Thursday, July 29, 2021
By Zoom Videoconference
Members Present: G. Harriman (Governmental Co-chair), D. Walters (Community Co-chair), P. Carr (Finance Officer), A. Abdul-Haqq, S. Altaf, F. Alvelo, L. Best, A. Betancourt, R. Brown, R. Bruce, M. Caponi, E. Casey, R. Chestnut, B. Cockrell, M. Diaz, M. Domingo, J. Dudley, B. Fields, R. Fortunato, T. Frasca, M. Gilborn, C. Graham, A. Lugg, D. Martin, J. Natt, G. Plummer, D. Powell, M. Rifkin, L. Ruiz, J. Schoepp, C. Simon, M. Singh, M. Thompson, R. Walker
Members Absent: M. Bacon, M. Baney, D. Beiling, P. Canady, J. Edwards, B. Fenton, MD, B. Gross, A. Roque, F. Schubert, T. Troia, B. Zingman, MD
Staff Present: DOHMH: D. Klotz, M. Lawrence, J. Carmona, J. Colón-Berdecía, K. Mack, E. Wiewel; D. Ferdinand, G. Navoa; Public Health Solutions: A. Feduzi, R. Santos; 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 June 24, 2021 meeting were approved with no changes.
Agenda Item #2: Recognition of Retiring Members
The Council paid tribute to the following members, whose terms end on August 31st: Ms. Best, Ms. Diaz, Mr. Domingo, Mr. Frasca, Ms. Roque, Mr. Schoepp, Ms. Singh, and Dr. Zingman. They were thanked for their commitment and contributions to the Council. Ms. Best and Ms. Diaz were thanked for their leadership as committee chairs.
Agenda Item #3: FY 2022 Application Spending Plan
Ms. Gilborn presented the FY 2022 Application Spending Plans approved by the Priority Setting & Resource Allocation Committee on July 12th. The EMA must submit separate Base and MAI spending plans in the annual grant application (Base includes Tri-County’s allocation). HRSA allows EMAs to request up to 5% over the current year’s Base award (max. $95,184,657 for 2022). The application spending request is a wish list and must be justifiable on the grant application narrative. In the fall and winter, PSRA plans for a likely reduction in the actual award.
For the Tri-County portion of the spending request (all Base funds), the plan calls for making the one-time carryover enhancement to Emergency Financial Assistance ($500,000) a permanent part of that category’s allocation. The enhancement will serve all eligible EMA residents, but program is housed at a TC agency, and so it appears in the TC spending plan. The PSRA also approved the Tri-County Steering Committee’s plan for a 5% across-the-board proportional increase to all categories, based on ranking scores.
The MAI award is completely driven by a HRSA formula based on the number of non-white PWH living in EMA relative to other EMAs. As in past years, PSRA requests level funding for FY 2022 ($8,235,205) in four categories (ADAP, Housing, MCM, EIS).
For the FY 2022 NYC Base Spending Plan, PSRA recommends two targeted increases: 1) an annualized allocation for Psychosocial Support for TINBNC PWH (targeted increase of $493,500) for programs starting on Sept. 1, 2021; 2) Six months of funding for the new service category of Oral Health Services ($250,000) for programs starting on Sept. 1, 2022. Finally, the balance of the increase is allocated through a 5% across-the-board proportional increase to all categories, based on ranking scores. PSRA also ranked new service categories under the HIV & Aging directive using the Priority Ranking Tool. The tool, using four criteria (payer of last resort, access to/maintenance in care, consumer priority, specific gaps/needs), assigned the two categories a rank (Outpatient Medical Care/core: #6; Referrals to Health and Support Services/non-core: #5), and they will be described in the grant application narrative, but the allocation will begin in FY 2023 (amount TBD based on cost analysis).
There was a discussion on the possible need for additional EFA funds when the eviction moratorium ends. It was noted that the application spending plan is for FY 2022, and that there is the possibility of additional enhancements to EFA in the current year through reprogramming and carryover. Also, PSRA will be able to assess the need over the fall and winter in the scenario planning process and make adjustments to next year’s allocation. As RWPA is payer of last resort, EFA funds will be used by clients only after exhausting other resources, including the $2.7 billion State-administered fund for rental arrears. It was noted that EFA can pay for emergencies other than rent, including utilities, household supplies, transportation and medical expenses. Finally, eviction is a lengthy legal process that involves housing court, and the end of the moratorium does not mean that people will immediately face removal from their homes.
