Download Ryan White Part A Fiscal Year 2014 Application

Ryan White Part A
Fiscal Year 2014 Application
County of Los Angeles
Department of Public Health
Division of HIV and STD Programs
Program Narrative
INTRODUCTION
Los Angeles County (LAC) is home to an estimated 58,000 people living with HIV/AIDS
—the second largest number of people with HIV/AIDS among the 52 Ryan White (RW) Part A
jurisdictions. The challenges of delivering HIV services in LAC go beyond the size of its
HIV/AIDS epidemic, and encompass extreme demographic, socioeconomic, cultural and
linguistic diversities. The burden of HIV/AIDS in LAC is further intensified by the large number
of HIV-infected individuals living in poverty, afflicted with other medical conditions, and
lacking health insurance – including a sizable population of people living with HIV or AIDS
(PLWHA) who are not eligible for insurance under the Affordable Care Act (ACA) or most
publicly-funded programs—who require multiple medical and social support services in order to
thrive. Of the eight Service Planning Areas (SPAs) used to administer LAC services, HIV/AIDS
is most prevalent in SPAs with the highest levels of poverty and impact from myriad other health
and social challenges, making delivery of comprehensive HIV/AIDS services in the County
extremely costly. RW Part A funding is critical to providing necessary services for people living
with HIV/AIDS in this Eligible Metropolitan Area (EMA).
NEEDS ASSESSMENT
1. DEMONSTRATED NEED
1A.
HIV/AIDS Epidemiology
Epidemiology Table
The AIDS incidence, AIDS prevalence, and the reported HIV (non-AIDS) prevalence
based on reported data in LAC are provided in Attachment 3.
Current HIV/AIDS Prevalence in the EMA
LAC has 26,877 people living with AIDS as of December 2012, of whom 3,181 were
newly diagnosed with AIDS between 2010 and 2012. As of December 31, 2012, there are
19,080 HIV (non-AIDS) cases reported in the enhanced HIV/AIDS Reporting System (eHARS)
in LAC. Another 1,500-2,000 cases are estimated to be unduplicated cases from code-based
reporting and laboratory notifications pending investigation. An additional 10,500 HIV cases are
estimated to be undiagnosed, making the estimated HIV/AIDS prevalence in LAC to be 58,000.
People Living with AIDS and New AIDS Cases. While Whites were the predominant
group affected by AIDS through the early 1990s in LAC, since 1997 more AIDS cases have been
diagnosed among Latino/as than any other racial or ethnic group. In 2004, Latino/as (40%)
eclipsed Whites (36%) as the highest proportion of prevalent (living) AIDS cases and remained
the highest proportion of incident (new) AIDS cases in the last three years.
The annual number of AIDS cases in LAC has decreased substantially from a high of
approximately 4,132 cases in 1992 to 1,165 cases in 2010 1. Surveillance data show continuing
increases of AIDS cases in communities of color. In 1992, Whites represented 49% of adults
and adolescents diagnosed with AIDS in LAC, while African Americans represented 20%,
Latino/as 29%, and Asian/Pacific Islanders only 2%. By 2012, however, Latino/as comprised
the largest proportion of annual AIDS cases (49%), followed by African Americans (25%),
Whites (22%), and Asian/Pacific Islanders (4%).
A notable shift has also occurred in age distribution. Today, the median age of PLWHA
1
Data for 2011 and 2012 are provisional due to reporting delay and therefore not included in all trend analyses
described in this application.
County of Los Angeles
FY 2014 Ryan White Part A Application
Program Narrative
Grant No. H89HA00016
Page 1 of 80
in LAC is 47 years, with almost three-quarters (73%) of PLWHA 40 years or older. The most
dramatic shift has been the proportion of AIDS cases among those diagnosed at age 50 years or
older, increasing from 11% in 1995 to 21% in 2010. The proportion of those 30-39 years old
living with AIDS has gradually decreased—from 38% in 2000 to 18% in 2012—while the
proportion of those 50 years and older has increased steadily, from 18% in 2000 to 48% in 2012.
As PLWHA live longer, co-morbidities associated with both natural aging and complications of
HIV disease develop. Figure 1 illustrates the distribution of people living with HIV/AIDS in the
County.
Figure 1: People Reported Living with HIV/AIDS as of 12/31/2012 by Service Planning
Area (SPA) in Los Angeles County.
SPA 1
SPA 2
SPA 3
SPA 4
SPA 5
SPA 6
SPA 7
SPA 8
Antelope Valley
San Fernando
San Gabriel
Metro
West Los Angeles
South Los Angeles
East Los Angeles
South Bay
Men represent 88% of PLWHA in LAC. The proportion of female AIDS cases rose to
14% in 2001 and declined slightly to 12% in 2010 and remained steady at 11-12% in the last
three years.
Male-to-male sexual contact is associated with the largest number of AIDS diagnoses for
every racial and ethnic group. However, from 1986 to 2010, the proportion of annual AIDS
cases attributable to male-to-male sexual contact has decreased from 85% to 77%. Conversely,
cases attributed to male-to-female sexual contact increased from 1% in 1985 to 11% in 2010.
The numbers and proportions of AIDS cases associated with injection drug use (IDU) and
perinatal transmission remain relatively low and stable.
People Living with HIV (non-AIDS). As of December 31, 2012, 19,080 names-based
HIV (non-AIDS) cases have been reported in LAC, and approximately 3,200 coded HIV cases
reported between 2002 and 2006 have not yet been named.
As indicated in Attachment 3, 39% of reported HIV cases are among Latino/as, 34%
among Whites, and 21% among African Americans. There is a higher proportion of women
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Program Narrative
among reported HIV (non-AIDS) cases than living AIDS cases, indicative of a rise in new
infection rates among women. Latinas and African American women comprise the majority of
women living in LAC with HIV/AIDS. Still, in LAC, male-to-male sexual contact remains the
primary mode of exposure for people living with HIV (80%).
Attachment 3 also shows that the age distribution of people living with HIV looks
similar to the age distribution of new AIDS cases, but differs from the distribution of prevalent
AIDS cases. The proportion of youth (ages 13-24) living with HIV (6%) is higher than the
proportion living with AIDS (1%). Among people with HIV (non-AIDS), the proportion of
adults over 50 years of age is lower (28%) than among people with AIDS (48%).
Disproportionate Impact. LAC is home to 26% of California residents, yet 41% of
reported HIV/AIDS cases in California are in LAC.
In LAC, the HIV epidemic disproportionately affects men who have sex with men
(MSM). Population estimates for MSM in LAC range from 4-13%; yet more than 80% of
people living with HIV in LAC are MSM. As with any population estimate of MSM, validity is
threatened by under-reporting, especially among MSM of color, and MSM/W.
African Americans comprise approximately 10% of the population of LAC, yet account
for 20% of living HIV/AIDS cases. African Americans overall have an extremely high
HIV/AIDS prevalence rate of 988/100,000, over twice the rate of Whites (486/100,000) and
Latino/as (379/100,000) (LAC Department of Public Health 2012 Annual HIV Surveillance
Report). Although it has declined significantly, the mortality rate for African Americans far
exceeds the mortality rates for other populations. The most recent analysis of the mortality data
in LAC revealed that HIV infection was the third leading cause of premature death for African
American men and the fifth leading cause of premature death for African Americans overall
(LAC Department of Public Health, Mortality in Los Angeles County 2009, October 2012).
In LAC, HIV also disproportionately affects the homeless. Homeless individuals
represent less than 1% of the County’s population but account for 10% of the diagnosed cases of
HIV and AIDS. Estimated HIV seroprevalence for this population is 3.5%. African Americans
are over-represented (44%) in the homeless population.
The HIV epidemic disproportionately affects LAC’s formerly incarcerated individuals.
The number of people released yearly from federal, state and local correctional facilities
represents approximately 1.6% of LAC’s adult population, but PLWHA with a history of
incarceration account for 10% of HIV/AIDS cases in the County. HIV seroprevalence for this
group is estimated at 2.9% (HIV Epidemiologic Profile, 2009).
Available data point to an alarmingly disproportionate impact on transgender
individuals. It is estimated that transgender individuals make up approximately 0.2% of the
adult and adolescent population (ages 13-64) in LAC, but represent 1% of people living with
HIV/AIDS. Transgenders have one of the highest infection rates, with an estimated HIV
prevalence of 15% for transgender women and 0.6% for transgender men. 2
Populations Underrepresented in the Ryan White (RW) Care System. Table 1
compares RW clients and PLWHA receiving care through other funding streams, including
Medi-Cal (California’s Medicaid program) and private sources, along with living HIV and AIDS
cases.
Table 1 reveals which populations are currently underrepresented in the RW care system
in relation to the impact of the epidemic on those communities. Individuals over age 50 are
2
Division of HIV and STD Programs, Los Angeles Department of Public Health, Los Angeles County Transgender
Population Estimates 2012.
County of Los Angeles
FY 2014 Ryan White Part A Application
Program Narrative
Grant No. H89HA00016
Page 3 of 80
underrepresented in the RW care system. As people living with HIV/AIDS age, they may access
care through alternate funding sources such as Medicare or private insurance. Whites and men
are under-represented in the local RW care system because more of them tend to have private
insurance or are able to access other non-RW funding.
The HIV continuum of care in LAC has focused on reducing barriers and disparities for
underserved and marginalized PLWHA who have challenges accessing the care system. Women
and people of color tend to be over-represented in the local RW care system.
Although African Americans are not under-represented in the RW system, they are still
the most disproportionately affected racial/ethnic group living with HIV, demonstrating the need
for increased efforts to enroll African Americans with HIV/AIDS into the system of care.
Table 1: RW Clients, RW Clients in Medical Care, Clients in Non-RW Medical Care,
Compared with Reported HIV and AIDS Cases.
RW Clients in
PLWHA in non-RW Reported Living HIV
RW Clients˚
Medical Care˚
Medical Care^
and AIDS Cases*
Number
%
Number
%
Number
%
Number
%
Race/Ethnicity
White
4,997
24.5%
3,854 23.1%
7,850
40.5% 15,354 33.3%
African American
4,765
23.4%
3,703 22.2%
3,599
18.6%
9,410 20.4%
Latino
9,752
47.8%
8,360 50.2%
6,289
32.4% 18,898 41.0%
Asian/Pacific Islander
722
3.5%
615 3.7%
1,247
6.4%
1,535
3.3%
Native American
81
0.4%
64 0.4%
75
0.4%
221
0.5%
Mixed/Other
85
0.4%
63 0.4%
338
1.7%
677
1.5%
Unknown/Missing
TOTAL
20,402 100.0% 16,659 100.0% 19,398 100.0% 46,095
100%
Gender
Male
17,570
86.1% 14,383 86.3%
17,419
89.8% 40,865 88.7%
Female
2,481
12.2%
1,997 12.0%
1,978
10.2%
5,230 11.3%
Transgender
351
1.7%
279 1.7%
0
0.0%
Unknown
0
0.0%
0 0.0%
<5
TOTAL
20,402 100.0% 16,659 100.0% 19,398 100.0% 46,095
100%
Age (Years)
<13
17
0.1%
4 0.1%
24
0.1%
40
0.1%
13-24
763
3.7%
591 3.5%
510
2.6%
1,315
2.9%
25-49
13,177
64.6%
1,128 67.4%
10,736
55.4% 26,578 57.6%
6,445
31.6%
4,836 29.0%
8,126
41.9% 18,162 39.4%
≥50
<5
<0.1%
Unknown
TOTAL
20,402 100.0% 16,659 100.0% 19,398 100.0% 46,095
100%
˚Data from the local RW client data system, Casewatch, March 1, 2012 through February 28, 2013.
^Data from the State unmet need database, PLWHA in HRSA-defined medical care through payer sources other
than Ryan White, 2012; Medi-Cal data added separately.
*Data from local Enhanced HIV/AIDS Reporting System (eHARS) for cases diagnosed as of December 31, 2012,
and reported as of June 30, 2012. Data are provisional due to reporting delay.
Latino/as are over-represented in the RW care system, due to the high number who are
uninsured, including clients who may be ineligible for other publicly funded services. For many
Latinos/as, RW programs are the only means to access necessary HIV care in LAC.
Estimated Level of Service Gaps. Service gaps result when consumers’ needs exceed
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FY 2014 Ryan White Part A Application
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Program Narrative
available services. In LAC, the estimate of service gaps is primarily based on analyses of HIV
needs assessment and service utilization data. The most recent needs assessment, Los Angeles
Coordinated HIV Needs Assessment (LACHNA 2011), used a two-stage probability
proportional-to-size sampling design to obtain a statistically representative sample of individuals
receiving RW-funded services. Four hundred and fifty participants were recruited for interviews.
Data from LACHNA suggest the care delivery system is effective in meeting the medical care
needs of people with HIV/AIDS, with participants reporting no gap between need and receipt of
ongoing HIV/AIDS medical services. LACHNA data indicated the top five needed services by
service category among PLWHA in LAC were ongoing HIV medical care, oral health care, case
management, medication access, and bus passes to access HIV medical care. Overall, most
services that were requested were received. Among all survey respondents, 34% reported they
needed oral health care but were unable to obtain it, resulting in the largest gap. Following oral
health care, additional service gaps were reported for housing and rental assistance, utilities and
emergency financial assistance (neither of which is funded by the local RW program), groceries
or food bank, nutrition evaluation and nutrition support, and bus passes.
These gaps reflect the effects of the economic decline and subsequent service reductions
in California and the effect of the epidemic on lower income populations, especially people of
color. Oral health services were eliminated from Medi-Cal during the 2009 California budget
cuts. LAC has allocated a significant portion of Part A and Minority AIDS Initiative (MAI)
funds to oral health care. The investment was timely as it prevented the gap from widening
following the State budget reduction. The oral health expansion to serve PLHWA in LAC
continues, as oral health care is not among the list of ten Affordable Care Act (ACA) “essential
health benefits “ and the re-establishment of California’s Denti-Cal through Medicaid expansion
remains uncertain. Significant investment is still needed to close the service gap.
LAC’s RW program provided medical or support services to 20,402 clients in 2012,
approximately 44% of the estimated people diagnosed with HIV/AIDS in LAC. Eighty-two
percent of clients served by the RW program in 2012 received at least one medical visit.
Approximately a quarter of these clients were later enrolled in other insurance or payer sources
while the rest continue to use the RW program for their HIV medical care. Although
California’s Low Income Health Program (LIHP), an early adoption of ACA, offer insurance
coverage for many PLWHA in LAC, wrap-around services that have been critical in retaining
PLWHA in HIV care will not be supported through ACA and will continue to be supported by
RW program funds.
LAC’s HIV care system is effective in providing services to individuals affected by the
epidemic once they are enrolled. However, gaps in initial access to care and disparities in
retention and viral suppression among specific populations persist. Significant funding is still
needed to further strengthen linkage to care and retention.
In addition to the considerable number of already diagnosed individuals who are not in
HIV care in LAC, there are an estimated 10,500 people infected with HIV who are unaware of
their infection. Targeted HIV screening, routine HIV testing and various demonstration projects
for case finding are funded to increase the rate of HIV diagnosis. Enrollment of people testing
positive for HIV into systems of care, combined with longer life spans, recent changes in
treatment guidelines and more complex healthcare needs, increases pressure on care systems, and
requires additional resources to reduce service gaps.
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FY 2014 Ryan White Part A Application
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Program Narrative
1B.
Impact of Co-morbidities on the Cost and Complexity of Providing Care
Impact of Co-morbidities, Poverty and Lack of Insurance
As people with HIV live longer, service needs become more complex. Co-morbidities of
sexually transmitted infections (STIs), tuberculosis (TB), mental illness, substance abuse and
homelessness complicate service delivery and undermine adherence to treatment. Poverty and
lack of insurance shifts the cost burden to the local RW care system.
In 2014, more LAC residents will have access to health insurance, as a result of Medi-Cal
expansion (for those with incomes up to 138% Federal Poverty Level or FPL) and the creation of
the state’s health insurance exchange marketplace, also known as Covered California. Health
insurance policies through the insurance marketplace will be available at different coverage
levels, and many individuals between 100 – 400% FPL will qualify for subsidies to purchase
coverage. However, LAC’s cultural and linguistic diversity will pose outreach and enrollment
challenges as individuals navigate through the new health care options. LAC’s high number of
recent immigrants and those with undocumented status will also create barriers to coverage. RWfunded services are needed to address the health care needs of individuals with co-morbid
conditions, as well as those whose immigration status renders them ineligible for coverage
available under the ACA.
The table in Attachment 4 compares the burden of co-morbidities, poverty, and lack of
insurance between PLWHA and the general population in LAC, revealing the increased
complexity of care required for PLWHA. The table also identifies recent trends in services and
fiscal resources as a result of budget cuts to HIV-related services.
Sexually Transmitted Infections (STIs). STI cases continue to increase in LAC. The
high prevalence of STIs is an indicator of high-risk sexual behavior, associated with increased
risk of HIV infection and transmission. There is a strong epidemiological association between
HIV/AIDS and other STIs, indicating a two- to five-fold increased risk for HIV among persons
who have other STIs (CDC Fact Sheet, 2010). In a geospatial analysis of new HIV, syphilis, and
gonorrhea infections in LAC from 2009 surveillance data, five cluster areas or “hot spots” were
found to represent the vast majority of HIV and STD disease burden within the County, with
84% of HIV cases concentrated in these five cluster areas.
Since 2000, LAC has experienced a resurgence of syphilis, with most new cases reported
among MSM. Between 2003 and 2012, early syphilis in LAC increased dramatically, from 845
to 2,151 cases. In 2012, approximately 60% of reported early syphilis cases were among HIVinfected individuals; among MSM, the rate of co-infection was 69% (DHSP, September 2013).
STI rates in LAC exceed statewide rates as a whole. In 2012, the rate for early syphilis in
LAC was 23.2/100,000, compared with 14.4/100,000 in California. The gonorrhea rate in 2012
was 122.9/100,000, compared to 89.3/100,000 in California. The 2012 rate for chlamydia was
521.3/100,000, compared to 448.9/100,000 in California (California STD Control Branch,
provisional data reported through 8/19/2013).
Syphilis still predominantly occurs among MSM. In 2012, Latinos/as and African
Americans constituted 43% and 22%, respectively, of early syphilis cases. Among female early
syphilis cases, 40% were among African American women and 47% were among Latinas
(DHSP, September 2013). Some of these women discovered that they had HIV/AIDS when they
sought treatment for syphilis.
The persistence of syphilis in LAC, particularly among MSM and communities of color,
presents an ongoing public health challenge. Emerging infected populations (such as women of
color) also require focused testing and treatment efforts in order to reduce the incidence of new
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Program Narrative
infections. In response, LAC continues to utilize syphilis serology screening, counseling and
treatment in its system of HIV care, which have been incorporated into service standards
(screening everyone annually, and those at highest risk every quarter) and data collection.
Syphilis screening for the RW medical care clients at an average cost of approximately $36 per
client per year imposes a direct cost of almost $600,000, with additional costs to support
treatment, client counseling, partner services and education.
Homelessness. With over 51,000 homeless on any given night, Los Angeles is the
homeless capital of the nation (United Way of Greater Los Angeles, Home for Good, 2012). The
2011 Greater Los Angeles Homeless Count projected an annual estimate of 120,070 homeless in
LAC. There are an estimated 4,960 homeless PLWHA in LAC, representing 10.8% of people
diagnosed with HIV and AIDS in LAC (HIV Epidemiologic Profile, 2009). The 2011 homeless
census indicated that 65% of homeless in LAC were male and 35% female. At 44%, African
Americans represented the largest racial group of the homeless population, followed by Latino/as
(28%), Whites (25%) and Asian/Pacific Islanders (2%). Nearly half (45%) of the homeless
people were found in SPA 4 (Metro) and SPA 6 (South Los Angeles), areas with the highest
rates of HIV/AIDS, poverty, and uninsured. Twenty-four percent of LAC’s homeless were
chronically homeless; 2% had HIV/AIDS; 33% were mentally ill; 34% were substance abusers;
13% were children under 18; 18% were veterans; and 10% were survivors of domestic violence.
LAC spends $875 million in public resources each year on homelessness (United Way of
Greater Los Angeles, Home for Good, 2012). Health costs make up a much larger share of total
costs needed to serve high-cost homeless individuals, such as people with HIV/AIDS and older
people with disabilities, mental illness and substance abuse problems. Public costs for typical
homeless General Relief recipients decrease 50 percent in the months they are not homeless, a
monthly saving of $1,896, or 54% per person, for people living with AIDS (Economic
Roundtable, 2009). In the downtown Skid Row area, 1,079 homeless patients spent a total of
11,406 days in three adjacent hospitals, at a cost of $39,316,508 (Ending Homelessness in Los
Angeles, 2007). At the same rate, the medical cost alone for the estimated 4,960 homeless
PLWHA would be $180 million.
Lack of Health Insurance. LAC has one of the highest rates of uninsured individuals in
the nation. According to the 2011California Health Interview Survey (CHIS), 17.4% of LAC
residents, or nearly 1.7 million nonelderly adults and children, were uninsured sometime during
the past year. Sixty-five percent of the uninsured population were Latino/a. Among RW clients,
60% had no insurance in 2012; over half (57%) were Latino/a.
Lack of insurance among low-income people in LAC underscores the severity of need for
additional resources for medical and support services. As California implements health care
reforms spurred by the Patient Protection and Affordable Care Act of 2010, more LAC residents
are expected to become insured in 2014. Many will be able to take advantage of expanded MediCal or subsidized private insurance through an affordable insurance exchange market place.
However, about 1.3 million people (13% of LAC’s population) are projected to remain uninsured
through 2019, including those who are eligible for Medi-Cal or insurance exchange but remain
un-enrolled due to enrollment barriers (Lucia, et al., September 2012).
Poverty. Low socioeconomic status is a powerful determinant of individual risk for HIV
infection, health care access, and health outcomes. Poverty is particularly associated with
increased morbidity and premature mortality. Unemployment, poverty and illiteracy are
correlated with poor access to health education, preventive services and medical care, resulting
in an increased risk for HIV infection and faster progression to AIDS.
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FY 2014 Ryan White Part A Application
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Program Narrative
CHIS 2011 found that 22.3% of LAC residents lived below FPL, compared to the statewide rate of 18.7%. While approximately 58% of LAC residents lived at or below 300% FPL,
approximately 75% of PLWHA live below 300% FPL (see Attachment 4).
While the FPL is the official measure of poverty used to determine income eligibility for
most public benefits programs, the measure is an outdated one, developed in the 1960s and based
solely on the cost of the basic food budget needed to meet minimum nutritional requirements.
The FPL does not take into account costs for housing, transportation, health care, and other
necessary living expenses. Thus, estimates of poverty based on the FPL more likely reflect a
picture of people living in extreme poverty. Continuing rates of high unemployment in LAC
compound the effects of existing poverty. As of July 2013, the unemployment rate in LAC was
10.8%, compared to 9.3% state-wide and 7.4% nationally (California Employment Development
Department; U.S. Bureau of Labor Statistics).
Additional Contributing Factors. Many other critical factors not listed in the
application guidance, such as prevalence of tuberculosis, hepatitis, mental illness, and substance
abuse, also contribute to the cost and complexity of care in LAC.
Tuberculosis (TB). People infected with HIV have an increased susceptibility to TB,
requiring regular screening and immediate treatment of both latent and active TB. In 2012, 625
active TB cases were reported in LAC. As shown in Attachment 4, the TB rate in LAC was
6.4/100,000, and 28 cases (4.5%) were co-infected with HIV (LAC TB Control Program, 2012).
TB is more prevalent among the foreign-born. People with HIV and TB have a wide
range of service needs including housing and services designed to ensure access to care for
immigrants and individuals with limited English proficiency. Given the transient nature of these
populations, TB persists as a public health concern in LAC, requiring frequent TB screening
among people with HIV. Directly Observed Therapy (DOT) for TB ensures care and
compliance with treatments for co-infected individuals.
Among RWP clients co-infected with HIV and TB, an estimated 11% could benefit from
DOT to ensure adherence to both TB and HIV medications. The cost for TB screening is
approximately $52 per client, and the cost to deliver DOT is $1,938 per treatment episode.
Screening all of the RW medical care clients would require at least $800,000 per year, a cost that
is further amplified by standards that require regular and multiple screenings for STIs and other
communicable diseases.
Hepatitis (HCV). Approximately 180,000 chronic HCV infections in LAC translate to
an overall prevalence of 1.8% (Hepatitis C Task Force for LAC, 2011). Multiple sexual partners
and male-to-male sex remain the most frequently reported risk factors for hepatitis B, and
injection drug use (IDU) is the most frequently reported risk factor for hepatitis C. IDU is the
strongest predictor of HCV infection. Hepatitis C infection is particularly prevalent among subpopulations such as the homeless. In a recent study of 534 homeless adults in Los Angeles
County, 26.7% tested positive for hepatitis C (Gelberg et al., 2012)
People who are co-infected with HCV and HIV are more likely than those with HCV
alone to develop end-stage liver disease. Monitoring viral hepatitis infections among people
living with HIV in LAC requires expanded multiple morbidity screening efforts. Screening and
of PLWHA at risk for hepatitis C continues to be the standard of care. The cost of hepatitis C
screening is approximately $10 per client. Treatment cost for HCV is an additional $10,000$15,000 per person. For those who are HIV/HCV co-infected and have advanced liver disease,
the lifetime cost of treatment is estimated to be $250,000 per person. The treatment cost for
hepatitis C alone for the PLWHA co-infected with HCV in the County could be $200 million.
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Mental Illness. Mental illness can affect the progression of HIV disease, medication
adherence, and the likelihood of engaging in high-risk behaviors that may result in HIV
transmission. The 2011 CHIS found that 10.6% of LAC respondents saw a health care provider
for emotional/mental health issues in the last 12 months. The California DMH estimates that
5.4% of the LAC population has a mental illness. Medi-Cal data indicate a similar rate (4.5%).
Depressive disorders are among the most commonly diagnosed mental illnesses. The
2011 Los Angeles County Health Survey found that 12.2% of adult respondents reported ever
being diagnosed with a depressive disorder. After substance abuse disorders, depression is the
most common psychiatric disorder among HIV-positive adults (Rabkin, 2008). In the context of
HIV/AIDS, depression has been associated with failure to maintain a proper diet and exercise
routine, and failure to adhere to medical care. Depression is also associated with isolation,
absence of pleasure, and social and vocational impairment. The most significant problem in the
management of depression among PLWHA is its identification: few providers routinely ask
patients if they are depressed, and few patients share the information spontaneously.
Fourteen percent of the RW clients receiving services in FY 2012 reported a recent
history of mental illness. Applying this ratio to PLWHA, there are approximately 6,600 people
diagnosed with HIV with mental health issues in LAC.
Because mental illness is highly prevalent among PLWHA in LAC, especially among
vulnerable populations like substance users and the homeless, it requires investment in addition
to the cost of HIV treatment, thus the combined care cost could exceed $350 million a year.
Substance Abuse. Unlike other parts of the country, the connection between substance
use and HIV in LAC centers on unsafe sex while under the influence of alcohol or other drugs,
rather than needle sharing. Substance abuse interferes with both adherence to medication
regimens and treatment efficacy. Analysis of injection of illicit drugs alone does not characterize
the impact of substance abuse on HIV infection in LAC. In LAC, aside from injecting illicit
drugs, syringes are shared by transgenders to administer steroids, vitamins and hormones. Field
research on transgender women suggests that the sharing of syringes for hormone therapy is seen
as an act of “sisterhood” rather than a potential health risk.
Almost one-fifth (18%) of persons who received publicly funded drug treatment in LAC
reported using methamphetamine (meth) (LAC Substance Abuse Prevention and Control
Program, 2010). Among MSM in LAC, meth use is frequently associated with increased sexual
activity and unsafe sex. Meth-using MSM are much more likely to have casual sex, multiple
sexual partners and report inconsistent condom use than MSM who do not use meth. Meth users
have numerous clinical challenges such as poor treatment engagement rates, high drop-out rates,
high relapse rates, severe paranoia, and declining oral health. The medical and psychiatric
aspects of meth dependency often exceed the capabilities of existing substance abuse programs,
requiring significant cost for training and education for staff to improve service delivery.
Impact on Cost and Complexity of Care. LAC Division of HIV and STD Programs
(DHSP) is the administrative agency for the local RW Part A program. DHSP analyzed
routinely collected RW client-level data to determine the impact of RW-funded services on
affected populations. The prevalence of co-morbidities such as mental illness, poverty, lack of
health insurance and homelessness among clients receiving RW services is high compared to the
general population in LAC. RW clients in LAC were three times as likely as an individual from
the general population to live in poverty. Special RW populations (i.e., those with a history of
incarceration) were significantly more likely to experience homelessness and lack health
insurance, compared to the general population.
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Table 2: Complexity of Care Indicators Related to Cost of Services in Los Angeles County.
General
RW FY 2012
RW FY 2012 Formerly
Indicator
Population
Clients
Incarcerated Clients*
0.3%
50.0%
60.8%
History of AIDS Diagnosis
10.6%
14.4%
14.9%
Mental Illness
1.2%
5.4%
49.6%
Homelessness^
22.3%
67.6%
90.5%
Poverty (<100% FPL)
17.4%
59.6%
56.9%
No insurance
*Clients who reported a history of incarceration within the last two years. ^Includes unstably-housed.
Rates of poverty, lack of insurance coverage, and disease progression particularly affect
the cost of service delivery in any jurisdiction. The complexity of care indicators are shown in
Table 2 to illustrate the challenges in the LAC EMA.
According to a health services cost and utilization study conducted by the HIV Research
Network (Gebo, 2006), the leading causes of hospitalization among HIV-infected adults are: 1)
AIDS-related conditions (e.g., pneumonia, PCP); 2) gastro-intestinal diseases (e.g., pancreatic
diseases, liver diseases); and 3) mental health–related conditions (e.g., substance use-related
conditions, including overdose, and affective disorders). The absolute number of people living
with AIDS in LAC and those who do not have any form of health insurance place tremendous
pressure on the public hospital system in the County. Many PLWHA, especially PLWHA of
color, have AIDS at the time of initial diagnosis, enter care with advanced HIV disease and comorbid illness; the complexity of their care adds to the overall cost of HIV care in LAC.
Including costs for inpatient and outpatient care and medications, the mean annual
expenditures per person for HIV care in 2006 were estimated at $19,912 (Gebo et al., 2010). For
those with CD4 cell counts 50 cell/mL or less, the cost was significantly greater, at $40,678.
Assuming average costs of $19,912 per person, providing care to the estimated 58,000 PLWHA
in LAC would require over $1 billion.
With health care reform, Medi-Cal service eligibility will be income-based rather than
based on AIDS diagnosis or other disabling conditions; more people will gain access to primary
HIV medical care. However, due to the challenges and complexity of care associated with
identifying PLWHA, linking them to medical care, and keeping them engaged in care,
considerable resources are still needed to achieve effective individual and community viral load
control. LAC bears responsibility for the provision of necessary and comprehensive medical and
wrap-around services to people with HIV, including low-income individuals whose residency or
citizenship status renders them ineligible for Medi-Cal. To reach the National HIV/AIDS
Strategy (NHAS) goals in the changing health care environment, RW Part A funding is even
more critical in ensuring that the care PLWHA receive is integrated, not fragmented—a feature
essential to achieving the desired individual and population-level health outcomes.
Trends in Services and Fiscal Resources as a Result of State and Local Funding Cuts
The federal budget sequestration triggered automatic spending cuts to government
programs that went into effect in March 2013. These cuts are expected to have a significant
impact on local HIV and STD services in LAC. DHSP anticipates federal funding reductions of
more than $11 million over the next 18 months. These cuts may reduce the availability of a wide
range of public health services, including HIV and STD diagnosis and treatment, HIV linkage to
care and retention in care activities, condom distribution, partner services, HIV and STD
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prevention programming, and non-occupational post-exposure prophylaxis services. A summary
of the anticipated cuts to local HIV and STD services are included in Attachment 4.
These cuts will eliminate significant progress achieved by decreasing the availability of
funding necessary to carry on programs that have been demonstrated to reduce infection rates
and improve linkage to care and treatment for HIV and STDs. These funding reductions will
make achievement of goals and objectives related to the NHAS impossible.
Impact on Service Delivery for Formerly Incarcerated Individuals
Incarceration destabilizes communities, disrupts family relationships, and magnifies the
accumulation of health and social disadvantage for already marginalized populations. Studies
and DHSP programmatic data suggest that the period immediately following release poses
substantial health and mortality risks for individuals living with HIV/AIDS. Incarceration is
associated with harmful effects on viral suppression, lower CD4 counts, and accelerated disease
progression (Springer et al, 2004; Stephenson et al, 2005). Pre-release planning, medical care,
ADAP enrollment, and interventions immediately following release from prisons or jails are
critical. Transitional care, health monitoring, and service planning are needed to ensure
continuity of care and positive health outcomes as former inmates re-enter their communities
(Sawires, 2007).
The LAC Sheriff’s Department (LASD) operates the country’s largest municipal jail
system. There are approximately 180,000 inmates processed annually, and 750 – 1,000 inmates
classified each day. HIV prevalence among men in the jails is 2.7%. About 500 HIV-positive
individuals are housed in the jails at any one time.
With the recent federal order to reduce California’s prison overcrowding and improve
medical care for inmates, the state began its “prison realignment plan” in October 2011 to release
lower level offenders, adult parolees, and juvenile offenders to the local county correctional
system. Under the new law, the sentenced population in LAC is expected to increase by about
7,000 over the next two years; the daily jail population will reach nearly 20,000 by the end of
2012 and peak at 21,000 by the end of 2013 (Austin et al., 2012). Additionally, 9,791
individuals from the state prison system will have been released on Post Release Community
Supervision to LAC when the realignment plan is fully implemented in late 2013 (California
Dept. of Corrections & Rehabilitation). Another 1,400-1,800 PLWHA are released from the
County jails each year.
LAC bears a tremendous burden in providing services for recently incarcerated
individuals. Over the past several years, DHSP staff have worked closely with the medical staff
within the LAC jails to improve both the HIV care provided for infected inmates, as well as the
level of communication between jail medical staff and the clinicians who were treating the
inmates prior to their incarceration. This has led to a dramatic improvement in the health status
of many HIV-infected inmates. Recent DHSP data show that inmates who have been treated for
HIV while incarcerated are often virally suppressed upon release from the jails (LINK LA,
2013), and current efforts are underway to strengthen their linkage to medical care post-release
in order to maintain viral suppression.
