Share, Structure, Succeed: Newly Funded Jurisdictions Building Capacity to Implement High Impact HIV Prevention
Technical Assistance Report May 7-8, 2013
Share, Structure, Succeed: Newly Funded Jurisdictions Building Capacity to Implement High Impact HIV Prevention
Attendees: Baltimore Health Department Patrick Chalk (Health Department) Broward County Health Department John Daly Patrick Jenkins William Eugene Green Jorge A. Gardela (Community Representative) Evelyn Ullah (Health Department) Fulton County Health Department Veronica Hartwell (Health Department) Ruby Lewis-‐Hardy Matthew McKenna, MD Rudy Carn (Community Representative) Peer Technical Assistance Marlene Lee McNeese-‐Ward (Houston) Israel Nieves-‐Rivera (San Francisco) Peter McLoyd (Chicago) Technical Assistance Consultants Dea Varsovcsky (UCHAPS) Marsha Martin (UCHAPS) Michael Shankle (HealthHIV) CDC Donna Alexander Reginald Carson Erica Dunbar Renata Ellington Wendy Harrington-‐Lyon June Mayfield Angel Ortiz-‐Ricard Shuenae Smith Vasavi Thomas
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Background On January 1, 2012, the Centers for Disease Control and Prevention (CDC) began a new five-‐year HIV prevention funding cycle with health departments across the United States and its territories to implement high-‐impact prevention, CDC's new approach to addressing HIV prevention. The goal of the PS12-‐1201 funding announcement is to reduce HIV transmission by building capacity of health departments to: focus HIV prevention efforts in areas where HIV is most heavily concentrated to achieve the greatest impact in decreasing the risks of acquiring HIV; increase HIV testing; increase access to care and improve health outcomes for people living with HIV by linking them to continuous and coordinated quality care and medical, prevention, and social services; increase awareness and educate communities about the threat of HIV and how to prevent it; expand targeted efforts to prevent HIV infection using a combination of effective, evidence-‐based approaches, including delivery of integrated and coordinated biomedical, behavioral, and structural HIV prevention interventions; and reduce HIV-‐related disparities and promote health equity. This health department funding announcement employed a new method for allocating core HIV prevention resources to better match the geographic burden of the U.S. HIV epidemic today. Funding is allocated to each state, territory, or city based on the number of people reported to be living with HIV/AIDS in that jurisdiction (the best measure of the HIV burden available in every U.S. jurisdiction). This approach, driven by the latest data, improves on prior health department funding allocations, which were previously based on AIDS cases. In addition, to ensure that funding reaches major urban areas where HIV is concentrated in the United States, the number of cities (metropolitan statistical areas) eligible for direct CDC funding was increased from six to ten. These ten cities account for approximately 37 percent of all Americans living with an HIV diagnosis. Under this funding announcement, the cities of Atlanta, GA (Fulton County Department of Health & Wellness); Baltimore, MD (Baltimore City Health Department); and Fort Lauderdale, FL (Florida Department of Health in Broward County) were newly funded. HealthHIV and UCHAPS proposed to the CDC Division of HIV/AIDS Prevention, Prevention Program Branch, an opportunity to bring together the newly funded CDC HIV prevention cities for peer-‐to-‐peer technical assistance and to develop a technical assistance (TA) roadmap for each jurisdiction to ensure success.
