Priority Setting & Resource Allocation Committee Minutes July 12, 2021

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Meeting of the Priority Setting & Resource Allocation Committee

Monday, July 12, 2021

By Zoom Videoconference

3:05 – 5:00

Members Present: Marya Gilborn (Co-chair), Jeff Natt (Co-chair), Fulvia Alvelo, Matt Baney, Randall Bruce, Paul Carr, Broni Cockrell, Billy Fields, Graham Harriman, Guadalupe Dominguez Plummer, Michael Rifkin, John Schoepp, Claire Simon, Terry Troia, Dorella Walters

Members Absent: Joan Edwards, Leo Ruiz

Staff Present: David Klotz, Melanie Lawrence, Scott Spiegler, Jennifer Carmona, Clare Biging, Ashley Azor, Eleonora Jimenez-Levi, Yaoyu Zhong, Frances Silva, Arnelle Vincent, José Colón-Berdecía, Kimbirly Mack, Karen Miller, Giovanna Navoa, Roland Torres (NYC DOHMH); Andrea Feduzi, Gemma Ashby-Barclay, Rosemarie Santos, Barbara Silver, Arya Shahi (Public Health Solutions)

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 June 14, 2021 meeting were approved with no changes.  Mr. Harriman announced that in-person meetings will resume in October with an option to participate electronically.

Agenda Item #2: FY 2022 Application Spending Plan

Service Category Rankings: HIV & Aging

Mr. Klotz explained that the new service directive approved by the Consumers Committee and to be reviewed and approved by the Executive Committee and full Council later this month, is divided into two new HRSA service categories: Outpatient Medical Care (core), and Referrals to Health and Support Services (non-core).  The EMA must submit a ranked list of service categories in the grant application.  Also, the ranking score will affect the spending plan if there is a proportionate, across-the-board increase or decrease.  The PSRA ranking tool assigns scores for each service category based on four weighted criteria: Payer of Last Resort (15%), Access to/Maintenance in Care (35%), Consumer Priority (25%), and Specific Gaps/Needs (25%).  An explanation of the criteria and scoring were provided.  Although there will not be an allocation for the FY 2022 spending plan (programs will start in FY 2023), it is important for PSRA to rank their priority for the narrative in the 3-year grant application.  

Mr. Harriman presented the new service directive.  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 Compassmodel  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, fFund 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.

A summary of the discussion on the Aging and HIV Service Directive follows:

  • While there are a number of RW Parts C and D clinics in the EMA that may provide medical services to this population, payer of last resort requirements would ensure that those programs do not “double dip” and bill for RWPA funds if they can be provided with existing resources.
  • Any RFP would include a statement that RWPA programs must enhance and not supplant existing funding.
  • The data reviewed by the Consumers Committee shows that even many well-funded clinics are not addressing the aging issues of PWH (e.g., testing for cognitive and gait issues).
  • Data reviewed by the Consumers Committee showed that here is a huge number of medical providers who are not Part C or D providers that need to update their services for aging PWH.
  • HRSA Ryan White guidance does not include specific aging-related guidance.
  • Many PWH receive primary care from HIV specialists and many need training on geriatric issues.
  • While referrals generally are rolled up into medical services, the other components of the directive, such as tracking, are not funded at all.
  • The focus of this directive is on people already connected to medical care.

The Committee, by consensus, assigned the following ranking scores to the new services:

Outpatient Medical Care: 5 (POLR), 5 (Access/Maintenance), 8 (Consumers Priority), 8 (Specific Gaps/Needs).

Referrals to Health and Support Services: 5 (POLR), 8 (Access/Maintenance), 8 (Consumers Priority), 5 (Specific Gaps/Needs).

FY 2022 Application Spending Request

Mr. Klotz explained that the Application Spending Plan is a request based on needs.  HRSA allows EMAs to ask for up to 5% over the current year’s Base award and the EMA traditionally asks for the maximum as a statement of need.  In the fall/winter PSRA will continue its scenario planning for the actual award using the data collected over the course of the year on each service category.

The MAI award is fully formula-driven, and as in past years, the request for the application is identical to this year’s award.  For the FY 2022 application, the Tri-County Steering Committee is requesting a 5% proportional across-the-board increase based on service category ranking scores.  Also, on the TC plan there is a targeted increase of $500,000 to Emergency Financial Assistance (EFA).  This proposal, based on the PSRA discussions last month, is to continue the one-time enhancement to this program made with carryover funds in 2022 (those funds end on Feb. 28, 2022).  EFA serves the entire EMA, but the category was originally created for the TC region and the provider located there, thus is placed in the TC spending plan.

The NYC Base spending plan shows the following additional targeted increases:

  • $250K for six months of the Oral Health service category (to start Sept. 1, 2022)
  • $483,500 to fully fund the PSS TIGNBNC category (currently funded for six months with programs beginning September 1, 2021)
  • The balance of the 5% increase is distributed proportionately across all currently funded service categories based on ranking scores.

In response to a question from Mr. Natt, it was clarified that EFA can pay for emergency rental arrears to prevent eviction, but does not pay for ongoing rental assistance.  It also pays for utilities arrears and many other essential expenses.

Motions were made, seconded and approved 14Y-0N to adopt the FY 2022 MAI, Tri-County and NYC Base spending plans as presented.

Agenda Item #3: Effectiveness of Housing on Engagement in Care and Viral Load Suppression

Ms. Zhong presented on the effectiveness of housing on engagement in HIV care and viral load suppression (VLS).  She explained the different program elements and goals in RWPA, HOPWA and HASA housing programs: Short-term Rental Assistance (SRA), Short-term Housing (STH), Housing Placement Assistance (HPA – NYC and Tri-County).  As demonstrated in many studies, stable housing is associated with better adherence to HIV treatment; lower HIV viral loads; higher CD4 T-cell counts; better mental health status; and reduced HIV risk behaviors.  Definitions of engagement in care and viral suppression were given.  Enrollment in HASA was associated with higher engagement in care than non-HASA PWH in NYC (96% versus 78%).  HASA consumers in independent housing or supportive housing were slightly more likely to be in HIV careand almost 1.5 times as likely to be virally suppressedcompared to those in emergency housing.  Longer housing enrollment and more supportive services are associated with better HIV outcomes.  Another study compared HOPWA clients with PWH with similar characteristics (age, income, region, etc.) who were not enrolled.  Consumers who were enrolled ≥ 1 yearimproved VLS from baseline to one year after enrollment.  

Housing assistance may be less effective if focused solely on providing housing without addressing the array of supportive services to address multiple needs (food insecurity, mental health, substance use).  RWPA housing consumers maintained high percentage of engagement in care and improved durable viral suppression over 5 years (99% engagement in care, 69% durable VLS).  These statistics were broken down by service type, with SRA showing the greatest effects.  In summary, stable housing can reduce homelessness, help PWH maintain HIV treatment, achieve lower viral loads, reduce HIV transmission, and help stop the HIV epidemic.  COVID-19 pandemic also highlighted the importance of affordable stable housing in navigating a public health emergency.

The Food & Nutrition Services Fact Sheet will be presented at the next meeting (October 18th) in a continuation of the review of the service portfolio.

There being no further business, the meeting was adjourned.