HIV care in the prison system is not so robust. Research suggests that individuals newly
released from prison in LAC experience a four times greater rate of active TB; a nine to 10 times
greater rate of hepatitis C; a five times higher rate of AIDS; a 1.5 to five times higher rate of
mental illness; and higher rates of substance abuse and chronic diseases (J. B. Orr, 2006; RAND,
2009). Most parolees have no medical insurance or stable sources of health care, often because
they lack appropriate identification and any permanent address. As recently incarcerated people
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re-enter communities, a majority return to the most impoverished regions in the County. These
are also areas with the highest concentrations of people living with HIV and AIDS, heightening
the serious health care problems experienced in those communities.
As previously illustrated in Table 2, formerly incarcerated PLWHA experience extreme
economic and health challenges. For FY 2012 RW clients reporting a history of incarceration in
the last two years, 90% lived below federal poverty level, 15% reported an active history of
mental illness, and 50% were homeless or unstably housed. DHSP estimates that there are 4,800
formerly incarcerated PLWHA in the County (HIV Epidemiologic Profile, 2009). That number
is expected to increase over the next year as federal and state inmates are released into the
general population in LAC. Based on the $20,000-$30,000/year cost estimates from the HIV
Research Network, the estimated cost for primary medical care alone for formerly incarcerated
PLWHA exceeds $100 million each year. Additional costs will be incurred by the local RW
system as parolees are screened for eligibility for other systems of care, and transitional case
management programs gear up for enhanced linkage to care programs designed specifically for
the recently released.
1C.
Impact of Part A Funding
Availability of Other Public Funding
LAC commits to using Part A funds for the most affected populations and as funding of
last resort by continuously assessing other available resources throughout the EMA. The table in
Attachment 5 describes availability of other public funding in LAC.
Coordination of Services and Funding Streams
While establishing FY 2014 priorities and allocations, DHSP and the Commission on
HIV (RW Part A planning council) reviewed existing and anticipated funding, including nonRW resources, and crafted funding allocations to ensure that Part A funds were directed to
service priorities not adequately supported by other resources. DHSP leverages funds from
local, state and federal sources to avoid duplication. Eligibility screening in the Casewatch data
system enables service providers to ensure the use of Part A funds as a last resort in the
healthcare reform environment.
Other RW Programs. LAC relies heavily on both Part A and other RW programs to
leverage limited, decreasing resources. Part B base grant funds, managed by the California
Office of AIDS (OA), have historically supported four programs in conjunction with state
general funds. Base funds are diverted to supplement ADAP earmark funds. OA-HIPP
(formerly CARE/HIPP), the state health insurance premium payment program, pays health
insurance premiums on behalf of people disabled because of HIV and at risk of losing their
health insurance coverage. OA is expanding its eligibility criteria to cover more individuals.
Additionally, OA started its Pre-Existing Condition Insurance Plan (OA-PCIP) in 2011 to
provide insurance payment for eligible PLWHA. LAC maintains active relationships with OA to
coordinate services for PLWHA during the patient transition to LIHP and the planning for ACA.
The magnitude of need and complexity of HIV care have resulted in rapid absorption of
local Part C resources and continue to place demand on Part A resources. A number of factors
continue to exert pressure on the local HIV medical outpatient care system, including the
increasing number of people who become eligible for RW services as a result of the economic
recession; the increasing number of people of color with HIV/AIDS; the prevalence of comorbidities and the increasing complexity of care required; the cost of viral load monitoring and
viral resistance testing; and the cost of supplemental medications. All LAC Part C grantees will
be DHSP-contracted services providers in 2014. Each is expected to allocate Part C and Part A
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resources individually for services supported by both funding streams. DHSP requires Part C
providers to submit their Part C budgets during Part A contract negotiations to prevent overlap.
Services to women, infants, children, youth and their families are coordinated with Part
D-funded providers. Public Health Foundation (PHF) and the University of Southern California
(USC) Medical Center’s Maternal, Child and Adolescent (MCA) Program have been the Part D
grantees for several years. As a Part D grantee, PHF disburses funds for children, infants and
youth living with HIV and their family members through a provider network administrator.
MCA operates a clinic for women and a special program to provide outreach and case
management to connect young people to care and other services, including mental health and
substance abuse treatment. The overall FY 2013 funding to the County was reduced. Both Part
D providers also receive Part A funding, which DHSP coordinates in the same way as Part C.
Oral health services are supported by the RW Part F Dental Reimbursement Program at
two locations in LAC: the USC School of Dentistry and the University of California, Los
Angeles School of Dentistry. Part A resources are used to provide partial support for several
County and community-based oral health programs, as well as the USC School of Dentistry.
LAC continues to pursue funding from RW Part F Special Projects of National Significance
(SPNS) Initiatives for innovative service delivery models. A SPNS women of color initiative
aims to improve access and retention in care for women of color in the County. Two agencies
will link transgender patients to medical care under the SPNS transgender initiative. A SPNS
medical home for the homeless project will connect homeless PLWHA to a medical home with
comprehensive care coordination. DHSP and the Commission collaborate with the local AIDS
Education and Training Centers in training sessions, consultations and conferences on topics
including viral resistance testing, mental health and the ACA consumer education.
State Medicaid Program (Medi-Cal) and MediCaid Expansion. The federal Medicaid
Program is administered by the State of California Medi-Cal Program. Californians have seen
significant reductions to Medi-Cal services in the past few years, including elimination of adult
oral health, optometry, hearing aids, podiatry, chiropractic, and some psychology services, and
changes in eligibility based on immigration status. DHSP contracts require service providers to
assess each client’s eligibility for Medi-Cal. For those who are eligible, every effort is made to
enroll them in Medi-Cal. All medical outpatient providers are also Medi-Cal approved.
In 2011, California began implementing its Medi-Cal Expansion under the 1115 Waiver
program. Seniors and people with disabilities have enrolled in Medi-Cal managed care plans.
Low-income health programs (LIHP) became available for individuals based on income level
(below 133% FPL) rather than disabilities. DHSP has worked tirelessly with the County
Department of Health Services (DHS), which administers the LIHP locally, to bring all RW
medical providers into the LIHP network and establish an ADAP-like pharmacy network to
ensure continuing medication access for RW patients eligible for the LIHP. The transition of
eligible RW patients into the LIHP began in July 2012, but with 100% overlap between RW
providers and LIHP medical homes for PLWHA, no former RW patients needed to change
medical providers. In January 2014, LIHP patients will be automatically transitioned to ACA
Medicaid Expansion and be covered by one of two insurance plans: L.A. Care or HealthNet.
Medicare and Medicare Part D. Medicare provides limited health coverage to U.S.
citizens or legal residents age 65 and older and people with disabilities who have received Social
Security Disability Insurance (SSDI) for two years. Because of its limited coverage, Medicare
alone does not provide sufficient health care, particularly for people living with HIV/AIDS.
State budget cuts continue to affect low-income individuals through benefits reductions such as
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discontinuing Medicare Part B premium coverage for people with a certain level of share of cost.
DHSP and the Commission monitor state demonstration projects to integrate care delivery and
financing for individuals dually eligible for Medicaid and Medicare services to assess the impact
on the RW population and the corresponding service delivery system. The Medicare Part D
prescription drug benefits that started in January 2006 improved Medicare coverage for some by
providing prescription drug benefits, but impeded access to prescriptions and health care for
PLWHA receiving both Medicare and Medi-Cal benefits. This barrier is eliminated under ACA.
State Children’s Health Insurance Program (SCHIP). California enacted the Healthy
Families Program in 1997 to implement SCHIP. The Healthy Families Program provides health
coverage for uninsured children in families with incomes up to 200% FPL and who are not
eligible for Medi-Cal services. Funding for California is generally on a two-to-one (federal-tostate) matching basis. Coverage is similar to that offered to state employees and includes dental
and vision benefits. The ACA maintains the broad SCHIP eligibility standards and increases the
federal matching funds. ACA also makes available additional federal resources to promote
enrollment to SCHIP. The use of RW funds to support primary medical care for children has
been restricted in LAC due to the availability of this funding source.
Health Insurance Marketplace Under ACA. According to the ACA provision,
individuals with income up to 400% FPL can get subsidies to purchase insurance coverage
through exchanges. In California, the exchange marketplace is called Covered California. The
insurance plans available under Covered California in LAC are: HealthNet, Anthem, Molina
Healthcare, L.A. Care, Blue Shield, and Kaiser Permanente. DHSP and the Commission have
been working with various stakeholders to ensure RW services appropriately wrap around the
primary health care services available through these exchanges for populations with different
levels of income and coverage. This includes surveying the landscape of which RW providers
have contracted with the marketplace insurance plans as well as conversations with the
California OA regarding its health insurance premium program, OA-HIPP.
Veterans Affairs Program. The Veterans Administration of Greater Los Angeles
Healthcare System (VAGLAHS), combined with the VA Long Beach Healthcare System, is the
largest and most complex system in the U.S. Department of Veterans Affairs. Together, the two
VA networks serve over 900 veterans with HIV/AIDS and their dependents in LAC. Services
include inpatient and medical outpatient care, housing, substance abuse treatment, pharmacy and
oral health services. Veterans remain eligible for ancillary and support services supported by
RW funds that are not available through the VA system.
Housing Opportunities for People with AIDS (HOPWA). The City of Los Angeles
receives approximately $12 million annually from the U.S. Department of Housing and Urban
Development (HUD) in HOPWA funds. Coordinated through the Los Angeles Housing
Department (LAHD), HOPWA funds are used locally for housing placement, assistance, housing
specialists, informational services and housing supportive services. Rental assistance for
PLWHA is coordinated through four housing authorities (County of Los Angeles, City of Los
Angeles, Long Beach and Pasadena). The lack of affordable housing in LAC remains a
significant barrier for PLWHA. DHSP and the Commission continue to coordinate with the City
HOPWA administration to reduce duplication of services. In addition, the City of LA HOPWA
administration has a representative on the newly integrated HIV planning council.
Centers for Disease Control and Prevention (CDC). LAC is one of 11 metropolitan
areas in the country to be directly-funded by CDC for HIV prevention. CDC-funded services
include targeted and routine rapid HIV testing, health education and risk reduction, partner
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services, and social marketing. DHSP implements CDC-funded partner services and social
network testing at RW-funded medical outpatient sites to identify undiagnosed infections.
Routine testing supported by CDC funds is in place at primary care sites to promote direct
linkage into affiliated RW care clinics. These efforts help identify undiagnosed PLWHA and
increase awareness of services available in their communities. Through CDC and HRSA
initiatives, services are coordinated with common goals laid out in the National HIV/AIDS
Strategy. At the community planning level, the Commission and the local HIV prevention
planning committee have completed the integrated HIV plan to guide local HIV services; and to
further the progress of integrated planning, the two bodies have completed the unification
process to create one integrated planning body for the whole continuum of HIV services in LAC.
Services for Women and Children. The Commission considers the HIV care needs of
women and children and the availability of services for women (e.g., Special Supplemental Food
Program for Women, Infants, and Children) when allocating resources. The HIV Program of
California Children’s Medical Services Branch provides funding to screen children at risk for
HIV and has provided infectious disease and immunology services to over 10,000 children since
its inception. After screening, children with HIV/AIDS are transferred to the California
Children’s Services program and linked to comprehensive HIV care and treatment services. The
state budget reduction to the Healthy Families Program may cause increased share of cost for the
County’s Children’s Medical Services Program.
State and County Social Service Programs. The LAC Department of Public Social
Services (DPSS) manages several general relief programs in coordination with programs
administered by the California Department of Social Services. Families with limited resources
may be eligible for cash assistance, housing, food, utilities, clothing or medical care. CalWORKs
assists eligible families to prepare for employment and financial independence. Transitional
housing is provided for emancipated foster youth to build skills for independent living. The
LAC General Relief (GR) Program provides temporary financial aid to individuals who are
ineligible for federal or state programs. Recently, eligible GR patients were auto-enrolled into
Healthy Way LA under Medicaid expansion, and were provided with a designated medical home
for their health care. The most recent state funding reduction seriously compromises
CalWORKs and other public benefits programs, placing millions of dollars of additional costs on
the County to provide these services. Available social services are considered during allocation
of funding to avoid duplication of services and to ensure RW funding is the payer of last resort.
Substance Abuse and Mental Health Services. Of the HIV set-aside funds that
California receives from SAMHSA, LAC receives $3,728,911 each year to support HIV care and
prevention services for alcohol and substance users. The funding supports a broad range of
services, including HIV testing programs for persons in drug treatment; residential substance
abuse treatment services for people with HIV/AIDS; and HIV education and prevention services
for injection drug users. A recent grant award from SAMHSA will provide comprehensive
mental health, substance use prevention and treatment to racial and ethnic minorities at a primary
care clinic located in one of the most highly impacted areas in the county. These resources, along
with services offered through the County Department of Mental Health and Department of
Public Health Substance Abuse Prevention and Control Program (including services available
through HWLA under Medi-Cal expansion and potentially through ACA), were considered
during the priorities and allocations process for Part A funding.
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1D.
Assessment of Emerging Populations with Special Needs
LAC is home to one of the most diverse populations in the nation, and the diversity is
reflected in the local HIV epidemic. Responding to the intricate service needs of various
populations, the Commission developed a series of special population definitions for groups that
have service needs including men who have sex with men (MSM); women of color; multiplydiagnosed individuals (mental illness and substance abuse); African Americans; Latino/as; and
transgenders. Each of these populations presents unique service delivery challenges.
Men who have Sex with Men (MSM)
Unique Service Delivery Challenges. In LAC, male-to-male sexual contact remains the
primary route of HIV transmission for all racial and ethnic groups. MSM (including MSM/IDU)
make up more than 80% of all reported HIV and AIDS cases in the County, and the absolute
number of infected MSM continues to increase. The estimated HIV/AIDS prevalence among
MSM is 14.9%. Among MSM, African American MSM have the highest prevalence rate, at
36.9%, followed by Native American MSM, at 26.1% (HIV Epi Profile, 2009).
Age and race are significant determining factors with regard to rates of new HIV
infection among MSM in LAC. HIV incidence rates among MSM are the highest among 18 – 29
year olds (DHSP 2012). African American MSM are at an increased risk of new HIV infection
across all age groups. African American MSM, age 18 – 24 years, experience the most dramatic
disparity in risk compared to Latino and White peers.
Though a high proportion of incident HIV/AIDS cases is found in people of color, cases
for White MSM still increase significantly each year—more than 500 new HIV/AIDS cases
annually. Many long-term survivors face disease progression and co-morbid illnesses associated
with aging, as well as treatment resistance and drug toxicity due to long-term use of antiretroviral drugs. This presents challenges to a care system that must evolve to respond to
HIV/AIDS as a chronic disease.
MSM of color who are long-term survivors share similar challenges. However, MSM of
color face additional barriers managing their HIV care. They tend to be poorer and lack health
insurance compared to their White counterparts. Language barriers are prevalent among MSM
who are immigrants. Gender role expectations, homophobia, stigma, social isolation and
rejection from friends, family, and community can create overwhelming emotional pressures
when dealing with an HIV diagnosis, especially for young MSM of color.
Many MSM, particularly MSM of color, do not self-identify as gay or bisexual, although
they have sex with other men. They are often deterred from seeking HIV services because
conventional service models that focus on men who identify as gay or bisexual are not culturally
appropriate. Isolation, drug use, incarceration, sexual abuse and exchanging sex for money or
drugs have been identified as co-factors experienced by non-gay identified MSM of color that
impact their service use.
According to DHSP RW client data from 2012, 58% of MSM had income below 100%
FPL, and 56% had no health insurance. Those who had insurance primarily had Medi-Cal and
Medicare. Forty-four percent of MSM receiving RW-funded services had an AIDS diagnosis,
and 14% reported a history of mental illness in the past year; about 5% were homeless.
Service Gaps. Top service needs expressed by MSM surveyed in LACHNA (2011) were
on-going HIV medical care, oral health care, case management, assistance with HIV
medications, and bus passes. The biggest gaps reported among this group were oral health care;
rental assistance; short-term rent, mortgage, and utility assistance; nutrition support (food bank);
and bus passes.
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This reflects the impact of poverty on persons with HIV, many of whom need basic subsistence
and transportation support to help them stay in care and maintain good health. Complications
related to substance abuse, mental health disorders, STIs and incarceration require intensive and
ongoing interventions. Fewer services funded by alternate payer sources are available to lowincome, uninsured men compared to women or children.
For young MSM and non-gay identified MSM, the most significant challenge to
experiencing better health outcomes is their reluctance to initially access care. LACHNA data
suggest that young MSM experience much larger gaps across many services compared to other
MSM. Aggressive outreach and early intervention for both groups of MSM are crucial.
Costs Associated with Delivering Services to this Population. MSM continue to
comprise the largest proportion of the HIV/AIDS epidemic in LAC. Applying the HIV Research
Network cost analysis to stages of disease among MSM in the DHSP RW client database, the
estimated cost to serve each individual in this population is $27,000 per year. DHSP estimates
that there are 34,411 MSM living with HIV/AIDS in LAC (not including those unaware of their
HIV status). The cost of HIV care for this population approaches $1 billion a year.
Women of Color
Unique Service Delivery Challenges. Though the absolute number of women living
with HIV or AIDS in LAC is relatively small compared to the number of men infected with HIV,
the rise in new infections in recent years among women, especially women of color, is alarming.
Many of these women do not perceive themselves to be at risk for HIV infection.
Among women overall, women of color make up 84% of living AIDS cases and 87% of
new AIDS cases. DHSP estimates there are about 5,230 women living with HIV and AIDS in
LAC. The majority (83%) of these are women of color; 17% are White. When the estimate is
limited to at-risk women (reported unprotected sex or injection drug use) ages 15-64, DHSP
estimates the HIV seroprevalence of women of color at 2.7% in 2007, compared to 1.0% for
White women. African American women in LAC have the highest HIV seroprevalence among
all at-risk women, estimated at 6.3%, followed by Native American women (2.9%) and Latinas
(2.4%) (HIV Epi, 2009).
Women of color living with HIV/AIDS have barriers that may prevent them from
accessing care, including poverty, lack of childcare, serving as single head of household,
transportation challenges, and medical care not tailored to the specific needs of female patients.
Service Gaps. Women of color participating in LACHNA had the same top five service
needs as MSM: ongoing HIV medical care, oral health care, case management, assistance with
HIV medications, and bus passes. Medical specialty was ranked higher for women of color as a
needed service. Service gaps for women of color were oral health care, nutrition evaluation/
support, groceries/food bank, Section 8 assistance, and referral services. Survey participants
reported not knowing services were available or not knowing how to access services as the main
barriers.
In FY 2012, the LAC RW service system provided medical outpatient care to 82% of
women of color with HIV/AIDS. Twenty-three percent of these women received case
management, a higher proportion than that of RW clients overall (16%), indicating a greater need
for assistance in coping with stressors and barriers in order to maintain their medical care.
Costs Associated with Delivering Services to this Population. Approximately 11% of
RW clients in 2012 were women of color. In FY 2012, DHSP spent about 13% of Part A funds
serving women (approximately $4.8 million). The estimated annual cost to provide services to a
woman living with HIV/AIDS in LAC is $27,000. To serve the estimated 5,100 women of color
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living with HIV disease, the care cost would reach $93 million a year.
Multiply-Diagnosed
Unique Service Delivery Challenges. A growing number of people living with HIV in
LAC are dealing with dual challenges of mental illness and substance abuse. Denial, stigma and
isolation create a vicious cycle of drug use to escape the harsh reality of living with HIV and
suffering from severe depression or other mental illness. In turn, the progression of drug use and
dependency compromises both health and the ability to manage HIV disease. Frequently,
PLWHA with multiple diagnoses of mental illness and substance abuse become homeless as they
lose coping skills and experience deteriorating health.
Studies have shown that psychiatric illness and substance abuse co-morbidity is prevalent
among HIV-positive individuals and MSM in Los Angeles (Galvan FH et al., 2003; Shoptaw S.
et al., 2003), and that nearly half of adults receiving HIV care had depression, dysthymia,
generalized anxiety disorders, or panic attacks (Bing EG et al., 2001). In 2012, 14% of local RW
clients reported experiencing mental illness during the past twelve months. Among the homeless
and unstably-housed RW clients in 2012, 19% reported mental illness in the previous 12 months.
In 2012, 93% of those diagnosed with mental illness and substance abuse who utilized
RW-funded services in LAC lived in poverty; 47% had no insurance, and 40% had been
diagnosed with AIDS. Decreases in health status, quality of life, income and emotional support
often result in or exacerbate isolation, mental illness and increased risk for other diseases.
Service Gaps. PLWHA who are mentally ill and/or substance abusers experience many
barriers related to access to care and treatment adherence. In the LACHNA survey, those with
dual challenges of drug use and mental illness reported that their most needed services were
medical care, bus passes, oral health care, food, assistance securing housing, and independent
subsidized housing. Significant gaps between services needed and received were expressed for
three of these needed services: subsidized housing, housing assistance, and oral health care.
Costs Associated with Delivering Services to this Population. Multiply-diagnosed
HIV-positive individuals are in need of integrated mental health and substance abuse treatment
options. California first-time offender drug laws result in increasing numbers of substance users
being referred to treatment, placing an additional burden on an overwhelmed substance use
treatment system. In LAC, it is estimated that the average HIV care cost for each multiplydiagnosed PLWHA is $30,000 a year. The cost of HIV care for the multiply-diagnosed RW Part
A clients exceeds $50 million, not including those who have fallen out of the care system.
African Americans
Unique Service Delivery Challenges. African Americans are 20% of the diagnosed
PLWHA but account for only 10% of the County’s population, making them the most
disproportionately affected racial/ethnic group. The impact on African American MSM is
particularly severe, with a 36.9% HIV prevalence rate. Besides high rates of HIV infection,
African Americans diagnosed with HIV are more likely to experience delayed linkage to care,
compared to Whites (Hu et al., 2012). A retention predictor analysis of the 2009 RW client data
indicated that African-Americans were approximately 1.5 times more likely to have a detectable
viral load (VL) compared to Whites (LAC ECHPP Plan 2011). These findings suggest a need
for more efforts focused on bringing African Americans with HIV into care, in order to slow
disease progression, improve health outcomes, reduce disparities, and prevent further
transmission.
Another service challenge is the high rate of incarceration and resultant recidivism,
particularly among African American males. Disclosing HIV status and accessing HIV care
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safely during incarceration are difficult. Connecting to care upon release is frequently not the
priority of newly released individuals, and inmates are often released with little or no HIV
medication. In the LAC jail system, 28% of inmates are African American. However, 51% of
inmates who are identified as HIV-positive are African American (LAC Sheriff’s Department,
2011). For inmates, regular HIV care is interrupted when they are incarcerated, and continuing
care upon release is often hindered by other immediate needs such as housing, substance use
treatment, mental illness, and family issues.
In addition to these structural challenges, community attitudes and beliefs about
HIV/AIDS pose problems for fighting the epidemic in African American communities. The
stigma associated with HIV/AIDS creates a barrier of shame and isolation that complicates both
efforts to prevent HIV, as well as efforts to provide care to those individuals who are infected.
Because these powerful social dynamics affect individual behaviors, they must be considered
and understood within the context of designing and implementing services specific to African
Americans and other communities of color.
Service Gaps. According to LACHNA (2011), the top five service gaps for African
Americans were oral health services; rental assistance; housing case management; bus passes;
and health insurance premiums and cost sharing assistance. Top needed services were medical
care; oral health care; psychosocial case management; bus passes; and ADAP enrollment
services.
Costs Associated with Delivering Services to this Population. DHSP estimates the
annual cost of providing care services to an African American client in LAC is $29,000. Many
African American PLWHA live in the most impoverished neighborhoods with scarce resources
for maintaining good health and quality of life. Additionally, aggressive efforts are required to
increase the initial enrollment in care for this group. DHSP estimates there are 10,640 African
Americans living with HIV/AIDS in the County, not including those who are unaware of their
status. The cost of caring for this population easily exceeds $300 million each year.
Latino/as
Unique Service Delivery Challenges. Latino/as are among the poorest populations
living with HIV/AIDS. Seventy percent of Latino/a clients seen by RW-funded providers in
2012 lived below 100% FPL. Lack of health insurance coverage is an issue faced by many
Latinos in LAC. Seventy-two percent of local RW Latino/a clients have no health insurance.
Immigration is a strong predictor of insurance coverage and health care use. Undocumented
Latinos were by far the most likely to lack insurance, compared to U.S.-born, naturalized, or
documented Latino/as (Butler and Shi, 2006).
Fear and stigma related to residency status, language and cultural barriers, and fear and
stigma about HIV/AIDS make it extremely difficult to develop accurate estimates for
undocumented PLWHA. One RW-funded agency serving the Latino community reported 3540% of its clients were undocumented (about 350 people), and most spoke only Spanish.
Health care utilization for undocumented Latino/as is low, largely due to fear of being
deported, lack of insurance and access to health care, and cultural and language barriers. HIVpositive undocumented immigrants face greater challenges. Because many HIV-positive
immigrants would face greater stigma for their HIV infection in their countries of origin, the fear
of deportation is even greater, compounding the barriers they face in accessing care.
Latinos newly diagnosed with HIV in LAC experience greater difficulty in initially
accessing medical care. A recent analysis found that the median time between first diagnosis and
first entry into care for Latinos was 27 days, longer than the 19 days for Whites (Hu et al., 2012).
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Service Gaps. For Latino/a participants in LACHNA (2011), the overall top five service
gaps included oral health care; rental assistance; medical nutrition therapy; short-term rent,
mortgage, and utility assistance; and nutrition support (food bank). Among Spanish speaking
Latinos, the top five service gaps were oral health care; medical nutrition therapy; medical
specialty; HIV LA directory; and psychiatry. Among English speaking Latinos, the top five gaps
included rental assistance; oral health care; short-term rent, mortgage, and utility assistance;
nutrition support/food bank; and medical nutrition therapy.
Once enrolled in care, Latino/as are more likely than other RW clients to access medical
outpatient services, and access them more consistently. Similar to the experience of the nonLatino/a PLWHA population, some of the gaps in services for Latinos/as were in those services
not supported by RW funds, indicating a need for increased service coordination.
Costs Associated with Delivering Services to this Population. Latino/as enter care at a
later stage than the average PLWHA, often when the disease has progressed to AIDS. Because
many Latino/as in LAC are undocumented immigrants, they are ineligible for certain
government benefit programs. This significantly increases the cost of caring for this population.
Based on the HIV Research Network’s HIV care cost information, it is estimated that the
minimum annual cost to care for each Latino/a client in LAC is $30,000. Specific intervention is
required to overcome cultural, social, linguistic, and economic barriers to ensure their enrollment
and retention in care. Due to the size of this population and its disproportionate reliance on RW
funding for HIV care, the burden on the RW system in LAC could exceed half a billion dollars.
Transgenders
Unique Service Delivery Challenges. Historically, transgender women (male-tofemale) and transgender men (female-to-male) have been ignored in population enumerations
such as the U.S. Census. Often, the transgender population and the prevalence of HIV and AIDS
in this population can only be estimated. DHSP responded to community concerns about the
lack of up-to-date population and HIV/AIDS prevalence data by releasing the LAC Transgender
Population Estimates in 2012. The report estimated that there are approximately 14,428
transgender persons living in LAC. The estimated HIV prevalence for transgender women is
15.1% and the prevalence for transgender men is 0.6%. Among transgender women, the
estimated HIV prevalence is highest for African Americans (48.3%), followed by Native
Americans (26.9%), Latinas (17.1%), Whites (4.0%), and Asian/Pacific Islanders (3.7%).
Very few studies have been conducted with the local transgender population. One of the
first, the Los Angeles Transgender Health Study (2001), surveyed over 200 transgender women
to assess socio-demographic characteristics, risk behaviors, and HIV incidence and prevalence in
this population. The study found that the HIV prevalence of 22% was among the highest of any
discrete population group reported in LAC.
A more recent study involving individuals who accessed HIV prevention services in LAC
found that transgender clients, compared to non-transgender clients, were more likely to
experience verbal stigmatization, engage in commercial sex work, share needles when injecting
hormones, and have unstable housing (Edwards, Fisher, & Reynolds, 2007). Of those who
reported an HIV test result, 52% of transgender clients reported being HIV-positive, compared to
22% of non-transgender clients. The high rate of HIV infection among transgender women has
been characterized as a “syndemic” problem, referring to the concentration within the population
of multiple, co-occurring epidemics interacting and reinforcing each other and ultimately leading
to additional problems (Operario and Nemoto, 2010). For transgender women, the challenges
include mental health problems, high rates of alcohol and drug use, high rates of violence and
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victimization, and elevated levels of poverty, unemployment, and homelessness. The syndemic
dynamics influencing transgender health suggest that multi-component interventions that address
the interactions between substance use, mental health, poverty, and HIV risk are needed.
The lack of cultural competence and sensitivity are key barriers to quality health care for
transgenders. Many service delivery challenges are related to inadequate provider knowledge
and provider insensitivity and hostility. In a study published by the National Gay and Lesbian
Task Force, nearly 1 in 5 transgenders surveyed were refused medical care outright (19%), with
an even higher proportion among people of color; approximately 1 in 4 were denied equal
treatment and harassed or disrespected at doctors’ offices and hospitals (Grant et al., 2011).
Though select providers in the County specialize in services for transgenders, lack of
training among providers is still common, making culturally competent health care for
transgenders elusive. Due to the unique needs of transgenders, many health care professionals
need training on the issues relevant to this population to provide competent care.
Service Gaps. The top five service needs reported by transgenders who participated in
LACHNA (2011) include medical care, oral health care, case management, bus passes, and
groceries or food bank services. The top five service gaps include oral health care, rental
assistance, medical specialty care, nutrition evaluation/nutritional support, and bus passes. With
only 47% receiving it, oral health care was the largest service gap experienced by transgenders.
Costs Associated with Delivering Services to this Population. Based on care cost
information developed by the HIV Research Network, the estimated annual cost to provide
services to a transgender person living with HIV/AIDS in LAC is $29,000, with the total cost to
serve the estimated 1,128 transgender individuals living with HIV/AIDS at $32.7 million a year.
1E.
Unique Service Delivery Challenges
The mix of extraordinary cultural and geographic diversity, along with economic and
planning challenges, defines LAC as being one of the most challenged EMAs in the country.
Following are some factors that make LAC service delivery unique, complex, and costly.
Coordination Across Vast Geographic Variations and Population Diversity.
Consisting of more than 4,000 square miles, LAC has 88 incorporated cities, containing some of
the country’s wealthiest and poorest communities. LAC has both highly urbanized and
extremely rural communities. LAC is one of the most geographically- and community-diverse
jurisdictions in the nation. These variations are reflected among persons living with HIV and in
the providers that serve them. LAC has the second largest number of AIDS cases among the 52
RW Part A jurisdictions. The geographic size of LAC creates additional burdens associated with
transportation costs and establishing and coordinating regional service centers. LAC is also
plagued by an inadequate public transportation system.
With almost 10 million residents, LAC is the most populous county in the country, and is
more populous than 42 of the 50 states. It is home to an extremely large number of immigrants
and many transient and marginalized populations. Aside from having the largest number of
Latino/a residents of any jurisdiction in the country, LAC has the largest Asian/ Pacific Islander
and Native American populations in the country and the second largest population of African
Americans (after Cook County, IL). Close to 80 Asian/Pacific Islander and 30 Native American
languages and dialects are spoken in LAC; as a result, the County is increasingly pressed to
respond to cultural/linguistic variations and distinctions among clients.
Aside from the populations discussed in previous sections, LAC has significant numbers
of sex workers, including those who exchange sex for money, drugs, shelter or food; on-screen
performers for adult films; and escorts. There are no reliable estimates of the size of these
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populations or their infection rates.
Increasingly Complex HIV Treatment and Chronic Disease Care. As one of the first
epi-centers of the HIV/AIDS epidemic, LAC’s HIV care system has had to evolve with the
disease trend. Today, the majority of PLWHA are living longer with effective HIV medications.
However, other challenges emerge as long-term HIV survivors age. Approximately 40% of
PLWHA in the LAC RW care system will be 50 years or older in 2012, meaning many have to
deal with chronic diseases commonly associated with aging and the complications of treating
those diseases, in addition to regular HIV treatment regimens. Both age and HIV infection
weaken the immune system, and strain kidney and liver function, leading older PLWHA (and
long-term survivors) to experience slower CD4 cell reconstitution, slower response to HAART,
and more severe treatment side effects than younger individuals.
HIV disease is like other chronic diseases that require a focus on slowing disease
progression, symptom/pain management, and maximizing quality of life. Viral resistance
requires costly genotypic and phenotypic testing; antiretroviral regimens demand adherence and
dietary requirements to be effective in the management of the disease and side effects. Many
PLWHA also live with multiple chronic illnesses such as diabetes, hypertension, hyperlipidemia,
cardiovascular diseases, liver dysfunction, and depression. Drug reactions and toxicity from
treatments for multiple diseases require careful monitoring, coordination and communications
among providers striving to maintain comprehensive and integrated health care for clients.
Leveraging Resources During Early Adoption of Health Care Reform and Extreme
Economic Conditions. At the same time resources for health services continue to be cut at the
federal level, local budget deficits continue to strain the health care system in LAC. A high
unemployment rate coupled with a prolonged state budget crisis imposes a tremendous burden
on the local RW programs to serve the neediest individuals living with HIV/AIDS.
RW funding is critical in helping maintain a safety net for those most underserved;
however, an increasing number of eligible clients who lost health coverage and other benefits
due to unemployment and government benefits reductions raised the pressure on the local RW
system. California began its Bridge to Health Care Reform before the full implementation of the
Affordable Care Act. With ACA becoming effective in January 2014, much effort must be
devoted to cross-walking service offerings, including pharmacy formulary and caps on services,
between insurance plans available in the marketplace and Ryan White services available locally,
in order to make sure RW services truly fill the gaps. Significant effort is also required for
ongoing monitoring of the transition and corresponding planning to ensure continuity of care,
pharmacy access, comparable formularies, timely access to specialty care, equitable standards of
care and accurate eligibility screening.
