Priority Setting & Resource Allocation Committee Minutes December 13, 2021

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Meeting of the Priority Setting & Resource Allocation Committee

Monday, November 8, 2021

By Zoom Videoconference

2:35 – 5:00

Members Present: Marya Gilborn (Co-chair), Jeff Natt (Co-chair), Fulvia Alvelo, Matt Baney, Paul Carr, Eunice Casey, Broni Cockrell, Joan Edwards, Billy Fields, Graham Harriman, Matthew Lesieur, Henry Nguyen, Scott Spiegler (for Guadalupe Dominguez Plummer), Michael Rifkin, Terry Troia, Victor Velazquez, Dorella Walters

Members Absent: Randall Bruce, Leo Ruiz, Claire Simon

Staff Present: David Klotz, Mary Irvine, DrPH, Nadine Alexander, Jennifer Carmona, Bryan Meisel, José Colón-Berdecía, Kimbirly Mack, Gina Gambone, Tye Seabrook, Grace Herndon (NYC DOHMH); Arya Shahi (Public Health Solutions)

Guests Present: Mary Brewster (Harlem United), Abigail Cerna,Delilah Gavilanes (Boom Health); Ramona Cummings (Alliance),Angeles Delgado (CAMBA),Laura Elliott (Family Services Network);Rebecca Kim (The Family Center), Michelle Melendez (SUNY Downstate); Annette Roque, Barbara Stern (La Nueva Esperanza); Chrystelle Touvoli, Nathalie Weeks (African Services)

Agenda Item #1: Welcome/Introductions/Minutes

Mr. Natt and Ms. Gilborn opened the meeting, followed by introductions and a moment of silence.  The minutes of the November 8, 2021 meeting were approved with no changes.  

Agenda Item #2: Review of the RWPA Portfolio: Medical Case Management/Care Coordination

Mr. Harriman noted that the Medical Case Management/Care Coordination Program (CCP) is by far the largest investment in the EMA’s RWPA portfolio, and it is crucial that the PSRA and Council have a deep understanding of how the program works and its effectiveness.  CCP is also the most studied service model and additional grants have been won from NIH.

Ms. Alexander presented the new fact sheet for CCP, a service category that supports retention in care by offering people with HIV (PWH) home- and field-based patient navigation services, coordinated medical and social services, counseling and coaching in adherence to treatment, directly observed therapy (DOT) for treatment, and health education to build the skills and knowledge needed to maintain stable health.  Programs associated with clinics that enroll PWH have to be – or become – patients of the clinic with which the program is associated.  Services are intended for people living with HIV who have demonstrable challenges to engagement in care, retention in care and adherence to treatment and the newly diagnosed or those with co-occurring conditions who may benefit from help coordinating care (e.g., PWH who have not achieved viral load suppression, have been out of care or new to care, new to antiretroviral treatment, and co-infected with Hepatitis C or pregnant). 

In 2020, there were 3961 active clients (down from 4824 in 2017).  Brooklyn and the Bronx had the most clients, followed by roughly equal numbers from Manhattan and Queens.  Heterosexual represented the largest risk factor, followed by MSM.  77% were between the ages of 30-64.  Ninety-one percent were either Black or Hispanic, and 62% were male.  Priority populations highly represented include Black MSM, women of color, older PHW and people with a disability.  

The most utilized service types in 2020 were client assistance (almost 61K units of service), outreach for reengagement (almost 45K), individual and group health education (over 42K), and client engagement (almost 38K).  Almost 3000 clients received directly observed therapy (25K units).  Service types with large numbers of units of service were described, such as client assistance, which can be any time a provider helps a client with accessing services (e.g., filling out a form). Client engagement (which was not a service type in the old model) involves a phone call with the client.  Modified DOT can be by phone or video chat and is a minimum of three times per week (reduced from five/week in the old model, which had been a barrier to some potential clients).  The DOT schedule is agreed upon by the client and provider.  The service category spent close to or slightly over its original allocation every year.

Some CCP services may be eligible for reimbursement by 3rd party payers, including intake assessment, reassessment, service plan development and update, self-management assessment, case conference, health promotion, modified directly observed therapy (mDOT), and immediate initiation of ART.  There are a variety of payers for the above-mentioned services, including Ryan White Parts C and D, NYS AIDS Institute, and NYS Medicaid/Medicare programs.  Clients may be dually enrolled in CCR and a Comprehensive Medicaid Case Management Program such as Medicaid Health Home.  For these clients, services that are eligible for reimbursement under Health Home are not eligible for reimbursement under the Care Coordination program.  Clients who are not eligible for Medicaid or are not enrolled in a Medicaid Health Home may receive the full range of services from the Care Coordination program.  Care Coordination services not reimbursed by Medicaid/Medicare should be provided to eligible clients as wraparound services.  Payment of last resort is monitored contractually as well as through site visits to ensure a service that is provided by the Ryan White funded program could not and was not billed to Medicaid.  With expanding Medicaid coverage offering Medical Case Management services to those covered, Care Coordination services should continue to be monitored to ensure the utilization of CCR as wrap-around services for clients dually enrolled.