Ms. Gilborn, on behalf of the PSRA Committee, moved to approve the FY 2022 Base, MAI and Tri-County Application Spending Plans as presented. The motion was adopted 28Y-0N
Agenda Item #4: Assessment of the Administrative Mechanism
Mr. Carr explained that the Ryan White legislation requires that the Council assess whether the Recipient used Part A funds as determined by the Council’s priorities and allocations. The Council also evaluates how quickly and efficiently the Recipient contracts with service providers and how long they take to pay them. Using fiscal reports and the quarterly spending reports that the Council receives, the Executive Committee assesses the Recipient on four measures: 1) How quickly funding has been committed and contracts executed. 2) How well the Recipient did in timely procurement (this measure is moot for this assessment as there were no RFPs in 2020); 3) Were sub-contractors paid in a timely manner; and 4) How well did the Grantee do in spending the grant over the course of the year.
In most years, the findings are that the Grantee was effective in committing and allocating funds and in paying sub-contractors in a timely manner. FY 2020 was a very different year, as the pandemic caused disruption to the Recipient’s work. Also, the master contract with Public Health Solutions rebid and negotiations delayed by 4 months, which caused major backups. The findings of the assessment are different from recent years, and the intent of the assessment is to have the Recipient address these issues so that there are no negative findings next year. A summary of the findings follows:
Contract Renewals: During FY 2020, while no new contracts were executed, a portion of the portfolio required renewals to be executed (47). These contracts faced delayed execution due to challenges posed by the COVID-19. Additionally, during FY 2020, we rebid our master contract which involved a lengthy process of negotiation and resulted in a 4-month contract delay, with a new contract registered on December 31, 2020. During this time, there was no contract mechanism for authorizations to be carried out which contributed to the delay.
Subcontractor Payments: During FY 2020, subcontractors were not paid in a timely manner. This was due to a variety of reasons: the challenges posed by the COVID-19 pandemic, Governor Cuomo’s NYS on Pause Executive Order (from March to July 2020), and the need to comply with NYC policy changes to reimbursement for non-profit organizations. Also, during FY 2020, we rebid our master contract which involved a lengthy process of negotiation and resulted in a 4-month contract delay, with a new contract registered on December 31, 2020. During this time, there was no contractual mechanism for DOHMH to pay PHS.
Spending: The Recipient reported spending for the 2020-2021 Ryan White Part A grant year for the 2nd and 3rd quarters, and through a final report. The report for the 2nd quarter showed 31% of the funds expended at that point in time. The Recipient’s Master Contractor assured the Council that expenditures were at less than 50% because a number of expenses were not yet accounted for, but they expected full expenditure by year’s end. The 3rd quarter showed 72% spending with another assurance that the grant would be fully spent. The Final closeout report, however showed 94% of the funds were expended with $4,911,567 in unspent funding. This amount was reported to the Planning Council at the June meeting which necessitated the development of a carryover plan in the same month. While the plan is sufficient, assembling a plan in a short amount of time is not optimal.
In summary, for the proposed 2020-2021 Assessment of the Administrative Mechanism, the Council will find that the Recipient was unable to present accurate expenditure reports which hindered the Council’s ability to conduct its planning responsibilities for services for people with HIV. The Council understands that this year was unprecedented due to the global pandemic, the temporary transition to cost-based reimbursement, the transition to work from home and the rebid of the master contract. Regardless of these circumstances, we ask that this finding be used for quality improvement to support the subcontractors’ receipt of timely payment and the Council’s timely receipt of accurate fiscal reports to conduct its planning responsibilities.
In response to a question from Mr. Frasca, Ms. Feduzi explained that during the period when there was no payment mechanism, PHS worked with providers to obtain low-interest loans within days from the Fund for the City of New York and there were no reports of layoffs. Unfortunately, the interest was not reimbursable through RWPA funds.
Mr. Carr moved that the Committee approve the Assessment of the Administrative Mechanism as presented. The motion was seconded and approved 28Y-0N.
Ms. Plummer added that the Recipient is already taking steps to address the findings in the assessment and is developing a written plan with concrete steps that will be shared with the Council.