It is expected that many of these patients will utilize RW programs for services not
available through Medicaid expansion or California’s insurance marketplace, Covered California
(e.g., oral health care). Continued assessment of their health outcomes and coordination of their
care across different funding sources presents challenges. Careful planning and coordination are
needed to help at risk individuals move through the continuum of care from testing, linkage to
care, retention in care, and optimal health status. The LAC continuum of care is a multi-faceted,
extremely complex, publicly-funded service delivery system composed of nearly 1,000 points of
entry, and consisting of 45 agencies contracted for RW-funded services. The coordination of
these services with non-RW-funded services in an environment with greatly reduced resources
adds to the challenges in providing high quality services to those living with HIV/AIDS.
1F.
Impact of a Decline in Ryan White Formula Funding
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Impact of Formula Funding Decline
The RW HIV/AIDS Treatment Extension Act of 2009 mandated that RW Part A formula
funding continues to be based on reported living HIV and AIDS cases, rather than the estimated
HIV prevalence in each eligible jurisdiction. This has caused tremendous funding impacts for
Part A jurisdictions in California, where HIV infections continue to increase, but the number of
HIV/AIDS cases certified by the CDC has been under-reported due to the relatively recent
implementation of CDC-endorsed HIV reporting methods. As of March 2013, there were still
3,228 coded HIV reports that have not been linked with names and therefore not counted toward
LAC’s RW formula funding. In LAC, the case verification process requires HIV surveillance
staff to travel across the immense landscape of the EMA to verify cases site by site, resulting in
slow case confirmation and significant underreporting. Currently there are an estimated 4,200
cases pending investigations.
LAC received a 7.5% reduction, or $2.6 million, in its formula funding for FY 2013.
This included the estimated 5.3% reduction due to sequestration. If the current law remains
unchanged, it is expected that further sequester-related reductions will ensue for FY 2014. This
combined with the impending reduction in formula funding due to the ending of the “Hold
Harmless” provision means that millions of dollars in services could be impacted.
Planning Council Response
The local RW Planning Council, the Commission on HIV, developed detailed plans to
provide guidance for allocations during times of both stagnant and decreasing resources. The Los
Angeles EMA lost 7.5% of the annual RW award amount, and DHSP, the administrative agency,
reallocated funding based on the Commission’s decreased funding scenarios and directives.
1G. Unmet Need
Unmet Need Framework
Attachment 6 shows an updated Unmet Need Framework for LAC. For the purposes of
this estimate, “primary medical care” is defined as receiving a viral load or CD4 test, or being on
anti-retroviral therapy (ARV) during calendar year 2012. Unmet need is the estimate of those
individuals who have been diagnosed with HIV or AIDS, know they are infected, and are not
receiving primary medical care as described.
In order to estimate the unduplicated number of people in care, the California Office of
AIDS (OA) has been providing Part A grantees unduplicated client-level data from eHARS,
ADAP, and Medicare by health jurisdiction. Medi-Cal data for 2012 were not included in the
database this year and were not accounted for in the analysis. OA requested the Medi-Cal data,
but for the second year did not receive it. Even so, it is estimated that the difference in identified
“met” need would be minimal, since there has been vast improvement with lab reporting for
eHARS. Based on analysis of the most recent dataset that included Medi-Cal, less than 3% of
records had “met need” identified exclusively through the Medi-Cal dataset.
The matched data from OA were linked with the local RW Casewatch client-level data
from the same time period for analysis of care patterns. Unmet need is calculated by subtracting
the number of people in care from the total number of PLWHA (aware) in the County. The
HARS data contain a full year of full lab reporting, which include PLWHA in private care;
therefore no adjustments were required for estimates of people in private care.
Population Estimates. Based on the linked databases for 2012, in LAC there were
28,751 people living with AIDS (PLWA), and 22,893 people living with HIV (non-AIDS). A
total of 51,644 people were estimated to be infected with HIV/AIDS and aware of their infection
as of December 2012 (Attachment 6).
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Estimates of People in Care. There were an estimated 38,315 people in care, including
21,204 people living with AIDS and 17,111 people with diagnosed HIV (non-AIDS) who
received HIV primary medical care as defined.
Estimates of Unmet Need. A total of 13,329 individuals (25.8% of PLWHA who were
aware of their HIV status) in LAC were not in care. Of these, 7,547 were living with AIDS
(26.2% of aware PLWA), and 5,782 were living with HIV (25.3% of aware PLWH).
Trend of Local Unmet Need
Table 3 below shows the four-year unmet need estimated for LAC.
Table 3. Estimated Unmet Need* in Los Angeles County for Calendar Years 2008 – 2012.
2008
2009
2010
2011
2012
Total
N
26,565
26,936
30,065
29,606
28,751
PLWA
Unmet Need
N
%
9,392
35.4%
10,084
37.4%
8,845
29.4%
8,755
29.6%
7,547
26.2%
Total
N
27,118
26,292
25,404
26,660
22,893
PLWH
Unmet Need
N
%
10,506
38.7%
8,677
33.0%
9,964
39.2%
9,913
37.2%
5,782
25.3%
Total
N
53,683
53,228
55,469
56,266
51,644
PLWHA
Unmet Need
N
%
19,898 37.1%
18,761 35.2%
18,809 33.9%
18,668 33.2%
13,329 25.8%
*Unmet need is defined as not receiving a viral load, CD4 test, or anti-retroviral therapy in a 12-month period.
Data Source: Linked CA databases of eHARS, ADAP, Medicare data and local client data from Casewatch.
The overall percentage of unmet need has been steadily decreasing over the last five
years. Between 2008 and 2012, the overall unmet need percentage in LAC fell from 37.1% to
25.8%. Even if Medi-Cal data were accounted for, the drop would still be significant. This is
evidence that the continuous efforts LAC has invested in HIV test-and-link activities in recent
years are working. Several initiatives have been implemented to further increase linkage to care.
For example, LINK LA uses peer navigators to link PLWHA released from the County jails to
HIV medical care. The LAC PATH project combines social network testing of high-risk
individuals and clinical linkage specialists to identify undiagnosed infection and immediately
engage newly diagnosed individuals in medical care. DHSP also implemented the HIV Rapid
Testing Algorithm (RTA), a testing methodology that uses different rapid tests to confirm an
original rapid test result, at most rapid testing sites after the demonstration project (2007-2009)
found that 100% of HIV-positive clients at the RTA sites received their results and were referred
to care on the same day. Increasingly, linkage-to-care efforts in LAC are coordinated with the
DHSP’s Public Health Investigators so that linkage to medical care after HIV diagnosis and
service referral can be systematically offered alongside partner services.
The Commission has accomplished the following planning objectives to assess and address
unmet need, which has contributed to the decline in unmet need:
• Identified and surveyed people characterized as having “unmet need” in LACHNA;
• Adopted a new continuum of care model in which services for “unmet need” patients/clients are
highlighted as a pivotal entry point and a focus of continuum planning;
• Incorporated analysis/assessment of system/service responses to “unmet need” in its new
methodology to evaluate service effectiveness;
• Allocated resources to an MAI plan designed primarily to help new “unmet need” clients access
services and engage care and treatment;
• Incorporated outreach planning into the standards of care that describe efforts providers will
take to identify and engage “unmet need” patients/clients in care;
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•
Developed “special population guidelines” to help providers and the administrative agencies
adapt the standards of care for populations with unique barriers to care; and
• Coordinated with other systems of care to ensure treatment retention and adequate care access.
Assessment of Unmet Need
Demographics and Location of PLWHA with Unmet Need
The combined data of eHARS, ADAP, Medicare and Casewatch are used to determine
who and where the unmet need populations are in LAC.
Table 4: Demographics of Individuals Diagnosed with HIV in 2012 with Unmet Need
% Unmet Need
PLWHA Not in Care
Total PLWHA
(n/N)
Gender
Race
Age
Total
Male
Female
Unknown
White
African American
Latino/a
Asian/Pacific Islander
American/Alaskan Native
Mixed/Other/Unknown
< 13
13-24
25-49
≥50
Unknown
n
%
13,329
11,615
1,709
5
3,788
2,768
5,068
338
39
1,328
23
373
7,748
5,174
11
100.0%
87.1%
12.8%
0.1%
28.4%
20.8%
38.0%
2.5%
0.3%
10.0%
0.2%
2.8%
58.1%
38.8%
0.1%
N
51,644
45,508
6,130
6
15,160
9,697
19,248
1,585
114
5,840
59
1,729
31,056
18,787
13
%
100.0%
88.1%
11.9%
0.0%
29.4%
18.8%
37.3%
3.1%
0.2%
11.3%
0.1%
3.3%
60.1%
36.4%
0.0%
%
25.8%
25.5%
27.9%
83.3%
25.0%
28.5%
26.3%
21.3%
34.2%
22.7%
39.0%
21.6%
24.9%
27.5%
84.6%
Source: Linked CA databases of eHARS, ADAP, Medicare data and local client data from Casewatch, 2012.
*”Not in Care” is defined as not receiving a viral load, CD4 test, or anti-retroviral therapy in a 12-month period.
Table 4 above describes the demographics of the unmet need population. Among the
51,644 individuals in the linked database, 13,329 were not in primary medical care as defined by
HRSA. These data provide important clues to the characteristics and locations of those who are
out of care in LAC: Native American, African American, Latino and mixed race individuals, as
well as women and young people under 24 years of age, were less likely to receive care.
The map below shows the distribution of the unmet need individuals across the eight
SPAs in the County and helps target efforts to locate them and connect them to medical care.
A second analysis using the 2007-2009 surveillance data to assess disparities in unmet need
revealed similar results. Among individuals newly diagnosed with HIV (N= 6,841), characteristics
associated with delayed linkage to care included being female, African American, Latino, 13-44
years of age, and exposure through heterosexual contact (Hu et al., 2012).
Assessment of Service Needs/Gaps/Barriers
The local needs assessment survey, LACHNA, includes a series of unmet need questions
for people who have HIV but are not currently receiving services, and for those respondents who
were out of care for more than a year in the last two years. The aggregated results provide data
about why and under what circumstances PLWHA leave or do not enter care. The 2011
LACHNA report informed the FY 2014 priority- and allocation-setting.
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In the LACHNA, 134 respondents were
surveyed about unmet need. The unmet need survey
indicates that employment, housing and immigration
status are key factors contributing to lack of access and
continuous HIV care. Approximately 46% of those
who had never been in care work full-time or part-time.
Of the foreign-born LACHNA respondents with unmet
need, 58% were undocumented. The top five reasons
identified by the HIV-positive individuals who did not
enter care were: unstable housing; good health (don’t
feel the need to see a doctor); unaware of free medical
care; not ready to deal with HIV; and fear of
discrimination/stigma.
For those people who left and returned to care,
the following reasons for leaving care were cited:
substance abuse; unstable housing; good/improved
health; incarceration; and unaware of free medical care
(for those who never entered care). Reasons cited most
frequently for returning to care were: illness; substance
abuse treatment; overcoming depression; ready to deal
with HIV; stabilized housing; heard about a new doctor or clinic; discovered that different
medications or treatments are available; and/or encouraged by friends and family.
LAC will continue efforts to assess service needs, gaps and barriers for the unmet need
population by implementing the unmet need activities detailed in its unmet need plan. The
remaining efforts include: 1) creating a public awareness campaign to promote service
availability, and 2) integrate the unmet need assessment with assessments from other health,
public health and social service programs. The Commission’s Priorities and Planning (P&P)
Committee will be updating the unmet need plan with new goals and objectives in light of ACA.
Efforts to Assist PLWHA in Accessing Primary Care
Aggressive case finding is a key component in all of LAC’s program planning. A
proportion of RW MAI funding is devoted to linkage to care activities in an effort to locate
PLWHA of color who have not accessed or have fallen out of care. All DHSP-funded HIV
Testing Services (HTS) providers are required to refer HIV-positive clients to HIV care and
achieve an 85% linkage-to-care objective, and track their linkage to care whenever possible. The
linkage from testing to care is tracked electronically and promoted by a fee-for-service structure
that pays for performance. Several initiatives are underway in LAC (described earlier and in the
EIIHA section) to identify undiagnosed PLWHA and connect them to primary HIV care and
other services that can facilitate their retention and adherence.
On the provider side, efforts to engage individuals and keep them in care primarily
involve calling clients who miss appointments and sending them correspondence by mail. All
providers follow up with lapsed clients by phone, postcards, and letters. Approximately onethird of that group also focuses their retention/adherence efforts by using home visits, support
groups, outreach in “former hangouts” and non-traditional settings, and incarceration settings. A
number of agencies also have designated staff who conduct home visits and street outreach to reengage clients. A quarter of the provider respondents use community outreach to target people
who have never been in care in order to enroll them into care.
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Use of Unmet Need Framework in Planning/Decision-Making
LAC used data from the Unmet Need Estimate, needs assessment findings and a provider
survey, and responded decisively with a number of planning strategies.
Data Analysis: The Commission incorporated the Unmet Need Estimate, and further
extrapolated its application to special and historically underserved populations, into LACHNA
and the annual service utilization reports used for the priority- and allocation-setting process.
Standards of Care (SOC): In response to community and provider recommendations
and upcoming changes that will be enacted with implementation of the Affordable Care Act
(ACA), the Commission has consolidated its 38 service categories into 17. The Commission has
updated its medical outpatient standard, revised its mental health and residential service
standards accordingly, and over the next six months will be developing standards of care for
Linkage to Care Services, Retention in Care Services and will be substantially revising substance
abuse and benefits support standards. The Commission has also incorporated language into all
standards requiring outreach plans for patients/clients who have unmet need and/or who have
fallen out of care, and has strengthened language requiring treatment adherence services in the
medical outpatient and medical care coordination standards.
Service Coordination/Medical Care Coordination (MCC): The unmet need estimate
was the principal guide for the SOC Committee’s development of MCC standard/service
descriptions that address key factors in reducing unmet need: case conferencing, points of entry,
integrating and consolidating the spectrum of case management services, and “gate keeping.”
This new framework of coordinated service delivery—being implemented system-wide during
FY 2013— has combined medical and non-medical case management services into a new
medically oriented model of care, consistent with the “medical home” model integrated into the
ACA. It is intended to help facilitate access to care for unmet need populations, and will be a
critical intersection point during the implementation of the ACA that ensures continuity of care
as RW patients migrate into other health care systems.
Minority AIDS Initiative (MAI): Since FY 2007, MAI allocations have been used to
fund oral health, early intervention, and medical case management services, focusing specifically
on activities that will identify and bring African American, Latino/a and API patients/clients into
or back into care. Those services will evolve into oral health, linkage to care and transitional case
management as new service models are integrated into the local system of care. In each of the
past three years, the Commission has also developed multiple directives to enhance the reach and
provide services to unmet need populations in those service categories.
Contracts: DHSP requires unmet need to be addressed by RFP respondents and will be
considered by reviewers and staff in the development and solicitation of contracts.
LAC now uses geo-mapping to help inform its decision-making. Data for the unmet need
estimates will be incorporated into the cluster mapping analysis. Visual representations of the
geographic areas where there is a higher prevalence of PLWHA, where services are located, and
where service gaps are identified, will inform additional planning and resource allocation.
METHODOLOGY
1. PLANNING AND RESOURCE ALLOCATION
1A.
1B.
Letter of Assurance from Planning Council Chairs
The Planning Council letter of assurance is included in Attachment 7.
Description of Priority Setting and Resource Allocation (P-and-A) Process
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The local RW Part A Planning Council (Commission on HIV) annually determines
priorities and allocations for Part A and Part B (from the State) funding in a single, consolidated
process. In 2011, the Commission revised its annual priority- and allocation-setting process to a
two-year cycle for more efficiency and better alignment with County procurement processes. In
the first year of the process, priority- and allocation-setting runs for at least six months, in order
to integrate community input at each benchmark: 1) developing an overall process framework,
paradigms and operating values; 2) reviewing the local epidemiology profile; 3) presenting needs
assessment and service utilization data; 4) ranking service priorities; 5) determining resource
allocations; 6) defining directives, considering process appeals, if any, and evaluating the
process. In the second year of the two-year cycle, the Commission reviews updated
epidemiological, service utilization and other related data from the prior year, and makes
necessary changes to priorities, allocations and directives.
In 2011, the Commission began integrating advanced linear mathematical modeling into
the P-and-A process to forecast changes driven by California’s early adoption of health care
reform in preparation for implementation of the ACA in 2014.
The Commission began its FY 2012 P-and-A process in March 2010 with the formation
of its Health Care Reform (HCR) Task Force. The HCR Task Force urged the Priorities and
Planning (P&P) Committee to consider how priorities and allocations might need to change in
FY 2012-2014 by considering two key cost variables: 1) enrollment of RW-covered patients to
LIHP, the essential services that LIHP will cover, and the resulting savings to the RW Program;
and 2) possible funding reductions, which would result in funding reductions to the RW
Program. Based on DHSP estimates that up to 5,000 current RW-funded medical outpatient
consumers (out of approximately 15,500) would be eligible for LIHP enrollment in FYs 2012
and 2013, the P&P Committee considered multiple-scenarios for considering FY 2012
allocations depending on the number of patients who enroll in LIHP and the size of any potential
budget cuts (above).
In order to understand the size of the cost variations, the P&P Committee calculated how
much funding might shift in each scenario by determining what services would be covered by
LIHP and which services RW would need to continue offering to LIHP patients, while remaining
mindful that up to two-thirds of current RW-funded patients would continue to rely on the local
RW-funded system for comprehensive HIV care. P&P Committee then identified the potential
funding implications for FY 2012, with possible extension into 2013.
Relying heavily on the Consumer Caucus recommendations, the P&P Committee
determined and the Commission approved allocations for its “base funding scenario” (or “flat
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funding”) in which fewer than 1,000 patients are enrolled in LIHP and federal budget cuts to the
RW Part A award are less than 7%.
In November 2012, DHSP fully implemented fee-for-service medical outpatient contracts
and medical care coordination (MCC) services. Those significant system changes were expected
to lead to substantial financial and service utilization shifts in 2013.
Planning for FY 2014 began in the Spring 2013, and was even more challenging given
that initial LIHP enrollment had not yet concluded, only initial start-up cost data from the new
medical outpatient and MCC contracts were accessible, and anticipating another round of system
changes two months in January 2014 when the ACA would be implemented. As a result, the
P&P Committee again recommended the continuing extension of the modified FY 2012
allocations with some modifications based on initial cost, spending and contractual patterns:
 The Medical Outpatient/Specialty allocation was decreased from 42.1% to 37.1% based on
new projections of additional savings due to the migration of patients into the LIHP/MediCal Managed Care and implementation of the fee-for-service contracts.
 The Oral Health allocation was increased from 11.3% to 20.0% to enable the third phase of
oral health services expansion, which will provide oral health coverage to all RW patients.
 The MCC allocation was increased from 14.1% to 16.0% to reflect projected additional costs
of providing those services to all RW patients.
 Benefits Support was increased by 25% in anticipation of additional need due to ACA.
In addition, the P&P Committee recommended and the Commission approved a new plan
to use Minority AIDS Initiative (MAI) funds exclusively to support oral health care, linkage to
care and transitional case management services in FY 2014. Finally, the P&P Committee agreed
to review and assess current FY 2013 allocations and expenditures monthly starting in October
2013, as more concrete financial and service utilization becomes accessible.
Considerations of Needs of People Not in Care, Unaware and Historically Underserved
Unmet Need and Early Identification of Individuals with HIV/AIDS (EIIHA). The
Commission, in conjunction with DHSP, conducted its biannual Los Angeles Countywide HIV
Needs Assessment (LACHNA) in 2011, using a scientifically rigorous, randomly sampled
survey that interviewed nearly 500 current RW patients in LAC. In addition to questions about
demographic information, barriers, and all services offered and received, unique questions about
special populations and past patient unmet need (if applicable) were included. Data were
presented to the P&P Committee and other community and consumer groups to incorporate into
P-and-A decision-making. The Commission finalized the 2013 – 2017 Comprehensive HIV Plan
and will confirm additional measures LAC must take to estimate, assess and address the needs of
unaware and out-of-care individuals, and to integrate that information into planning and P-and-A
processes. In the near future, the Commission will contract with Emily Gantz McKay, one of the
nation’s leading experts on unmet need, to advise on ways to expand next year’s LACHNA in
ways that will better and more directly collect, quantify and elaborate on (qualify) unmet need
data, and on ways the Commission can better target services for people who are aware of their
HIV status but who are not accessing care.
Historically Underserved Populations. In 2008, the Commission created a list of criteria
(disenfranchised/vulnerable; unique challenges; higher prevalence/incidence rates; targeted
services needed; and larger portions of the population rely on publicly funded services) to
identify and designate 15 key, priority and “emerging” HIV-impacted populations (as detailed in
the Comprehensive HIV Plan). Size estimates of those populations have been determined or
estimated by DHSP’s Surveillance and Epidemiology unit, composite needs profiles have been
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created, service guidelines for each population are in development, and plans are underway for
key population focus groups and studies, all in an effort to identify where varied priorities,
enhanced allocations and specific directives needed to advance more effective service delivery
for each of the populations. Specific emphasis has now been given to those populations that
would not be eligible for health care reform coverage in 2014.
Involvement of PLWHA
In LAC, HIV service consumers, other PLWHA and other community stakeholders are
involved in every stage of the P-and-A process. In the first year of the two-year P-and-A cycle,
forums are held in the County’s eight Service Planning Areas (SPAs) and at numerous
community and consumer group meetings. For the FY 2013 P-and-A process, the Commission’s
P&P Committee has been incorporating priority- and allocation-related input, prompting HIV
community dialogue and advancing thoughtful P-and-A decision-making. The P&P Committee
made multiple presentations of all of the data and sought extensive feedback and input from the
full Commission, the Commission’s Consumer Caucus, and other community stakeholder and
provider groups. There are three principle mechanisms to ensure consumer involvement in Pand-A and other planning activities:
1) Consumer Caucus: In 2008, the Commission formed its “Consumer Caucus,” which
comprises all the consumer members of the Commission and its committees, and regularly opens
its meetings for participation by other consumers. The Caucus is a vehicle for the Commission’s
consumer members to review issues at the Commission, educate each other about those issues,
create a more cohesive consumer voice, and to share experiences.
2) Commission Representation/Reflectiveness: Nearly half of the Commission members
are PLWHAs and one-third of the Commissioners are non-aligned consumers, and there are an
additional half-dozen unaffiliated consumer alternates. One of the Commission Co-Chairs, up to
three of the committee co-chairs, and one Executive Committee At-Large member are
unaffiliated consumers. The percentages of non-aligned African American, Latino and female
consumers are consistent and reflect their proportions in the local epidemic, although recruitment
of sufficient Latino unaffiliated consumer members remains a challenge. The unaffiliated
consumer members are actively involved in all committees and the consumer caucus, and review
and approve P-and-A decisions; at least a third of the P&P Committee members are consumers.
All Commission meetings are open to the public. Non-Commissioner PLWHA also participate in
these meetings, needs assessments and focus groups in order to inform the P-and-A decisions.
3) LACHNA (Consumer Needs Assessment): The Commission’s 2011 LACHNA
collected in-depth needs-related and unmet need information, and data about perceived and
actual barriers preventing or delaying access to services. Approximately 500 PLWHA were
randomly selected and interviewed, with special recruitment efforts targeting those who were
out-of-care and disenfranchised.
Use of Data to Increase Access to Core Services and Reduce Disparities
An epidemiologic profile of HIV/AIDS, the final needs assessment report, and DHSP’s
annual service utilization report are the primary data tools used to make priority and allocation
decisions. Data from the needs assessment are further analyzed by gender, ethnicity, disease
acuity, geography, risk or exposure category, and historically underserved populations, and
correlated to the epidemiological information from the Epi Profile.
Annually, DHSP generates the prior year’s Service Utilization Report, which compiles
service utilization, cost, patient census and demographic data by service category. For each of
the service categories, the report addresses epidemiological, demographic and geographic
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information; service definitions, minimum standards, service model and best practice
information; unmet need, service utilization data, and out-of-care and special populations data,
reported by gender, ethnicity, and age; prior years’ allocations, cost utilization, per unit cost, cost
effectiveness and cost-efficiency information; other sources of known or anticipated funding;
and outcomes and service effectiveness assessments.
Service category rankings are driven primarily by needs information (from LACHNA,
the Consumer Caucus, and other sources), HIV/AIDS epidemiologic trends, demographic and
service utilization data, health status outcomes (primary health care) and other documented
studies. All priority and allocation data are cross-tabulated in the service utilization report to
identify particularly important historically underserved population needs and reflect them in
service category priorities and Commission directives.
The beneficial impact of improved coordination among service providers is evident in the
relatively low level of barriers identified in the needs assessment. Responses from LACHNA
were categorized as structural, organizational or individual barriers. LACHNA measured
prevalence of the barrier and its severity [rated on a scale of 1 (very small) to 5 (very big)].
Barriers, when cited, usually fell within the “small” to “moderate” range. “Individual” barriers
were more common among populations relatively new to the epidemic, the disenfranchised or
complexly ill. Part A service funding can be allocated to address structural and individual
barriers, enhance access, and reduce disparities, while DHSP contract monitoring, service
procurement and/or quality management activities address organizational and other individual
barriers.
Informed by LACHNA and service utilization data, the Commission ranked service
priorities. Needs assessment data suggested that consumers prioritized highest those services in
the primary health care core (medical outpatient, oral health). The Commission also confirmed
that while medical outpatient was the most available service, oral health care represented the
largest service gap and did not meet consumer need—especially given the State’s elimination of
Medi-Cal dental care in 2009. The Commission continues to allocate increasing amounts of RW
funds to oral health services to address this gap.
Changes and Trends in HIV/AIDS Epidemiology Data
Since changes and trends in the HIV epidemiology data underscored the increasing
impact of the LAC epidemic on communities of color, the Commission relied on population
analyses in the epidemiology data to guide its decision-making. These data were considered in
the context of needs expressed by these populations and actual service utilization, with a focus
on expanding access, removing barriers and reducing disparities.
Primary epidemiological data sets used in the P-and-A process were the 2012
Epidemiological Profile of HIV/AIDS (an analysis of special populations developed by DHSP
based on surveillance data and a wide variety of studies) and additional presentations from
DHSP staff and members of the P&P Committee.
Secondary data reviewed included special studies and surveys such as the AIDS Project
Los Angeles Client Survey, the Los Angeles Transgender Health Study, and Young Men’s
Survey. Additional data sources included the HIV Prevention Plan 2009-2013, State of an
Epidemic: HIV/AIDS in LAC, and the Housing Authority of Los Angeles Strategic Plan.
Cost Data Used in the Priority- and Allocation-Setting Process
The P&P Committee uses both service and utilization costs, as well as cost-efficiency and
cost-effectiveness ratios, when determining allocations. Cost-efficiency considerations have
previously driven specific Commission funding decisions (e.g., eliminating allocations for van
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transportation). All known and available cost data are incorporated into the utilization report.
The Committee also reviews other sources of funding for all prioritized services and
determines allocations in light of ability to access other funds. As a significant proportion of the
Ryan White patient base will enroll in Medi-Cal or other health plans over the course of the next
year, the Commission, and its P&P Committee in particular, will be monitoring patient migration
and service utilization trends on a monthly basis. The P&P Committee will be evaluating
whether Medi-Cal and Covered California’s “essential” services are sufficiently available and
accessible, and is poised to modify FY 2013 and 2014 allocations to re-direct funding to fill
identified gaps in continuity of care.
The gradual integration of fee-for-service reimbursement and/or unit cost rates combined
with implementation of specific service and health outcome measurement aligned with the
Commission’s standards will yield increasingly improved cost-effectiveness information in the
future. DHSP’s shift to fee-for-service medical outpatient contracts is expected to yield more
precise data for future priority- and allocation-setting decision-making.
Unmet Need Data Used in Priority and Allocation Decisions
During both priority-ranking and allocation-setting, the Commission’s P&P Committee
assesses how individual service categories contribute to mitigating unmet need identified in the
local unmet need estimate, and how delivery of the service impacts unmet need. The Committee
evaluates whether the service’s contribution to unmet need or its potential impact on unmet need
merits higher prioritization and/or additional allocations. In several service categories, such as
MCC, linkage to care (LTC), substance abuse services, and benefits support, unmet need
consideration resulted in additional allocations or averted allocation reductions.
The Committee also considers the rates of unmet need in the County (based on the unmet
need framework) in comparison to utilization of services by new clients in order to define an
acceptable standard and expectation in future years. Last year, the Commission recommended
that specific allocations to target unmet need and linkage strategies in certain service categories
(e.g., MCC/LTC services) may be considered following Medicaid expansion and the full
implementation of the ACA, and as a result, the Committee will identify ways to ensure
increased allocations of funds to address and reduce unmet need.
LACHNA included specific sections to query consumer respondents about issues related
to unmet need. Patients not in care and those who have previously been out of care for at least a
year were surveyed about reasons for failing to access care, dropping out of care, and/or barriers
to care, in order to guide future priority and allocation strategies that mitigate unmet need.
Proactive Planning for Part A Award Increases/Decreases
Following determination of the base funding allocations for FY 2012, the P&P
Committee analyzed the financial and service utilization implications of other funding scenarios.
Recognizing that the uncertainty of RW funding and the prolonged enrollment of patients into
the LIHP would not allow the administrative agency to determine the financial impact at any one
specific point in time, and that it takes the County time to implement system changes once
patterns have been detected, the P&P Committee concluded that it would develop directives
rather than specific allocations for the other funding scenarios. The P&P Committee then
developed, and the Commission approved, two sets of directives in those scenarios in which
there might be significant cost savings or funding reductions, giving the administrative agency
the time and flexibility to shift the funding as it discerns the size of savings or reductions. Due to
the delay implementing LIHP enrollment until July 2012, the Commission agreed to extend those
directives into FY 2013, and will continue using them as a guide in FY 2014.
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In developing the two sets of directives, the P&P Committee relied most heavily on
determining the service mix in LIHP (including what LIHP services may be capped) and
consumer input. If there are significant cost savings (due to higher LIHP enrollment and lower
budget cuts), the directives dictate sustaining medical outpatient services and the re-allocation of
available cost savings to strengthen and increase medication assistance and access, oral health,
LTC, benefits support, MCC, mental health services and medical nutrition therapy. In the
funding reduction scenarios (lower LIHP enrollment and significant budget cuts), directives
require the administrative agency to hold certain core medical services harmless and to eliminate
support services starting from those service categories with the lowest priority rankings.
Already, those directives have proven useful as DHSP and the Commission collaborated
on defining re-allocation of medical outpatient savings from the combined implementation of
fee-for-service reimbursement and LIHP enrollment to other core medical services as defined by
those directives. It is expected that the contingency funding scenario directives will continue to
help shape re-allocation of funds as the Commission monitors the migration of patients from
LIHP to Medi-Cal managed care, enrollment of patients in Covered California, health plan
variations in essential services, caps and cost-sharing, and other service delivery and service
utilization patterns through 2014.
Minority AIDS Initiative (MAI) Consideration
In June 2013, the P&P Committee concluded its review and assessment of the MAI plan
it had adopted in 2007. In February 2011, DHSP presented an extensive overview of oral health
care services, including current service delivery, continuing gaps in care, specific practice and
procedure needs, and progress expanding the RW system’s oral health service capacity. The
Commission approved re-allocation of remaining MAI roll-over funds to oral health care,
consistent with consumer needs expressed in LACHNA and other forums, service utilization and
needs data, and ongoing waiting lists, and consequently approved allocations to fund the second
and third phases of oral health expansion. DHSP made similar presentations in August 2011
covering medical case management (MCM) and EIS, currently funded by MAI allocations. In
June 2013, the Commission approved a new MAI plan for FY 2014, but allowed for the possible
continuation of currently funded MAI services through FY 2014 in light of so many substantial
and concurrent system changes already underway.
The new MAI plan entails increased funding for oral health care (from 30% to 40% of
MAI funding) consistent with continuing efforts to expand the system’s oral health capacity
expansion for all RW patients, but shifted prior funding for MCC and EIS to LTC (40%) and
transitional case management (20%). The P&P Committee concluded after its lengthy review
that LTC and transitional case management services are more consistent with intent, spirit and
purpose of MAI: to help populations of color access services and ensure that more of those
services are available for populations of color. All three service categories are also funded, in
part, by Part A/B funds to ensure that they are not restricted to only populations of color.
How EIIHA Data were Used in P-and A- Process
Until recently, the extent of EIIHA data used during the P-and A- process has been
focused on addressing unmet need (PLWHA who are aware of their HIV infection but not in
care), and coordinating with the formerly separate HIV Prevention Planning Committee (PPC)
on increasing awareness and diagnosis of HIV. For the past year, the Commission/PPC
Integration Task Force has been developing a single Comprehensive HIV Plan for LAC, which
has entailed revisions to and development of multiple new comprehensive planning, P-and-A and
standards of care strategies. Recent efforts have included strengthening allocations to outreach
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and LTC models. Similarly, the P&P and SOC Committees have begun discussions about how to
incorporate and allocate to routine/targeted screening and testing services, partner services and
biomedical approaches to clinical care/medical services. Following unification of the
Commission and the PPC in July 2013, all of the Commission’s processes are being modified to
integrate equal consideration of prevention and STD needs and activities. EIIHA and DHSP’s
resulting collection, analysis and presentation of EIIHA-related data, combined with the
Comprehensive HIV Plan, will be the principle guide the P&P Committee will use to revise the
P-and-A process in accordance with its expanded mission.
How Data from Other Federal HIV/AIDS Programs were Used in P-and A-Process
Throughout the year, the Commission has invited guest presenters, such as local
researchers and program administrators, to present data and findings at the full Commission or
Committee meetings to inform the heavily data-driven process. During the FY 2013, critical data
and expert projections of cost and service utilization trends were presented on topics such as
biomedical interventions; syndemic planning and analysis; youth, populations of color and
substance use; new EMR technology platforms; benefits access and support; Medi-Cal and
Covered California; substance abuse services; services for the undocumented; and other
important and related topics. This year’s Annual Meeting will be devoted to the managed care
environment and finding ways to effectively collaborate with Medi-Cal and other managed care
plans in which RW clients will enroll under the ACA.
P-and-A data, including data from other federal programs, is regularly shared with the
P&P and SOC Committees by representative members on each committee from DHSP and other
stakeholder representatives. Commission staff and representatives participate on DHSP’s
Medical and Oral Health Advisory Committees. The Commission’s new membership structure
includes formal representation by the local administrator of HOPWA, and more housing and
homelessness data will become available as the Commission develops an integrated
HOPWA/RW plan through a HUD SPNS grant.