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Meeting Goal Through a two-‐day, in-‐person, peer-‐to-‐peer technical assistance activity, HealthHIV and UCHAPS will facilitate newly funded HIV prevention jurisdictions to: • Identify successes and challenges with implementation of PS12-‐1201; • Discuss infrastructure and policy limitations; • Share strategies to enhance program delivery; and, • Identify TA needs and develop a TA implementation plan. Jurisdiction Participation and Preparation Health Department representations from the jurisdictions of Atlanta, GA (Fulton County Department of Health & Wellness); Baltimore, MD (Baltimore City Health Department); and Fort Lauderdale, FL (Florida Department of Health in Broward County) confirmed their attendance at the meeting on May 7-‐8, 2013. Each jurisdiction was asked to invite a least one health department representative and one community co-‐chair from their respective HIV planning groups. In preparation for the technical assistance meeting each jurisdiction was also asked to supply the following documentation to the facilitators: 1. Current organization chart 2. PS12-‐1201 Annual Progress Report (APR) 3. CDC Post Award Site Visit Report/Technical Review (if available) 4. HIV Planning Group Membership Roster 5. HIV Planning Group Bylaws/Operations Manual Additionally, each jurisdiction was asked to prepare a 30-‐minute PowerPoint presentation that described the overall landscape of the health department and community services as they relate to HIV prevention. Each presentation was expected to: 1. Review the basic organizational structure of the health department and how HIV prevention is housed within that structure (including HIV care, STD, TB, hepatitis, and surveillance); 2. Provide a snapshot of health department’s HIV prevention staffing; 3. Provide a snapshot of the community infrastructure; and 4. Highlight how the jurisdiction is implementing PS12-‐1201, highlighting activities in the following program areas: HIV testing, comprehensive HIV prevention with positives, condom distribution, policy initiatives, evidence-‐based interventions for high-‐risk negatives, social marketing, PrEP and nPEP. UCHAPS identified three experienced jurisdictions (Chicago, Houston, and San Francisco) to participate in the meeting and provide peer-‐to-‐peer technical assistance to the newly funded jurisdictions. Marlene Lee McNeese-‐Ward
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(Houston) and Peter McLoyd (Chicago) attended both days of the TA meeting. Israel Nieves-‐Rivera (San Francisco) attended the first day. Meeting Format HealthHIV and UCHAPS set the theme of the meeting as Share, Structure, Succeed. Jurisdictions were asked to share their challenges and successes, to structure capacity building assistance needs, and, ultimately, to succeed as a newly funded jurisdiction. The full agenda can be found in Appendix A: Share, Structure, Succeed Meeting Agenda. An overview of the proposed agenda and objectives is outline below. May 7, 2013 (Day One): Each jurisdiction will present: the state of HIV prevention services and community affairs in their jurisdiction when new funds arrived, existing health department infrastructure, community engagement processes around HIV prevention, and epidemiological profile and surveillance capacity within their jurisdiction. Jurisdictions will also respond to the process of moving to full implementation of PS12-‐1201; the identification of infrastructure gaps, knowledge gaps, capacity/expertise gaps; and contract/grant administration and leadership challenges both within the health department and the community. May 8, 2013 (Day Two): Each jurisdiction will address: What is working and how long will it take to emerge as 'a directly' funded jurisdiction with capacity to manage the HIV prevention portfolio? What is not going well? What is necessary from the state and local health department leadership and the CDC to support the implementation locally? Jurisdictions will also identify TA needs; the type, area/issue of focus, how long TA will be needed; and develop a TA plan.
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Meeting Notes On May 7, 2013, Marsha Martin and Michael Shankle opened the meeting by welcoming attendees and citing the historic nature of this meeting – the first time in decades that CDC newly funded jurisdictions have come together to discuss their successes and challenges. Participants were encouraged to be open and provide honest responses to what is really happening on the ground. They acknowledged that it might be intimidating with their funder, CDC, in the room. However, CDC representatives are also very committed to being open and supporting the technical assistance (TA) that newly funded jurisdictions need to succeed. Dea Varsovcsky asked participants to introduce themselves, describe their role in the HIV planning process, and share their goals for the meeting. Additionally, Michael asked each participant to provide one-‐word that describes his/her views on PS12-‐1201 implementation.
Participant views of PS12-‐1201 implementation in their jurisdiction. May 7, 2013. Atlanta, GA.