Agenda Item #5: Service Directive: Aging & HIV
Mr. Bruce and Ms. Best introduced the new Aging & HIV service directive, noting that this was the first time that the Consumers Committee has undertaken the task of developing a service directive. The need to address aging with HIV has long been a high priority for consumers. The Committee underwent a seven-month development process for the Directive. They received presentations from a number of subject matter experts (Jules Levin on the state of HIV and Aging research, Moises Agosto-Rosario on Health inequities for Aging PWH, Dr. Anjali Sharma on issues for Women with HIV, and Dr. Eugenia Seigler on considerations for the Healthcare system. The Committee conducted an HIV and Aging Community Forum on June 4 where community members provided feedback and edits on the Directive. The Directive seeks to address gaps in a service system that needs to transform to meet the changing needs of Aging PWH. The Directive includes Outpatient Medical Care, Referral for Healthcare and Supportive Services, leveraging existing services to include prevention and wellness activities to support aging PWH, and additional training resources for funded provided to support them to acquire new expertise in addressing the needs of this population. The Consumers Committee is proud to present this groundbreaking work. The concept and service model will be presented today for approval, and the Consumers Committee will meet next week to make some minor refinements to the text of the directive, which will be presented to the full Council in the fall.
Mr. Harriman presented the new Aging & HIV service directive approved by the Consumers Committee. PWH over 50 represent a majority of the total PWH population (59% of PWH in NYC in 2019) and yet their intersectional needs are often unaddressed by HIV service organizations. PWH over 50 have achieved the highest proportions of sustained viral suppression of any age group and yet care for their comorbid health conditions remains suboptimal and they have shorter life expectancies than those not living with HIV with two thirds of deaths among PWH due to non-HIV-related causes. Much data shows the need for improved resources for PWH over 50, including services to address social isolation, coordination between programs, benefits navigation, services offered in Spanish, and to address medical conditions of women with HIV over 50. The services included in the Outpatient Medical Care (OMC) component include: 1) Increase capacity to treat the complex needs of PWH over 50 mirroring aspects of the Golden Compass model through use of clinical staff(MD, RN, Pharmacist, Medical Assistant) to address comorbidities and to provide health education; 2) Geriatric, Psychiatric, and Cardiology consultation, and referrals to ongoing specialty care; 3) Resources provided by RWPA to address gaps in current care provided at clinical sites; and 4) support improved self-advocacy/ self-management so that PWH over 50 can talk to their medical providers about broader health concerns.
The services in the Referrals component are: 1) Increase the knowledge of resources available to support PWH over 50 among RWPA funded providers; 2) Improve referral tracking to ensure PWH over 50 are engaged in needed services; 3) Adapt referral practices from the ARTAS model (i.e. the development of referral partnerships), communication/outreach/education, navigation and transportation if needed. The programs will strengthen PWH networksand fund organizations that provide social support services for older people living with HIV, fund social support for exercise (e.g., set up buddy systems, making contracts with others to complete specified levels of physical activity, orset up walking groupsand 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 toleverage technology for social support and overcome barriers that older people living with HIV face. There will also be funds for provider training to ensure that they are able to effectively support PWH over 50 through increased ability toidentify comorbidities, and link PWH over 50 to needed resources.
The full Directive’s text will receive a final review and small edits from the Consumer Committee next week. The resulting full text Directive will be brought to the Executive Committee and the Full Council in the Fall. The Executive Committee approved the concept of the service model to address Aging and HIV so that it can be described in the three-year Ryan White Part A grant application as part of the EMA’s plan to improve care for this priority population.
Comments on the Aging & HIV Directive included that New York State is working on a major HIV and Aging initiative, starting with a statewide survey. The EMA needs to be looped into their work to ensure coordination. The Directive includes close collaboration with Project PROSPER, the local Ending the HIV Epidemic initiative, as well as leveraging other programs, such as the Medical Monitoring Project. It was also noted that HIV and aging is a unique clinical challenge, and the skills set of clinicians is the key to improving care, as there are few people who are expert in both aging and HIV care.
Mr. Bruce, on behalf of the Consumers Committee, moved to approve the concept of a service model to address Aging and HIV, with the final directive to be presented to the Executive Committee and Council in October after additional review by the Consumers Committee. The motion was adopted 28Y-0N.