How Anticipated Changes due to the Affordable Care Act (ACA) were Considered in
Developing Priorities
Forecasting changes and effects resulting from implementation of the ACA has been
LAC’s top priority for the past two years, due to California’s role as an early adopter of health
care reform. As the foregoing information detailed, the Commission’s P&P Committee
developed a new linear regression model to use in the development of allocations in an
environment where the number of patients, access to other systems of care, service delivery and
utilization, service limitations and caps, comprehensive or limited RW consumer service needs,
and the availability of funding were all in question or largely undetermined. Also as detailed
above, the P&P Committee developed a new contingency funding scenario format which gave
the administrative agency more flexibility to respond more quickly to emerging service delivery
or cost patterns as they were detected. Throughout these past two years, Commission staff and
members have remained in constant, almost daily, contact with DHSP principals to assess,
consider, trouble-shoot, and problem-solve as new wrinkles in Ryan White and LIHP service
delivery implementation or procurement developed.
In particular, the Commission has expanded its reach to ensure that as the LIHP enrolls
RW patients, services provided by DHS, the LIHP administrator, remain consistent with the
Commission’s standards (minimum expectations). DHS has responded favorably with extensive
discussions about how to implement a new pharmacy access network that mirrors the ADAP
network, reconciling minimum service expectations by DHS and the Commission, on the use of
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Delivery System Reform Incentive Pool (DSRIP) funds that accompanied the enactment of the
LIHP, on the formation of the Community Health Clinic Board (CHCB) for the LIHP, and with
ongoing reports of patient enrollment and service usage. Similarly, the Commission has engaged
discussions with the Department of Mental Health to ascertain how mental health services under
Medicaid expansion will be delivered. Likewise, the Commission/PPC unification has enabled
the Commission to be better prepared to address the full spectrum of HIV and STD services
following ACA implementation.
Now that the initial year of LIHP enrollment has concluded, DHSP and the Commission
are refocusing its energy and deliberation on the other forthcoming changes under the ACA rollout: the transfer of LIHP patients to Medi-Cal managed care, and the enrollment of additional
patients in the insurance marketplace (Covered California). In February 2013, the Commission
organized a local forum with the Office of National AIDS Policy in which preparation for the
ACA was a primary topic, and invited expert speakers locally and from around the state to
address its complexities and suggest strategies from multiple perspectives. The Commission has
organized multiple colloquia and presentations to address aspects of ACA implementation,
focusing on how the local treatment cascade and continuity of care can be maintained, how
service gaps can be identified and filled, and prevention, care and biomedical strategies can be
integrated in this new landscape.
The Commission has worked directly with the State Office of AIDS (OA) and HRSA to
employ ADAP eligibility and core medical services waiver requirement strategies that would be
more functional under the ACA, and is currently working with OA and DHSP to identify costsharing gaps that may develop and strategies to allocate Part A Health Insurance Premium/CostSharing or Net County Cost (NCC) funds to mitigate those additional cost burdens on
consumers. Likewise, the Commission has begun to place more emphasis on how key and
priority populations will fare in this new healthcare landscape and to develop strategies for
improving health outcomes, access and retention in care as members of these populations receive
their care from other healthcare agencies/plans.
1D.
Funding for Core Medical Services
The FY 2014 priorities and allocations are detailed in Attachment 8. The Commission
allocated 90% of LAC’s combined Ryan White Part A and Part B funds for FY 2014 to core
medical services. DHSP ensures that a minimum of 75% of the Part A funds are expended in the
delivery of core medical services. For FY 2013, 92.9% of Part A funds are for core medical
services. Other HRSA-defined core medical services did not receive RW allocations because
funding for those services is available elsewhere.
1E.
Early Identification of Individuals with HIV/AIDS (EIIHA)
1) EIIHA PLAN BACKGROUND SUMMARY
1a. Overall EIIHA Plan
DHSP receives HIV prevention funding directly from CDC, and is the public health
agency in LAC responsible for coordinating the County’s response to HIV through
comprehensive screening, prevention, linkage, care and treatment services. The majority of the
EIIHA activities are currently supported by funding from CDC, while RW funds are used to
enhance linkage to medical care and support services to reduce potential barriers to care.
EIIHA Strategy and Objectives
LAC has developed the EIIHA strategy with three primary objectives: 1) Normalize HIV
testing; 2) Target HIV response in high-risk, high-prevalence geographic clusters using
epidemiologic evidence; and 3) Implement a seamless testing, linkage, care plus treatment
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(TLC+) continuum. The strategy and the resulting implementation activities are based on: a)
published studies in peer reviewed journals, including articles based on local epidemiologic data;
b) HIV testing program data and analyses from matching results with surveillance and HIV care
and treatment data; c) unified community planning to develop the County’s first Comprehensive
HIV Plan; d) service provider feedback; and e) CDC and HRSA guidance.
1) Normalize HIV testing: Since stigma surrounding HIV disease persists and many
HIV infections occur as a result of unrecognized, underestimated or ignored risks, this approach
aims to make screening for HIV a routine part of regular health care. LAC supports this
objective through the implementation of social media strategies, routine opt-out testing at health
care facilities and dental clinics, social network testing, and other testing initiatives that aim to
reduce stigma associated with HIV testing. Studies have shown that HIV stigma is a barrier to
HIV testing (Valdiserri, 2002) and access to care (Sayles, 2009), and racial disparities exist in
timely HIV diagnosis and entry in medical care (Johnson et al., 2006; Hu et al., 2012). LAC’s
strategy for normalizing testing includes increasing the number of sites where testing is
available; social network testing which reduces stigma by enlisting peers to promote access to
testing services; targeting testing messages among high-risk communities in geographic areas
with high HIV prevalence; and increasing the number of medical clinics and emergency
departments that include HIV screening as a part of the routine battery of tests for all patients..
By normalizing HIV testing, and making HIV testing available in numerous venues and settings,
especially in highly impacted areas, LAC has seen consistent progress in increasing number of
tests conducted and identifying undiagnosed infection.
2) Target HIV response in high-risk, high-prevalence geographic clusters using
epidemiologic evidence: LAC has an area of more than 4,000 square miles with a population of
almost 10 million residents, requiring limited EIIHA resources to be carefully targeted for costeffective results. LAC’s targeted HIV strategy is based on geospatial analysis of multiple cooccurring health and socio-economic conditions to identify neighborhoods at increased risk for
HIV. DHSP uses “spatial epidemiology” to examine disease burden and the interrelationship
between two or more diseases. Surveillance data for HIV, syphilis, gonorrhea and chlamydia, as
well as HIV testing and care data are triangulated to identify geographic areas where the nexus of
diseases is especially evident. Testing resources are targeted to high-risk populations within
those areas to focus efforts where HIV is more likely to be undiagnosed, and positivity rates are
higher. DHSP set the performance measure standard for all HIV testing contracts at a positivity
rate of 1.03% for new positives. Using clinic and surveillance data, DHSP staff estimate
County-wide rates of suppressed HIV viral load, ART coverage, and PLWHA out of care
(including unmet need) in order to identify geographic areas and particular subpopulations that
require intensive interventions.
3) Seamless testing, linkage, care plus treatment (TLC+) continuum: LAC’s EIIHA
strategy targets efforts at various points throughout the service continuum where individuals are
affected by HIV. To close the gap in awareness of HIV infection, a key strategy is creating a
seamless testing, disclosure and linkage-to-care pathway to foster testing and diagnosis within an
optimal timeframe. LAC strives to achieve 100% disclosure, 100% referral to partner services,
100% referral to medical care, and 85% linkage to care for newly diagnosed individuals. The
efforts are invested in a comprehensive menu of service modalities, innovative testing strategies
and initiatives (e.g., Rapid Testing Algorithm [RTA]), incentive payments to testing providers
who can document linkage to care for positive testers, and solidifying partnerships between
testing sites and medical providers.
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Implementation Activities and Collaborations
In order to normalize HIV testing LAC implements broad-based testing programs such as
universal opt-out perinatal HIV screening for pregnant women, expanded routine HIV testing at
hospitals, community clinics and health centers, and HIV testing at health fairs in highly affected
neighborhoods. HIV screening is also conducted in County courts, substance treatment centers,
County jails and detention facilities to identify individuals unaware of their HIV infection.
Because LAC is so large, geography is often used as a proxy for risk in order to
efficiently target HIV testing services (HTS). DHSP-contracted agencies provide comprehensive
testing modalities that include storefront testing; mobile testing units; multiple-morbidity testing
for HIV, STDs and viral hepatitis in one visit; partner services; social network testing; and
routine HIV testing in clinical settings. These testing programs target high-risk individuals
within high-prevalence neighborhoods. Partner notification, counseling and testing are key
strategies in identifying the sexual and needle-sharing partners of those already diagnosed and
getting them linked to prevention, care and treatment. Public health investigators (PHIs) also
perform partner elicitation and investigation for clients with syphilis. Some PHIs are embedded
within HIV service agencies and conduct partner services activities immediately on site with any
patients who are diagnosed with HIV, or are HIV-positive and have new STD infections.
All HIV-positive testers are referred to HIV medical care to ensure seamless linkage to
care and treatment. If a client tests HIV-positive, options for three primary medical care
providers are given, and an appointment at the clinic of the client’s choice is made directly by the
counselor. The counselor also provides other linked referrals to address the client’s health and
social needs. To promote ongoing linkage efforts, DHSP pays an enhanced rate to HTS
providers for linked referrals. This strategy has been very effective in increasing linkage rates
and is discussed in more detail later.
Partnerships with community-based organizations (CBOs) and other health facilities and
institutions are crucial in implementing LAC’s EIIHA strategy. DHSP collaborates with the
County Sheriff’s Department to provide HIV and STD screening routinely at the largest jail
system in the country. DHSP also collaborates with 22 community-based organizations to offer
HIV testing through 35 testing programs, including nine mobile units that conduct testing at over
200 sites, saturating the County’s highest morbidity areas with multiple testing options.
Several RW-funded medical clinics are Federally Qualified Health Centers (FQHC) that
serve as both HIV clinics and general primary care clinics. They partner with DHSP to support
and champion routine testing in clinical settings within their own institutions. RW program
directors work with FQHC medical and administrative leadership to provide technical support
for implementing routine HIV testing in the primary care clinics and to incorporate the testing
process into the clinic flow. RW programs within the County DHS system facilitate routine HIV
testing in hospitals, emergency departments, urgent care centers and primary care clinics in a
similar way, through educating the institution leaders and executives about the importance of
routine HIV testing and the best practices for incorporating HIV screening into clinical settings.
Other Ryan White Parts are important partners as LAC implements its EIIHA activities.
California OA requires local health jurisdictions receiving Part B funding to submit their EIIHA
plan when they submit budget requests, so that local efforts are coordinated with the State.
Locally, referral to medical care is where significant coordination with Part B and Part D occurs,
and this coordination will continue in 2014. For example, Part B-funded transitional case
management is critical in engaging jail inmates and referring them to needed services before they
are released, and providing follow-up once they are out of the correctional system.
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Program Narrative
DHSP also coordinates with prevention and disease control/intervention programs to refer
clients who tested negative to appropriate prevention services. In 2011, DPH went beyond CDC’s
program coordination and service integration (PCSI) concept to integrate legacy Office of AIDS
Programs and Policy, HIV Epidemiology Program and the STD Program into one entity (Division
of HIV and STD Programs or DHSP) to eliminate fragmented interventions and duplicated
services and to streamline data sharing and reporting. Since then, DHSP has focused on syndemic
planning that examines spatial relationships between multiple factors or co-occurring epidemics,
and has used the results to target HIV testing efforts.
EIIHA Target Groups
In LAC, the HIV epidemic continues to be driven largely by sex between men. LAC
identifies the following as the EIIHA Target Groups: 1) Latino and African American MSM; 2)
Young MSM (age 18-29); 3) Transgenders; 4) Latina and African American Women; 5) Partners
of HIV-positive Individuals; and 6) Incarcerated and Post-released Individuals. The selection is
based on local data—including factors such as HIV incidence and prevalence, and disparities in
awareness of HIV infection, linkage to care, retention in care and viral suppression—and
considers input from community planners.
In LAC, the estimated HIV seroprevalence rates are very high among African American
and Latino MSM—37% among gay-identified African American MSM and 17% for Latino
MSM. They comprised approximately 66% of MSM newly diagnosed with HIV in LAC in the
last three years. Homophobia and stigma are still prevalent in the African American and Latino
communities. Silence and non-acceptance among family and community members exacerbate
risky behaviors that increase their risks of infection. African American MSM continue to exhibit
low linkage and retention rates, as well as low viral suppression. For young MSM, family
rejection can result in immediate homelessness. Survival sex and substance use heighten their
HIV risks, and getting screened for HIV is a lower priority than immediate survival needs. More
than one third (36%) of newly diagnosed MSM in 2010 were between ages 18 and 29. Young
African American MSM in particular had new HIV infection rates three times as high as their
White and Latino counterparts. Young PLWHA had the lowest linkage and retention rates
among all age groups, and experience challenges with ART and achieving viral suppression.
For transgenders, the on-going stigma, discrimination, harassment and even violence are
more acute. The pervasive oppression from nearly every social and economic institution creates a
domino effect of risk factors for transgender individuals, including multiple sex partners,
unprotected sexual activity, and sharing needles for street drugs, medically unsupervised
hormone therapy and silicone injections. DHSP estimated that the HIV prevalence of
transgender women (male-to-female) is 15%. Transgender women of color have an even higher
rate, with the estimated HIV prevalence for African Americans at 48%, followed by Native
Americans (27%), and Latinas (17%).
For Latina and African American women in LAC, being unaware of their sexual
partners’ HIV risks is a primary factor placing them at risk for infection. A local Supplemental
HIV/AIDS Surveillance study reveals that 58% of Latinas interviewed had no idea how they
became infected. Lack of health insurance or a regular source of care due to poverty or
immigration status, along with the lack of knowledge and awareness about available services,
prevent them from learning of their HIV infection.
Distrust and stigma of having HIV in a correctional environment can be pervasive. As a
result, some incarcerated individuals do not reveal their HIV infection when they are booked, or
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resist being tested for HIV because of confidentiality or privacy concerns. DHSP estimated that
6% of new HIV cases in 2010 were for those diagnosed while incarcerated.
Because unrecognized risks remain pervasive, sexual and injection partners of HIVpositive individuals are elicited at every opportunity to encourage them to get tested. HIV
positivity rates from partner services testing remains the highest (5%) among all publicly funded
HIV testing modalities.
The following table highlights the EIIHA challenges for these target groups:
Table 5. Barriers to Awareness of HIV Status for EIIHA Target Populations in LAC
Target Groups
1 Latino and African
American MSM
2 Young MSM (Ages 18-29)
3 Transgenders
4 Latina and African
American Women
5 Partners of HIV-positive
Individuals
6 Incarcerated and Postreleased Individuals
Barriers to Awareness of HIV Status
Unprotected sex; multiple sex partners; meth and alcohol use; domestic
violence; stigma and homophobia; lack of support/acceptance in
family/community; mental health; immigration status, language barriers
and acculturation degree for Latinos; lack of health insurance;
inconsistent health care; poverty; incarceration.
Family rejection; domestic violence; runaway/homelessness; survival
sex; meth and other substance use; mental health; poverty; lack of
health insurance.
Stigma and discrimination; family rejection; physical violence and
harassment; lack of social support; mental health; unemployment; sex
work; substance use; needle sharing for drugs, unsafe hormone therapy
and silicone injections; poverty; homelessness; unprotected sex;
multiple sexual partners; lack of health insurance.
Unrecognized risks; competing needs e.g., child care; substance use;
mental health; lack of self-care(caring for families first); immigration
status; language barriers; no regular health care or health insurance.
Unrecognized risks; domestic violence; relationship power and
economic dependence on partner; substance use; mental health.
Mistrust; stigma; confidentiality/privacy issues; violence; barriers to
and interruption of quality health care; substance use; mental health;
lack of health insurance.
Collection and Application of EIIHA Data
Beginning in July 2011, DHSP switched its data collection for HIV testing to the HTS
data system, an integrated data collection system that captures HIV testing, partner services,
linkage to care and HIV case reporting, and tracks matched data between HTS and HARS
surveillance data. HTS includes two primary data collection modalities. Providers who have
electronic health records (EHR) enter data directly into their EHR and electronically transfer
their data to DHSP. Providers who do not have an EHR collect data on standardized hard copy
forms, scan at the provider site and electronically transfer data to DHSP where data are read
using Teleform scanning software. This hybrid data collection system is a cost-effective
approach that minimizes duplicative data entry and allows for programming changes to be
completed with less time and resources.
All HTS data must be received by DSHP Research & Evaluation staff (data management
team) within seven days from the test date, and all forms for HIV-positive cases must be reported
to DHSP within 72 hours of the test date. DHSP employs a comprehensive data QA protocol to
ensure that the most accurate and valid data are obtained from contracted programs. This plan
includes data verification and validation procedures which include automated validation checks
of data elements, including the identification of missing or inaccurate data. Data verification
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Program Narrative
begins once DHSP receives the data or after the data are scanned on-site. This validation
includes matching and checking for discrepancies between data within the database record and
the original data collection form. Data security and client confidentiality are critical components
of program monitoring and quality assurance. DHSP adheres to CDC’s Data Security and
Confidentiality protocol and follows the Rules of Behavior for Data Systems.
The HTS system relieves the provider of manual data entry and allows providers to have
more time to deliver, evaluate and improve services. Since the implementation of this data
collection system, both the number of HIV tests performed and the HIV positivity rate have
increased. Agency staff, together with DHSP, can monitor their performance and identify issues
that need to be addressed for continuous quality improvement.
DHSP also uses STD and HIV data to conduct syndemic planning and geospatial
analysis. Syndemic planning and spatial statistical analyses have enabled DHSP to identify
geographic clusters with highest disease burden. This approach identified five geographic
clusters that represent 89% of new HIV infections and allows DHSP to target EIIHA-related
services in areas of greatest need. DHSP plans to analyze multiple years of HIV/STD
surveillance data to examine cluster trends. These types of geospatial analyses identify smaller
geographic clusters at the neighborhood-level, and offer insights for effective, efficient planning
of interventions and strategies for target populations.
Successes and Challenges of the EIIHA Plan
As the administrator for RW and the CDC’s High Impact HIV Prevention for Health
Departments Cooperative Agreement (now referred to as “Flagship”) and expanded testing
funding, DHSP is responsible for the overall HIV response in LAC and plays a critical role in
leading the coordination among organizations that offer services along the HIV services
continuum. This unification supports fully integrated HIV and STD prevention, care and
treatment planning within DHSP and the community.
In addition to the HIV community providers, partnerships beyond the HIV service arena
have contributed to the increased awareness and availability of HIV tests. These included Public
Health STD clinics, Substance Abuse Prevention and Control program (SAPC), Sheriff’s
Department and DHS to facilitate HIV testing in County jails, detention centers, public hospitals
(both ER and outpatient clinics) and health centers, and social service agencies. Partnerships
with private hospitals in high-burden areas have broadened the reach of routine HIV testing. For
organizations that do not have contractual relationships with DHSP, numerous executive-level
meetings have occurred in the past two years to make the case for routine testing and provide TA
and other support for implementation of HIV screening and linkage to care.
Table 6 below summarizes the HIV testing results from 2010 to 2012. Notable successes
in the last year included: increased number of HIV tests and HIV-positive individuals identified;
2.06% new positivity rate for routine HIV screening at community STD clinics; 1.16% new
positivity rate for targeted store front HIV testing sites, 4.67% for social network testing, and
2.13% for bath houses/sex clubs.
Table 6. HIV Testing Results in Los Angeles County, 2010-2012.
Test Volume
Positives Identified
New Positives Identified
Targeted Testing Using
Geo-spatial Data
County of Los Angeles
Grant No. H89HA00016
2010
100,686
1,203 (1.19%)
1,024 (1.02%)
# of Tests New Positive
45,179
497 (1.10%)
2011
109,411
1,287 (1.18%)
1,041 (0.95%)
# of Tests New Positive
55,323
609 (1.10%)
FY 2014 Ryan White Part A Application
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2012
131,550
1,396 (1.12%)
1,266 (0.96%)
# of Tests New Positive
80,864
892 (1.10%)
Program Narrative
27,829
285 (1.02%)
30,433
343 (1.13%)
45,917
532 (1.16%)
Storefront
9,262
79 (0.85%)
18,796
138 (0.73%)
26.063
222 (0.85%)
Mobile Testing Unit
707
44 (6.22%)
818
35 (4.28%)
1.178
55 (4.67%)
Social Networks
1,984
31 (1.56%)
1,868
65 (3.48%)
1,975
42 (2.13%)
Bathhouses/Sex Clubs
*Data Source: DHSP HIV Testing Services (HTS), 2010-2012. Data only include DHSP-supported HIV tests.
DHSP-funded HTS contracts require contractors to document where the client was referred
for HIV medical care services using agency-specific linked referral forms. The referring agency
must follow up and verify that the client was in medical care through confirmation with the client
(self-report) or the surveillance coordinator, and through verification by the medical clinics. The
majority of RW-funded programs (medical clinics and others) are also funded for HIV testing to
achieve immediate linkage to care, and can provide confirmation of care linkage.
The linkage verification is expected of HTS contractors whether the client was referred to
a privately or publicly funded provider, and the same standards and procedures for
reimbursement apply. For clients referred to private providers, self-reported information about
when they completed their medical appointments is verified by the PHIs. The role of PHIs in the
EIIHA plan has been expanded significantly in the last two years, because of their successes in
identifying previously undiagnosed individuals and also in verifying that newly diagnosed
people have been successfully linked to HIV care.
DHSP now has in place the infrastructure and ability to routinely match HIV testing data
and HIV surveillance data. This allows staff to determine “previously” diagnosed HIV positive
testers versus newly diagnosed HIV infections, thus providing a more accurate picture of the
reach and impact of our HIV testing programs.
Rapid Testing Algorithm (RTA) is a critical component of LAC’s EIIHA strategy
because of its success in identifying and confirming infection, and immediately referring HIVpositive individuals to medical care. Currently, about 85% (56/66) of rapid HIV testing sites are
implementing the RTA, with a goal of 100% implementation by end of 2013.
The biggest challenge LAC faces in implementing EIIHA strategies is the lack of
adequate funding for HIV testing. Despite recent funding reductions from CDC, LAC is doing
its best to preserve HIV testing services; however, the funding level is far below what is
necessary to reach everyone who does not know his/her status. Current local prevention funding
supports more than 135,000 publicly funded HIV tests per year, well below the minimum
estimated number needed to provide annual testing for HIV-negative MSM, let alone other risk
groups.
Normalizing HIV testing is critical in reducing stigma associated with HIV infection;
however, the approaches must work within the needs and cultures specific to these groups. The
targeted approach will not have its intended effect unless at a societal level, broader economic,
health and social policy changes also occur to overcome the structural barriers. Stigma,
discrimination, and isolation continue to affect gay, bisexual and transgender individuals, and in
turn result in distrust of the health system, fear of disclosure, and personal denial of possible HIV
infection. Lack of HIV knowledge and its associated unrecognized risks prevent people from
getting tested. Funding reductions mean that opportunities are missed in educating and
countering the stigma and homophobia that continue to contribute to HIV transmission, lack of
engagement in care, and health disparities in LAC.
In a County as large as LAC, following up with people who did not receive their positive
test results can mean traveling from Long Beach in the south across nearly 100 miles to Palmdale
in the north. Timely notification and follow up may be compromised as a result. Lack of public
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Program Narrative
health investigators (PHIs), which present challenges in informing unaware HIV-positive
individuals of their status, further exacerbates challenges in linking those infected to care.
Contributing to National HIV/AIDS Strategy Goals
The EIIHA plan in LAC is designed to promote awareness of and access to HIV
prevention, care and treatment services and aimed to contribute to the overall system-wide goals
of reducing HIV incidence, optimizing health outcomes, and reducing health disparities. These
goals are aligned with the National HIV/AIDS Strategy (NHAS) goals of 1) reducing the number
of people who become infected with HIV; 2) increasing access to care and improving health
outcomes for people living with HIV; and 3) reducing HIV-related health disparities. EIIHA has
been a crucial step in reaching these goals. These specific indicators are assessed annually to
reveal progress and remaining gaps: lower the annual number of new infections by 25%, increase
to 85% the proportion of newly diagnosed patients who are linked to medical care within three
months, and increase the proportion of HIV-positive gay and bisexual men in care with
undetectable viral load by 20%.
DHSP has been increasing the number of HIV tests each year since 2009, and has thus
identified increased numbers of HIV-positive individuals. LAC plans to conduct nearly half a
million HIV tests in the next three years aimed at reaching NHAS objectives.
Among 2,192 adults/adolescents diagnosed with HIV in 2010, 79% or 1,740 were linked
to care within 3 months. Asian/Pacific Islander MSM, White MSM, and people who were 45
years or older had the highest proportions linked to care (85%, 85%, and 84%). MSM/IDU,
youth 13-24 years of age and African Americans had the lowest proportions of linkage to care
(65%, 75%, and 76%).
For PLWHA who had one or more viral load tests reported in 2010, 79% were virally
suppressed. The highest proportions of viral suppression were seen among persons over 65 years
of age (90%), Whites (85%) and Asian/PI (84%). The lowest proportions of viral suppression
was seen among persons 13-24 years of age (59%) and African American MSM (66%).
DHSP continues to move towards the NHAS goals through normalizing HIV screening,
targeting HIV tests using spatial epidemiology, and implementing TLC+ activities across LAC
However, disparities in accessing HIV screening and care services cannot be addressed by HIV
programs alone. Some of the underlying co-factors that contribute to these disparities are
structural—e.g., poverty, stigma, homophobia, and discrimination—and will take larger societal
efforts to combat. People are not likely to seek HIV testing or treatment if they fear that it would
result in isolation and discrimination..
1b. Data for Three Target Populations in the EIIHA Plan
Table 7 below summarizes EIIHA data for the three target populations as compared to
the overall test events.
Table 7: EIIHA Data for All HIV Tests, and Tests Conducted for Three EIIHA Target
Populations in Los Angeles County (January 1, 2013 – June 30, 2013)
TOTAL HIV TEST EVENTS
Newly Diagnosed Positive HIV Test Events
Newly diagnosed confirmed positive test events
Newly diagnosed positive test events with client
County of Los Angeles
Grant No. H89HA00016
Overall
Latino
&African
American
MSM**
Young
MSM**
Transgenders
59,389
12,820
5,485
679
512
244
59
19
388
216
182
108
49
30
18
8
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Program Narrative
linked to HIV medical care*
Newly diagnosed confirmed positive test events
with client interviewed for Partner Services
Newly diagnosed confirmed positive test events
with client referred to prevention services
Newly diagnosed confirmed positive test events who
received CD4 cell count and viral load testing***
Previously Diagnosed Positive HIV Test Events
Previously diagnosed confirmed positive test events
Previously diagnosed positive test events with client
re-engaged in HIV medical care*
Previously diagnosed confirmed positive test events
with client interviewed for Partner Services
Previously diagnosed confirmed positive test events
with client referred to prevention services
Previously diagnosed confirmed positive test events
with linked CD4 cell count and viral load testing***
345
156
47
14
191
90
27
3
70
31
6
5
81
41
17
6
58
29
11
5
54
30
11
4
56
29
11
5
46
24
8
4
20
11
6
4
Data Source: HIV Testing Services (HTS) System as of 9/9/2013; includes HIV tests through the CDC Flagship
funding. *Linked to care according to self-report only this is an under-representation of the rate when data for 12
months are matched with surveillance data (around 70-75%). Due to the time frame of the data required for the
application, full surveillance matching data for this time frame are not yet available.
**MSM includes male clients who 1) reported having sex with men or transgender or 2) self-reported bisexual or
gay sexual orientation. ***These numbers only include 3 months of surveillance matching data and are underrepresenting clients who got linked to medical care and received both CD4 and viral load tests.
2) FY 2014 EIIHA PLAN
2a. FY 2014 Planned Activities
Estimated Number of PLWHA Unaware of Their HIV Status
DHSP estimates that in FY 2014 there will be approximately 10,600 individuals living
with HIV/AIDS who are unaware of their status in LAC, based on the following methodology.
p = Proportion undiagnosed with HIV = 18.1% (based on CDC’s national estimate)
n = Number of individuals living with HIV in LAC as of 12/31/2012 = 46,095 (based on
eHARS data reported as of June 30, 2013)
e = Estimated number of reported HIV/AIDS cases pending investigation that are unduplicated
cases = 2,000 (based on DHSP’s Epidemiology Unit estimate)
N = Number of individuals diagnosed and living with HIV/AIDS as of 12/31/2012 = n + e =
46,095 + 2,000 = 48,095
Estimated Undiagnosed PLWHA in LAC = [p/(1-p)] x N = 10,629
Target Populations
The target populations for the LAC FY 2014 EIIHA plan will remain the same. Table 8
illustrates the relationships each target population has with the overarching EIIHA focus locally.
Table 8: Los Angeles County EIIHA Target Populations Matrix
All individuals unaware of their HIV Status (HIV-positive and HIV-negative) in Los Angeles County
Individuals NOT tested for HIV in the past 12 months
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Individuals
tested for
HIV in past
12 months
Program Narrative
Individuals in High-Risk, High-Prevalence Zip Codes
Latino &
African
American MSM
Young
MSM (ages
18-29)
Transgenders
Latina & African
American
Women
Partners
of HIVpositive
individuals
Incarcerated
and postreleased
individuals
Individuals
uninformed
of test
results
Activities and Interventions
LAC’s EIIHA activities for FY 2014 will begin with increasing the overall number of
tests conducted, increasing the number of health care facilities implementing HIV Rapid Testing
Algorithm (RTA) and routine HIV testing programs, and promoting screening through social
marketing. Routine HIV testing and targeted testing in high-burden neighborhoods are the
primary means to identify individuals unaware of their HIV infection. This allows the targeted
programming to follow not only HIV/AIDS incidence and prevalence but also the co-factors that
contribute to people’s risks and lack of awareness. Improvements will focus on the following
areas: streamlined data collection and reporting, the HIV counselor training and re-certification
process, integration of new HIV testing technology, partner services, integrated HIV/STD
testing, laboratory services, and an innovative new reimbursement schedule.
Table 9 below summarizes the EIIHA activities planned for FY 2014.
Table 9. FY 2014 EIIHA Implementation Plan Activities in LAC
Activities
Time Line
Collaboration/Partners
Social marketing: bus, billboards, social media, events
IE
DMPC
Increased routine testing in ER, urgent care, primary care sites
IE
DHP
Routine testing in County jails, courts, and substance Tx facilities
IE
D Sh P
Increased storefront, mobile target testing in high burden areas
IE
DPC
Perinatal universal opt-out testing and prevention
I
DHO
Partner Services and field case investigation/follow-up
IE
DP
Increased social network testing
IE
DP
Testing at Public Health and STD clinics
IE
DO
HIV nucleic acid amplification testing
IE
DP
Testing at commercial sex venues
IE
DP
Multiple morbidities testing at Public Health clinics and via Mobile
IE
DOPC
Testing Units (MTUs)
Performance- and tier-based reimbursement structure
IE
DP
HIV RTA to facilitate immediate medical care referrals
IE
D P Sh H
Medical care coordination: Collaboration with HTS for care linkage
IE
DPHC
Transitional case management & Link LA navigation
IE
D Sh P U
Integrated surveillance/STD/testing/care data for client tracking
IE
DP
Timeline: I = Implemented through 2013; E = Extended/Expanded in 2014; N = New Program
Responsible: D = DHSP; Sh = Sheriff’s Dep’t; P = Providers/CBOs; H = hospitals/health centers; C = Community
planning/input; M = Media/KCBS Marketing; O = other DPH Programs; U = UCLA
The FY 2014 EIIHA plan builds on the successes of the last three years and implements
new processes that aim to further improve outcomes. In addition to activities described earlier,
perinatal universal opt-out testing and multiple morbidity testing (HIV, STD, and viral hepatitis
screening) in venues such as the County jails, public health clinics, community health centers
and via mobile testing units, will continue to be implemented to identify undiagnosed individuals
who are unlikely to seek testing.
LAC’s FY 2014 EIIHA plan also focuses on ensuring that standardized HIV disclosure
procedures are followed according to California Health and Safety Codes. For individuals who
tested for HIV but did not receive their HIV test results, the following strategies apply: 1)
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Develop HTS contract language specific to disclosure procedures that must be followed, with
realistic goals to be reached; 2) Modify the HTS fee-for-service structure to offer financial
incentives for the delivery of results, particularly to HIV-positive persons; 3) Increase field
notification for confirmatory disclosure of HIV-positive test results by increasing the number of
STD PHIs and community-embedded PHIs; 4) Expand RTA that uses up to two different HIV
rapid tests in sequence to inform clients of confirmed HIV status within one hour, eliminating the
need for a return confirmation visit; and 5) Refer preliminary positive testers in select high risk
venues, such as commercial sex venues, directly to HIV care services with care providers
disclosing or providing the HIV confirmatory testing. These strategies will not only improve
confirmatory rates but also assist with linkage to care rates.
All Ryan White parts in LAC are key partners in providing or facilitating linkage to
medical care for previously unaware individuals newly diagnosed with HIV. All but one Part C
and Part D providers in LAC are part of the Ryan White Part A/B network of providers funded by
DHSP and coordinate with DHSP’s HIV testing efforts. Several Part F SPNS-funded initiatives
(each of which also receive other Ryan White Parts funding for care and treatment services) are
dedicated to linking hard-to-reach populations to medical care, e.g., women of color, transgender
and homeless individuals. For FY 2014, the emphasis will be on linkage to care, including
actively facilitating the connections and contacts between the DHSP-funded HTS and MCC
providers through periodic integrated provider meetings.
Planned Outcomes of the EIIHA Strategy
DHSP’s EIIHA plan has a combined cost reimbursement and performance-based fee-forservice structure for all DHSP-contracted HTS providers other than routine HIV testing sites.
The four performance measures for non-routine HIV testing programs are: 1) conducting a
threshold number of HIV tests; 2) meeting a minimum 1.03% new HIV positivity rate; 3)
documented successful linkage to medical care for at least 85% of HIV-positive persons; and 4)
100% of new HIV-positive clients (index cases) offered and referred to DPH partner services.