Participant meeting goals of what they hope the meeting will achieve: • Learn from each other (other jurisdictions) • Hear where jurisdictions are with implementation of PS12-‐1201 and their plans to move forward • Get all individual’s questions answered • Be surprised by innovative models that are working • Hear how other jurisdictions specifically identified challenges and developed resolutions • Learn new ways of doing business • Develop a strong, effective TA plan
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• • • • • • • • • •
Identify opportunities to right the wrongs and develop some sort of TA plan Understand how to integrate care and treatment Listen, learn, and implement ideas to advance local jurisdiction work Opportunity to learn from the advanced (oldies) jurisdictions Opportunity for CDC to hear what we need regarding PS12-‐1201 implementation Explore lessons learned and best practices Understand the complexities of implementing PS12-‐1201 Listen and really hear other jurisdictions’ successes and challenges, areas of opportunity, and ways those efforts can be supported Build organizational structure and capacity Create partnerships and provide the tools necessary for success
Israel Nieves-‐Rivera reiterated that the conversations over the next two days have to be no holds bar. Participants must be able to have honest and respectful conversations in order to create a supportive atmosphere. He discussed that an opportunity such as the current training could have prevented missteps that were taken when they first started implementing HIV planning. His hope is that participants will learn from past mistakes and build a program with successful models. Nieves-‐Rivera compared the support from peer jurisdictions, TA providers, and CDC to be like that of the Verizon network – jurisdictions have an entire team behind them. While newly funded jurisdictions learn from older jurisdictions, older jurisdictions also have the opportunity to learn from newly funded jurisdictions. Michael Shankle reviewed the Loudermilk facility logistics and the agenda. Power Point presentations from each jurisdiction commenced, followed by a facilitated question and answer session, discussions around health department and community infrastructure, program planning and implementation, and internal and external support structure and relationships. Full presentations are available on the UCHAPS intranet, WebexOne. Presentation and Discussion Highlights Fulton County The High-‐Impact HIV Prevention program is housed within the Communicable Disease Branch of the Fulton County Department of Health & Wellness (FCDHW). For the first four months following the PS12-‐1201 funding there was no staff on board. As such, the primary priority was to develop a staffing plan and recruit/hire. By October 2012, the department was 85% staffed. The health department is engaged in several efforts to scale up the program. Their efforts include geo-‐ mapping HIV testing and condom distribution to ensure that HIV testing and distribution sites are accessible to high-‐risk populations (i.e., in neighborhoods with high risk and incidence). The program also has established the HIV planning group. In September 2012, FCDHW worked with HealthHIV to engage the community in the
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development of the new HIV prevention program through a series of community meetings. FCDHW is coordinating services with the Ryan White program to leverage resources. Community infrastructure: Evaluation web data has been helpful with mapping how many HIV tests are performed with each funding source. The challenge has been moving community-‐based organizations (CBOs) from one testing technology to another, utilizing a more cost-‐effective testing algorithm that requires a blood specimen (away from Orasure to venipuncture). Currently, these agencies have to use an out-‐of-‐state lab that is cost-‐prohibitive with unsatisfactory result delivery timelines. Challenges Identified • Relationship with the State: The working relationship with the Georgia Department of Public Health (DPH) is being developed. The lack of strong collaboration between the two agencies is impeding Fulton County’s ability to make programmatic decisions and fully implement their program. Specifically, Fulton County does not have direct access to and has not been able to retrieve surveillance data from the DPH. This impacts the ability to direct funding and target programs accurately. The DPH also has a significant backlog of reporting forms. It is permissible by law for laboratories to report results directly to Fulton County; however, the reporting system is currently set up so that laboratories report all lab results directly to DPH. A review of the laws and established processes has to take place for this to be amended. Additionally, the DPH and FCDHW have not coordinated in the distribution of funding. Some agencies are funded by both DPH and FCDHW to provide the same services. • Contracting delays: There are a number of contracting issues, as the Fulton County Commissioners must approve all contracts. This process is very slow and cumbersome. • Perinatal transmissions: There have been a number of perinatal transmissions reported as of late, many of which are in FQHCs. FCDHW is working with the local AETC to improve protocols and screenings among pregnant women. • Quality assurance at CBOs: There is a significant need for quality assurance measures to be implemented in CBOs. There have been instances of CTRS forms being found unsecured in CBOs and turned in months after the fact. • Staffing: The staff members are all new at FCDHW. FCDHW is working to build staff skills, but is not far enough along. Additionally, the position of Director is currently unfilled. The FCDHW also needs tools for data collection and to build an infrastructure to collect and manage data.