Dr. Irvine presented data from two studies on the effectiveness of CCP, which was launched in 2009.  CHORDS was a study that ran from 2013-29 to assess if the program would effectively address barriers to care and promote better outcomes along the care continuum, relative to usual HIV care in NYC.  The program uses evidence-based or evidence-informed components that make up the CCP: case management, patient navigation including accompaniment, adherence support with DOT for those who need it, and structured health education. The intensity and focus of these services can be tailored to meet individual needs.  The staff model was also described and the roles of care coordinator, patient navigator and other parts of the care team.

Data sources were provider reporting through eShare and the NYC HIV Surveillance Registry.  To create the usual-care group, the study assigned non-CCP individuals a time point from which to monitor their outcomes in the Registry, and then matched CCP enrollees to those in the usual-care group on characteristics predicting CCP enrollment, start dates of follow-up and baseline treatment status.  Demographic, clinical and neighborhood variables as predictors of CCP enrollment were included.  

The first comparison-group analyses looked at viral suppression (VS) at 12 months after enrollment.  CCP clients who were newly diagnosed with HIV and CCP clients with no evidence of VS in the year prior to enrollment were more likely to be virally suppressed at the last viral load in the 12-month follow-up period than their counterparts in usual care.  For the previously diagnosed individuals who had any viral suppression in the year before the start of follow-up, there was no significant effect of the CCP on the 12-month viral suppression outcome.  The next comparison-group analyses looked at “durable viral suppression,” defined as viral suppression out to 36 months of follow-up. For this longer-term outcome, the CCP advantage over usual care was limited to previously diagnosed individuals with no evidence of VS during the previous year.

CCP enrollees with no evidence of viral suppression in the year prior to enrollment were significantly more likely to achieve durable viral suppression (DVS, defined as achieving undetectable viral load for three years on lab tests performed at least yearly) when compared to usual-care recipients in the same baseline status group. This represents a 16% increase in durable viral suppression for the CCP as compared with usual care.  For those who have been out of care, CCP enrollment resulted in significantly greater odds of care engagement and viral suppression in the first 12 months of follow-up.  Specifically, at 6 months after enrollment, 69% of the CCP had achieved VS, while that proportion was not achieved by the non-CCP PWH until 12 months after pseudo-enrollment.  Thus, CCP PWH reached VS 6 months faster.

The PROMISE study, initiated in 2018 and ongoing, measures outcomes after program revisions were integrated into the CCP model in the 2017 re-bid of CCP contracts, based on the Council’s revised service directive.  Features of the revised intervention include: Structured assessment and reassessment of capacity areas involved in HIV self-management; DOT available to anyone willing to try it for ≥3 days/week and via video-chat, with option to pause/discontinue at any time; Reimbursement for coordination with prescribing providers to yield “immediate” ART access (0-4 days); and conditions for reimbursement no longer tied to meeting thresholds for frequency of contact.  TVS levels were essentially stable at 53-54% during the course of this 27-month trial.  There findings saw no statistically significant effect of the revised program versus the original regarding timely VS.  The early findings of this study do not support a need for changes to the CCP, nor a need to roll back revisions made in NYC.  PROMISE will also analyze long-term outcomes of revised CCP relative to NYC usual care, and will look at program implementation preferences and what drives CCP engagement using qualitative interviews to better understand clients’ and providers’ program experiences.  

In conclusion, the original CCP model shows short- and long-term VS benefits among previously unsuppressed PWH, and short-term benefits among newly diagnosed and previously out of care, however, there remains room for improvement.  The proportion with DVS was low (37%), despite 90% of the cohort (CCP and non-CCP) achieving VS at least once in months 13-36.  Among clients without evidence of VS in the year prior to enrollment, only 43% achieve VS at 12-month follow-up and only 21% achieve DVS.  Revised CCP does not yet show a difference in short-term effectiveness, but improved implementation without decreased effectiveness is still a ‘win’.  Long-term effects will further inform overall assessment of revisions.