These measures must be met to obtain maximum compensation.
To improve documented linkage to care for the newly diagnosed, DHSP will be revising
the linkage to care performance measure within its pay-for-performance model to further
incentivize linkage to care. The model will be modified to offer graduated financial incentives
for providers as annual linkage rates improve. While the overall expectation is for an annual
linkage rate of at least 85%, DHSP will provide graduated incentives beginning at a 70% linkage
rate for agencies that are striving to meet the performance goal. In addition, DHSP will continue
to review the New Directions performance measures to identify sites that have the highest testing
volume, highest actual number of new positives, highest linkage to care rates, and most effective
provision of Partner Services, in order to shift resources to those sites that are most productive.
2b. How FY 2014 EIIHA Plan Contributes to the NHAS goals
The integrated five-year comprehensive HIV plan focuses on three principle priorities:
1) Planning and preparation for the implementation of the Affordable Care Act (ACA) in 2014;
2) Adjusting and modifying services, models, standards, best practices and contracting in order
to enhance linkage to and retention in care; and
3) Aligning services to meet or exceed the goals and objectives of the President’s NHAS.
Following the release of the NHAS, DHSP revamped HIV testing services and launched
the New Directions HIV Testing Program. This reallocated funding to the most productive
testing modalities and the most successful contracted agencies in an effort to meet NHAS
objectives locally. In 2014, DHSP will expand on the New Directions and focus on refining
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investments that support the most efficient identification of undiagnosed HIV. The priority areas
include: streamlining the number of data variables collected, reimbursement restructuring and
pay-for-performance, increased implementation of the RTA, streamlining the certified HIV
counselor training and re-certification process, maximizing STD and hepatitis screening or
vaccination opportunities, and increasing access to and acceptance of partner services.
DHSP has identified social network testing and comprehensive prevention with positives
programming as two of the most effective strategies addressing HIV testing goals and reduced
HIV transmission consistent with NHAS. Early testing among social and sexual networks has
been shown to reduce stigma among high-risk groups yielding higher numbers of tests; and
linkage into care, retention in care, and ART adherence for individuals who are already infected
are critical for reducing infection rates.
LAC will have an estimated 10,600 undiagnosed individuals living with HIV in 2014.
Routine opt-out screening is one of several HIV testing modalities that will be scaled up to
ensure that LAC has less than 10% undiagnosed HIV infection by 2015, consistent with the goals
of the National HIV/AIDS Strategy, and that detection at earlier disease stage is achieved. Given
the vast geography (over 4,000 square miles) and limited resources, LAC can only prioritize
routine opt-out screening for the EIIHA target populations in geographic areas with the highest
disease burden (defined as co-occurring epidemics in HIV, syphilis, and gonorrhea).
To inform the deployment of these interventions, LAC will use surveillance data to
identify areas most impacted by HIV and STDs, as well as to identify individuals in need of
linkage and retention interventions. Full scale implementation of these strategies will
significantly reduce new infections by increasing the proportion of individuals linked and
retained in HIV care, improving treatment and medication adherence, reducing community viral
load, and improving health outcomes for PLWHA. Trend analysis will be conducted to identify
outcomes and gaps, and realign resources to ensure that NHAS goals are achieved.
2c. How Unmet Need Estimate and Activities Inform EIIHA Activities
As described in the Unmet Need section, State OA conducted cross-matching of multiple
databases to estimate the number of individuals aware of their HIV status who are not in care.
DHSP performed data matching from the surveillance data of the LAC residents with the local
RW client data to estimate local unmet need. Similar collaboration with Part B is anticipated for
the state-wide effort to identify unaware individuals.
A diverse mix of TLC+ initiatives has been implemented to connect out of care
individuals to services they need throughout the continuum of care. These include youth-focused
linkage workers, early intervention, Antiretroviral Treatment Access Study (ARTAS) linkage
case management, clinical linkage specialists and peer navigator interventions. Transitional case
management helps refer post-released individuals to medical and support services.
DHSP’s internal TLC+ workgroup meets monthly to discuss Unmet Need and EIIHA
related topics, including: defining linkage to care for testing providers; defining re-engagement
and retention in care, including consideration of RW Planning Council service definitions for
linkage and retention in care; a review of linkage to care programs implemented across the
country; and updates and trouble-shooting for local TLC+ demonstration projects. Additionally,
innovative partner services efforts are implemented through seven Community Embedded
Disease Intervention Specialists (CEDIS) who are placed in CBOs that serve areas and
populations with the highest HIV and STD morbidity. These efforts have helped identify
previously unaware individuals, and link newly diagnosed and out-of-care PLWHA to HIV
treatment.
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2d. Planned Efforts to Remove Legal Barriers
California state law has adopted language to facilitate routine HIV testing. Minimal legal
barriers exist in LAC to implement routine HIV testing. DHSP is collaborating with the State to
address the case reporting challenges with the California Code of Regulations and the Health and
Safety Codes. This partnership continues to ensure that laboratories and DHSP-funded programs
adhere to the California State law that mandates reporting of all viral load and CD4 tests to local
HIV surveillance programs. Coordination within DHSP is resolving data matching and data
sharing issues while adhering to state confidentiality and privacy laws.
Other local structural challenges involve laws and regulations regarding case reporting
and the extent to which surveillance data can be shared for linkage-to-care purposes.
California’s Assembly Bill (AB) 682 not only removed the requirement of a separate written
consent specific to HIV for pregnant women obtaining services from a health care provider, but
for all individuals testing at a health care facility. The law follows CDC’s finding that written
consent was a barrier to routine HIV testing in clinical settings. However, AB 682 did not
provide the same freedoms for non-health care settings.
Recent changes in state regulations regarding HIV surveillance data use, as well as the
integration of HIV surveillance and HIV program legacy departments, have allowed for a
significant shift in how LAC uses surveillance data. DHSP is exploring ways to use existing
clinic and surveillance data to identify individuals who have tested positive for HIV but have not
accessed medical care, as well as using data to identify individuals who have dropped out of
care. Efforts are underway to expand the role of PHIs to include re-engagement in medical care,
and several demonstration projects will examine different methods for finding people who are
out of care and linking them to medical care.
2e. Three Target Populations for FY 2014 EIIHA Plan
Three EIIHA Target Populations
LAC identifies the following three Target Groups for FY 2014: 1) Latino and African
American MSM; 2) Young MSM (18-29); 3) Transgenders.
In LAC, the racial, ethnic and socioeconomic groups affected by HIV increasingly are
lower income people of color, especially men of color who have sex with men (MSM). The
geographical regions in LAC most significantly impacted by the HIV/AIDS epidemic are the
central and southern corridors, where the highest number and concentration of African
Americans and Latinos reside. The three target populations present the highest disparities of new
HIV infections, linkage to care, and viral suppression. Using the most recent complete HIV
surveillance data from 2010, approximately 13% of adult/adolescents diagnosed with HIV
infection in 2010 were African American MSM, 28% Latino MSM, and 36% MSM between 1829 years of age. Approximately 90% of newly diagnosed youth age 18-29 were MSM. Among
those who had at least one viral load or CD4 test within three months after an HIV diagnosis,
defined as “linked-to-care,” youth ages 13-24 had a lower care linkage rate (75%), compared to
other demographics (e.g., 84% for adults 45-64 years of age, and 79% for adults 25-44 years of
age). Youth and African American MSM also had significantly lower retention rates—at 50%
and 54% respectively, compared with 56% for overall newly diagnosed individuals. The most
serious challenge was with viral suppression. The overall proportion of viral suppression for the
newly diagnosed PLWHA in 2010 who had at least one viral load test was 79%; however, the
viral suppression rates for youth and African American MSM were extremely low—at 59% and
66% respectively. These disparities present serious challenges in reducing the number of new
HIV infections. For transgenders, there has been a lack of surveillance data on these indicators
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across the HIV care spectrum. What is known is that the HIV seroprevalence among this group
(especially for male-to-female transgender women) is extremely high (15%), owing partly to
tremendous obstacles they face in trying to access culturally sensitive health care services. LAC
continues to invest significant efforts to address these persistent health disparities.
Challenges, Opportunities, and Planned Activities
DHSP started to implement new HIV screening services in five areas highly impacted by
HIV and STDs in LAC in 2011. These five areas, known locally as clusters, are identified based
on mapping of the epidemiologic data for HIV, syphilis, gonorrhea and chlamydia. When
mapped across the County, it becomes clear that five geographic areas of the County account for
over 80% of the disease burden, yet these areas make up less than 20% of the County land mass.
This mapping allows for more targeted resource distribution across the County. Two of these
cluster areas–the central and south cluster areas–represent 64.7% of new HIV cases identified in
the County. Mobile testing sites were redirected to both the central and south cluster areas, and a
routine screening site was introduced in the south cluster area.
For FY 2014, DHSP will continue to shift resources into geographic areas with
demonstrated high level of disease. As DHSP refines the HTS resource allocations, new
contracts will require that agencies are located within one of the five cluster areas. Store front
programs target these populations at increased risk for HIV transmission (African-American
MSM, young MSM, and transgenders), as well as geographic areas with high disease burden
(central metro, Hollywood, south central, Long Beach). They yield the highest positivity rates,
followed by testing programs at the commercial sex venues. DHSP also supports testing in
medical centers that are located in epidemiologic hotspots.
LAC will identify unaware Latino and African American MSM through routinizing HIV
testing in clinical sites that serve large numbers of MSM as well as targeted HTS storefront and
mobile HIV testing sites in highly impacted zip codes and neighborhoods. Multiple data sources
are used to map co-factors that contribute to HIV risks and unawareness of HIV status, helping
to target limited resources to high burden areas. The targeted programs will be supported by
social marketing campaign messages that are aimed at African American and Latino MSM.
Public-private partnerships that offer HIV testing in commercial sex venues (e.g., bath houses
and sex clubs) will continue, as will routine and acute HIV screening at men’s wellness centers
and sexual health programs serving MSM. Acute HIV infection diagnosed at these targeted sites
with Nucleic Acid Amplification Testing (NAAT) identifies one infection in every 250
specimens screened, an effective way of identifying recent, acute infection before conventional
testing methods will identify HIV. Implementing innovative testing strategies such as social
network testing will help to identify hard-to-reach, high risk MSM. Jail-based initiatives will be
implemented to strengthen access to care for the post-released Latino and African American
MSM who experience tremendous challenges in care engagement. Transitional Case Managers
and Nurse Liaisons work in jails to refer HIV-positive Latino and African American inmates and
establish linkage to HIV medical care and other services upon release. Navigator Interventions
will be used to improve linkage to care and retention for Latino and African American MSM and
recently released inmates, and improve their adherence to antiretroviral therapy to reduce viral
loads.
DHSP targets young MSM through expanded testing implemented at locations youth
frequent, along with community health centers and STD clinics. Young MSM may often choose
not to use family doctors or their parents’ health insurance coverage, and instead visit public
clinics for STD tests. This use of public clinics presents an opportunity to identify HIV infection
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while screening for and treating other STDs. LAC dispatches mobile testing units that conduct
outreach and testing, with consistent presence and predictable days/times, to runaway and
homeless youth, many of whom engage in high risk survival sex. Social network testing efforts
will continue targeting young MSM and transgenders.
DHSP collaborates with Children’s Hospital Los Angeles (CHLA), the local Adolescent
Medicine Trials Network for HIV/AIDS Interventions clinical trial site, to implement YouthFocused Linkage Workers to improve the identification and linkage to care of young MSM and
transgenders with undiagnosed and newly diagnosed HIV infection. DHSP and CHLA will
continue a successful model whereby all newly diagnosed youth in LAC are referred to a linkage
worker who ensures that the youth are linked to HIV medical care, often by personally escorting
them to their initial medical appointment.
Transgenders face tremendous barriers to get any kind of health care. To reduce HIV
transmission and health disparities among this group, DHSP is planning a transgender wellness
center that provides a comprehensive array of services, including HIV/STD screening, medical
and ancillary services. The center will be formed through collaborative efforts and offer
culturally competent transgender services. Targeted and social network testing in highprevalence neighborhoods will provide additional access points for transgenders to get tested.
For all residents at risk for HIV in LAC, the early adoption of the Affordable Care Act in
California has provided new opportunities for health care engagement. DHSP has been at the
forefront of discussion with the agencies that will provide health insurance for uninsured and
underinsured residents, and has worked diligently to include routine access to HIV screening,
and access to HIV medication, within the plans. In addition, DHSP continues to support robust
engagement through community agencies in recruiting and screening area residents for eligibility
in the health care plans and health insurance exchanges. Through these activities, tremendous
opportunities exist for the engagement of hard-to-reach populations in regular health care in
general, and HIV prevention and treatment in particular.
SMART Objectives and Planned Outcomes
Based on the Los Angeles County Five-Year Comprehensive HIV Plan (2013-2017) and
specific EIIHA plan for FY 2014, the following table summarizes the SMART objectives to
identify, inform, refer, and link the three targeted EIIHA populations in LAC. Note that these
objectives only apply to HIV testing and awareness activities supported through DHSP funding.
Table 10: 2014 Los Angeles County EIIHA SMART Objectives Dashboard
EIIHA
SMART Objectives
Target Outcome Benchmarks*
Baseline
AA&
Latino
MSM
Young
MSM
(18-29)
Transgenders
Resp.
Party
Identify
By 12/31/2014, increase the percentage of HIVpositive individuals who know their HIV infection.
79%
81%
81%
81%
D, Sh,
P, H,
M, O
Inform
By 12/31/2014, increase the percentage of individuals
newly diagnosed with HIV informed of their HIV test
results.
95%
98%
98%
98%
D, P,
H, O
Refer
By 12/31/2014, maintain 100% medical care referrals
for individuals newly diagnosed and informed of their
HIV infection.
100%
100%
100%
100%
D, P,
H, Mh,
O
Link
By 12/31/2014, increase the percentage of newly
diagnosed PLWHA tested through DHSP who are
70%
75%
75%
75%
D, P,
H, Mh,
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linked to care within 90 days of their HIV diagnoses.
O
By 12/31/2014, decrease the percentage of PWLHA
33%
30%
30%
30%
D, P,
Unmet
who are aware of their HIV infection but not in care.
H, Mh
Need
*The benchmarks here are based on DHSP-funded HIV testing. Some EIIHA numbers cited throughout this
application are based on surveillance data, which include all reported cases. DHSP holds no control of performance
over those payers. Responsible: D = DHSP; Sh = Sheriff’s Dept; P = Providers/CBOs; H = hospitals/health centers;
Mh = HIV medical homes; M = Media/KCBS Marketing; O = other DHS & DPH Programs.
The objectives and outcome expectations outlined in Table 10 require the efforts and
collaboration of many parties and organizations. These include community agencies, hospitals
and health centers providing HIV tests, medical homes providing HIV care, other County
programs such as TB Control, Communicable Disease Program, and the Sheriff’s Department.
In collaboration with DHSP, RW providers work with clinical sites implementing routine
screening to develop protocols and QA plans that expedite linkage of newly diagnosed and outof-care patients to HIV care, including the development of MOUs with primary care sites that do
not have HIV clinics to link diagnosed patients to care in the RW clinics.
HIV RTA allows for immediate referral and linkage to care upon confirmed results with
two consecutive positive rapid tests. All HIV positive clients at the RTA sites receive their test
results and are referred to care on the same day. DHSP has expanded the RTA in all targeted
HIV testing sites, as well as many health centers, County jails, and homeless shelters.
DHSP has been expanding coordination with PHIs to improve opportunities for referring
newly diagnosed persons and the sexual and needle-sharing partners of HIV-positive individuals,
to appropriate medical and other care and prevention services. DHSP also works closely with the
local TB Control Program and Communicable Disease Control Program to refer HIV-positive
individuals co-infected with TB, HCV and HBV to HIV medical care.
2f. Dissemination of EIIHA Plan and Outcomes
DHSP disseminates EIIHA data on an ongoing basis through internal staff meetings (e.g.,
TLC+ workgroup and the Quality Improvement Committee), provider meetings, community
planning group meetings, local and national conferences, CDC, HRSA and the State Office of
AIDS, and various program reports and peer reviewed journals. Depending on the dissemination
channels, not only the EIIHA plan and data are presented, but program successes and challenges
are also shared. In some cases, the EIIHA-related activities will translate into training curricula
and standards development.
The planned dissemination methods for FY 2014 include: LAC Comprehensive FiveYear HIV Plan, updated annually and shared broadly online; DHSP HTS annual report published
online; HTS quarterly reports published online; HTS year-to-date data, accessible to HTS
providers; quarterly HTS coordinators meetings; quarterly Medical Care Coordination (MCC)
providers meetings; periodic HTS and MCC provider meetings; annual presentation at
Commission on HIV, the newly integrated HIV planning body; presentations at the
Commission’s Standards of Care and Best Practices Committee meetings; monthly DHSP TLC+
workgroup meetings; internal monthly DHSP Quality Improvement Committee meetings; and
annual “State of the Epidemic” address to the community by DHSP director on World AIDS
Day. Additionally, DHSP staff members submit abstracts to present at national and regional
conferences and peer reviewed journals on an ongoing basis. DHSP also presents EIIHA data
during funders’ site visits and reports EIIHA plans and data as part of its funding requirements to
CDC, HRSA and the State Office of AIDS.
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WORK PLAN
1. ACCESS TO HIV/AIDS CARE AND THE FY 2014 IMPLEMENTATION PLAN
1A.
Continuum of Care for FY 2014
The EMA’s Established Continuum of HIV/AIDS Care
Continuum of HIV Services. No single set of services can effectively address the wide
range of ethnicities, social identities, risk behaviors, clinical needs and service expectations of
HIV-positive clients in LAC. The most effective service delivery lies in a continuum of care that
ensures access and entry into care at any point, and coordinates required core medical and
support services specific to each patient’s needs.
Figure 2 depicts the multi-dimensional nature of LAC’s HIV/AIDS services, focusing on
specific outcome goals and objectives. It further describes where process and health indicators
impact patient and process outcomes, and models mechanisms for improving service
interventions to achieve better client- and population-level results. Adopted by the Commission
in 2007, it preceded Gardner’s “treatment cascade” by almost three years, but is remarkably
similar in scope and intent: both identify the key steps towards individual viral suppression and
lowered community viral load as diagnosis, linkage/entry into care, retention in care, and
adherence; both provide a vehicle to measure system effectiveness at each stage; and both
indicate pathways to improved health and population outcomes. During the development of the
Comprehensive HIV Plan last year, the Commission prioritized viral suppression as the primary
“health status outcome” and aligned the population goals with the three primary goals from the
NHAS in order to mirror accepted national strategies in the local continuum of prevention/care.
Figure 2: HIV/AIDS Continuum of Care, County of Los Angeles.
At the core of the diagram is a population flow map (resembling the treatment cascade)
illustrating the path of individual clients through the system of care, beginning with people at
no/low risk of HIV through primary, secondary and tertiary prevention activities, then to care
and treatment for those in need. Integration of prevention with care/treatment is a chief
component of this new continuum. It emphasizes that care and treatment effectiveness is
measured by the ability of services to increase patients’ awareness, facilitate their entry and
retention in care, and help them maintain treatment adherence, which leads to improved health
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status, quality of life and self-sufficiency. With arrows in both directions, the diagram
acknowledges that individuals can also fall out of care or become treatment non-compliant.
Below the population flow map is a diagram of how services in the LAC continuum of
care intersect, whether funded by RW or by other sources. In this portrait of “treatment as
prevention,” it reiterates how treatment is part of care, and both are part of prevention. RWfunded services only represent a portion of the entire service tapestry in LAC, but the model
indicates that prevention, care and treatment services can be offered by multiple, diverse
mechanisms. The services enable HIV patients to move towards adherence and HIV-negative
clients to move towards low risk—the ultimate goals of care/treatment and prevention,
respectively. Adequate resources and defined standards of care (minimum expectations for
quality of care) are the foundation of the entire continuum.
Like the treatment cascade, the patient flow map indicates desired process outcomes: risk
reduction, diagnosis, linkage to care, retention and adherence. The system’s ability to achieve
those outcomes promises better patient/client outcomes (above the patient flow diagram)—health
status, quality of life, self-sufficiency—and improved population outcomes (above the individual
outcomes) reflecting the NHAS goals: reduced HIV incidence, greater access to care and
optimized health outcomes, and reduced HIV-related health disparities.
Integrated HIV Prevention/Care Planning. July 2013 marked the conclusion of two
years of considerable structural and foundational planning for the integration of HIV prevention,
care and treatment into a single, ongoing planning effort, and the beginning of a year of process
review and planning that will enable a fully integrated system of HIV prevention, care and
treatment. In February – March 2013, the Commission and the Prevention Planning Committee
(PPC) unanimously approved a comprehensive HIV plan (2013-2017) that combines prevention,
care and treatment strategies into a single integrated blueprint for LA County’s continuum of
HIV services (from prevention through treatment adherence and viral suppression).
As the plan was being finalized, the County’s two principal HIV planning groups
(Commission and PPC) began their work to merge into a single HIV planning body. The two
groups concluded the structural reorganization for the new, unified planning body (the
Commission) when the local governing ordinance was enacted, new membership installed, and
new bylaws were ratified on July 11, 2013. Responsibilities for the newly unified Commission
now encompass planning for the scope of HIV prevention, care and treatment and STD control,
prevention and treatment services. The Commission is simultaneously in the midst of leading the
development of a comprehensive, integrated HOPWA/RW plan to ensure coordination between
RW services and HOPWA-funded housing and supportive services.
Since July, the Commission has selected new community planning leadership, established
new work committees, and is beginning to develop an integrated work plan. The work plan will
entail a review and modification of all Commission duties and processes to ensure that they
adequately and equally address the needs for HIV prevention and STD planning concurrent with
HIV care/treatment planning. Processes for annual priority- and allocation-setting; evaluating
service effectiveness; standards/minimum expectations development; and defining new,
integrated HIV service models, strategies and best practices, among many others, will be
appropriately revised to reflect this new, integrated community HIV planning approach.
Changing Service Delivery due to the Implementation of the Affordable Care Act
(ACA). As an early adopter of health care reform, California begin enrolling HIV patients in
low-income health programs as a precursor to Medicaid Expansion more than a year ago. The
initial year-long enrollment of former RW medical patients into Healthy Way LA (HWLA, LA
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County’s LIHP) concluded in July 2013, and DHSP and the Commission are examining
continuity of care, access to comprehensive health care, and continuing HIV care effectiveness in
both the LIHP and the RW Program.
DHSP and the Department of Health Services (DHS) began encouraging all RW
providers to contract with the LIHP as well in order to facilitate the seamless transition of
services for patients. DHSP, DHS and the Commission worked for months to develop a
pharmacy access network that locally resembled the ADAP network throughout the State.
Preparing for and monitoring of this patient migration into a new health care system required the
Commission to develop advanced modeling tools with which to forecast how allocations would
need to be redistributed, what services would be covered by the LIHP or the RW program, what
“wrap-around” services would need to be strengthened, and how gaps in continuity of care could
be corrected in short time frames. DHSP and the Commission have adjusted multiple services to
accommodate the transition: the MCC “medical home” model was implemented as the primary
gateway into care for all RW patients and as a key vehicle to improve patients’ retention in and
adherence to care. The benefits support services were launched more than two years ago in
anticipation that patients/clients would need even more advocacy and education to navigate the
upcoming complexity of the ACA. Oral health services continue to be expanded as Medi-Cal’s
dental program (Denti-Cal) was cut in 2009 due to statewide economic shortfalls. Likewise, the
Commission consolidated its more than 30 standards into 17 to make them more manageable, as
the Commission urges the adoption of local HIV standards by the other health plans in Covered
California (the insurance exchange).
As the initial LIHP enrollment of RW patients has closed, planning for the next sequence
of ACA preparations has begun: migrating LIHP patients into Medi-Cal managed care and
Covered California. The Commission has been hosting forums on Covered California
requirements, and will dedicate its Annual Meeting in November 2013 to the new managed
health care landscape. DHSP has been polling all of the RW providers to ensure that they are
contracted with at least one of the selected Covered California health plans to enable RWP
patients to stay with their HIV specialty providers. Both the Commission and DHSP are
currently reviewing essential services under each of the health plan options in order to better
understand what service allocations should be maintained, increased or reduced as patients move
into Medi-Cal or the other health plans, and are monitoring the ongoing enrollment in Covered
California to discern emerging gaps in service delivery or continuity of care. Special attention is
being paid to health plan formularies and the provider prescription exemption requests that will
be required, the extent and limitations of mental health services, and where and if substance
abuse services will be offered by health plans. DHSP and the Commission are developing a new
cost-sharing strategy with the State Office of AIDS to pay for additional, individual patient
healthcare costs where allowed under Health Insurance Premiums/Cost-Sharing (benefits
support), and trainings are underway to prepare benefits specialists and MCC teams for the more
complex and varied service mixes that will emerge from Covered California enrollment.
Additionally, both the grantee and the planning council are considering how traditional HIV
prevention services and biomedical interventions will be addressed by Medi-Cal and the Covered
California health plans, and how the integration of prevention and care services in the RWP and
under ACA can facilitate increased early diagnosis and access and entry into care.
Outreach/Enrollment of Part A Clients into New Health Coverage Options. Covered
California has funded several RWP providers to offer information and education to RW and
other patients during its enrollment period. The RWP will collaborate with these “enrollers”
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through three primary vehicles: benefits support, MCC and information/ referral services.
Benefits specialists are being prepared to help RWP patients who are eligible for Covered
California to navigate multiple health plan choices. MCC teams will help them develop
comprehensive treatment plans involving services from multiple payer sources, while continuing
to coordinate comprehensive HIV care for those patients who are not covered by the ACA.
Consistent with its responsibility to “promote the availability of services,” the Commission will
launch an information/referral service to answer patients’ health care options questions, refer
them to appropriate health plans and providers as necessary, and to correct the rising tide of
misinformation and unauthorized broker information that is increasingly confusing consumers.
Access and Retention for the Newly Infected, Underserved, Hard-to-Reach, and
Disproportionately Impacted Communities of Color. LAC’s HIV care system focuses on
engaging PLWHA in each of the stages from diagnosis, access to care, retention in care, and
treatment adherence. To ensure a smooth transition from diagnosis to treatment, the continuum
of care links HIV testing and wrap-around support services with 40 primary HIV medical care
sites throughout the county. A variety of service modalities target different intervention points
throughout the continuum of care to support access and retention to achieve viral suppression
and decreased community viral load.
• HIV Testing Services (HTS): Over 200 publicly-funded HTS sites primarily funded by the
CDC bring awareness of HIV status to many with special service needs. Various expanded
HIV testing initiatives endeavor to find people who may not be aware of their HIV risks and
connect them with the medical care they need.
• Linkage to Care: Linkage to Care (LTC) services encompass early intervention and
transitional case management (TCM) and support access to care for HIV-positive individuals.
Early intervention services emphasize outreach efforts and serve as important portals for the
hard-to-reach and out-of-care PLWHA to be linked into the HIV continuum of care. TCM
targets two highly vulnerable populations: youth ages 13-24, with an emphasis on youth of
color, and HIV-positive individuals in County jails (the majority of whom are people of
color) to ensure continuity of care from inside the jail system to re-entry into the community.
• Medical Care Coordination (MCC) and Benefits Support Services: To support adherence and
optimal health outcomes, patient-centered medical homes with MCC will be the anchor of
care for RWP patients. MCC blends medical and non-medical case management and
treatment education to coordinate care for patients through the development of
comprehensive treatment plans that address both clinical and psychosocial needs of the
patients, as well as referrals to other services such as mental health and substance abuse
treatment. Benefits support services help enroll patients in non-RW public assistance
programs. These serve to support HIV patients who experience significant barriers accessing
services and remaining in care.
• Minority AIDS Initiative (MAI): Service availability and scope of services for MAI-funded
oral health have been expanded significantly in previously underserved areas to address
needs identified by the needs assessment and with a goal of oral service availability to all
RW clients. Starting in 2014, MAI will begin funding LTC and TCM to expand service
access and availability for the three targeted populations described above and overrepresented in communities of color.
• Medication Assistance and Access: AIDS Drug Assistance Program (ADAP) Enrollment
provides access to FDA-approved HIV medications available from the California ADAP
Program. LAC also allocates Ryan White funds for pharmaceutical assistance in order to
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provide access to drugs not covered by the ADAP Program.
• Retention in Care: Multiple services are provided to facilitate retention in care, including
medical transportation and nutrition support. Several retention interventions are being tested
for potential scale-up implementation, e.g., retention navigation, clinical linkage specialists,
and a social network re-engagement strategy.
1B.
FY 2014 Implementation Plan
Attachment 9 includes the four core services and two support services for which the
Commission has allocated the largest proportion of Part A funding for FY 2014. These core
services are medical outpatient services (including medical specialty services), oral health care,
medical case management (medical care coordination), and mental health services; the support
services are non-medical case management (benefits specialty services and transitional case
management for youth and incarcerated individuals) and substance abuse residential services.
The plan also identifies the top two services allocated the most MAI funding: oral health care
and non-medical case management (linkage case management).
1C.
Narrative
Needs Assessment, Comprehensive Plan, Service Priorities and Implementation Plan
RW legislation requires the Part A Planning Council (Commission on HIV) to prioritize
services and make RW resource allocations. The local comprehensive plan, Los Angeles County
Five-Year Comprehensive HIV Plan (2013-2017), was developed through an integrated planning
process formed by local HIV prevention and care planning experts. Using results from the needs
assessments, unmet need estimates, and analysis of epidemiologic, HIV testing and HIV care
service utilization data, the plan identifies overarching goals and objectives for the next four
years and guides specific implementation efforts. The most recent needs assessment is the
LACHNA-Care 2011 Report.
The new Comprehensive HIV Plan outlines a comprehensive, sustainable, and accessible
system of HIV care through a continuum of services that addresses consumer needs though the
entire HIV continuum from screening to diagnosis, to achieving viral suppression and other
positive health outcomes. Goals outlined in the current plan include: 1) Eliminate new HIV
infections; 2) Optimize health outcomes for all PLWH; 3) Ensure universal access to and
maximize engagement with quality HIV and related services; 4) Eliminate HIV-related
disparities; and 5) Create a seamless system, inclusive of public and private sectors,that best
responds to HIV and related social determinants of health. The new comprehensive plan is an
integrated prevention and care plan, constructed through the lens of NHAS and ACA elements.
The Comprehensive HIV Plan describes system-wide goals and objectives to guide the
implementation of the established priorities. The FY 2014 implementation plan is guided by the
strategies identified in the Comprehensive HIV Plan. The relevant strategies include reducing
CD4 count and achieving viral suppression among PLWHA, implementing the medical care
coordination model to improve access to LAC’s continuum of HIV services, and improving
retention in care and treatment adherence among PLWHA. The FY 2014 implementation plan
follows the Commission allocations, and outlines measurable goals and objectives consistent
with the Comprehensive HIV Plan.
Core Services Not Allocated RW Funding
A number of core medical services were not allocated RW funds because other funding
sources pay for these services. They include: ADAP enrollment, medical nutrition therapy,
home health care, and outpatient substance abuse treatment. In most cases, Medi-Cal, Medicare,
and other State resources were the sources of funding for these services. SAMHSA and the
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County General Fund also contribute funding.
HIV medications are a high priority in LAC, but since California’s ADAP remains intact,
to maximize Part A funding as payer of last resort, the Commission has allocated limited Part A
funds to support HIV-related medications not included in the State ADAP formulary. All DHSPfunded medical care providers participate in the 340B Drug Pricing Program.
Although Medicaid expansion and the ACA insurance marketplace will provide many
RW clients the essential health benefits prescribed by the law, a significant number of clients
will remain ineligible for coverage. Several core services still receive RW allocations, but at a
reduced percentage for this reason.
Increased Access to the HIV Continuum of Care
With an estimated 58,000 PLWHA dispersed across more than 4,000 square miles, the
planning and delivery of effective services must be responsive to an evolving epidemic.
Increasingly, DHSP is using cluster mapping to identify “hot-spots” to target HIV screening, and
the TLC+ model to expedite enrollment of newly diagnosed and out-of-care individuals into HIV
medical care. LAC leverages federal, state and local resources to increase access to the HIV
continuum of care for PLWHA. This begins with identifying and informing undiagnosed
persons with HIV through a wide spectrum of HIV testing modalities, and immediately linking
those who are diagnosed with HIV to medical care.
Health care reform efforts in California have led to significant changes to the local health
care systems. Ryan White clients who enrolled in HWLA will automatically become Medi-Cal
clients under Medicaid expansion of the ACA. In 2014, additional clients will begin to transition
to Covered California marketplace. With the changes in insurance coverage and, for some,
changes in care access points, RW-funded MCC, benefits support, and LTC will offer assistance
to help PLWHA navigate the new care systems to access HIV medications and treatment.
The Commission still allocates substantial Part A funding to medical outpatient and
specialty services to provide access to HIV care for patients who are not eligible for care under
ACA. Since November 2012, DHSP has increased the number of medical outpatient clinic sites
from 32 to 42, increasing the access points by 38%. Each of these clinics serves as the medical
home for their HIV patients, and provides effective care that supports patients’ viral control and
optimal immune status. With MCC co-located at each of these medical homes and a designated
linkage to care liaison as part of the MCC team, patients are linked to care from HIV testing
sites, and immediately connected to supportive services based on their assessed need and acuity.
Oral health is critical in supporting HIV medication adherence and good health outcomes
for PLHWA. In response to the need to improve access to oral health care, LAC has expanded
the dental service provider network to meet high demand. By adding new providers and
enhancing the capacity of existing providers, DHSP has increased oral health service delivery
capacity from 3,182 clients as of March 2012 to a projected 9,987 clients for FY 2013. This
represents a 210% increase in overall system capacity in just two years.
Linkage to care (LTC) services funded by MAI in FY 2014 will perform a critical role in
engaging or re-engaging PWLHA in care. Establishing relationships with HIV testing sites and
outreach to identify newly diagnosed and out-of-care populations will be a key strategy for LTC.
DHSP will introduce interventions that have been proven effective, e.g., Antiretroviral Treatment
Access Study (ARTAS) linkage, to increase access to HIV care for newly diagnosed individuals.
In addition to the medical homes, PLWHA receiving other services such as housing,
nutrition support/food bank, substance abuse treatment, mental health services or STD treatment
can be connected to HIV primary care by active referrals and client linking mechanisms.