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Baltimore Baltimore City Health Department employs a matrix management model and thus promotes an integrated care team approach. Staff at the health department conducts the majority of services provided under PS12-‐1201. The program has had a number of robust HIV prevention programs already implemented. Baltimore City has the only confidential syringe exchange program in the country funded by general funds from the city and state, as well as a comprehensive outreach project, the Block Project, which engages non-‐traditional partners and health care providers working with high risk, marginalized groups. The health department has been building trust with the community and now the department funds a number of mini-‐balls throughout the city. Currently, the health department is working to fully integrate programs in order to provide comprehensive services to at risk populations. They are also evaluating HIV testing in emergency departments to determine the impact of health care reform and whether the health department will need to continue to support testing. Baltimore City receives Category C funding for a project to increase early diagnoses of HIV. The health department is also working to finalize the HIV planning group structure. Internally, the health department is attempting to leverage services with one another. For example, they have linked HIV and STD disease intervention specialists to leverage STD funding. Mayor Rawlings-‐Blake has been exceptionally supportive and has allowed provocative messages to appear on city buses. As the program scales up, the health department has slowly been picking up programs from the state, with which they have an excellent relationship. The City has experienced a number of fiscal cuts to programs – Ryan White, TB, viral hepatitis – yet has experienced increases in cases of HIV, STDs, and syphilis. They are evaluating existing programs and eliminating under-‐performing programs. Challenges Identified • Staffing: Baltimore City Health Department is operating with a number of vacancies. • Procurement: The procurement process has posed barriers in getting contracts to delegate agencies on time. • Community Engagement: Community engagement has also posed a challenge, as there are limited numbers of community-‐based organizations (CBO) operating in the city -‐-‐ increasingly fewer funding sources available to them to support the infrastructure. • Unrestricted funding: There is a need for unrestricted funds in the city. However, the relationship between local philanthropic groups and CBOs is plagued with broken promises. Foundations and CBOs need to work collaboratively and in partnership. • HIV planning: The Mayor has set up a Mayor’s Commission on HIV. This body is established through a legislative process and needs to become the HIV planning group. Chalk is trying to start fresh, but that would require the Commission be dismantled.
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Broward County Broward County Health Department receives PS12-‐1201 funding through the Florida Department of Health. Broward County has been working to strengthen programs reaching vulnerable populations, including men who have sex with men (MSM), as well as the Latino and transgender communities. It is also working to increase venues offering integrated testing programs for HIV, STDs, and hepatitis, and is developing a strong social marketing campaign. The health department has also been working to develop an integrated HIV treatment and prevention plan based on meeting the goals of the National HIV/AIDS Strategy. The health department also plans to compile a Florida guide on billing, a toolkit to be utilized by providers and hospitals, and will hold a symposium on the topic. Challenges Identified • Role of the State: The unique role of the state as local, county-‐based health services implementers poses a unique set of challenges for program design, implementation, and monitoring. Developing infrastructure and capacity for a true local response is limited. • Relationship with the State: The state and jurisdiction are having a difficult time working together. There has been a great deal of focus on Broward County, however, due to the lack of coordination between the state and the jurisdiction, sustainable results are unlikely to occur. • Staffing: Scaling up health department infrastructure as a directly funded jurisdiction has been delayed. Specifically, Broward County Health Department reported difficulty in recruiting and hiring staff. • Access to data: Access to timely and accurate data has also been a challenge and poses barriers to program planning and monitoring. There are no data sharing agreements in place, which impedes the health department’s ability to share data across programs, i.e., Ryan White and ADAP data, or between county and state departments.
