Priority Setting & Resource Allocation Committee Minutes November 8, 2021

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Meeting of the Priority Setting & Resource Allocation Committee

Monday, November 8, 2021

By Zoom Videoconference

2:35 – 5:05

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, Guadalupe Dominguez Plummer, Claire Simon, Terry Troia, Victor Velazquez, Dorella Walters

Members Absent: Randall Bruce, Henry Nguyen, Michael Rifkin, Leo Ruiz,

Staff Present: David Klotz, Melanie Lawrence, Scott Spiegler, Faisal Abdelqader, Jennifer Carmona, Cristina Rodriguez-Hart, Chi-Chi Udeagu, Liz Tang, Staci Barton, Stephanie Hubbard, Aparna Shankar, Maria Ma, Nadine Alexander, Karen Miller, Giovanna Navoa, Roland Torres, Bryan Meisel (NYC DOHMH)

Guests Present: Ellen Epstein, Allison Dansby (NYC H+H Correctional Health Services); Nilda Ricard, Ann Travers, Adrian Assing (Fortune Society)

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 October 18, 2021 meeting were approved with no changes.  

Agenda Item #2: Draft Framing Directive

Ms. Lawrence presented the draft Framing Directive approved by the Integration of Care (IOC) and Executive Committees and voted down by the full Council.  The Directive is being presented to the Council’s committees and the public for additional feedback and revision.  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.

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. 

A summary of the discussion follows:

  • Pay equity issues around disparities between people doing similar jobs due to factors such as gender and race need to be addressed and is a systemic issue that even DOHMH faces.  Issues around compensation related to job titles is affected by collective bargaining agreements is beyond the purview of the Council, particularly for providers where the RWPA contract is a small part of a larger organizations (e.g., hospitals).
  • The purpose of the Framing Directive is to have providers start discussing pay equity issues and think about normalizing practices and making plans to address the issue.
  • CTP would be responsible for ensuring implementation of the directive and deciding how to address contractors who are not making progress towards the goals.  
  • Many of the goals will require a great deal of technical assistance and capacity building from the Recipient.  This will require considerable staff and financial resources.  CTP is reviewing its staffing structure so that there can be adequate resources to implement the directive and other emerging needs.
  • The old Master Directive was very focused on health outcomes and closing gaps in testing, engagement in care, viral load suppression.  The new directive overreaches on broader policy issues.
  • The purpose of the directive is to help the RWPA system overcome barriers, including systemic barriers, to optimal care.  The directive expands the language around how the Recipient can help providers identify best practices.  
  • Some of the issues raised in the directive would be more appropriately addressed by the Policy or Needs Assessment Committees.  
  • The directive is a long, challenging document to read and to parse, and there is a lot that is beyond the Council’s purview.  It should focus on what is actionable by providers.  If the Council wants to move the needle on racial equity, it should focus on doable actions that CTP and providers can take, rather than the broad societal issues.
  • Any actions mandated by the directive will require agencies to devote staff time and resources, which further will take away from providing direct services (i.e., opportunity costs).  Agencies already have a high burden of administrative work, and there needs to be a greater emphasis on direct client services.

Feedback from this and other meetings, as well as the survey that went out, will be brought back to the IOC for discussion and possible revision of the directive before being brought to the Executive Committee and full Council for consideration.

Agenda Item #3: Review of the Service Portfolio, Continued

Non-Medical Case Management/Incarcerated (NMI)

Mr. Abdelqader presented the new NMI Fact Sheet.  This service provides case management for people who are currently incarcerated at Riker’s Island or who are recently released.  Incarceration driven by systemic racism contributes to the disparate impact of HIV on Black and Latino communities.  Jails and prisons may offer an opportunity to engage people with HIV with the services they need to achieve connection to care and other services when they are released.  In 2005, NYC Health + Hospitals (H+H) Correctional Health Services found that while many organizations provided services in city jails, service delivery was not coordinated or designed to track engagement in care.  This led to the establishment of program goals for those incarcerated in NYC jails to have at least one face-to-face transitional services session prior to release, and to be linked to a community health provider within 30 days of release from jail.  The NMI program engages people with HIV prior to their release and ensures that they are linked to a healthcare provider in the community within 30 days of their release.  NMI staff are trained to use a ‘warm transitions’ approach to linkages, applying social work tenets to public health activities for those with chronic health conditions including HIV.  NMI offers a ‘one-stop’ model of coordinated care where non-medical case management, housing assistance, substance use and mental health treatment, and employment and social services are provided after incarceration through effective discharge planning and routine follow-up by program staff.  