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Needs of Emerging Populations
As indicated in the implementation plan, services for emerging populations are blended
into the overall service delivery system in the EMA, given that the majority of PLWHA in LAC
are poor, have inadequate or no health insurance, or have co-morbid conditions. With the
implementation of ACA, an emerging need for PLWHA is to navigate the new insurance
screening and enrollment system to maintain continuity of their medication access and HIV care.
Some patients who had traditionally relied on the Ryan White Program for HIV care will now
need education on basic knowledge of navigating care within new provider environments.
For clients who will remain in the Ryan White system, access to primary medical care
remains the highest priority. Medical providers are trained to be keenly aware of the impact of
co-morbidities. Therapeutic monitoring and viral resistance testing address the drug resistance
frequently seen among populations that experience difficulty adhering to treatment regimens.
Although cultures or communities are commonly defined by ethnicity, race, language,
and sexual orientation, it is imperative to also consider age, gender, homelessness, and substance
use when serving populations with challenges in accessing and adhering to care. When services
are provided to these vulnerable populations, DHSP ensures that staff members of contracted
agencies are sensitive to and aware of these socio-cultural factors and have specific plans for
responding to the particular characteristics of the local epidemic. Funding that targets specific
populations such as Latino/as, African Americans, women of color, substance users, mentally ill
persons, transgenders and youth is distributed to agencies that have connections to and expertise
with these groups, with a focus on identifying and keeping people engaged in care.
A spectrum of core medical and support services are funded to help emerging populations
achieve optimal health. Medical outpatient and medical specialty services respond to the greatest
needs expressed by service consumers. Many RW-funded HIV medical homes provide
culturally-sensitive services for gay, lesbian, and bisexual individuals. Several HIV medical
homes are located in south Los Angeles, where Latino/a and African American PLWHA reside
and where health disparities persist. A new HIV medical home specializing in serving the
homeless is located near Skid Row, an area of downtown Los Angeles with a large concentration
of homeless individuals. Two medical homes are youth clinics specializing in serving
adolescents and young adults. One medical home is known for its services for HIV-positive
women. A medical home is located in an area where long distances and transportation to any
health center have been major challenges. MCC is operating in every RW-funded HIV medical
home so that members of the vulnerable populations can address challenges and have early,
consistent access to HIV services. MCC will also function as a link for clients who have private
insurance for their medical care but still need support to achieve and maintain optimal health.
To ensure access to care by hard-to-reach populations, Part A funds are distributed to
agencies that provide transitional case management in the LAC jail system, where some
individuals first learn of their HIV infection and need assistance transitioning back into the
community, and to agencies in south Los Angeles and Hollywood/West Hollywood areas where
a majority of young men who have sex with men (MSM) and transgender youth reside or
socialize. Transitional case management can assist youth in the process of maintaining
medication adherence by providing education and social support, as well as helping youth
navigate a complex health care system and attend scheduled medical appointments.
Oral health services are funded to reduce health disparities—especially among African
Americans and Latino/as. LAC has taken significant strides to expand capacity for oral health
services in the County. These include increased access points and more dental chairs available to
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serve RW clients; funding for treatment procedures to avoid unnecessary tooth extractions; and
identifying endodontists to perform more complex dental procedures to help clients retain teeth.
Considerable funding is allocated for mental health and residential substance abuse
treatment to help individuals overcome impediments to optimal health and functioning.
Keeping PLWHA Engaged in HIV/AIDS Primary Medical Care
All Part A-funded services in LAC share the same ultimate program goal: to help
PLWHA engage in primary medical care, achieve viral suppression and the best possible health
outcomes. This is accomplished through offering services that help address barriers to consistent
medical care, obtaining viral load and CD4 tests to monitor disease progression, and adhering to
prescribed medication regimens.
Medical care coordination is the most critical service in the new HIV care environment to
help PLWHA engage or re-engage in HIV medical care. MCC services are co-located at every
Ryan White HIV medical home to facilitate engagement in care for newly diagnosed patients and
patients who are not in care consistently. Self-managed patients will be screened twice a year to
assess their need for MCC, since patients’ acuity levels fluctuate as their life situations or ability
to adhere to care regimens change. A full MCC team consists of a Registered Nurse medical
care manager, a Master’s level social worker who acts as a patient care manager, and several
case workers. These team members are responsible for conducting comprehensive assessments,
determining each patient’s acuity level (i.e., severe, high, moderate, or self-managed), and
developing integrated care plans to promote linkage to and retention in care. The medical care
manager acts as the team leader to ensure that the patient’s medical needs are met and care is
coordinated. The patient care manager works with the medical care manager to ensure
comprehensive assessment of the patient’s psychosocial needs, particularly as they relate to
mental health and substance abuse issues. Case workers assist the medical care manager and
patient care manager with patient care coordination, follow-up, and data entry. MCC provides
holistic, coordinated, and integrated services across providers, and brief interventions (e.g.,
treatment adherence, risk reduction counseling, disclosure assistance) that are intended to help a
client identify a problem and motivate him or her to resolve it.
Under the MCC model, individuals with severe and high acuity levels receive more
intensive and frequent follow-up meetings to ensure that barriers to care are removed. The MCC
team is responsible for coordinating necessary referrals and connecting patients to other Ryan
White and non-Ryan White-funded services (e.g., medical specialty, housing, mental health and
substance abuse treatment) —to help them stay in care.
Part A and MAI funding is allocated to a range of core medical and support services to
support patients’ engagement in care. Mental health and residential substance abuse treatment
are funded to address the serious challenges with mental health and substance abuse issues
experienced by many PLWHA in LAC. Home-based case management provides care at
patients’ homes by teams of RNs and social workers to assist patients who are too sick to access
services outside their homes. Benefits enrollment services help connect patients to various
public programs to gain assistance to continue treatment. Taxi, bus, and rail transportation
services enable Ryan White clients to attend their appointments. Nutrition support services
provide critical home-delivered meals and groceries to support the nutritional needs of PLWHA.
DHSP funds residential care using County funds to help disabled clients or clients with unstable
housing situations to access or maintain their HIV medical care in a safe and stable environment.
With health care reform well underway in California, RW patients with income below
133% FPL have been transitioning to the LIHP for primary medical care. To maintain continuity
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of care for all patients who receive publicly funded HIV care, DHSP worked with DHS, the
LIHP administrator, to bring all RW Part A medical providers and pharmacies into the LIHP
network, so that patients will not need to change medical providers in order to access LIHP
benefits. Approximately 4,000 RWP patients already use the LIHP for their primary medical and
medical specialty care. Services are structured around each patient’s medical home under the
MCC model to address access barriers to HIV medical care regardless of payer sources to ensure
both access and quality of medical care. LIHP clients will automatically be transitioned to MediCal services as health care expansion progresses in 2014. Additional clients will be eligible for
Covered California. LAC has been working with California OA to keep people in HIV care, and
will leverage the OA plan to expand OA-HIPP, the state’s insurance premium assistance
program for PLWHA, to assist the increased number of people who can get health coverage with
minimal cost to the RWP.
Parity of HIV Services
Geographic Access. It is challenging to ensure geographic parity so that services are
accessible where clients reside or where special populations congregate. The County is divided
into eight Service Planning Areas (SPAs) for health planning purposes. Re-solicitations for
services and renewals of service contracts are guided by SPA-based planning, with a goal of
achieving parity between the distribution of low-income people with HIV/AIDS and the
distribution of resources for services throughout the County. The 42 HIV medical care provider
sites are dispersed County-wide, forming interlocking hubs of service delivery that provide the
foundations for building and maintaining systems of care in each area.
Quality of Services. Joint efforts of program monitoring and quality management ensure
all DHSP-funded HIV care services meet or exceed the national treatment guidelines and local
standards of care. Service objectives and outcomes are clearly stipulated in the contracts.
DHSP’s quality management team annually assesses providers’ performance and their progress
in quality improvement. These activities are coordinated with performance-based contract
monitoring (PBCM) conducted by program managers. PBCM has expanded to reviews and
trending of patient CD4 counts, viral loads, STIs, TB services and other health and process
outcomes. Performance measures include those published by HRSA’s HIV/AIDS Bureau
(HAB). The Patients’ Bill of Rights and “grievance line” for consumers and others to report
service challenges or file complaints provide additional measures to assess the delivery of
services, and identify quality of care issues and opportunities to improve the quality of services.
Comprehensiveness of Services. Funds for the RW services are allocated through
careful consideration of need, available services or resources, and modalities of services. Core
medical and wrap-around services (designed to promote service access and retention, and reduce
gaps and barriers) provide comprehensive HIV care for PLWHA in LAC. Within each service
category, a comprehensive approach is crucial Medical outpatient services provide
comprehensive education, prevention, diagnostics, and therapeutic treatment to promote optimal
health and quality of life. Local standards of care mandate multi-disciplinary case conferencing
among providers, so that clients can be assessed and referred to the spectrum of services
available. DHSP requires contracted providers to use the electronically-linked referral system so
that referrals to other services can be tracked and followed.
Cultural Appropriateness. DHSP continues to follow guidelines published in the
National Standards for Culturally and Linguistically Appropriate Services in Health Care
(DHHS Office of Minority Health, 2001), and supports service providers through trainings to
ensure cultural competency. DHSP also provides ongoing trainings and educational material
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translation services to extend provider cultural competency beyond racial and ethnic awareness
to include health literacy and other special population needs. More than half of DHSP-funded
agencies are providers who have also served predominantly communities of color for many
years. Bilingual staff are required for services for Latino/as. Language Services funded through
County resources assist other non-English-speaking and hearing impaired people access care.
Culturally and Linguistically Appropriate Services
Culture encompasses beliefs, values, communications, and practices that characterize
racial, ethnic or social groups. It delineates how clients perceive the nature of their illness, and
how they receive information and express symptoms or concerns. Given the cultural and
linguistic diversity in LAC, and HIV’s associated stigma and the resulting fear of disclosure, it is
critical to provide culturally and linguistically appropriate services to PLWHA so their health is
not compromised because of these barriers. DHSP ensures that culturally appropriate services
are provided by agencies with a track record of appropriately serving communities of color and
special target populations. Both local standards of care and service contracts require, at a
minimum, bilingual (English/Spanish) staff on site and availability of assistance for other
languages. Beyond that, DHSP expects providers to be culturally competent in order to
recognize and respond to various health beliefs and cultural values to enhance treatment efficacy.
These standards are achieved through staff diversity that mirrors client demographics, and also
through ongoing training and education. Essential materials and consents, as well as signage at
service sites, must be provided in the languages at appropriate literacy levels.
National HIV/AIDS Strategy
The White House released the National HIV/AIDS Strategy (NHAS) in July 2010 with
three basic goals: 1) reducing new HIV infections, 2) increasing access to care and improving
health outcomes for people with HIV, and 3) reducing HIV-related health disparities. Many of
the services that are part of LAC’s implementation plan support the NHAS goals. Medical
outpatient and pharmaceutical assistance services provide care and medications that enable
patients to live longer, healthier lives, achieve viral suppression, and ultimately reduce the
likelihood of transmitting the virus to others. Medical care coordination services increase access
to care, enhance retention in care, and aim to reduce health disparities, particularly among high
acuity patients with complex health problems, and emerging populations affected by HIV.
Mental health and substance abuse services address co-morbid conditions that otherwise create
barriers to care and treatment adherence.
Healthy People 2020
LAC’s commitment to help increase individuals’ life expectancy, improve the quality of
care and quality of life, and eliminate health disparities between distinct segments of the
population is consistent with HRSA’s mission and the goals outlined in Healthy People 2020.
The Healthy People 2020 framework includes the following overarching goals: 1) attain
high quality, longer lives free of preventable disease, disability, injury, and premature death, 2)
achieve health equity, eliminate disparities, and improve the health of all groups, 3) create social
and physical environments that promote good health for all, and 4) promote quality of life,
healthy development, and healthy behaviors across all life stages.
To promote healthy behaviors, DHSP-funded medical outpatient providers are expected
to screen clients for risk behaviors, communicate prevention messages to clients, discuss drug
use and sexual risks with clients, and positively reinforce changes to safer behavior. RW clients
in LAC routinely receive diagnostic screening and prophylactic services. The standard of care
requires that 100% of clients entering care will receive a CD4 test, viral load test, antiretroviral
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therapy and opportunistic infection prophylaxis, as clinically indicated for clients who are in
care. The goal is that at least 80% of clients will maintain undetectable viral loads and have
stabilized or increased CD4 counts from their initial assessment. Annual TB, hepatitis and STD
screenings are part of the standard of care for HIV medical outpatient visits. Current standards
necessitate screening for gonorrhea, syphilis and chlamydia for at least 90% of clients in care and
TB screening for at least 75% of clients in care.
Though LAC is still challenged by high HIV incidence and high proportions of
historically underserved populations who are diagnosed and enter care at a later stage of HIV
disease, care provided in LAC has decreased mortality and improved patients’ health outcomes
(HIV Epidemiologic Profile, 2009; Sayles J., 2011).
Resource Allocations to Women, Infants, Children and Youth (WICY)
In FY 2012, 16.72% of Part A funds available for direct services were used for WICY
populations. This percentage exceeds the 14.64% of HIV and AIDS cases reported among WICY
populations. Contracted providers are required to document the number of WICY clients served
and to track Part A funds spent on the WICY population. These data are reported in Casewatch,
the data management system used for DHSP-funded HIV care services, and in monthly financial
and program reports.
Use of Minority AIDS Initiative (MAI) Funding
The FY 2013 MAI plan allocates funding for medical care coordination (MCC), linkage
to care, and oral health, in order to continue improving health outcomes and reducing disparities
to access for racial/ethnic minorities.
During the FY 2014 priority- and allocation-setting process, the Commission adopted a
new MAI plan that continues to fund, in part, the current oral health care expansion efforts and
expanding LTC services, but replaced the allocation for MCC with an allocation for Transitional
Case Management (TCM). While MCC will continue to be funded with increased Part A dollars,
is aimed at helping providing “bridge” case management services for youth, homeless and
PWLHA leaving incarceration facilities—all key populations in which HIV impacts minorities
significantly—into MCC. Given the substantive changes already underway related to ACA
implementation and in the local RW Program, the Commission agreed to a flexible timeline for
implementing the new MAI plan in FY 2014, or possibly delaying it until FY 2015.
The MAI program plays an integral and critical role in the LAC’s continuum of HIV
services, because it represents one of the most clearly directed efforts aimed at addressing unmet
need and serving disenfranchised populations of color. MAI-funded services enhance access to
care and improve the clinical outcomes for populations of color by increasing availability of
critical core medical services such as oral health care, outreach to vulnerable and out-of-care
populations, and supporting retention/adherence through medical care coordination.
Use of Unmet Need Analysis in Planning Council’s Allocation Decisions
The Commission’s P&P Committee assesses how each service category contributes to
reducing unmet need. The Committee evaluates whether the service’s potential impact on unmet
need merits higher prioritization and/or additional allocations. In several service areas, such as
MCC, LTC and benefits support, addressing unmet need has resulted in increased allocation
levels or has averted allocation reductions. Rates of unmet need are compared to service
utilization by new clients in order to define an acceptable threshold and expectation in future
years. Analysis of the unmet need populations from the needs assessment is also considered. This
strategy has resulted in a steady decline in the estimate of unmet need among PLWHA in LAC
over the last few years. In the forthcoming year, the Commission will engage the services of an
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unmet need expert, Emily Gantz McKay, to help implement new strategies to target services and
activities more specifically to reduce unmet need.
Considering the Need for HIV Medications During Allocation Process
HIV patients receiving RWP-funded treatment in LAC are fortunate that California’s
ADAP (funded by RW Part B, the State general fund and pharmaceutical rebates) has one of the
most comprehensive medication formularies in the country, and that leadership throughout the
State in multiple administrations has kept that formulary intact in spite of the State’s past
negative economic climate. The Commission has included funding for local medication access
and assistance beyond the ADAP formulary in the combined 39% allocation for medical
outpatient/medical specialty/medication assistance and access.
The Commission consolidated its medication assistance/access service category to
facilitate medication access if ACA implementation in 2014 or the California’s continuing
stagnant economic climate leads to formulary changes in the future. For FY 2014, the
Commission has allocated 2% of available funding for direct services to this category.
During the transition to the LIHP, DHSP and the Commission actively consulted with
DHS to ensure consistent pharmacy access and formulary coverage for RW patients enrolling in
the LIHP. During the course of several meetings with DHS’ Pharmacy Services staff, the
Commission underscored the need for DHS to expand its network of covered pharmacies to
ensure adequate access, especially for those from underserved populations or geographically
isolated locations, and helped shape the eventual pharmacy program for the LIHP. Since then,
DHS has continued to request Commission feedback that it has gathered from consumers, and
dialogue with the Commission on anticipated medication gaps that may develop in the insurance
marketplace (Covered California).
Addressing Population Groups in EIIHA During Allocation Process
Local needs assessment data includes the full spectrum of data from people at risk of
HIV, unaware of their HIV status, with unmet need, and in the care system. These data were
analyzed based on special need populations identified by the Commission and the Prevention
Planning Committee, which include target populations for HIV testing, prevention, care and
treatment services. The data were presented to the P&P Committee along with the updated HIV
Epidemiologic Profile to be considered in the planning and allocations decision-making.
Although the majority of local EIIHA activities are funded by the CDC, the Commission
considered needs, gaps and barriers for individuals throughout the entire continuum of care when
making allocation decisions. Due to the recent unification of the Commission and the PPC, this
process will be fully integrated by the time the Commission begins in FY 2015 priority- and
allocation-setting process in January 2014.
EVALUATION & TECHNICAL SUPPORT CAPACITY
1. CLINICAL QUALITY MANAGEMENT
1A.
Description of CQM Program
a) CQM Plan Goals and Infrastructure
LAC established a Clinical Quality Management (CQM) Program for HIV/AIDS services
in 1998. Consistent with the overall mission of DHSP, the CQM Program has as its core the
commitment to ensuring the most effective and evidence-based HIV prevention, testing,
care/treatment, and support services for people living with or at risk for HIV/AIDS. It places
particular emphasis on assessing the system of care and ensuring that the range of HIV services
provided is evidence-based and consistent with the Public Health Services (PHS) Guidelines and
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locally adopted standards of care.
Vision, Purpose and Goals. The purpose of DHSP’s CQM Program is to promote the
delivery of responsive, evidence-based, high quality HIV testing, care and support services to
persons at risk for, living with, or affected by HIV in LAC. The CQM Program, guided by
DHSP’s CQM plan, facilitates ongoing, integrated performance improvement activities, uses
data collected from clinical/performance indicator monitoring and other sources to guide and
prioritize quality improvement activities, and provides technical assistance for service providers
through sharing of performance data and other quality resources. The CQM plan establishes
expectations for on-going collaboration with contracted agencies, planning bodies, experts in the
field and consumers in order to achieve goals of reducing the number of people who become
infected with HIV, increasing access to care and optimizing health outcomes for people living
with HIV, and reducing HIV-related health disparities.
Roles and Responsibilities. The CQM Program is supported by strong leadership and
commitment to quality goals. Since its inception, the CQM Program is clinically guided by
DHSP’s HIV Medical Director and supported by its Executive Director and Senior Management
Team. The HIV Medical Director oversees the Quality Management Division (QMD), which,
led by the Chief of Quality Management, is responsible for the facilitation and implementation of
CQM activities for the entire organization. The QM Chief meets bi-weekly with the HIV
Medical Director to review routine CQM activities and progress. Internal quality issues are
referred to the QMD for action and resolution. The QMD is responsible for ensuring continued
facilitation of quality assurance activities including performance measurement using evidencebased and nationally recognized indicators, and for providing training and TA as needed.
In June 2013, DHSP revitalized its Quality Improvement Committee (QIC) based on the
organizational assessment conducted by a TA consultant whom DHSP requested through
HRSA’s National Quality Center. The QIC is composed of DHSP’s senior management team,
chaired by the DHSP Director, and facilitated by the QM Chief. The QIC’s charter stipulates its
role and responsibilities which include: reviewing quality related reports and other information;
providing recommendations; and prioritizing actions to address issues related to quality, risk,
safety and barriers affecting DHSP’s ability to carry out its mission.
Quality data, reports and priorities are shared with the QIC. The QIC meets monthly to
receive and review data and to discuss operational and other issues related to core business
functions. There is a strong culture of proactive problem identification and quality improvement
within DHSP. The QIC sets the strategic direction for quality HIV services. The HIV Medical
Director and QMD oversee the implementation and ongoing monitoring of the CQM Program,
recommend policy decisions, analyze and evaluate the progress and outcomes of QI activities,
and institute needed actions and ensure follow-up. The HIV Medical Director and the QMD team
are actively engaged in various work groups and collaborative efforts. By acting as agents of
change, quality of care and service issues are identified and improvement activities are
facilitated. Implementation updates, outcomes and follow-up activities are fed back to the QIC.
DHSP also shares data and results of measurement activities with the Commission on HIV and
with providers through presentations at the Standards of Care Committee, regular Commission
meetings and at provider meetings. Feedback from these bodies is directed back to the QIC and
QMD for action.
The QMD has a staff of 25 employees; 10.81 FTEs are supported by RW Part A funds.
These include registered nurses and allied health staff, health educators and administrative staff.
QMD activities are focused on the following critical functions: 1) on-going quality assurance
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activities for DHSP and its funded service providers; 2) performance measurement and proactive
problem identification; and 3) continuous quality improvement activities and program support
services including provider training and technical assistance for QM.
QMD staff work closely with program staff on annual site monitoring activities such as
monitoring tool development, client chart reviews sampling methodology, data reporting,
provider meetings, technical assistance and training. DHSP requires all of its funded agencies to
have an agency-wide QM plan and a quality improvement process for their services. Systemwide CQM activities are conducted by internal QMD and DHSP program staff. The only
contracted entity supporting CQM activities is an information system consultant whose purpose
is to provide direct technical assistance to service providers and DHSP staff regarding the
Casewatch system that collects RW Program data.
CQM Resources and Training. DHSP staff provide onsite training and technical
assistance to the contracted providers during and after monitoring site visits where opportunities
or problems are identified. QMD staff provide one-on-one training for providers who need
assistance with developing or enhancing their existing QM plans. Curriculum development and
focused trainings related to specific program implementation or performance improvement
initiatives are offered throughout the year. For example, during the implementation of
QuantiFERON (QFT) TB testing, a QM specialist is assigned to coordinate QFT training and
tracking deliverables and completion of the QA plans. Likewise, with implementation of routine
HIV testing in healthcare settings, a team of QM specialists, including public health nurses and
health educators, are assigned to implementation sites to assist with HIV test kit competency
training and quality assurance activities. In addition, to support the implementation of the
performance-based medical outpatient services and medical care coordination (MCC), DHSP has
trained providers on a tier-based payment structure based on pre-determined performance
measures, and has developed an evidence-based MCC protocol, performance measures and
training curriculum to train MCC providers through FY 2014.
QMD staff participate in training offered by the National Quality Center, and attend the
quarterly regional HIVQUAL meetings held at DHSP. These resources are shared with other
DHSP staff as appropriate. Pursuant to the recent integration of STD and HIV programs, DHSP
will hold a full day training for DHSP staff. The core curriculum will include basic HIV and
STD 101,and review of current initiatives and care/service delivery models used within the EMA
to reduce incidence of HIV and STDs, and increase capacity to deliver HIV and STD services.
b) CQM Program Processes and Activities
Clinical and Performance Indicator Monitoring. The local Continuum of Care model
depicts the relationships between interventions and services, the patients’ status in the system of
care, and their impact on patient and health outcomes. The Commission and DHSP developed
specific indicators within the standards of care for all HIV core medical and support service
categories. These indicators were designed to measure the appropriateness and effectiveness of
the service delivery, as well as client satisfaction level.
DHSP collaborates with the Commission to implement funding and other
recommendations based on performance measurement data. Improvements in clinical care for
various populations are trended yearly to show progress and identify further opportunities.
DHSP has adopted 22 measures from the final HRSA/HAB clinical performance
indicators for adults and adolescents. Data are collected for these measures on an annual basis as
part of programmatic reviews conducted for each contracted service provider using a
Performance-Based Contract Monitoring (PBCM) methodology. Examples of medical
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outpatient and medical case management (using a medical care coordination service model)
performance measures for FY 2013 are highlighted in Table 11.
Table 11. FY 2013 Medical Outpatient and Medical Case Management Services Indicators
Threshold for
Select Medical Outpatient Services Performance Indicators
Compliance
ARV for pregnant
women
HAART
PCP prophylaxis
Viral suppression
Percentage of pregnant women prescribed ARV during the
second and third trimester during the measurement year
Percentage of patients with CD4 T-cell counts <500
cells/mm3 or an AIDS-defining condition who were
prescribed ART during the measurement year
Percentage of patients with CD4 T-cell count < 200
cells/mm3 who were prescribed PCP prophylaxis
Percentage of patients on ART 12 weeks or more before
last viral load (VL) and with at least one VL test, with the
last VL undetectable or <200 copies/mL
Select Medical Case Management (MCM) Performance Indicators
Access to care and
comprehensive care
plan
Adherence to ART
Percentage of active MCM clients who had 3 or more
medical visits at least 90 days apart within past 12 months
Percentage of active MCM clients who had a MCM care
plan documented and updated once every 6 months
Percentage of active MCM clients who adhere to their
HIV medication regimen (viral suppression <200
copies/mL) after 3 months of receiving MCM services
100%
95%
95%
80%
Threshold for
Compliance
90%
100%
100%
DHSP uses two methods to collect quality data: a centralized electronic client-level data
system (Casewatch) and manual medical/client record reviews. Data analysis for clinical
indicators include: 1) provider performance on key indicators, i.e., how providers compare to the
national benchmarks from HIV Quality of Care Project (HIVQUAL), and whether providers
meet the benchmarks established in the contracts or in local standards; and 2) client health status
on key outcomes indicators, i.e., whether clients’ health status improved, declined, or remained
unchanged during the review period.
Summary of CQM Data Collected to Date. Since 2006, DHSP has collected clinical
performance measures recommended by HRSA/HAB for medical outpatient services. With the
implementation of PBCM in 2007, DHSP measures overall performance of individual agencies
and performance for individual measures. DHSP collected nine clinical performance measures
for medical outpatient services in 2011 and 2012 using an abbreviated monitoring tool. Service
provider median scores indicate that providers have met and/or exceeded thresholds for
compliance for all 9 clinical performance measures. For this performance measure activity,
DHSP sampled 24 provider sites and 414 client medical records/charts for medical services.
Results of the core measures for medical outpatient services are highlighted in Table 12.
For the majority of performance measures, mean scores increased between 2009 and 2012.
Table12. Medical Outpatient Provider Performance Measures Results, 2009, 2010, 2011/12
Core Measures (TFC)
ARV for pregnant women (100%)
HAART (95%)
PCP prophylaxis (95%)
Adherence counseling (95%)
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2009^
100%
100%
98%
99%
2010^
100%
100%
100%
100%
2011/12^
100%
100%
100%
98%
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Cervical cancer screening (90%)
Hepatitis C screening (90%)
HIV risk counseling (95%)
Syphilis screening (90%)
TB screening (75%)
89%
95%
98%
99%
86%
88%
97%
100%
100%
92%
90%
99%
96%
99%
88%
TFC = Threshold for compliance; ^Score indicates provider mean performance score.
DHSP shares performance results in graphic formats with providers to show not only
their own progress or decline but also how they compare with expected benchmarks and other
providers’ performance (usually with the agency names blinded). Beginning in 2013, for
medical outpatient services, the measures are tied to payments. Providers have further incentives
to perform quality improvement projects to reach their desired results.
CQM Data Review, Validation, and Sharing with Grantee and the Planning Council.
DHSP actively collects and trends data from all performance measurement activities such as the
grievance and incident management programs, HIV viral load and resistance testing quality
assurance activities, ADAP monitoring, clinical and support services program monitoring, agency
QM plan reviews, and client-level data from Casewatch. Data are shared with internal and external
stakeholders and committees, including the RW Planning Council, to measure and evaluate progress
towards established goals to improve health and process outcomes, to guide future quality
improvement initiatives, and inform future prioritization and allocation by the Planning Council,
completing the QM feedback loop between DHSP and the Planning Council.
DHSP has established mechanisms to review and validate CQM data internally. Review
of performance improvement data is prepared by the QMD and undertaken by the Medical
Director and QIC who collectively are responsible for addressing performance gaps and
compliance issues, and prioritizing efforts to improve clinical outcomes and care. The HIV
Medical Director also oversees the Research and Evaluation Division, which is responsible for
data management and analysis. Together with QMD, the CQM data are prepared and validated
before they are reviewed by the QIC and other senior management meetings. During the QIC
review, CQM data may call for immediate actions to resolve problems or recommendations to
address identified disparities in the quality of care. The recommendations are prioritized and
tracked for implementation and evaluation.
CQM, PBCM and aggregate grievance data are presented to the Commission’s Standards
of Care (SOC) and Priority and Planning (P&P) Committees. The SOC Committee reviews the
aggregate information to determine standards of care modifications necessary to improve clinical
outcomes, and the P&P Committee reviews the information for discussion during service
prioritization and allocation.
The Commission developed tools for its first Evaluation of Service Effectiveness (ESE)
on selected medical services in 2011 and implemented the provider survey and data collection
for oral health services in 2012. Based on the Balanced Scorecard® method of assessing
effectiveness, the ESE will rely on outcome, service utilization, cost and allocation, and needs
and best practices data to determine both service and system effectiveness. The ESE will compile
aggregate service- and system-level patient and health outcome data primarily collected through
DHSP’s PBCM, unmet need and utilization frequency of clinical best practices and combine
them with cost and satisfaction data. Conducting the ESE exercises in subsequent years will
provide measurable comparisons to show improvements or declines in clinical and related
services. LAC intends to use the ESE findings for more targeted resource allocation and
planning, technical assistance, focused management, quality assurance and quality improvement,
integration of best practices, standards of care revisions and increased transparency.
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Prioritizing and Monitoring of QI Projects. DHSP continuously assesses the quality of
services provided by its contracted service providers through a myriad of performance
measurement activities designed to identify problems, risks and opportunities for improvement.
These activities include: 1) performance-based contract monitoring (PBCM); 2) HIV testing,
viral load and resistance testing quality assurance; 3) grievance and incident report management;
4) administrative, fiscal, facilities and operations reviews; and 5) review and approval of
individual contracted service provider QM plans. Quality improvement projects are prioritized
by the QIC with guidance and direction from the HIV Medical Director and Executive Director.
Performance measurement is a vital process for improving the quality of services that
allows DHSP to determine whether the care that clients receive meets or exceeds the desired
quality as stipulated in the service providers’ contracts and established in the PHS Guidelines, as
well as by local and national benchmarks. The provision of HIV care and support services is
accomplished through a complex, multi-provider network. As the grantee of RW Program funds,
DHSP is responsible for monitoring all contracts with service providers. DHSP achieves this by
conducting annual on-site programmatic reviews for each contracted agency, including
administrative, fiscal, facilities, operations and agency QM program reviews. DHSP program
staff use service specific monitoring tools to conduct these reviews.
Contract monitoring is central to continuous improvement as it measures the service
providers’ performance and how this changes over time. DHSP implemented the PerformanceBased Contract Monitoring (PBCM) model for contract monitoring in 2007. PBCM has been
effective in providing quantitative and qualitative data for programmatic reviews and has
streamlined the contract monitoring process across DHSP divisions, thus addressing historical,
systemic contract monitoring challenges. PBCM adopted the HIVQUAL Project sampling and
randomization methodology for programmatic medical/client record reviews. By using this
validated sampling and randomization method, DHSP is able to provide a snapshot of how
services are provided across funded agencies, support program evaluation activities, and provide
a standardized method for data validation.
The PBCM and MAI outcomes data allow for trending of services provided to
communities of color. MAI outcomes are compared with overall RW clients for the same
services. DHSP collaborates with the Commission to implement funding and other
recommendations based on MAI outcome data. Improvements in clinical care for the MAI
population are trended yearly to show progress and identify opportunities to further improve
care. For example, despite increased access points and service availability for oral health
services, there remains disparity in utilization of oral health services among African Americans.
As a response to address barriers to access, e.g. long wait time to get a dental appointment, LAC
increased investment to create a more comprehensive network of primary and specialty oral
health services, including expanding capacity in areas where the majority of African American
clients reside. DHSP continues to work with contracted agencies to monitor and address issues
related to access to and utilization of the expanded network.
DHSP has an active grievance management program that allows consumers and other
entities to report problems, challenges, and concerns they have encountered with services.
Clients are informed and become familiar with the grievance line through posters at the service
provider sites, service provider brochures, reports to planning bodies and other community
meetings, and from the DHSP website. DHSP receives grievance reports via phone, fax, email,
and mail or through an online form on DHSP’s website. As part of service contracts, DHSP
requires providers to report specific patient events and incidents following established
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guidelines. All grievances and incident reports are investigated, tracked and trended, offering an
opportunity to identify and correct immediate problems, and to work with clients and service
providers in the investigation and resolution of quality of care concerns.
Quality Improvement (QI) Projects Currently Implemented. Several QI projects are
currently under way in the EMA:
QI Project #1: Enhancing Tuberculosis Screening with QFT-GIT
Tuberculosis screening has been identified by PBCM as an area that needs improvement
at several clinic sites. From 2010-2011, DHSP collaborated on a QI project with CDC and the
state TB Control Program to conduct assessments and define best practices for current TB
screening and treatment activities at two targeted RW-funded clinics that provide care to many
HIV-positive immigrants and minority populations at high risk for TB-HIV co-infection. The
collaboration aimed to enhance current TB screening/treatment activities and to optimize health
outcomes for TB-HIV co-infected RW patients. This study was concluded in August 2011 and
data showed, among other things, profound challenges in TB screening efforts using Mantoux
testing when patients do not return after 3 days for reading of their skin tests. To address the
screening problem, implementation of QuantiFERON® -TB Gold In-Tube (QFT-GIT) was
selected as a QI project with the goal of implementing this blood-based screening test for latent
tuberculosis in all DHSP funded clinics. DHSP collaborated with local stakeholders including
the TB Control Program, Public Health Laboratory, and the QFT-GIT manufacturer to
implement a pilot test at one clinic. Efforts began in late 2011 with QFT implementation in
another clinic after the successful pilot program. Since 2011, DHSP has helped implement QFT
screening in 17 funded medical outpatient clinics, with the goal of having this test available in all
DHSP funded clinics. Another five clinics will implement before the end of this year.