Agenda Item #6: FY 2020 Revised Framing Directive
Ms. Fortunato introduced revised Framing Directive approved by the Integration of Care Committee, which worked most of the year to revise the document. Formerly known as the Master Directive, this document guides all services in the Ryan White Part A 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 Ryan White Part A portfolio is considered as the intervention.
Dr. Rodriguez-Hart described the Implementation Science Logic Model used for the Framing and Aging & HIV directives. Evidence-based practices (EBPs) are the convergence of the best scientific evidence with clinical experience and patient values, but EBPs are often not used in the real world. Implementation Science (IS) is the study of methods to promote the uptake or integration of research findings into healthcare practice. Traditional HIV research is usually focused on health outcomes at the level of the patient or individual coming in for services, like HIV status, timely linkage to care, and viral load. In contrast, IS focuses on strategies that target health systems and providers so that we can get the best evidence to the patient or community. The field of implementation science, which focuses on studying how we can get interventions we know to work adopted, used, and sustained over time. The IS Logic Model was described, showing Determinants (What can influence effective implementation of your intervention), Implementation Strategies (How will you get systems, programs, and/or staff to use the intervention?) Mechanisms (Why do the strategies you picked create your implementation outcomes?), Interventions and Outcomes (What changes will happen in your setting that will tell you if implementation of a new intervention occurred?).
Ms. Fortunato presented the details of the directive. The Integration of Care Committee received presentations on: Stigma & HIV Care (Dr. Rodriguez-Hart); CHAIN and Consumer Needs & Service Utilization (Angela Aidala, PhD); The Consumer-led QI Project: Integrating the Lived Experiences of People Living with HIV into Recommendations for HIV Care Quality Improvement (Dr. Rodriguez-Hart, PhD, Ms. Best, Ms. Diaz, Mr. Martin, Mr. Fields); Gender Affirmation & Intersectionality (Octavia Lewis, MPA); and Ensuring the RWPA Portfolio Embeds Equity in Planning (Tracie Gardner, JD). Multiple service category directives were reviewed to identify the following critical areas for inclusion: Patient Centered Care; Trauma Informed Care; Data Burden; Implementation Science; Health Equity; Anti-Racism; Race Equity; and Anti-Stigma.
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 Ryan White Part A 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 within one year of contract award. 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. The range of measures includes: RWPA programs that have completed a stigma assessment within 24 months of the award; RWPA programs that have a written stigma reduction plan within 12 months of completing the stigma assessment %% of organizations that identify a quality management champion; reduction in staff turnover over a period of 12 months; increase in referral completion over 12 months; consumers providing feedback to inform best practices over 12 months; increase in client perception of self-management skills; clients that rate services as satisfactory or better; increase in provider awareness of gender affirmation; increase in staff with lived experience and who identify as Black, Latinx, youth, TIGNBNC; organizations that have a system for identifying and supporting clients who request accommodations for their disability; organizations that conduct case conferencing and navigation for all clients as appropriate to service delivery (care coordination, harm reduction, and mental health services); organizations that implement best practices for centering client care through accessible hours, follow-up for missed appointments, etc.; organizations that utilize the live resource & site map for clients, as needed; organizations that develop and implement crisis plans for clients that include non-police alternatives; decrease in clients lost to care; organizations that delivered services in the language spoken by clients served; organizations that have/launch a social space for peer-to-peer engagement/support among clients; and clients that rate that social space as satisfactory or better.
CTP will also measure the following client outcomes: increase in PWH aware of their status, retained in care, and virally suppressed; increase in PWH quality of life; increase PWH satisfaction with HIV services; and decrease in anticipated and internalized stigma reported by clients.
A summary of the discussion on the Framing Directive follows:
- The goals and objectives section of the existing Directive come from the NYS Integrated Plan. There is a lot of overlap in the directives, particularly in a focus on patient-centered care (through enhancing cultural and linguistic competence, trauma-informed care and other elements). The existing Directive did not have a stigma and equity focus, which are essential to address.
- The measurable outcomes in the Framing Directive are almost all stigma and equity focused, when the primary goal of the Ryan White program is to improve health outcomes.
- Stigma is a major barrier to improving health outcomes, as clients who feel stigmatized will not access care
- The focus on stigma and equity is part of a global conversation on these issues.