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Overarching Discussion Highlights Each newly funded jurisdiction demonstrated great progress toward systems development and program implementation; however, they share a number of challenges. Health Department Infrastructure Challenges with existing infrastructure in order to implement programming: • Vacancies in key positions with direct impact on the programs • Disconnect between program and procurement needs • Need to streamline processes and improve quality assurances • Legislative and policy barriers to effective implementation • Enhancing collaborations and partnerships both internally and externally • Maximizing resources and leveraging other program resources Health Department Program Implementation Challenges with access to timely and accurate surveillance data: • Identify barriers, if any, to the legal sharing of data within each jurisdiction, across jurisdictions (local and state), and between programs. • Support health departments in the development and implementation of data sharing agreements. CBO Infrastructure Challenges with local CBO infrastructure’s ability to meet high-‐impact HIV prevention program needs: • Identify technical assistance plan for CBOs in each jurisdiction • Technical assistance for CBO leadership development Health Department Procurement Challenges in ability to release contracts and grants in a timely way as a result of cumbersome internal procurement processes: • Engage CDC Project Officers and PGO in communicating the importance of a timely procurement process needed to meet grant deliverables. • HIV prevention programs should engage the health department procurement divisions to establish collaborative relationships to facilitate expedited development and release of funding announcements and grants/contracts. Program Integration Challenges in working towards strong program integration: • Health departments are working to identify how certain programs currently being funded will be impacted once health care reform is fully implemented and how integrated programs will need to be funded in the future. • CBOs need additional support moving toward collaborating/merging with clinical care providers. • Health Departments and CBOs need support to develop third party billing systems and fiscal diversification and sustainability to leverage public funds.
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Limitations The primary limitation of the technical assistance engagement was the amount of time allocated for each jurisdiction to present. Jurisdictions provided an extensive overview of their programs, successes and challenges and areas for TA support. While the agenda defined these areas within specific time parameters, the participants and facilitators decided to forgo the agenda timing. Jurisdictions presented the overview of their programs while participants asked questions and provided input and peer-‐to-‐peer TA. Approximately 2.5 to 3 hours was allocated for each jurisdiction to discuss their programs. As a result, jurisdictions did not have time to develop individualized TA plans on-‐site. However, facilitators were able to outline areas of need for each jurisdiction based on the presentation and sequent discussion. Next Steps Following the TA engagement, HealthHIV and UCHAPS were instructed by the CDC PO to work together in developing individualized TA plans for each jurisdiction. Follow-‐up conversations with each jurisdiction will ensue following the meeting. TA requests will be entered into the CRIS system by UCHAPS.
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APPENDIX A: Meeting Agenda
Share, Structure, Succeed: Newly Funded Jurisdictions Building Capacity to Implement High Impact HIV Prevention May 7-8, 2013 The Loudermilk Conference Center 40 Courtland Street North East s Atlanta, GA 30303
Agenda Goal: Through a two-day in person, peer-to-peer technical assistance program, HealthHIV and UCHAPS will facilitate newly funded HIV prevention jurisdictions to: identify successes and challenges with implementation of PS12-1201; discuss infrastructure and policy limitations; share strategies to enhance program delivery; identify TA needs and develop a TA implementation plan. Tuesday, May 7 8:30 a.m.
Continental Breakfast
9:00 a.m.
Welcome Marsha Martin, UCHAPS Michael Shankle, HealthHIV Angel Ortiz-Ricard, Wendy Lyon-Harrington, CDC
9:30 a.m.
Introductions: Jurisdictional participants and goals for the meeting
10:00 a.m.
Jurisdictional Presentations: Baltimore, Broward County, Fulton County
12:00 p.m.
Lunch
1:00 p.m.
Discussion: Identify gaps in infrastructure, knowledge, and capacity/expertise; contract/grant administration and leadership challenges within the health department and community
3:00 p.m.
Break
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3:15 p.m.
Discussion: Partnerships and collaborations needed from the state, local health department leadership and CDC to support successful implementation of HIV prevention programs locally.
5:00 p.m.
Adjourn day one
6:00 p.m.
Dinner
Wednesday, May 8 8:30 a.m.
Continental Breakfast
9:00 a.m.
Discussion: Review gaps, limitations, and challenges identified during day one and develop detailed TA/CBA plan.
12:00 p.m.
Lunch
1:00 p.m.
Finalize TA/CBA work plan and implementation timeline
3:00 p.m.
Adjourn
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