QFT-GIT assay is a whole blood test used as an aid in diagnosing tuberculosis infection,
including latent tuberculosis infection and tuberculosis disease. This test addresses the main
barrier of tuberculin skin tests (TST), which required clients to return within 3 days for reading
of test results. Low screening rates for TST are due to clients not returning for their test results
within the required timeframe, and other factors such as allergic reactions, false positive/
negative tests and delayed reactions. With QFT-GIT, only clients who test positive are called
back to the clinic for further medical evaluation and proper treatment as needed.
QI Project #2: Technical Assistance for DHSP’s QM Program
DHSP received approval for technical assistance from HRSA’s National Quality Center
(NQC) in May 2012. This quality improvement project addresses DHSP’s need, following the
integration with the STD Program, for a formal, internal quality committee that integrates STD
and HIV quality improvement activities under one quality umbrella. In June 2013, DHSP’s QIC
held its first monthly meeting. Prior to establishing the QIC, DHSP’s senior management team
acted as the “quality improvement” committee. The QIC strengthened DHSP’s quality
infrastructure by establishing a dedicated quality committee representing both STD and HIV
components. DHSP also aims to establish an expanded external quality committee that hosts
funded providers, other local providers and consumers.
QI Project #3: Implementation of Routine HIV Testing in Clinical Settings
Since CDC’s 2006 recommendation of routine HIV testing for individuals 13 to 64 years
of age when they receive services in clinical settings such as medical outpatient clinics, urgent
care centers and emergency rooms, DHSP has increased the offerings of routine HIV testing at
more hospitals and general ambulatory care clinics each year. In order to improve disclosure and
linkage to care rates, DHSP implemented HIV Rapid Testing Algorithm so that newly diagnosed
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HIV positive patients are linked to HIV medical outpatient clinics for immediate evaluation and
care. HIV testing data are then matched with the surveillance data to validate the number of
patients who actually made their HIV medical appointments and received viral load tests.
QI Project #4: Technical Assistance for DHSP’s Oral Health Program Services
DHSP received technical assistance from HRSA to review the EMA’s overall system
capacity for oral health services and to assess provider productivity and establish appropriate
benchmarks for oral health care for the HIV population. The HRSA consultant completed his
assessment in August 2013 and is finalizing his recommendations on approaches for providers to
reach the national HRSA benchmarks for productivity. DHSP has requested from HRSA
additional TA for LAC’s oral health program to: 1) develop tools and training curricula that will
assist the oral health providers to meet thresholds of productivity identified in the current TA; 2)
provide on-site TA for providers experiencing particular productivity challenges; 3) recommend
two options for revising compensation for oral health providers in order to move away from cost
reimbursement towards payment methodologies that reward performance and efficiency.
CQM Program Implementation, Monitoring and Evaluation. DHSP’s CQM program
implementation is built on a redesigned, expanded QM infrastructure that provides for appropriate
staffing and resources, strong clinical focus and administrative oversight. In 2010, DHSP
embarked on an organizational redesign and aligned quality-related activities residing in individual
program divisions under the QMD to coordinate and standardize oversight for quality improvement
activities. The CQM Program is implemented following the activities outlined in the QM plan and
timeline. Data collected from various performance measurement activities are analyzed and shared
with stakeholders. The responsible stakeholders review the data, make recommendations to address
performance gaps, implement corrective actions and identify opportunities to improve services. The
QMD conducts annual and quarterly evaluations of core CQM activities and progress towards
meeting long-term and annual quality goals. Evaluation findings are reviewed by the HIV Medical
Director and QIC for action.
At the provider level, DHSP requires each contractor to develop an agency-wide CQM
plan that encompasses all HIV/AIDS care and prevention services. The CQM plans are
submitted to the QMD for review and approval. This process is essential to ensure that agencies
have the infrastructure and appropriate CQM processes in place. DHSP QMD staff monitor and
evaluate each agency’s QM implementation. These activities are accomplished through in-house
review of agency plans or may include on-site monitoring visits, where QM staff use specific
monitoring tools to check on the agency’s QM plan, relevant policies and procedures to reconcile
whether actual QM activities are routinely occurring (e.g., review QM committee minutes,
participants rosters, and Plan-Do-Study-Act activities), and through ongoing training and
technical assistance based on evaluation findings and agency requests.
Clinical and performance data are shared directly with service providers as part of the
annual on-site programmatic, facilities and operations review, and during scheduled provider
meetings as appropriate. Using the PBCM model, DHSP staff present providers with their
performance reports using a numerical and graphical format that includes past performance
scores. This immediately informs service providers of areas where there is a downward trend in
performance, as well as those areas where providers continue to meet or exceed expected
thresholds for compliance. Following established procedures for correcting areas of noncompliance, agencies are required to submit plans of corrective action that are reviewed and
approved by DHSP program and QM staff. All areas of non-compliance are reviewed during the
following year’s on-site review to verify compliance. Depending on the severity of nonCounty of Los Angeles
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compliance, site visits may be conducted at more frequent intervals until DHSP verifies that the
service provider has implemented changes to correct the deficiencies.
DHSP QM staff have been actively involved in the regional HIVQUAL meetings, which
QM representatives from different RW Parts-funded organization attend each quarter. Most
RW-funded organizations in LAC participated in the “in+care” campaign, a national quality
improvement initiative sponsored by HRSA through collaboration with the NQC. DHSP has
participated in “in+care” conference calls and webinars and reported measures on linkage to
care, retention in care, and viral suppression.
Consumer Involvement in the Implementation and Evaluation of CQM Activities
Consumer involvement is a critical piece to the implementation and evaluation of
DHSP’s CQM program. In addition to the consumer participation in the Standards of Care
Committee, the Commission’s Consumer Caucus invites DHSP staff to their monthly meeting to
discuss specific service-related issues or concerns from the community. DHSP has a phone line
dedicated for consumer grievance issues, and QMD staff will investigate grievance claims with
the consumers if they are not anonymous. Every three years or so, the Commission hosts a series
of County-wide “Meet-the-Grantee” consumer forums to give the RW service users a safe space
to express directly to DHSP, without the presence of their providers, concerns or problems they
encounter. DHSP also plans to host periodic consumer focus groups for specific quality related
issues and initiatives requiring consumer input and feedback. To establish these focus groups,
DHSP will work closely with the Commission on selection, process, roles and responsibilities.
DHSP is also working on establishing within the next 24 months an external quality
improvement committee that includes consumers in its membership.
1B.
Data for Program Reporting
Management Information System (MIS) for Data Operations
DHSP currently uses Casewatch Millennium®, a centralized computer information
system application that facilitates coordination of services and communication across all DHSPfunded agencies that provide direct services to PLWHA, to capture all care related data.
Casewatch Millennium® is written in MUMPS and is a Windows client-based front end
application written in Visual Basic. Casewatch’s back-end database is Caché and is hierarchical.
DHSP-funded medical clinics have adopted various electronic medical records (EMR)
systems over the years, and imported data to Casewatch. Challenges remain in certain areas
where lab values for clients are collected but not captured in Casewatch. One way of addressing
this is to share QM and performance review findings with providers so that deficiencies prompt
corrective actions, including better data reporting in Casewatch. With the introduction of Fee for
Service (FFS) payment for medical services, one of the Core Performance Measures is a data
validation indicator which requires complete and accurate data reporting through Casewatch as a
condition for reimbursement. This reimbursement method creates stronger incentives for
improving data accuracy at the agency level.
DHSP is continuously enhancing and modifying the system, and advancing strategies to
strengthen data validity so that the data can be reliably used for analyzing trends, improving
quality of care, and predicting need for the local care system. Finding and enrolling clients in
care as soon as they are diagnosed remains a top priority for DHSP. This includes matching
client-level data for HIV care with HIV surveillance testing data systems to monitor progress
through each step of the HIV continuum of care, from diagnosis to viral suppression.
Client Level Data Capabilities and RSR Reporting
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DHSP has been collecting client-level data for RW services since 1994. All of DHSP’s
RW care providers have been reporting client-level data for more than a decade. Since 2005,
DHSP included in its contract language the requirement that Casewatch, a single client-level data
collection system, be used to manage the RW service eligibility, demographic and utilization
data, medical and support service outcomes, and linkages and referrals to other services.
Casewatch was originally designed as a case management system, but expanded over the
years into a comprehensive HIPAA compliant system that collects a wide spectrum of data,
including client-level service utilization and outcome data, and provides contract management,
billing, and reporting. Outcome indicators currently collected in Casewatch include quality of
care measures such as CD4 count, HIV viral load, STD and hepatitis screening and treatment.
In addition to the mandated RSR reporting, client-level data from Casewatch have been used for
planning, monitoring, and quality improvement.
To prepare for the RSR client-level data collection in 2011 and 2012, the Casewatch
vendor worked directly with HRSA to determine the best way to submit client-level data.
Currently, providers upload the XML dataset directly onto the HRSA RSR website, which takes
less user time than the RDR submission. All providers successfully submitted 2012 client-level
data for core medical and support services.
HIV Casewatch generates error/exception reports regularly as providers enter data in the
system. DHSP’s Research and Evaluation team is developing a series of automated reports to
summarize this information so that Care Services Division program managers can get these reports
on an ongoing basis to monitor provider data reporting quality. Data completeness reports for 2012
revealed that data error rates are related to whether providers enter data directly into Casewatch or
through electronic interface data transfer between Casewatch and agencies’ electronic health record
(EHR) systems. Provider sites with data elements that exceeded 5% missing/unknown rate tended
to be sites that have their own EHR or practice management system, and report data by interfacing
their systems with Casewatch. Sites that use Casewatch exclusively had fewer missing/unknown
data elements. Since January 1, 2013 when DHSP implemented the fee-for-service reimbursement
model for medical outpatient services, clinic providers have been reviewing the Casewatch
exception reports more thoroughly in order to get accurate reimbursements.
Using Data to Improve Outcomes for Service Delivery
The collection and management of CQM data and its transformation into useful
information are fundamental to the success of the CQM Program. Data are necessary to describe
client needs and gaps in service delivery, evaluate performance of service providers, establish
goals for improvement, monitor progress and document changes in HIV care and support
services. Improvements cannot be achieved without adequate and accurate measurement.
Providers must be able to document, report, and measure health indicators. DHSP continues to
use PBCM as its primary tool to collect accurate, timely data on health outcomes for all Part A and
MAI funded clinical and support services. A feature in the PBCM model allows DHSP program
managers to provide a visual report of compliance with each review criteria during the exit
conference. These reports of compliance focus on those indicators where the thresholds for
compliance were not met, and they guide onsite technical assistance provided by DHSP staff.
DHSP implemented a Fee-for-Service (FFS) model of reimbursement for HIV primary
care that includes a “pay for performance” component in November 2012. In this model,
providers are evaluated on 11 Core and 11 Supplemental DHSP Performance Measures, which
are based on HRSA/HAB measures and allow for comparison with national benchmarks.
Providers are expected to meet the threshold for compliance (TFC) on the 11 Core Performance
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Measures in order to qualify for additional reimbursement. Those providers who meet the TFC
for the Core Performance Measures will be eligible for additional payment based on their
performance on the 11 Supplemental Performance Measures. Providers who do not meet the
TFC for the Core Performance Measures must submit improvement plans to address
deficiencies, and are closely monitored until thresholds are met or contracts are terminated.
ORGANIZATIONAL INFORMATION
1.
GRANTEE ADMINISTRATION
1A.
Program Organization
Part A and MAI funds awarded to Los Angeles County (LAC) are accepted by the
EMA’s chief elected official (CEO), and the County Board of Supervisors (BOS). The BOS
delegates the administration of Part A and MAI funds to the Department of Public Health (DPH),
the grantee, which delegates the responsibility of Part A and MAI program administration to the
Division of HIV and STD Programs (DHSP), the administrative agency. The Commission on
HIV (Planning Council) determines priorities and allocations for RW funding, creates the
comprehensive care plan, and collaborates with DHSP in the development of standards.
An organizational chart in Attachment 10 shows the agencies involved in the
administration of Part A and MAI funds in LAC and other RW Program stakeholders, including
the Commission members, DHSP-funded service providers, and consumers of RW-funded
services. The chart also indicates the organization of DHSP’s Financial Services, which houses a
section responsible for fiscally managing HRSA grants.
DHSP coordinates the overall response to HIV/AIDS and STIs in LAC with federal,
state, and local County resources. The Executive Office (EO) occupies the top of DHSP’s
organizational structure. The EO includes Government Relations, which is responsible for policy
analysis and external communications. Under the EO are: 1) Office of Planning, which supports
grant development and reporting, program planning, and HIV social marketing activities, and
whose subsection, Contract Administration, oversees solicitation and procurement; 2) Care
Services, which provides contract and program monitoring of core medical and supportive
services; 3) Prevention Services, which provides contract and program monitoring of HIV and
STI screening and prevention services; 4) Financial Services, which performs accounting, fiscal
management and auditing and compliance functions; 5) Management Services, which oversees
human resources and information technology; 6) Office of the Medical Director, which includes
Quality Management (QM) and Research and Evaluation that are responsible for data
management and analysis, clinical oversight, quality assurance, quality improvement, training
and evaluation; and 7) Surveillance and Epidemiology, which monitors the HIV/AIDS and STI
epidemics in LAC, investigates case reporting, and analyzes trends.
For the Commission, the Executive Director and office staff support all of the planning,
operation, and evaluation activities of the current 46 member Commission.
Part A and MAI funds support a total of 41.98 Full-Time Equivalents (FTEs) who
provide administrative, programmatic, quality management, and planning council support to HIV
care programs. The Part A and MAI administrative budgets support 23.67 FTEs of DHSP staff
and 7.5 FTEs of Commission staff. The QM budget supports 10.81 FTEs (all DHSP staff) of the
total 41.98 FTEs. Currently there are no vacancies for key positions.
Local Part A and MAI providers are also funded by other RW programs (e.g., Parts B, C,
D, F). In order to avoid duplication of services, these funding streams are carefully considered
during the allocations process. Beyond that, providers are required to report client data
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according to contract numbers programmed in the data system. The number of clients each
contractor is expected to serve is agreed upon during the contract negotiation process. Accurate
data submission is required for providers to receive payment; however, under the cost
reimbursement payment structure of some contracts, it has been difficult to ensure that providers
are not reporting duplicate clients or services to different RW funding streams. Thus far, fiscal
audits conducted by the County’s Auditor-Controller and DPH CMD have been the most
successful approach to identify, retroactively, the duplicated clients/services reported. In those
cases, reimbursements for services charged to other RW parts are required to be returned to
DHSP. DHSP implemented fee-for-service for medical outpatient services payment in
November 2012, using a base rate resulting from a comprehensive rate study. Providers must
ensure accurate service mapping between their EMR and Casewatch, so that encounter data can
be accurately collected and reported; subsequently, Casewatch will generate invoices based on
face-to-face visits with a physician, nurse practitioner or physician’s assistant.
1B.
Grantee Accountability
Implementation of National Monitoring Standards
During FY 2011, DHSP staff (fiscal, program, contract administration, QM and grant
management staff) conducted a thorough review of the National Monitoring Standards released
by HRSA, and compared the HRSA standards with existing local monitoring policies and
procedures. From the review, DHSP’s workgroup identified gaps in its monitoring processes
(e.g., eligibility screening twice a year; annual on-site fiscal reviews of all contractors) and
developed a work plan to implement necessary changes for full compliance. To date, DHSP has
completed modifications in Casewatch regarding eligibility screening processes to include the
six-month re-assessment of eligibility. Language from the standards not already included in
contracts has been added. Monitoring tools have been updated, including adding additional
fiscal monitoring components. DHSP has also revised its budget instructions to clarify relevant
standards, e.g., rent must be categorized as administrative cost; requirement that agencies submit
their cost allocations based on all of their funding streams in their annual budget submissions and
negotiations. DHSP has also notified its contractors of expectations and changes related to the
HRSA National Monitoring Standards.
To ensure parity and fairness and prevent bias and conflict of interests resulting from inhouse staff conducting fiscal monitoring, DHSP is moving toward having the County’s AuditorController (AC) and Department of Public Health’s (DPH) Contract Monitoring Division (CMD)
conduct full fiscal audits of its contractors annually. To be compliant with the annual fiscal audit
standard, DHSP has worked with both entities to assess resources needed to conduct full fiscal
audits for over 100 contracts annually. In the interim, DHSP fiscal staff will accompany DHSP
Contract Administration Division staff when they conduct annual provider site visits for the
administrative, and facilities and operations reviews. Certain fiscal audit questions used by the
AC have been incorporated into the monitoring tools for these site visits.
Distribution and Tracking of RW Part A and MAI Funds
Process for Tracking Formula, Supplemental, Unobligated, and Carry-over Funds.
DHSP’s Financial Services (FS) has established unique cost center codes that separately track
expenditures for both the formula and supplemental allocations of the Part A award and
expenditures for the MAI award through the electronic Countywide Accounting and Purchasing
System (eCAPS). As provider invoices are analyzed and payments approved for services are
made, the costs are posted to these unique cost center codes. Grantee program or administrative
costs are also posted to these cost center codes. LAC’s eCAPS captures and maintains the
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accounting history of all the expenditure transactions. Various eCAPS expenditure reports are
used as source documents for billings to the federal funding agencies and for audit purposes.
DHSP uses eCAPS reports that identify actual year-to-date costs along with other internal
grant expense tracking and forecasting reports to project the full year expenditures for the Part A
and MAI awards. LAC has been able to expend all of its Part A funds each year by closely
monitoring monthly grant expenditures to ensure that the full year forecasts are accurate, and by
working with the Commission to redirect any funds from under-spent categories. Monitoring of
MAI expenditures and projections of full term spending is also managed in this way. Whenever
any unobligated or carry-over funds are identified and approved for carry-over, specifically for
MAI, separate tracking reports are used to validate that those funds were exhausted by the end of
the subsequent grant term.
Timely Redistribution of Unexpended Funds. LAC fully expends its Part A funds each
year. DHSP’s Financial Services provides grant expenditure reports to the Commission each
month. When Part A or MAI expenditures (tracked by service categories) are below full year
projected spending, the Commission’s Priorities & Planning Committee evaluates the overall
grant spending pattern and recommends shifting funds to other services to maximize service
delivery. DHSP redistributes the funds accordingly to ensure complete grant expenditure.
Monitoring, Process for Corrective Actions, and Technical Assistance (TA)
In LAC, the activities to ensure accountability for the administration of the RW Part A
and MAI funds involve two levels of monitoring and audits: 1) programmatic monitoring and
fiscal review and tracking by DHSP, including monitoring funding distribution, expenditures
tracking, monitoring of contract and program compliance, quality management, as well as
monitoring site visits that include administrative review, facilities and operations review, and
program review; and 2) fiscal audits of contracted providers by both the Department of Public
Health’s (DPH) Contract Monitoring Division (CMD) and the County’s Auditor-Controller (AC)
to assess adherence to grant compliance, including examining compliance with OMB Circular A133 requirements (Single Audit).
Fiscal and Program Monitoring Process. DHSP conducts fiscal reviews and program
monitoring site visits annually for every contracted service provider.
Fiscal monitoring ensures that contractors appropriately charge DHSP for services in
accordance with their contracts. Fiscal monitoring evaluates the adequacy of an agency’s
accounting records, internal controls and compliance with the contract and applicable federal
fiscal guidelines governing the RW Part A and MAI programs. Fiscal reviews also examine
whether contracted agencies charged DHSP for services provided to eligible participants.
Fiscal monitoring includes the review and approval of costs submitted on monthly
invoices and annual cost reports, analysis of annual audited financial statements, and fiscal and
administrative reviews. To resolve discrepancies identified through the review of monthly
invoices and cost reports, DHSP’s Finance staff contacts staff from contracted agencies for
additional information or support documentation, and will disallow costs when necessary.
Audited financial statements and A-133 audits are tracked, reviewed and analyzed annually by
DHSP’s Finance staff, who also prepare an audit compliance report that lists identified noncompliance. Finance staff will request a Plan of Corrective Action (POCA) with established time
limits for responses and implementation that will bring the contracted agency into compliance.
DHSP’s contracted agencies also undergo pre-scheduled fiscal contract audits by the
DPH’s CMD. The CMD also conducts annual fiscal viability reviews based on the agency’s
audited financial statements to determine if an agency meets the 60-day solvency requirement of
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their contracts. Additional pre-scheduled fiscal audits are conducted on behalf of DHSP through
a departmental service agreement with the County’s Auditor-Controller (AC). The AC audits are
coordinated with the DPH CMD audits to avoid duplication. In some instances DHSP requests
special fiscal reviews of agencies outside of the regularly scheduled audits. Additional site visits
related to fiscal monitoring are conducted by DHSP Financial Services staff as part of the annual
administrative review and facilities and operation site visits.
Program monitoring occurs through annual administrative reviews, facilities and
operation site visits, performance-based program monitoring site visits, and monthly desk audits.
These monitoring reviews are based on contractual agreements, and local, state and federal
guidelines, and consist of chart audits, activity observations, client interviews, and review of
facility operations, personnel records and implementation of QM activities. DHSP’s Contract
Administrative Division (CAD) staff conduct the administrative reviews and facilities and
operation site visits. These monitoring activities aim to ensure adherence to the legalities of the
contracts, including compliance with all applicable licenses and permits, insurance and leases for
service delivery sites, and time records of contractor staff funded through the RW program.
DHSP’s Care Services Division (CSD) staff are responsible for the annual program
monitoring site visits. Program monitoring site visits focus on PBCM (described in more detail
in the CQM section) with pre-determined performance measures and benchmarks. The site visits
begin with an entrance conference to review the purpose (e.g., compliance, evaluating and
improving services, identifying technical assistance needs), the components of the review, the
client medical records review process, and the agency’s service delivery accomplishments and
challenges for the past year. Monitoring tools are specific for each service category and include
performance measures for process compliance (e.g., client eligibility screening documentations)
and program performances (e.g., number and percentage of clients on HAART). These tools are
refined based on revised or newly adopted standards of care, changes in services, newly solicited
services, legal mandates and recommendations from HRSA.
Findings from the program monitoring reviews, along with service utilization trends,
barriers to the provision of care, and programmatic recommendations are discussed during the
exit conference. Depending on the type and severity of unsatisfactory program review findings,
technical assistance is provided on site or scheduled shortly thereafter. Within 30 days of the
exit conference, DHSP sends a report of findings to the agency.
Program desk audits involve DHSP program managers reviewing providers’ monthly
progress reports. The reports include service units delivered by Service Planning Area (SPA),
client-level data and a narrative report discussing progress, challenges, accomplishments, and
any areas requiring technical assistance. Program managers track expenditures, services
provided, and projections of future services, using tools specific for each service category.
Table 13 summarizes the frequency of monitoring reviews, site visits, reports, and the
number of contractors undergoing fiscal and program monitoring during FY 2013 and number of
contractors site visits planned for FY 2014.
For FY 2013, DHSP funded 39 directly contracted agencies and 12 departmental services
agreements using RW Part A and MAI resources. As of June 2013, DHSP has completed
administrative reviews and facilities and operations site visits at 100% of Part A and MAI
supported contracts for the FY 2012/13 contracts. DHSP will begin its review of FY 2013/14
contracts in October 2013 and expects to complete 100% of the contractors by June 2014. As of
August 2013, program site visits involving chart reviews based on specific performance
measures were conducted for 40 agencies and 51 contracts/schedules. DHSP expects to conduct
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Program Narrative
onsite program reviews for 100% of Part A and MAI contracts in FY 2014. Eighteen out of the
51 agencies (35%) received a full fiscal audit in FY 2013 by either DPH CMD or the County’s
Auditor-Controller. During FY 2014, DHSP will ensure that annual fiscal site visits or full
financial audits occur for every contract.
Table 13. Summary of Fiscal and Program Monitoring in FY 2013.
Review of
Contractors
Frequency of
Review
Frequency of
Site Visits
Frequency of
Reports
Reviewed to Date
Reviews Planned
for FY 2014
Fiscal Monitoring
Program Monitoring
DHSP
CMD
AC
DHSP
Monthly;
annually
Annual fiscal
viability review;
biannual audit
Biannual
audit
Monthly; annually;
ongoing as needed
Annually; and
as needed
Biannually
Biannually
Monthly
Biannually
Biannually
51
6
12
Annually; and
as needed
Annually; and
as needed
51
49
12
37
49
Process for Corrective Actions. Based on findings in an agency’s independent audit,
fiscal or program monitoring reports, DPH CMD, AC or DHSP can request a Plan of Corrective
Action (POCA). For fiscal and program monitoring, POCAs are reviewed to ensure that action
plans address and resolve findings including reimbursement of monies owed to DHSP. DPH
CMD and the AC manage fiscal POCAs, and require compliance within six months after the
final report has been issued. Subsequent follow up meetings are scheduled with providers to
validate the proposed actions identified in the POCAs. Failure to meet the requirements may
result in delayed reimbursement, contract suspension, and even County debarment.
For program monitoring, within 30 days of the exit conference, DHSP sends the agency a
monitoring report that documents program review findings by contract and recommendations for
compliance. The agency is asked to respond with a POCA within 45 days of receipt of the
report. If the POCA does not address the identified findings, DHSP will provide written
notification and TA to help the provider develop an appropriate POCA. DHSP assesses provider
progress in implementing POCAs through ongoing review of monthly reports, with confirmation
during a follow-up site visit. Failure to meet the requirements of a POCA may result in contract
suspension or termination. DHSP uses POCAs as a means to improve service quality, service
delivery and provider performance, and requires a POCA even when the findings are minor.
Technical Assistance (TA) for FY 2012. DHSP provides fiscal and programmatic
technical assistance throughout the year, in the form of formal training and site visits, or through
communication between the agency staff and DHSP program managers and accountants. During
FY 2013, approximately 46 of the 51 contracted providers (90%) requested and received TA
from DHSP’s Finance staff to discuss and clarify billing requirements, the roles and
responsibilities of fiscal staff, and expectations of fiscal document submission. These meetings
are especially important when the contractors hire new finance staff.
DHSP’s Financial Services also provides TA regarding completing accurate monthly
invoices and year-end cost reports. Cost reports show the actual annual expenditure by budgeted
contract lines. These actual expenditures should match the agency’s internal General Ledger
reports. DHSP gives written feedback to each agency after the analysis and review of the cost
reports and provides assistance in clarifying and resolving differences between the amounts
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Program Narrative
reported on the cost reports and the reimbursements made during the contract year.
Approximately 38 Part A and MAI funded agencies received direct assistance in completing
their cost reports during FY 2013.
Programmatically, TA enables contractors to improve their service delivery and the
administration of their grant funded programs. TA is provided through special meetings, during
program reviews and upon agency request when challenges related to service provision (e.g.,
standard charting, maintenance of documents in client files) and programmatic capacities are
identified. Approximately 95% of DHSP contractors will receive this type of TA in FY 2013.
For FY 2012 and FY 2013, the bulk of programmatic TA has been focusing on: 1)
implementation of and transition to the Low Income Health Program (HWLA-Medi-Cal 1115
Waiver expansion) for medical and mental health services; 2) implementation of the new
medical care coordination programs; 3) implementation of medical outpatient fee-for-service
reimbursement model; 4) strengthening capacity of the ADAP enrollers and benefits counselors
in preparation for the full implementation of ACA; and 5) implementation of HRSA national
monitoring standards. Other TA topics include: documentation of client assessments and
treatment plans; monthly reports; data collection and reporting; formulating POCAs in response
to program review findings; implementation of rapid testing programs in medical outpatient
clinics and emergency departments; HRSA/HAB clinical measures and DHSP performance
indicators; clarification of clinical guidelines for viral load/resistance testing; administrative
duties and referral requirements for ADAP enrollment services. Assistance with capturing and
maintaining client-level documentation remains one of the most requested forms of TA.
Audit Findings and Provider Compliance
Audit Findings/Improper Charges and Corrective Actions. DHSP invests Part A and
MAI funds to support 107 contracts with 51 agencies. Due to the space limit of this application,
it is impossible to summarize all the audit findings here. The most frequently cited fiscal audit
findings include failure to provide supporting documentation, submitting required reports and
invoices after the due dates, not maintaining financial records on a current basis, billing variable
costs based on 1/12 of the budget as opposed to billing actual costs, not maintaining and using a
cost allocation plan for shared costs or not having or not maintaining adequate timekeeping or
allocation records of staff time spent on funded programs. POCAs submitted by agencies address
timelines for compliance, ensuring that proper safeguards for compliance are implemented and
reviewed by agency management, that proper documentation is maintained, that training for staff
is provided, and that procedures are developed and implemented that promote consistent
compliance with federal and County requirements for expenditures, reporting and
documentation. The DPH CMD, Auditor-Controller, and DHSP staff all monitor timelines and
resolutions identified in the POCA to determine when findings are successfully resolved.
The following scenarios provide examples of audit findings and subsequent actions taken.
Example A: A fiscal audit found that a provider did not appropriately allocate shared program
expenditures in accordance with their Cost Allocation Plan. As a result, the agency overcharged
DHSP for leased space costs. The finding included a repayment to the County for the
overcharged amount. The provider would be instructed to reimburse DHSP for the entire amount
due. If reimbursement is not received timely, DHSP will immediately follow up with the
provider through written correspondence identifying a date when payment is due. If payment is
not received by the due date, a second letter is sent to the provider indicating that suspension of
future contract invoice payments has been implemented pending receipt of the amount owed. If
necessary, referral of the provider’s amount owed to the County’s Treasury Tax Collector’s
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Program Narrative
office for collections is submitted. Example B: A fiscal audit found that an agency charged
DHSP for costs not supported by entries in their General Ledger or by any other source
documentation. These costs were determined to be unallowable and will need to be repaid in full
to DHSP. In addition, the financial management system of the agency was identified as being
deficient and a POCA was requested. For the sake of transparency, most audits are reported on
the County’s audit compliance website. DHSP’s monitoring standards workgroup has
recommended that all fiscal audit reports be posted to the County website.
Compliance with the POCA issued by DPH CMD and the Auditor-Controller is defined
as documented resolution of the finding in the subsequent years’ audited financial statements.
Failure to meet the requirements of a POCA may result in delayed reimbursement or contract
suspension. DHSP closely monitors subcontractor compliance with the OMB A-133
requirement to submit annual Audited Financial Statements (AFS) and the more detailed A-133
audits within nine months after the end of the agency’s Fiscal Year. If providers are delinquent
in submitting their required audit reports to DHSP, follow up letters are immediately sent to the
agency. Currently, 33 out of the 36 community-based organizations (91%) providing direct
client services are in compliance with the OMB Circular A-133 requirements or AFS
submission. Three of DHSP’s Part A funded contracts to community-based organizations for
medical transportation/taxi services are considered vendor contracts and not subject to the audit
submission. For all direct services providers, if the required AFS or A-133 audits are not
submitted within the 9-month window, payments from DHSP can be suspended.
Process for Reporting and Reconciling Program Expenditures with Fiscal Staff
Process for Receiving Vouchers or Invoices from Contractors/Subcontractors. DHSP
requires all subcontracted agencies to submit invoices no later than 30 days following the month
of service delivery. DHSP records the receipt of monthly invoices in a Microsoft Access
database that tracks by agency name and service category the date of invoice receipt, contract
and contract schedule numbers and verification that submission of required monthly
programmatic reports were received. If the invoice(s) are received without the required monthly
reports, the invoice(s) will be stamped “Missing Required Reports,” the agency will be
contacted, and the invoice will be held for payment until the required report(s) are submitted.
Once a complete invoice(s) is received, it is forwarded to an accountant in DHSP’s Financial
Services for review, analysis, adjustments if needed, and reimbursement.
Process of Payment Made to Contractors/Subcontractors. Once a complete invoice is
ready for review and analysis, the accountant tracks the monthly expenditures against the
approved line item budgets. The accountant monitors the monthly expenditures against the
contracted line item budgets to determine if amounts billed exceed the approved budget amounts.
Adjustments are made to the invoices disallowing billed costs that exceed the line item budget,
have calculation errors, are deemed unallowable, or are billed for costs that were never budgeted.
To resolve discrepancies identified through the invoice review process, DHSP staff contacts
contracted agency staff for additional information and supporting documentation, and disallows
costs when necessary. For Fee-For-Service reimbursed contracts, the accountant ensures that the
established fee rate and units of service are not exceeded. Invoice reimbursements require at
least two levels of approval before payment can be released through eCAPS.
Fiscal Staff Accountability: Reporting, Reconciliation, and Expenditures Tracking
Process and Coordination. Aside from the monthly activities outlined above, section
managers of Care Services and Office of Planning staff participate in bi-monthly Grant
Expenditure Report (GER) meetings led by the Chief of Finance. These meetings are intended
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Program Narrative
as another level of accountability in DHSP’s efforts to ensure timely reporting, reconciling and
tracking program expenditures consistent with HRSA guidelines and established contract
language. During these meetings, DHSP staff review the GERs that list, by the different service
categories, the contracted agencies’ monthly expenditures, year to date expenditures against
projected full year costs, and any delinquent invoice submissions. Periodically, contractors are
required to submit special reports or data separately from the client-level data reporting. In some
instances, special handling of invoices is required, which entails fiscal staff working directly
with program managers to reconcile invoices with additional primary source documents and
activity reports before payment is released, thus ensuring that payments match activities billed.
An organizational chart including fiscal staff is included in Attachment 10.
1C.
Third Party Reimbursement
Monitoring Third Party Reimbursement and Ensuring RW Funds as Payer of Last Resort
DHSP monitors RW-funded service providers to ensure that RW funds are used as funds
of last resort. All DHSP providers utilize a centralized client-level data collection system
(Casewatch) which includes a standardized registration and screening process on the system to
determine clients’ eligibility for services. All clients entering care are assessed for ADAP, MediCal, Medicare, Healthy Way LA (LAC’s low income health program or LIHP) and VA benefits
eligibility, as well as private health insurance. Providers are required in their contracts to screen
a client’s eligibility for these programs before providing services supported by RW Part A or
MAI funding. Client eligibility is re-assessed every six months according to the HRSA National
Monitoring Standards. If Casewatch detects a client’s likely eligibility for another payer source,
the agency is prevented from billing DHSP for that client’s services until eligibility issues are
resolved. During fiscal monitoring, if there are instances uncovered of inappropriate or duplicate
billing to the RW program when the clients or services were eligible for other insurance
coverage, DHSP will demand payment back from the agencies.
