Integration of Care – Minutes – 3/2/22



Veronica Fortunato & Donald Powell, IOC Co-Chairs

Wednesday, March 2nd, 2022, 10a-12p

Zoom Meeting



Donald Powell (co-chair)Veronica Fortunato (co-chair) Mitchell CaponiBilly Fields
John SchoeppDeborah GreeneDorothy FarleyFrancine Cournos
Bill GrossGraham Harriman (Gov’t Co-chair)Cassandre MooreTim Frasca
Karen McKinnonBrenda Starks-RossJames WalkupMichael Ealy
Ralph HendersonCharmaine Graham  

Guests: Milton Wainberg


Frances SilvaCullen HunterBryan MeiselArya Shahi (PHS)
Johanna AcostaKimbirly MackNoelisa MonteroScott Spiegler (Acting Recipient)
Perminder KhosaIva Magas  

Agenda Item #1: Welcome/Introductions w. Pronouns/Moment of Silence/Review of Minutes

Dorothy Farley led the moment in honor of Nina Rothschild, in recovery after a senseless attack leaving work. Minutes were accepted with submitted changes. Link to video of this meeting (unfortunately, only half the meeting is available, found here:

Agenda Item #2: Overview of Models of Integration & the Rationale for Integration

Graham Harriman presented to the committee. 

The World Health Organization’s (WHO) mental health pyramid highlights the importance of informal community care and self care as the foundation of mental health (noted in a previous meeting as often untracked support that may provide better insight into a client’s wellbeing.

Current RWPA expenditures in the behavioral health (BH) portfolio are Mental Health $3,904,131 (9 contracts), Harm Reduction $7,608,131 (17 contracts), Supportive Counseling $3,051,371 (15 contracts) (includes services for persons who inject drugs).

Donald Powell noted that an agency can apply to the NYSDOH to become a compensated SEP (Tier I) or materials only (Tier II).

The framing directive has incorporated strategies (now approved and undergoing implementation in phases) that support improved integration of care: As a Pre-planning Strategy, to assess racial and pay equity. As planning strategies to develop a comprehensive organizational stigma, implicit bias and racism assessment and plan; to develop supportive plans for clients in crisis grounded in research and local resources; to develop mechanisms to enhance/modify programs mid-contract to incorporate new evidence or evaluation.

In Quality Management, strategies in the framing directive mandate the provision of links for a comprehensive, portfolio wide internet-based resource map to enhance support for optimal health outcomes and for the Care and Treatment Program to provide technical assistance to enhance uptake of current and emerging technologies that reduce client and staff burden.

It continues with training & educating stakeholders: To engage consumers and providers in a bi-annual planning group that develops outreach protocols; in partnership with consumers, develop a dynamic PWH-led training for providers to improve service delivery based on the report: The Wisdom of Experience:  A Report on How to Improve Consumer-Provider Relationships and Keep Consumers Engaged in HIV Care from the Perspective of People Living with HIV/AIDS in New York City and the Tri-County Region; to conduct ongoing training on harm reduction and trauma informed care and to empower clients to achieve self-management as well as the coordination of HRSA funded (and hopefully beyond) training calendars to facilitate access for providers (and consumers).

A set of concepts for enhanced training in the directive include sex positivity, gender affirmation, health equity and referrals as warm hand-offs. In service delivery, inclusion, particularly at leadership levels, is lacking. The framing directive incentivizes the inclusion of disproportionately impacted populations of PWH including people of TIGNBNC[1] experience, Black, Latino, youth, in direct service roles, especially in leadership positions, such as through hiring peers and value-based payment structures.

The directive also mandates infrastructural changes to better support clients:  CTP will support (through linkage to other resources or use of contracted program RWPA funding, as appropriate and allowed) modifications to existing spaces, resources, and materials to ensure reasonable accommodations to persons with any type of disability: e.g., large print brochures/forms, ramps, appointment reminders, accessible websites; DOHMH will modernize and streamline data collection to minimize data burden and improve identification of unmet needs, and conduct stratified intersectional data analyses; CTP will set up an anonymous suggestion box to field questions/comments from program staff; funded sites will set up mechanisms for clients to provide each other with social support to reduce stigma and isolation, where these do not presently exist.

In thinking about the new BH directive, it is important to consider: 

  • Community oriented services 
  • Home visits, support groups, ongoing facilitation of support networks
  • Requiring capacity to bill Medicaid- figure out how to address licensure hurdles to ensure person centered care
  • 10% of funding to capacity building
  • Real time linkage with MH, Physical health , and substance use services (seamless)
  • Required services in all 5 boroughs (services located in neighborhoods/UHF/Zip Codes- disproportionately impacted) that invest in neighborhoods, 
  • Build tools to facilitate and support accessibility, to account for gentrification, etc.     

The aging directive considers the increased need for social support through the following strategies: Strengthen PWH networks and fund organizations that provide social support services for older people living with HIV;  fund social support for exercise: set up buddy systems making contracts with others to complete specified levels of physical activity, or set up walking groups and other groups to facilitate friendship and support; fund navigation, structured health education, and practical and emotional peer support services to increase engagement in care and promote self-care; and identify how to leverage technology for social support and to overcome barriers that older people living with HIV face.