Client demographics were described.  Residents of the Bronx were the most highly represented, followed by Brooklyn and Manhattan.  Almost half of clients reported heterosexual risk.  The largest age group was 30-40, followed by 40-50.  Sixty-two percent of clients were Black and 31% Hispanic.  The vast majority were men (86%), followed be equal numbers of women and TGNCNB.  Two priority populations (older PWH and Black/Hispanic cisgender MSM comprised significant proportions of clients.  The number of clients has dropped from 1177 in 2028 to 502 in 2020.  Allocation amounts and spending have stayed stable.

The largest number of service units provided were Coordination with Service Providers (4756 in 2020) and Client Assistance (3984 in 2020).  Large numbers of unit of service in escort, outreach for reengagement and care plan development were also provided.  Most client numbers and units of service provided went down in 2020 due to COVID-19, but Coordination with Service Providers increased.

Health care for incarcerated people are not covered by third party payers.  States are prohibited from using Medicaid money to cover inmates unless they are taken to a hospital. Incarcerated individuals who are Medicaid-eligible cannot receive Medicaid reimbursement for services prior to release, with the exception of care delivered outside the institution (e.g., hospital, nursing home) for those who were covered by Medicaid prior to their detention.  Upon release, Medicaid coverage is reinstated.  Incarcerated individuals are not eligible to enroll or continue enrollment through an ACA Marketplace.  While coverage options are limited in correctional facilities, New York hopes to become the first state to provide Medicaid to prisoners up to 30 days before their release.  The Fortune Society’s NMI program provides linkage to care for the recently incarcerated to ensure engagement in care.  Their work seeks to transition PWH to long-term MCM or Health Homes support.  Given this, the Recipient will monitor for updates to ensure that services are adherent to payer of last resort (POLR) requirements. Services provided under NMI are also offered to those without insurance coverage, including transportation, case management, and substance use screenings/referrals, through the NYS AIDS Institute, HASA, Medicaid Health Homes, Special Needs Plans, and Ryan White Part B.  RWPA Care Coordination and Supportive Counseling provide similar case management services, however, these programs are not specifically for the  currently or formerly incarcerated.

The City’s plan to close Rikers and build borough-based jails will likely shrink the jail system in dramatically and reduce the total system capacity by nearly three-quarters.  The number of people in NYC jails in 2019 declined by more than 67% since its peak in 1991. Between 2014 and 2019, there was a 50% reduction in admissions to NYC jails.  While promising, these trends may change with the incoming Mayor. Changing POLR considerations for the incarcerated (especially those on Rikers), indicate that NMI services will need to be closely monitored to ensure fidelity to the program model and to account for potential duplication of services provided in correctional facilities.

A summary of the discussion follows:

  • Providing services is made more challenging in a jail as the discharge date can change quickly.  The program initiates a main service plan, but has a backup plan if a release comes early (e.g., identifying a clinic that will take a walk-in appointment).
  • The vast majority of the jail population are awaiting trial or sentencing.  The clients served by the NMI program are slated to be released and not transferred to a State prison.
  • Many of the issues that make the population difficult to work with are due to their life challenges, such as not having permanent housing.
  • NMI programs are cost-based and the main expense is personnel, so expenditures remained high even though the number of clients diminished considerably.
  • Medicaid is usually activated within 2-4 days after release.  The program works with clients to get them coverage as soon as possible.  
  • Approval of a Medicaid waiver will have an impact on what NMI can pay for and needs to be monitored.