- Many outcomes lack data points, whereas VLS is highly measurable.
- There are financial implications for providers. The amount of each contract that pays for grant administration means that additional resources will have to be allocated to data collection, which may impact the amount available for direct client care, especially for small agencies.
- The issues around outcomes data points can be addressed in the working group outlined in the Directive.
- Client satisfaction measures must include any negative feedback.
Ms. Fortunato, on behalf of the Integration of Care Committee, moved to approve the Framing Directive as presented. The motion was defeated 5Y-12N.
Ms. Fortunato moved that that the Framing Directive be referred back to the Integration of Care committee to address the issues raised at this meeting. The motion was seconded and approved 27Y-0N.
Council members who had issues with the Directive were urged to send them in writing to Ms. Lawrence, who will compile them for consideration by IOC. Clear and concise recommendations for changes will be helpful. Mr. Harriman added that the intent of the Directive is to change the way the RWPA system works, which can be uncomfortable, and the Directive addressed important issues around stigma and equity that CDC, HRSA and other funders have identified as priorities.
Agenda Item #7: Recommendations for Serving PWH with Serious Mental Illness (SMI)
Ms. Thompson explained that the Needs Assessment Committee spent over two years to develop recommendations to address SMI-related needs. SMI is defined as a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities. Offer all clients, across all RWPA service categories, a clinical diagnosis/evaluation (by referral if necessary) to appropriately identify all clients who qualify for additional MH services. A two-stage screening process is recommended to facilitate appropriate triaging: differentiate between PWH with SMI from PWH without SMI, then confirm an SMI diagnosis, if appropriate. Appropriate services should be delivered to all clients, including those without SMI, and providers should 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.
To address mental health-related stigma, NAC recommends embedding evidence-based stigma-dismantling practices into service delivery, require agencies to conduct organizational stigma assessments to inform responsive plans, support the development and implementation of policies that address and dismantle stigma, and support implementation of the NYS-NYC organizational stigma assessment and application of best practices.
The intersection of mental health and HIV is well documented but a full picture of PWH with SMI is unclear, even within Ryan White Part A, where mental health assessments are not conducted across all service categories. NAC recommends to improve capacity of CBOs 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 evaluation; 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.
Clients with a mental health diagnosis in RWPA have higher rates of engagement but lower rates of viral suppression. NAC recommends 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). Clients who either self-disclose or receive a mental health diagnosis should qualify for additional support services that facilitate viral suppression. Provide modified Directly Observed Therapy for all medications. Ensure provision of appropriate navigation services to all clients discharged from all mental health inpatient services.
NAC recommends to integrate and coordinate care for behavioral health, substance use and HIV care through the development of single site access for all services; facilitate case conferencing, and more staff training on Motivational Interviewing, SMI and referral; improve capacity of CBOs (Community Based Organizations) to manage people with HIV who may have SMI; collaboratively develop best practices to inform agency specific crisis action plans; streamline & accelerate access through strengthened and formalized partnerships; and implement client specific plans to maximize the likelihood that PWH with SMI achieve viral load suppression through Collaborative Care and Focus on resources for psycho-social rehab.
Data shows the need to diagnose HIV earlier, as later stages of HIV disease progression are associated with poorer health outcomes. NAC recommends developing strategic partnerships to enhance capacity and establish routine HIV testing at sites where people with SMI regularly access care.; bolstering HIV testing access to increase the identification of PWH with SMI at all available sites; and building capacity among behavioral health and psychiatric care providers to support HIV testing, prevention and navigation.
Mr. Frasca noted that the work on SMI will continue, including through a working group that includes important other stakeholders, such as the NYC DOHMH Division of Mental Hygiene and OASAS.
Ms. Thompson, on behalf of the Needs Assessment Committee, moved to approve the SMI Recommendations as presented. The motion was adopted 21Y-0N.
Agenda Item #8: Public Comment
Mr. Fields stated that the Council has always created the best possible products, and thus it is important to make sure everything is of the highest quality. He also thanked the retiring members for their outstanding contributions.
Ms. Best and Mr. Schoepp thanked the Council for their support and collaboration during their terms. Ms. Best added that having people who speak out respectfully is necessary for an successful planning process.
Mr. Harriman reminded everyone about the member appreciation event on August 6th.
There being no further business, the meeting was adjourned.