A summary of the discussion follows:

  • The studies were not able to break down data between clinical and non-clinical sites, as this information was impossible to obtain for the non-CCP PWH from the registry.
  • Constraints of procurement rules did not allow for consideration of experience as prior contractors, but the award process did consider experience providing care coordination services overall.
  • The changes to the model were done to make it more accessible and reimbursable.  For example, DOT requirements are more relaxed, as many people found that five appointments per week was too high a barrier to participation.
  • The new model also lessened administrative burden (e.g., eliminating reimbursement based on tracks that clients were assigned to).  This allows for more staff resources to concentrate on serving clients.
  • There is no demographic data on Health Homes to compare with CCP.  
  • Unlike Health Homes, CCP staff work as integral members of the client’s care team.
  • PSRA needs to be mindful of the overlap between Health Homes and CCP and avoid duplication of services.  
  • At the January Council meeting, Mr. Shahi will present on how PHS monitors for payer of last resort (POLR) issues.  It has always been known that certain CCP service types are available in both CCP and Health Homes.  Monitoring for POLR can be strengthened.  

Agenda Item #3: Review of the RWPA Portfolio: Supportive Counseling (SCG)

Ms. Alexander presented the SCG Fact Sheet from 2020.  The program provides individual supportive counseling services that aim to overcome barriers to access and facilitate continued engagement in medical care for PWH, and family-focused services that reduce stressors in the lives of PWH in order to remove barriers to engagement in HIV care and adherence to treatment.  SCG enrollees’ eligibility requirements were described (including PWH’s families as defined by the client and which is not necessarily a biological relationship).  Also, client and/or family members need not have a DSM diagnosis.  Services provided for family members must aid in reducing the stressors in the lives of the PWH to facilitate removing barriers to engagement in HIV care and adherence to treatment.

Client demographics show that a majority of clients are from Bronx or Brooklyn, Black or Hispanic, and Older PLWH.  Heterosexuals are over-represented compared to the general HIV population.  Four years of service unit data shows that the service type of “Supportive Counseling” (the core service provided in this category) comprised the bulk of service units (13,855 in 2019).  Client Assistance and Coordination with Providers were other service types with large number of units provided.  Before this category was rebid it used to regularly over-perform.  It now generally spends close to its original allocation.

There is no federal payer for SCG.  The NYC Administration for Children’s Services offers programs in family home care, childcare, head start/early start, transitional childcare, and family services for domestic violence counseling, mediation, anger management, and crisis intervention.  Target population-specific services are offered by NYSDOH AI and NYS OTDA for HIV infected women and their families and clients who are unstably housed, respectively.  SCG services are not Medicaid billable due to the absence of a DSM diagnosis. 

Mr. Meisel presented qualitative data based on questions posed to SCG providers.  He prefaced that by explaining the benefits of the service: 1) Bridges the gap between case management services and comprehensive mental health care; 2) it is well suited to smaller CBOs that are well known in their community as compared to the MHV grant which requires a co-located Article 28 or 31 clinic; 3) it is able to engage consumers who are in a “pre contemplation” stage of accessing mental health care due to stigma or other barriers.  One program reported being set up for Medicaid reimbursement, but this does not affect the SCG program.  Medicaid reimbursement requires a DSM diagnosis, while SCG services can be accessed without one.

Two programs have other departments within their agency (i.e.: health homes or case management) that are set up for Medicaid reimbursement (but do not impact their SCG programs).  The most common presenting issues for which counseling services are provided are depression and anxiety, family and relationship issues, stigma, grief and loss, housing, and medical issues/navigating the healthcare system.  

Program Managers can address these issues through case management, the ability to refer to resources within the agency, warm handoffs (i.e.: referral of care where the handoff occurs in front of the patient).  All respondents reported that timely, personalized referrals (including to onsite services) are their biggest tool in meeting client’s needs.  Some unique services that may be provided include: services in multiple languages, flexible hours, and partnerships with realtors who work with clients who have housing vouchers.  

Several providers gave details about their programs.  Highlights include:

  • Programs often provide referrals (which usually involve accompaniment) for psychiatric evaluation so that more serious mental health issues can be addressed.
  • SCG serves as a crucial link between the client and clinicians (including psychiatric providers).
  • SCG is usually provided by small CBOs that are known and trusted in the community.  Trust building is essential to the success of this service.
  • Psychoeducation, addressing issues around aging, and daily living skills are part of the program.  Programs also help clients resolve housing issues.
  • During COVID, some clients were discouraged from seeking mental health services, and SCG served as a bridge and reassurance to stay connected to care.  Programs also assisted with getting clients vaccinated for COVID.

The presenters were thanked for their excellent and informative presentations.

There being no further business, the meeting was adjourned.