As the Consumers Committees considers how to better support youth, those recommendations should also be incorporated into the BH directive.

Agenda Item #4: Persons with Serious Mental Illness Referred to Select Bureau of Mental Health Services and Matched to Persons with HIV

Perminder Khosa, MPH presented on the analysis of the match between the NYC HIV Registry and the Bureau of Mental Health’s two databases: SPOA, Single Point of Access and AOT, Assisted Outpatient Treatment. Key points of the presentation follow:

  • Compared to PWH in NYC overall, HIV diagnosis among PWH-SMI was more likely to occur at a hospital.
  • Stage of HIV infection at diagnosis among PWH-SMI was relatively steady from 2014-2018.  
  • Compared to PLWH overall, PLWH-SMI had poorer outcomes along the care continuum
  • Compared with PLWH-SMI of other race/ethnicity groups, Hispanic/Latino PLWH-SMI had highest HIV care rates. 
  • Similar to trends among PLWH overall, compared with PLWH-SMI of other race/ethnicity groups, Black PLWH-SMI in HIV care had the lowest viral suppression. 
  • Among PWH-SMI, 37% with an HIV-related cause of death were virally suppressed within 6 months prior to death and 56% with a non-HIV-related cause of death were suppressed within 6 months prior to death.
  • Compared with PWH overall, death rates among PWH-SMI were consistently higher between 2014 and 2018. 

Karen McKinnon noted that research lit shows HIV rates of 4-23% for people with SMI in US

Agenda Item #4: Mental Health Diagnoses among HIV-Positive New York City RWPA Clients

Noelisa Montero presented on the analysis conducted among RWPA clients and matched to the NYC HIV Registry. Key points from the presentation follow: 

  • 59% (n=4,335) of 7,317 NYC RWPA clients in GY2018 had one or more lifetime MH diagnoses
    • Among these clients, the most frequently reported types of MH diagnoses were:
      • Depression: (49.6%; n=3,629)
      • Anxiety disorder: (28.7%; n=2,097) 
      • Bipolar disorder: (17.5%; n=1,283)

NYC RWPA clients with one or more lifetime MH diagnoses (N= 4,335)

  • Engaged in care: 98.8% (n=4,282) 
  • Retained in care: 90.3% (n=3,913)
  • Virally suppressed: 75.9% (n=3,292)

NYC RWPA clients without a lifetime MH diagnosis (N=2,933) 

  • Engaged in care: 98.3% (n=2,884)
  • Retained in care: 86.6% (n=2,540)
  • Virally suppressed: 81.5% (n=2,390)
  • Treatment strategies in NYC RWPA MH programs should focus on addressing depression, anxiety disorder, and bipolar disorder as these were the most frequently reported MH diagnoses
  • There is a need to improve viral suppression among PLWH with a MH diagnosis. Viral suppression seemed particularly low among people with a diagnosis of psychosis and bipolar disorder

Limitations on the analysis: 

MH diagnosis question: 

The information source for the MH diagnosis questions is not recorded in eSHARE and could include: 

  • Client self-report 
  • Observation/impression (mental health provider/any provider)
  • Measures assessing the presence of a MH diagnosis
  • Diagnostic information from a client’s electronic medical record

Service categories for which assessment forms do not include MH diagnosis questions: 

  • Case management (non-medical), Food bank/home-delivered meals, Legal services, Psychosocial support services, Medical transportation
  • Clients who were only served in those RWPA service categories were not included in our sample

Council follow up: For engagement in care for people with MH diagnosis – what does the service utilization look like?

RWPA requires providers to ensure clients are engaged in care.

Agenda Item #4: PWH with SMI RWPA Recommendations from the Needs Assessment

Presented by Melanie Lawrence. Key points follow:

  • Offer all clients, across all RWPA service categories, offer a clinical diagnosis/evaluation (by referral if necessary) to appropriately identify all clients who qualify for additional MH services​
    • Two stage screening process recommended to facilitate appropriate triaging​
      • 1st stage will differentiate between PWH with SMI from PWH without SMI​
      • 2nd stage will confirm an SMI diagnosis, if appropriate
        • Appropriate services will be delivered to all clients, including those without SMI
    • Identify all clients that have SMI with a confirmed diagnosis conducted by an appropriately licensed provider. ​
    • Client identification can occur through self-report, confirmed by a psychiatric evaluation or chart review ​
  • Embed evidence-based stigma-dismantling practices into service delivery4
    • Require agencies to conduct organizational stigma assessments to inform responsive plans​
    • Support the development and implementation of policies that address and dismantle stigma​
    • Support implementation of the NYS-NYC organizational stigma assessment and application of best practices​
  • Improve capacity of CBOs (Community Based Organizations) to identify people with HIV who may have SMI​
    • Ensure all clients are offered a referral for a psych evaluation across all service categories ​
    • Use mental health opportunity presented by pandemic to offer everyone an evaluation5
    • Modify data systems to accurately track referral completion, especially for mental health and support services​
    • Develop internal care report card dashboards that highlight clients’ care status through medication prescriptions, ART access/adherence, and viral load measures across all appropriate service categories (name the appropriate service categories)​
    • Collaboratively develop best practices to inform agency specific crisis action plans​
    • Streamline & accelerate access through strengthened and formalized partnerships to support enhanced access to external support services, i.e., HARP,  AOT, inpatient stays and other appropriate interventions, support and referrals​
    • With assistance from designated ombudsperson, as needed​
    • Reduce staff turnover to strengthen client trust and engagement​
    • Address burnout, compassion fatigue and vicarious trauma​
    • Support trauma informed supervision and care ​
    • Lower client loads to sustain and support high quality, sustained care & relationship development​
    • Support professional development and promotion opportunities​
    • Support collaborative leadership that values staff input​
    • Support appropriate market salary rates​
    • Streamline data collection to reduce administrative burden​

