paid less.) They will also have to develop a plan to make progress on this issue.
- The Recipient and PHS would ask for a plan to be submitted by applicants in the RFP process. The Recipient will find best practices and models that sub-recipients can adapt.
- Small organizations will need technical assistance and additional resources just to perform this analysis, which may constrain some from even applying for RWPA funding.
- PHS does not have data on the racial or gender breakdown of contractor staff.
- The goal of the Directive is to shift the culture of care to center staff as well as consumers to optimize health outcomes and reduce inequities.
- The hope is that programs that use peers will provide them with a living wage.
- Trainings mandated in the Directive focus primarily on front line staff, but directors and medical/clinic directors need these trainings too.
Ms. Plummer stated that the Recipient enthusiastically supports this Directive, as it aligns with the NYC Board of Health’s recent declaration of racism as a public health crisis. The Recipient is committed to implementing this in partnership with all stakeholders. She acknowledged that the process will be imperfect, but that they will use continuous quality improvement to share best practices, make adjustments to work out any snags, and ensure that work is not duplicative.
Mr. Powell, on behalf of the IOC, moved that the Executive Committee adopt the Framing Directive as presented. The motion was adopted 14Y-0N.
Agenda Item #4: 2nd Quarter Commitment and Expenditure Report
Mr. Carr noting that this committee is tasked with reviewing quarterly spending reports from the Recipient as part of the Council’s legal obligation to “assess the effectiveness of the administrative mechanism in rapidly disbursing Part A funds”. The report that the Recipient will present today is for the first two quarters of the current grant year, March through August 2021. The difficulties in spending down the grant that we experienced last year continue into this year.
Ms. Plummer reviewed the details of the 2nd quarter report. ADAP expenditure percentage is typically low during the 2nd quarter because of late billing submission. The ADAP program uses RWPA funding as they require hence the late billing. PSS TIGNCNB is a new service category (started Sept. 1, 2021) and deliverable-based for the first six months of implementation. Over the past year and a half, all RWPA funded programs have reported high staff turnover. Organizations report that they have struggled to retain staff due to accelerated burnout during the pandemic, fear of catching COVID at work, and low salaries. Medical case management, specifically care coordination programs in NYC, is at 25% because of staff turnover and long vacancies. Programs continue to provide services in-person and virtually. There was hope that in-person services would increase significantly after the vaccine became available, but the increase has been as much as expected. Mental Health services in NYC are at 18% because of payer of last resort issues. Mental Health services in Tri-County is at 18% but the program is starting to slowly improve their performance given the ongoing TA provided. The program is fully staffed and continues to enroll additional clients each month. In addition, the program recently partnered with Hudson Valley Community Services to provide wellness services to promote more client enrollments. Medical transportation services in Tri-County is at 18% because many services are still being delivered virtually, but transportation services are slowly picking up again for face-to-face services.
Ms. Navoa reported that Housing programs are on track with spending and will most likely spend down all funds by the end of the contract period. We will get a better sense of the current trends as soon as we finalize the mid-year modifications for our housing programs.
Mr. Harriman added that at the end of the second quarter, we should be seeing expenditures at about 50% if programs are spending evenly (the report typically shows spending in the 40% range due to reporting/payment lags). This year, programs are not spending at the rate they should, and this scenario looks similar to our spending at the same time last year, which eventually led to a $4.9 million carryover. HRSA has issued a waiver that allows us to carry over more than 5% of the formula funds. However, if we do expect a large carryover, now is the time to think about how some of that money can be spent during the year. The Council’s reprogramming plan permits the grantee to move money to ADAP and would permit the Recipient to enhance over-performing service categories (if performance-based reimbursement for contracts is re-initiated). If the Recipient finds that this money cannot be spent, the Council should think about what we can fund on a one-time basis for a carryover request which will be submitted in June or July 2022. The Council should also be sure that the EMA is spending its current carryover (from GY 2020), as any unspent carryover will be deducted from subsequent awards. A proactive plan to spend down the carryover should be presented to the Committee in January.
Mr. Carr pointed out that agencies might have higher expenditures if they offered in-person services. This is especially true for congregate meals, which are particularly vital for clients with no other food support or who benefit from connection to other services when they access meals. Mr. Harriman responded that DOHMH is working with agencies to educate them on COVID safety so that they can provide more in-person services, but can not mandate them.
In response to a statement from Mr. Carr, Ms. Plummer noted that late payments of sub-recipients has been an ongoing issue that DOHMH is addressing with Public Health Solutions.
Mr. Powell announced that SAMHSA issued their first harm reduction request for proposals on Dec. 8th.
Mr. Harriman thanked Ms. Rupert for her assistance through the transition to a new project officer.
There being no further comment, the meeting was adjourned.