Early Intervention Services (EIS)

Assess, Connect, Engage (ACE) Program

Ms. Udeagu presented on the ACE program, which uses HIV surveillance data to identify people with HIV (PWH) who may be out of care for at least 13 months or who never have engaged in HIV care after their diagnosis.  The program’s goals are to: 1) Ensure PWH are aware of their diagnosis; 2) Facilitate linkage to HIV care and treatment for PWH;  3) Facilitate HIV preventive services for partners of PWH (e.g., HIV testing, PEP, PrEP); and 4) Identify and address barriers to engagement and retention in care.  The “data to care” flow was explained.  The 2019 and 2020 numbers of those confirmed not in care and linked to care were shown (numbers declined significantly in 2020 due to COVID-related staffing constraints.  The proportions of people linked to care did not change much (65% in 2019, 60% in 2020).  The same was true of the proportion who received referrals to services (76%/81%).  The partner services were described, from eliciting sex- and needle-sharing partners from clients to linking clients to care or prevention services.  In 2020, there were 1454 new HIV diagnoses reported to ACE, 1188 (82%) interviewed, and 360 partners elicited, of whom 46% were tested and 21% tested positive (55% of those who tested negative were offered PrEP).  The program goes to great lengths to safeguard client privacy and confidentiality, as required by law.  Partner services were already using remote means to contact clients (mostly telephone) and so did not have to make major adjustments in response to COVID-19.  One innovation was to start mailing out home test kits to those who wanted one.

Hepatitis C Services

Ms. Tang presented on the services for PWH co-infected with hepatitis C.  This work is a continuation of the HRSA SPNS grant (Project SUCCEED), which was awarded after the Council and the recipient prioritized services and hepatitis C cure for coinfected people.  The services are funded under both the EIS and MCM categories, within the Council directives for those services with the aim to support HIV and HCV coinfected persons to be cured of HCV.  The program matches HIV and hep C surveillance data and lab reports to analyze the co-infected population, with RWPA supporting the case investigation, linkage to care and health education activities.  The program also provides provider education.  In 2019, 388 clients were served with 63 identified as in need of hep C treatment and 48 who received treatment.  The numbers fell significantly in 2020 due to COVID-19.  

Early Intervention Services (EIP/TPT)

Ms. Barton presented an overview of EIS, which has two service models.  TPT provides targeted HIV testing and linkage (to care for HIV+, PrEP for HIV-) among priority populations in non-clinical settings.  EIP targets a re-offer of HIV Testing to those who are most likely HIV-infected and never tested in a NYC jail setting.  The model provides funding for refusal-reversal HIV testing of those who declined testing during the traditional jail-based health clinic encounters.  HRSA issued a notice that EIS funding provided to CBOs to focus testing in priority populations is exempt from payment of last resort rules.  Our RWPA funding only supports community-based testing and linkage for priority populations.  EIS funding provided to programs at DOHMH and Rikers solely provide services that occur in environments that cannot be paid by Medicaid.  

In 2018 and 2019, TPT programs spent their full award amounts.  2020 had a little less than $100,000 underspent, as many contracts were unable to spend down due to the pandemic.  Several agencies closed their offices for a while, reduced their hours of operation or reduced their in-person services (esp. outreach).  Some agencies furloughed staff or had their staff work remotely.  Additionally, fewer clients were accessing services.  The EIP (Rikers) spent their full amounts every year, even during COVID-19.  

The testing cascade (number of tests, newly diagnosed, linked to primary care or reengaged) shows that the numbers fell dramatically during COVID-19 (e.g., the number of tested was 7449 in 2019, 1543in 2020.  Several agencies with TPT contracts shut down their physical locations for several months, preventing them from providing in-person HIV Testing.  As a way to continue providing testing to their clients, many TPT contracts enrolled in the NYC DOHMH’s Community Home-test Giveaway Program which allowed them to order free oral swab HIV tests that could be sent directly to the client’s home.  If clients tested positive, they could still link them to iART or HIV primary care remotely, or they could ask the client to come in so they could link them to services in person.  Rikers staff were unable to provide their clients with HIV testing during the spring and summer months of 2020 in an effort to reduce the spread of COVID-19 in the jails.  While staff were able to resume testing in the fall, they were unable to resume large group education sessions in the housing areas, they were only able to conduct individual or small group education sessions in the clinic or supportive services area.  Despite these challenges over the past year and half, staff have continued to engage clients and provide testing.  They expanded their health education sessions to include information on COVID-19 and they now require staff and clients to wear face masks when receiving HIV testing.  This contract is only used to test clients who are HIV negative/unknown; if a client tests positive or if a client enters Rikers already knowing they are positive they would be enrolled in their NMI contract which is for HIV-positive individuals.