Designate Additional Client & Program Support

  • Designate an ombudsperson team for the Ryan White Part A portfolio to support agency management of clients in crisis, identify additional resources and facilitate support for PWH with SMI (a combination of providers from legal services to social work may be most effective; ideally through an initial consultancy to be incorporated into BH service model)​
    • Coordinate resources and protocols with the Bureau of Mental Health & Department of Mental Hygiene to address clients in crisis in real time to ensure continuity of care, i.e., access to HIV meds during psych stays​
    • One member of the team is required to be a peer with lived experience​
    • Utilize RHIO, PSYCKES or similar data to identify and properly manage clients who may have been discharged without appropriate care for SMI and HIV ​
    • Assist all types of licensed facilities, including Article 28, 31 and 32 providers across all in navigating newly diagnosed/out-of-care PWH with SMI ​
    • Clients who either self-disclose or receive a mental health diagnosis should qualify for additional support services that facilitate viral suppression, including:​
    • Coordinated cross organizational case conferencing for relevant service categories​ – as Graham Harriman notes – to support clients who bounce around to different agencies and programs
  • Care navigation for all services, including those outside of the Ryan White Part A portfolio​
  • Provide modified Directly Observed Therapy (mDOT) for all medications including psychotropic prescriptions in the behavioral health service categories, as appropriate​
  • Incentivize the inclusion of community health workers, ideally peers with lived mental health and HIV experience to deliver services to people with SMI​
  • Ensure provision of appropriate navigation services to all clients discharged from any and all mental health inpatient services, including psychiatric hospitals and Assisted Outpatient Treatment (AOT)​
  • Leverage the UniteUS citywide referral system​
  • Prioritize confirmation of diagnoses for clients who either self-report an SMI diagnosis or exhibit behavior consistent with SMI symptoms or a have history of in-patient or psychiatric care​
  • Implement innovative programs to increase access to behavioral health providers, including psychiatrists, who are linguistically competent and promote cultural safety ​
  • Telemedicine​
  • Psychiatric nurse practitioners​
  • Ensure access to a network of geographically diverse low threshold services to facilitate client readiness for treatment: i.e., walk-in, late, drop-in & weekend hours, etc. (included as part of the recipient mandated live resource map)​

Integrate care:

  • PWH with SMI often receive siloed treatment due to regulatory and funding barriers. Clients with serious mental illness are more vulnerable to becoming lost to care or experiencing gaps in treatment. Research shows that integrated care can increase HIV treatment access and improve overall health outcomes.​
  • Integrate and coordinate care for behavioral health, substance use and HIV care through the development of single site access for all services​
    • Single site access can be accomplished through MOUs and linkage agreements that facilitate same or next day appointments​
  • Facilitate case conferencing for PWH with SMI​
    • Utilize telehealth to coordinate conferences and reduce burden​
    • Support conferencing & continuity of HIV care during psychiatric in-patient stays​
    • Support conferencing & continuity of care in other care sites​
  • More staff training on Motivational Interviewing, SMI & referral script. ​

Implement client specific plans to maximize the likelihood that PWH with SMI achieve viral load suppression​

Supportive mechanisms include: ​

  • Collaborative Care model: Psychiatrists can train medical providers on how to prescribe psychotropic medicine, currently used to help alleviate cost​
  • Focus on resources for psycho-social rehab and assistance to build and support  interpersonal relationships – how to live your best life with serious mental illness​
  • Assess barriers to ART access/adherence


  • Develop strategic partnerships to enhance capacity and establish routine HIV testing at sites where people with SMI regularly access care6
  • Bolster HIV testing access to increase the identification of PWH with SMI at all available sites including Article 28, 31 & 32​
    • Track rates of testing among people with SMI ​
  • Build capacity among behavioral health and psychiatric care providers to support HIV testing, prevention and navigation6
    • Ensure PEP/PrEP access & navigation​

Karen McKinnon asked what we know about current prescription practices among primary care providers regarding mental health prescriptions.

Francine Cournos noted that we have models of intersecting small amounts of care across mental health and HIV, but when you have to intersect a lot of these types of care, that’s where it is not happening.

Brenda Starks-Ross affirmed “Don’t treat and ignore, accept and support our folks!”

[1] Transgender Intersex Gender Non-Binary Non-Conforming