For clients not receiving Medi-Cal or other insurance and benefits, providers are
contractually required to document the following: client referral to the program to which they
appear to be eligible; client application to Medi-Cal or other programs and application
disposition; final approval or rejection of application; and necessary next steps. Providers also
assess client income to determine level of poverty and eligibility for RW services.
The electronic eligibility screening is a required part of client enrollment for services and
is linked to invoicing and financial reimbursement. Providers can only bill for services once
client eligibility has been determined and documented via Casewatch. The screening process
begins at the point of entry into services and occurs semi-annually thereafter. Automated
reminders alert providers when eligibility re-screening is required.
All medical and psychiatric treatment providers are Medi-Cal certified. As additional
coverage options become available through the implementation of ACA, DHSP has been
monitoring and comparing new benefits options to ensure effective use of RW funding as payer
of last resort. DHSP is developing training and TA to help providers of various services, such as
mental health and substance abuse services, to seek appropriate reimbursement from Medi-Cal
and insurance exchange plans. DHSP is also working with the Commission and community
stakeholders to educate consumers about coverage options and enrollment information.
Monitoring Program Income and Rebates
Monthly invoices received from DHSP-contracted providers include a section to indicate
if program income was collected. The year-end cost report is the final document used by the
contracted providers to report program income. The Casewatch eligibility screening process can
County of Los Angeles
Grant No. H89HA00016
FY 2014 Ryan White Part A Application
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Program Narrative
capture some level of program income, especially for those services operating on a fee-forservice payment system. Through the review of monthly invoices and cost reports, DHSP's
Financial Services staff continually monitor the reporting of program income. DHSP also relies
on the fiscal audits conducted by the County Auditor-Controller and DPH CMD to review the
actual receipt and disclosure of program income. In cases where misreporting of program income
is identified, DHSP staff and the fiscal auditors are responsible for following up on agencies’
corrective actions and collecting reimbursement of any funds owed.
1D.
Administrative Assessment
The Commission conducts Assessments of the Administrative Mechanism (AAM)
biannually, alternating between comprehensive assessments, and follow-up topical assessments
to address any specific areas of concern with the prior year’s recommendations. The
Commission’s Operations Committee oversees both the assessments and monitoring
recommendations for implementation. In the past several years, rather than assessments, the
Operations Committee has focused on implementing recommendations for improvement—most
in the areas of procurement timeliness and efficiency.
The AAM framework entails the Operations Committee selection of an independent
contractor to conduct the assessment, compiling data for the assessment, developing
recommendations, and monitoring implementation of the recommendations. The AAM scope of
work evaluates seven central administrative functions: timeliness, clarity and accuracy of
information, availability, quality, tools, relationships, and follow-up to prior years’ AAMs. Its
methodology is based on tracking time lapses, expediency, obstacles, and challenges by
“administrative events”—the significant, pre-identified benchmarks in administrative processes.
The last AAM concluded with high marks or notable progress for: DHSP’s
disbursement, management, and monitoring of funding, and improved transparency in
operations; involving more or a greater diversity of providers in service delivery; decreasing the
time it takes to execute contracts; the Commission’s relations with its other partners; the
Commission’s efforts to involve the community, especially consumers, in priority- and
allocation-setting; and operational improvements at both the Commission and DHSP. Areas
where findings indicated a need for further and more direct attention were: the overall timeliness
of the procurement process; renewing service contracts when/if there are questions of service
delivery quality; the grievance process; and the contract monitoring process. DHSP and the
Commission continue to work on addressing these concerns and improving timeliness and
expediency with help from the County’s Chief Executive Office.
An electronic assignment tracking system is used to track AAM recommendations. To
date, all recommendations are either completely enacted or in progress. Most remaining
recommendations that have not yet been concluded are related to the grantee’s timely
procurement of services. In the past year, DHSP implemented fee-for-service medical outpatient
services and a medical care coordination (“medical home”) model, and expanded its oral health
services substantially—all consistent with past year Commission priorities and allocations,
standards and directives. Since these service delivery improvements have been implemented, all
of the past AAM recommendations have been resolved. The Commission has re-initiated its
regular schedule of AAMs to identify additional needed areas of improvement, if any.
1E.
Maintenance of Effort (MOE)
The table with MOE budget elements and the amount of expenditures for HIV/AIDS core
medical and support services for FY 2011 and FY 2012, and the process used to determine the
amounts are included as Attachment 11 as required.
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FY 2014 Ryan White Part A Application
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Program Narrative
Attachment 1: Staffing Plan, Position Descriptions, and Biosketches for Key Personnel
Following are key personnel leading the Ryan White Part A and MAI programs at the Division
of HIV and STD Programs (DHSP).
Chief, Office of Planning: Michael Green, Ph.D., M.H.S.A. The Chief of Planning oversees
planning, solicitation and procurement of care services. The Chief of Planning manages 33 staff
assigned to conduct administrative review, contract development, solicitation activities, grant
management, and community planning. Dr. Michael Green has over 18 years of health
administration experience. Prior to joining DHSP in 2004, he was the Bureau Chief for
HIV/AIDS/STD Grants and Programs (2002-2004), and the Director of Quality Improvement,
Evaluation and Training (2001-2002), at the St. Louis Department of Health.
Chief, Care Services: Carlos Vega-Matos, M.P.A. The Chief of Care Services is responsible
for overseeing the delivery of local HIV clinical and supportive services including program
development and contract monitoring. The Chief of Care Services manages a total of 33 staff
persons in Care Services, the majority are program mangers/contract auditors, including public
health nurses. Mr. Vega-Matos has also been the Deputy Executive Director for Programs at the
AIDS Alliance for Children, Youth, and Families; Associate Executive Director and Project
Director for National Association of State Boards of Education’s Adolescent, School Health and
HIV Prevention programs; Director for El Centro Human Services Corporation’s Milagro AIDS
Project; and Project Director for the National Alliance for Hispanic Health’s Southwest Border
AIDS Project.
Medical Director: Sonali Kulkarni, M.D., M.P.H. The Medical Director is responsible for
providing clinical direction, technical assistance and clinical reviews to contracted service
providers, and also oversees quality management, research and evaluation activities at DHSP.
The Medical Director manages 25 nurses, health educators and program managers in the Quality
Management Division, and 14 researchers and support staff in the Research and Evaluation
Division (including data management). Dr. Kulkarni is currently the Principal Investigator (PI)
on a California HIV Research Program funded study to create an HIV patient centered medical
home to improve retention in care and health outcomes within the safety net. She is also co-PI of
a Centers for Disease Control grant to use HIV surveillance data to inform testing and retention
program development in Los Angeles County.
Chief, Quality Management: Mary Orticke, R.N., M.P.H. The Chief of Quality Management
is responsible for ensuring that the delivery of Ryan White Part A funded services is consistent
with local and nationally accepted standards of care for the treatment of HIV disease. The Chief
manages 25 staff persons assigned to conduct performance measurement, training and technical
assistance. Ms. Orticke’s previous positions and experience include Accreditation and
Continuous Compliance/Joint Commission Coordinator, Quality Improvement Manager at
LAC+USC Healthcare Network and Quality Improvement Manager at LAC DHS Quality
Improvement and Patient Safety Program.
Chief, Financial Services: David Young, B.S. The Chief of Financial Services ensures
departmental compliances with all budget and financial grant requirements, and ensures that a
large volume of financial related transactions are processed rapidly and accurately within DHSP.
The Chief of Financial Services supervises 20 staff, primarily accountants, to perform fiscal
grant management, general accounting and reporting, and audit and technical assistance. Dave
Young has worked in DHSP Financial Services since 1999. Prior to DHSP, he served as Health
Care Financial Analyst in the Los Angeles County Department of Public Health, where he
supervised six staff in the federal grants section.
County of Los Angeles
Grant No. H89HA00016
FY 2014 Ryan White Part A Application
Attachment 1
Page 1 of 1
Attachment 2: FY 2014 Agreements and Compliance Assurances (including Delegation of Authority Letter)
County of Los Angeles
Grant No. H89HA00016
FY 2014 Ryan White Part A Application
Attachment 2
Page 1 of 2
County of Los Angeles
Grant No. H89HA00016
FY 2014 Ryan White Part A Application
Attachment 2
Page 2 of 2
Attachment 3: Newly Diagnosed Cases of AIDS for 2010-2012 and Numbers of Persons
Living with HIV and AIDS in Los Angeles County through December 31, 2012
AIDS
AIDS
Reported HIV
HIV/AIDS
Incidence
Prevalence1
(non-AIDS)
Prevalence1
Category
2010-2012
Prevalence1
#
%
#
%
#
%
#
%
Race/Ethnicity
White
723 22.7% 8,701
32.4%
6,434 33.7% 15,354 33.3%
African American
767 24.1% 5,292
19.7%
4,075 21.4% 9,410 20.4%
Latino 1,483 46.6% 11,583
43.1%
7,452 39.1% 18,898 41.0%
Asian/PI
130
4.1%
854
3.2%
702
3.7% 1,535
3.3%
Native American
22
0.7%
118
0.4%
93
0.5%
221
0.5%
Multi-race
54
1.7%
312
1.2%
282
1.5%
618
1.3%
Unknown/Un specified
<5
-17 <0.1%
42
0.2%
59
0.1%
Gender
Male 2,814 88.5% 23,966
89.2% 16,756 87.8% 40,865 88.7%
Female
367 11.5% 2,911
10.8%
2,324 12.2% 5,230 11.3%
Age (Years)
<13
<5
-9
0.0%
31
0.2%
40
0.1%
13-24
256
8.0%
287
1.1%
1,077
5.6% 1,315
2.9%
25-49 2,242 70.5% 13,795
51.3% 12,733 66.7% 26,578 57.6%
≥50
681 21.4% 12,786
47.6%
5,239 27.5% 18,162 39.4%
TOTAL 3,181
100 26,877
100% 19,080 100% 46,095
100%
2
Exposure Category, Adult/Adolescent
MSM 2,506 79.3% 20,168
75.5% 15,267 80.6% 35,411 77.3%
Injection Drug Use
167
5.3% 1,720
6.4%
720
3.8% 2,453
5.4%
MSM-IDU
163
5.2% 1,907
7.1%
885
4.6% 2,936
6.4%
Heterosexual
320 10.1% 2,830
10.6%
2,021 10.7% 4,848 10.6%
Other Blood-borne
<5
-86
0.3%
17
0.1%
103
0.2%
Maternal HIV Risk
0
0.0%
<5
-0
0.0%
<5
-Other/Unknown
<5
-<5
-25
0.1%
30
0.1%
Subtotal 3,160 100% 26,716
100% 18,935 100% 45,783
100%
Exposure Category, Pediatric
Maternal HIV Risk
21 100%
126
78.3%
130 89.7%
260 83.3%
Other Blood-borne
0
0%
29
18.0%
9
6.2%
39 12.5%
No Identified Risk
0
0%
6
3.7%
6
4.1%
13
4.2%
Subtotal
21 100%
161
100%
145 100%
312
100%
TOTAL 3,181 100% 26,877
100% 19,080 100% 46,095
100%
Data Source: LAC HIV/AIDS Reporting System (eHARS) cases reported as of June 30, 2013.
Due to possible migration to and from LA County between the time of HIV and AIDS diagnoses, the AIDS
prevalence and HIV prevalence may not sum up to the HIV/AIDS prevalence.
2
Adult and adolescent HIV and AIDS cases with undetermined risk were redistributed according to CDC multiple
imputation methods.
1
County of Los Angeles
Grant No. H89HA00016
FY 2014 Ryan White Part A Application
Attachment 3
Page 1 of 1
Attachment 4: Co-Morbidities and Trends in Fiscal Resources in Los Angeles EMA
Indicator
General Population
Rate
Number
(per 100,000)
Early Syphilis (1)
Gonorrhea (1)
Chlamydia (1)
Tuberculosis (2)
Homelessness
No Insurance
(Including those without
Medi-Cal and Medicare)
Poverty
(<300% FPL)
Mental Illness
PLWH/A*
Rate
Number
(per 100,000)
2,151
11,425
48,462
625
23.2
122.9
521.3
6.4
1,027(5)
838(5)
1,044(5)
28(6)
2,228
1,818
2,265
61
Number
120,070(3)
Percentage
1.2%
Number
4,960(7)
Percentage
10.8%
1,697,000(4)
17.4%
16,622
36.1%(8)
5,687,000(4)
58.4%
34,387
74.6%(8)
779,000(4)
10.6%
6,638
14.4%(9)
Trends in Services and Fiscal Resources in Los Angeles County
Anticipated Impact of Federal Sequestration
Fiscal Year
on HIV/STD Services
2013
-$6,133,574(10)
2014
-$5,224,841(10)
Total Reduction
-$11,358,415
*
Estimates are based on an estimated 46,095 diagnosed PLWH/A in Los Angeles County.
Los Angeles County Department of Public Health, Division of HIV & STD Programs (DHSP), STD CaseWatch
System data reported as of August 2013.
(2)
Los Angeles County Tuberculosis Control Program, 2012 data reported as of 8/26/2013.
(3)
Los Angeles Homeless Services Authority, 2011 Greater Los Angeles Homeless Count.
(4)
UCLA Center for Health Policy Research, California Health Interview Survey (CHIS), 2011; mental illness
defined as number of people who saw any healthcare provider for emotional/mental and/or alcohol/drug issues in
the last 12 months.
(5)
Estimates based on Los Angeles County DHSP eHARS data as of June 30, 2013, and the co-infection rates from
STD and HIV/AIDS Case Registry Matching to Estimate California STD-HIV/AIDS Co-infection, September
2011.
(6)
Los Angeles County Tuberculosis Control Program, 2012 data (provisional) reported as of August 23, 2013.
(7)
Los Angeles County HIV Epidemiology Program, An Epidemiologic Profile of HIV and AIDS, 2009.
(8)
Los Angeles County Ryan White Client Data 2012; CHIS 2011 for PLWH/A outside of Ryan White care system.
(9)
Los Angeles County Ryan White Client Data 2012; clients receiving RW-funded mental health services in the
past 12 months.
(10)
Los Angeles County Division of HIV and STD Programs, August 2013.
(1)
County of Los Angeles
Grant No. H89HA00016
FY 2014 Ryan White Part A Application
Attachment 4
Page 1 of 1
Attachment 5: Report on the Availability of Other Public HIV Funding for FY 2013 - 2014
Estimates/Projections
RW Part A
Other Federal
State
Ambulatory Outpatient Medical Care
FY 2013 Amount
17,732,843
18,416,000
0
FY 2013 Percentage
38.77%
40.26%
0.00%
FY 2014 Amount
11,691,861
22,500,000
0
FY 2014 Percentage
24.65%
47.44%
0.00%
State AIDS Drug Assistance Program
FY 2013 Amount
0
45,440,000 31,014,000
FY 2013 Percentage
0.00%
59.43%
40.57%
FY 2014 Amount
0
45,440,000 31,014,000
FY 2014 Percentage
0.00%
59.43%
40.57%
Home & Community-Based Support Services
FY 2013 Amount
2,123,471
26,121,000
3,200,000
FY 2013 Percentage
5.96%
73.31%
8.98%
FY 2014 Amount
4,301,469
26,000,000
3,200,000
FY 2014 Percentage
11.44%
69.15%
8.51%
Other Outpatient/Community-Based Primary Medical Care Services
FY 2013 Amount
5,439,065
20,859,800
0
FY 2013 Percentage
20.52%
78.70%
0.00%
FY 2014 Amount
4,687,210
20,308,600
0
FY 2014 Percentage
18.41%
79.78%
0.00%
Oral Health Care
FY 2013 Amount
1,552,263
4,800,000
0
FY 2013 Percentage
23.87%
73.82%
0.00%
FY 2014 Amount
5,397,394
4,800,000
0
FY 2014 Percentage
52.15%
46.37%
0.00%
Substance Abuse & Mental Health
FY 2013 Amount
3,054,817
4,551,271 10,031,000
FY 2013 Percentage
17.03%
25.38%
55.93%
FY 2014 Amount
2,329,402
3,230,200 10,031,000
FY 2014 Percentage
14.62%
20.27%
62.95%
Minority AIDS Initiative
FY 2013 Amount
3,038,947
87,399
0
FY 2013 Percentage
97.20%
2.80%
0.00%
FY 2014 Amount
2,887,000
83,029
0
FY 2014 Percentage
97.20%
2.80%
0.00%
HIV Counseling and Testing Services
FY 2013 Amount
0
6,333,731
0
FY 2013 Percentage
0.00%
96.72%
0.00%
FY 2014 Amount
0
6,017,044
0
FY 2014 Percentage
0.00%
96.65%
0.00%
County of Los Angeles
Grant No. H89HA00016
FY 2014 Ryan White Part A Application
Local
Total
9,591,414
20.97%
13,235,402
27.91%
45,740,257
100.00%
47,427,263
100.00%
0
0.00%
0
0.00%
76,454,000
100.00%
76,454,000
100.00%
4,185,100
11.75%
4,100,000
10.90%
35,629,571
100.00%
37,601,469
100.00%
207,800
0.78%
458,829
1.80%
26,506,665
100.00%
25,454,639
100.00%
150,000
2.31%
153,198
1.48%
6,502,263
100.00%
10,350,592
100.00%
298,500
1.66%
343,512
2.16%
17,935,588
100.00%
15,934,114
100.00%
0
0.00%
0
0.00%
3,126,346
100.00%
2,970,029
100.00%
215,000
3.28%
208,544
3.35%
6,548,731
100.00%
6,225,588
100.00%
Attachment 5
Page 1 of 1
Attachment 6: Unmet Need Framework for Calendar Year 2012
Population Sizes
Number of persons living with AIDS
(PLWA) in 2012
Value
Data Source(s)
28,751
Linked databases of HARS, Casewatch,
ADAP
Row B.
Number of persons living with HIV
(PLWH)/non-AIDS/aware in 2012
22,893
Linked databases of HARS, Casewatch,
ADAP
Row C.
Total number of HIV+/aware in 2012
Care Patterns
Number of PLWA who received the
specified HIV primary medical care during
2012
Number of PLWH/non-AIDS/aware who
received the specified HIV primary
medical care during 2012
Total number of HIV+/aware who received
the specified HIV primary medical care
during 2012
Calculated Results
Number of PLWA who did not receive the
specified HIV primary medical care
Number of PLWH/non-AIDS/aware who
did not receive the specified HIV primary
medical care
Total HIV+/aware not receiving the
specified HIV primary medical care
(quantified estimate of unmet need)
Row A.
Row D.
Row E.
Row F.
Row G.
Row H.
Row I.
County of Los Angeles
Grant No. H89HA00016
51,644
Value
Value
21,204
Linked databases of HARS, Casewatch,
ADAP
17,111
Linked databases of HARS, Casewatch,
ADAP
38,315
Value
Value
7,547
26.2%
Value = A – D; Percent = G/A
5,782
25.3%
Value = B – E; Percent = H/B
13,329
25.8%
Value = G + H; Percent = I/C
FY 2014 Ryan White Part A Application
Percent
Attachment 6
Page 1 of 1
Attachment 7: Planning Council Letter of Assurance
County of Los Angeles
Grant No. H89HA00016
FY 2014 Ryan White Part A Application
Attachment 7
Page 1 of 1
Attachment 8: Planned Services Table
Service Category
Medical Outpatient/Medical Specialty Care
 Medical Outpatient/Medical Specialty
 Pharmaceutical Assistance
Oral Health Care
Non-Medical Case Management (Linkage to Care Services)
 Benefits Screening and Enrollment
 Linkage to Care
 Transitional Case Management
Health Insurance Premium & Cost-Sharing Assistance
Medical Case Management (Medical Care Coordination)
Mental Health Services (Psychiatry & Psychotherapy)
Outpatient Substance Abuse Treatment
Residential Substance Abuse Services
Housing Supportive Services
 Direct Emergency Financial Assistance
Residential Care and Housing Services
Nutrition Support
Medical Transportation
Long-Term and Palliative Care (Hospice & Skilled Nursing)
Home Health Care
Home-Based Case Management (Home & Community
Based Services)
Medical Nutrition Therapy
Child Care
Language Services
Rehabilitation Services
Respite Care
Psychosocial Support Services
TOTAL CORE MEDICAL SERVICES FUNDING
TOTAL SUPPORT SERVICES FUNDING
FY 2014 Allocations
39.0%
37.0%
2.0%
19.0%
2.7%
2.0%
0.5%
0.2%
0.5%
16.0%
8.2%
0.0%
4.6%
0.0%
0.0%
0.0%
1.0%
1.7%
0.5%
0.0%
6.8%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
90.0%
10.0%
Bolded services are core medical services.
County of Los Angeles
Grant No. H89HA00016
FY 2014 Ryan White Part A Application
Attachment 8
Page 1 of 1
Attachment 9: FY 2014 Los Angeles County Implementation Plan
PART A CORE MEDICAL SERVICES
Service Goal: To provide primary health care services, in accordance with Public Health Service
treatment guidelines and EMA-approved standards, in order to improve health status and quality of life
1. Medical Outpatient
Care (including Medical for individuals living with HIV/AIDS, including those who are the most vulnerable and those with
special needs. Related Comprehensive Plan Strategy: Eliminate new HIV infections; Optimize health
Specialty)
outcomes for all PLWH.
Clients
Service Units
FY 2014
Service Unit
Time
Objective(s)
to Be
to Be
Funding
Definition
Frame
Served
Provided
Allocation
Objective 1: By 2/28/15, a minimum of 5,233 clients
will receive clinical assessment and treatment for
HIV/AIDS available through Ryan White funded
medical outpatient care services.
Service Unit
Definition
Medical
Outpatient Visit
5,233
clients
36,637
visits
3/1/20142/28/2015
Objective 2: By 2/28/15, a minimum of 2,188 clients
will be referred to and receive Ryan White funded
medical specialty care services (i.e., cardiology;
ophthalmology; dermatology; ear, nose, and throat;
gastroenterology; endocrinology; gynecology;
neurology; oncology; pulmonary medicine; podiatry;
proctology; general surgery; and urology services).
Service Unit
Definition
Medical Specialty
Visit
2,188
clients
3,852
visits
3/1/20142/28/2015
$15,556,964
Objective 3: By 2/28/2015, a minimum of 2,821
Service Unit
2,821
135,408
3/1/2014clients will receive pharmaceutical assistance to help
Definition
them obtain medications that are not covered by the
clients
prescriptions 2/28/2015
Prescriptions
California AIDS Drug Assistance Program.
Service Goal: To provide psychiatric treatment and mental health counseling, consistent with Public
Health Service guidelines and those outlined by Bartlett and Gallant (Johns Hopkins), American
2. Mental Health Services Psychiatric Association, and EMA approved standards, to eligible PLWH/A to promote mental stability
and capacity to attend to their health care needs. Related Comprehensive Plan Strategy: Optimize
health outcomes for all PLWH.
County of Los Angeles
Grant No. H89HA00016
FY 2014 Ryan White Part A Application
Attachment 9
Page 1 of 4
Objective 1: By 2/28/15, a minimum of 1,779 clients
Service Unit
will receive psychiatric services to stabilize mental
Definition
1,779
8,492
3/1/2014- $1,156,800
clients
hours
2/28/2015
health conditions and improve their ability to adhere to Psychiatric
Treatment Hour
HIV care and treatment.
Objective 2: By 2/28/15, a minimum of 3,222 clients
Service Unit
will receive psychotherapy to help improve or decrease
Definition
3,222
30,251
3/1/2014- $2,114,151
psychological symptoms, and improve their
Mental Health
clients
hours
2/28/2015
functioning and ability to adhere to HIV care and
Treatment Hour
treatment.
Service Goal: Medical case management is conducted as part of medical care coordination services
(MCC). MCC services are patient-centered activities which focus on access, utilization, retention, and
adherence to primary health care services, as well as coordinating and integrating all services along the
3. Medical Case
continuum of HIV care. The goals of medical care coordination are to facilitate and support HIVManagement (Medical
positive individuals’ access and adherence to HIV primary medical care and to enhance their capacity
Care Coordination)
to manage their HIV disease. Related Comprehensive Plan Strategy: Ensure universal access to and
maximize engagement with quality HIV and related services.
Objective 1: By 2/28/15, a minimum of 3,534 clients
Service Unit
will receive medical care coordination services to
Definition
3,534
127,389
3/1/2014$6,382,344
Medical Care
improve access and retention in HIV care and support
clients
hours
2/28/2015
positive health outcomes.
Coordination Hour
Service Goal: To provide preventive, comprehensive and accessible oral health care services in order
to improve oral health status and quality of life among PLWHA. Related Comprehensive Plan
4. Oral Health Care
Strategy: Optimize health outcomes for all PLWH.
Objective 1: By 2/28/15, a minimum of 15,100 clients Service Unit
will receive dental services (including specialty care
Definition
15,100
51,375
3/1/2014- $7,579,034
such as endodontics) to maintain and/or improve their
Oral Health Care
clients
visits
2/28/2015
oral health status.
Visit
PART A SUPPORT SERVICES
County of Los Angeles
Grant No. H89HA00016
FY 2014 Ryan White Part A Application
Attachment 9
Page 2 of 4
1. Non-Medical Case
Management (including
Transitional Case
Management, Benefits
Specialty and Linkage to
Care)
Service Goal: To facilitate HIV-positive individuals’ access to, maintenance of, and adherence to
primary health care through ongoing assessment of client’s needs and support systems, and timely
linkages to core medical and support services; ensure populations with special needs are linked to core
medical and support services; and facilitate clients’ access to additional programs and services
supported by other public and private funding. Related Comprehensive Plan Strategy: Ensure
universal access to and maximize engagement with quality HIV and related services.
Objective 1: By 2,28/25, a minimum of 64 recently
incarcerated and youth clients will receive transitional
case management services to gain access to
community-based HIV medical and support services.
Service Unit
Definition
Transitional Case
Management Hour
64
clients
1,005
hours
3/1/20142/28/2015
$79,779
Objective 2: By 2/28/15, a minimum of 3,821 clients
Service Unit
will receive benefits counseling so they can access all
Definition
3,821
22,577
3/1/2014$797,793
public and private benefits program for which they are
Benefits
clients
hours
2/28/2015
eligible and receive appropriate HIV medical and
Counseling Hour
supportive services.
Objective 3: By 2/28/2015, a minimum of 111 clients
Service Unit
will receive linkage case management that includes
1,960
Definition
111
3/1/2014$199,450
outreach to identify clients who are not in care, brief
Linkage Case
clients
2/28/2015
hours
interventions to remove barriers to care, and follow-up
Management Hour
activities to monitor progress in being linked to care.
Service Goal: To provide substance abuse treatment for HIV-positive chemically dependent clients
according to EMA-approved standards and accepted harm reduction and abstinence models in order to
2. Substance Abuse,
improve clients’ capacity to adhere to HIV treatment regimens. Related Comprehensive Plan
Residential
Strategy: Optimize health outcomes for all PLWH.
Objective 1: By 2/28/15, a minimum of 258 clients
Service Unit
258
14,590
3/1/2014will receive 24 hour residential, non-medical substance Definition
clients
days
2/28/2015
abuse services to ensure adherence to HIV treatment.
Rehabilitation Day
$1,834,924
Service Unit
Objective 2: By 2/28/15, a minimum of 211 clients
Definition
211
1,450
3/1/2014will receive medically assisted detoxification services
Detoxification
clients
days
2/28/2015
to ensure adherence to HIV treatment.
Day
County of Los Angeles
Grant No. H89HA00016
FY 2014 Ryan White Part A Application
Attachment 9
Page 3 of 4
Objective 3: By 2/28/15, a minimum of 85 clients will
receive interim housing with supportive services to
ensure adherence to HIV treatment.
Service Unit
Definition
Transitional
Housing Day
85
clients
3,891
days
3/1/20142/28/2015
MINORITY AIDS INITIATIVE (MAI) SERVICES
Service Goal: To improve the oral health outcomes of racial and ethnic minorities living with
HIV/AIDS, through the provision of preventive, comprehensive and accessible oral health care services
1. Oral Health Care
in accordance with EMA-approved and other accepted standards of care. Related Comprehensive
Plan Strategy: Optimize health outcomes for all PLWH; Eliminate HIV-related disparities.
235
948
African
Objective 1: By 2/28/15, a minimum of 1,052 racial
Service Unit
visits
Americans
and ethnic minority clients will receive dental services
Definition
3/1/201429
145
(including preventive care, patient education, and
Oral Health Care
$1,183,265
2/28/2015
Asians
visits
specialty care such as endodontics), in order to
Visit
maintain and/or improve oral health status.
788
3,139
Latinos
visits
Service Goal: To identify and link racial and ethnic minorities who are not in care to HIV medical care
and provide ARTAS-based (Antiretroviral Treatment Access Study) linkage case management to
2. Non-Medical Case
Management (Linkage support clients who are experiencing difficulty engaging in care. Related Comprehensive Plan
Strategy: Ensure universal access to and maximize engagement with quality HIV and related services;
to Care)
Eliminate HIV-related disparities.
211
3,735
Objective 1: By 2/28/15, a minimum of 652 racial and
African
Service Unit
hours
ethnic minority clients will receive linkage case
Americans
Definition
management that includes outreach to identify clients
3/1/2014- $1,183,265
Linkage Case
33
584
who are not in care, brief interventions to remove
2/28/2015
Management Hour
Asians
hours
barriers to care, and follow-up activities to monitor
408
7,212
progress in being linked to care.
Latinos
hours
County of Los Angeles
Grant No. H89HA00016
FY 2014 Ryan White Part A Application
Attachment 9
Page 4 of 4
Attachment 10: County of Los Angeles EMA Organizational Chart
Surveillance &
Epidemiology
HIV/STD Surveillance
Epidemiologic Analysis
Case Investigation
DHSP disburses funds to contracted agencies
County of Los Angeles
Grant No. H89HA00016
FY 2014 Ryan White Part A Application
Attachment 10
Page 1 of 1
Attachment 11: Maintenance of Effort
The methodology LAC uses to determine the MOE amount includes the following: a)
reportable expenditures (as newly defined by HRSA) from the direct, fixed annual County
contribution to DHSP; b) expenditures from the County Department of Health Services
outpatient HIV clinics for direct provision of HRSA-allowable services for PLWHA; and c)
expenditures from the general funds of other local jurisdictions in the EMA, i.e., health
departments of City of Long Beach and City of Pasadena; the City of Los Angeles AIDS
Coordinator’s Office; and the City of West Hollywood’s Department of Community and Social
Services. Only expenditures for HIV core medical and support services are counted. For FY
2011 and FY 20012, City of Los Angeles and City of Long Beach had no local contributions for
HIV services.
DHSP obtains these budget elements by requesting expenditure data from each identified
department or government unit using a standardized form with eligible budget elements clearly
listed, along with a list of RW service definitions. Included on the form are signatures by the
fiscal officer of the agency. The same form will be used consistently for tracking and
documentation purposes for the subsequent years. For County departments, actual expenditures
are tracked by funding source in the electronic Countywide Accounting and Purchasing System
(eCAPS), as well as by tracking the individual monthly contractor reimbursements and the
administrative agency’s direct, program and administrative expenditures. The annual fiscal yearend closing reconciliations of these two records validate the full expenditure of local
contribution. A similar process is used with each partner jurisdiction in the County to reconcile
and validate their general fund HIV service expenditures.
ITEM DESCRIPTION
AGENCY/DEPARTMENT/
GOVERNMENT UNIT
EXPENDITURES
FY 2011
FY 2012
HIV-RELATED CORE MEDICAL SERVICES
County of Los Angeles
Outpatient/Ambulatory Medical
City of West Hollywood
Care
City of Pasadena
County of Los Angeles
HIV Counseling and Testing in
City of West Hollywood
Care Settings
City of Pasadena
County of Los Angeles
City of West Hollywood
Oral Health Care
City of Pasadena
County of Los Angeles
Mental Health Services
City of West Hollywood
City of Pasadena
Home & Community Services County of Los Angeles
City of West Hollywood
Outpatient Substance Abuse
City of Pasadena
County of Los Angeles
Medical Case Management
City of Pasadena
County of Los Angeles
Other (Medical Nutrition
Therapy)
City of Pasadena
County of Los Angeles
Grant No. H89HA00016
FY 2014 Ryan White Part A Application
$9,584,414
$0
$100,000
$43,992
$145,488
$25,000
$0
$79,623
$70,000
$78,830
$28,071
$30,000
$0
$67,290
$10,000
$166,565
$16,000
$0
$10,000
$13,225,402
$55,086
$400,000
$43,056
$101,610
$0
$73,575
$94,493
$0
$138,828
$69,012
$0
$75,025
$169,549
$35,000
$287,219
$0
$80,585
$0
Attachment 11
Page 1 of 2
ITEM DESCRIPTION
AGENCY/DEPARTMENT/
GOVERNMENT UNIT
TOTAL CORE
HIV-RELATED SUPPORT SERVICES
County of Los Angeles
Case Management (NonCity of West Hollywood
Medical)
City of Pasadena
Residential Substance Abuse
City of West Hollywood
County of Los Angeles
Housing Services
City of West Hollywood
City of Pasadena
City of West Hollywood
Outreach
City of Pasadena
City of West Hollywood
Food Banks/Delivered Meals
City of Pasadena
County of Los Angeles
Transportation
City of West Hollywood
City of West Hollywood
Referral
County of Los Angeles
Other (Peer Support, Legal,
City of West Hollywood
Language)
City of Pasadena
TOTAL SUPPORT
County of Los Angeles
Administration/In-kind Support City of West Hollywood
City of Pasadena
TOTAL
County of Los Angeles
Grant No. H89HA00016
EXPENDITURES
FY 2011
FY 2012
$10,455,273
$14,848,440
$0
$148,714
$16,000
$84,323
$4,087783
$92,353
$5,000
$139,563
$0
$67,348
$15,000
$29,171
$25,000
$0
$198,396
$139,823
$10,000
$5,058,474
$3,234,839
$114,187
$150,000
$19,012,773
FY 2014 Ryan White Part A Application
$5,380
$44,488
$0
$77,503
$1,213,044
$168,281
$0
$197,046
$150,000
$78,457
$0
$32,448
$25,000
$8,179
$272,632
$140,544
$0
$2,413,002
$1,986,806
$115,823
$0
$19,364,071
Attachment 11
Page 2 of 2