In response to COVID-19, more home test kits were mailed directly to clients.  Agencies continued to link clients to PrEP and PEP either virtually or in-person during the pandemic, however many programs reported that their clients were less interested in these services due to COVID-19.  Many clients reported that they needed to get their more immediate needs met first before they could think about HIV prevention and treatment services.  The need for harm reduction services, STI screening & treatment and food and nutrition services were some of the top needs that clients requested.  Many clients also reported changes in their sexual behavior due to the pandemic, having less sex or fewer sexual partners so their need/interest in HIV prevention services decreased.

The majority of clients enrolled in TPT programs during the 2020 grant year were either 45 years of age or older, or 25-34 years of age.  Most were men who identified as Hispanic/Latino.  The priority population served most was Black or Latina heterosexual women but this could be due to an underreporting of same-sex behavior among men.

The number of tests done in Rikers fell from 1865 in 2019 to 391 in 2020.  The majority of the clients enrolled in the EIP program at Rikers were 45 years of age or older, men and Black.  There are multiple housing jails at Rikers but only one is for women, so overall, the majority of those admitted to Rikers are men, which is why the majority of clients enrolled in this program are men.

PlaySure Network

Ms. Hubbard presented on the PlaySure Network 2.0 (PNS), which provides a comprehensive health package of HIV-related services in healthcare and non-healthcare settings using an equity-focused one-stop shop and holistic client-centered model.  Despite declining numbers of new HIV diagnoses and generally high engagement in care, stark inequities persist in the burden of new diagnoses and in clinical outcomes by race/ethnicity, gender, age, and neighborhood, largely due to structural racism, sexism, homo/transphobia, etc.  Advancing equity is a key strategic priority of DOHMH’s HIV response and a goal of PSN, which involves over 50 agencies to promote client-specific approaches to sexual health and HIV prevention,

access to HIV testing, PrEP and emergency PEP, and linkage to HIV care.  PSN intervenes at the organizational, interpersonal and individual levels, with agencies acting as hubs where clients can receive services in one location using an approach to sexual health in the context of sexual pleasure and well-being, moving away from risk-based screenings and assessments.  The program focuses on priority populations based on documented health inequities (e.g., Black and Latino MSM, Black transgender women, youth 13-29).       

Programs funded under PSN will provide one-stop services at their sites, establish formal partnerships to ensure all service are available and identify innovative modes of service delivery (e.g., virtual engagement, mobile sites).  Services provided will include: outreach, navigation, HIV prevention in health and non-health settings (HIV & STI testing, linkage), supportive services (mental health, substance use), and evidence-based interventions (optional).  

A summary of the discussion follows:

  • ACE services are triggered for any diagnosed person with no history CD4 or viral load lab test for 3 to 6 months after diagnosis.  The program will assess what barriers the client has had to engagement in care and make appropriate referrals.  Those who were previously in care will be contacted if they have not had a lab test within the past 13 months.
  •  Hep C treatment is provided by the client’s insurance (usually Medicaid).
  • Privacy concerns can be a barrier to using home test kits, and the program allows people to pick them up from a provider site (also useful if the person does not have a fixed address).
  • PSN activities to address stigma are multi-pronged, such as through infrastructure (e.g., assuring a site has gender-neutral bathrooms).  The program will use a number of indicators obtained through client surveys and other means to measure progress.

The presenters were thanked for their excellent and informative presentations.

There being no further business, the meeting was adjourned.