1. The Role of Federal and State Agencies in Supporting Integrated HIV Care Services Presented to IOM Panel Stewart Landers, Senior Consultant June 21, 2010

2. Context HIV as a disease of impoverishment Service providers struggle with a panoply of needs for many clients Ryan White HIV/AIDS Program addresses most essential access to care (primary care and medications) –This is threatened by current fiscal crisis –Health Care Reform may add to threat

3. Systems of Integration Integration of HIV/AIDS with closely related infectious conditions including Sexually Transmitted Infections (STIs), Viral Hepatitis and Tuberculosis (TB) Integration HIV/AIDS Medical Services with case management, mental health and substance use treatment, transportation, translation services, dental care

4. Systems of Integratoin (cont’d) Integration of HIV/AIDS with “upstream” services that impact social determinants such as housing, education, job training, legal services and refugee and immigrant services Integration of HIV/AIDS into mainstream health care, and in particular, the chronic care model

5. Functions of Integration Referral and navigation functions Payer functions Data functions Client-centered functions Each of these functions may take place within an organization/institution or across a network of separate institutions

6. Role of Government Supports quality standards for care delivery Supports networks Provides funding streams to support systems and functions Requires data collection and supports this function

7. Federal Support for Quality Standards Ryan White Program requires implementation of quality assurance programs Functions of coordination and integration in standards not explicit –Support of federal and state government is necessary (Roy,1995) Evidence of effectiveness unproven –Title III (Part C) QA study found minimal impact (Landon, 2004)

8. Federal Support for Network Development Ryan White supports networks through Part A Eligible Metropolitan Areas (EMAs) and their Planning Councils Has often created rift in community Consortia conducted “outreach” to communities of color (McKinney, 1993) Some evidence against effectiveness of networks (Mor et al., 1993)

9. Federal Support for Network Development (Cont’d) Study of Part A EMAs (n=324) –Perceived quality of services high for primary care and case management –Perceived quality of services lower for mental health, substance abuse, transportation, housing, dental and translation/interpretation (Hirshhorn, 2009)

10. Federal Support for Network Development (Cont’d) Relationship between Primary Care Providers and Case Managers –Both report high levels of contact with each other –Grantee support for communication between them not rated highly (Hirshhorn, 2009) Patient navigators found to be effective in maintenance in care (Bradford, 2007)

11. Federal Role in Funding Streams Some funding streams integrated; others are not –Prevention of HIV closely linked with prevention of STDs and viral Hepatitis –When non-HIV infected individuals are identified, they are not eligible for services that may support care and prevention such as housing or benefits counseling or even case management

12. Federal Support for Data Collection Support for Information Technology (IT) by local government grantees seen as limited –A little more than 70% of Medical Directors and Case Management Directors thought there was support for IT –Less than 50% of Medical Directors or Case Management Directors said common intake forms are supported by grantee (Hirschhorn, 2009)

13. Integration of HIV Care with STIs, Viral Hepatitis and TB Integration of HIV and Hep C care has been and is being studied –Costs found to be higher –Model being studied at UCSF Reductions in state funding may force integration Health Care Reform in Massachusetts reduced/eliminated stand-alone STI and TB Clinics

14. Pilots by Feds to Support Integration Encouraged Programs could enhance integration on a limited basis by supporting integration of care services for people with HIV, STIs, Hep C, or TB Programs could enhance integration on a limited basis by supporting integration of care services for populations (i.e. gay/bi/MSM; refugees/immigrants; etc.)

15. Integration with Mainstream Care – The Chronic Care Model

16. Integration with Mainstream Care – The Chronic Care Model (cont’d) Implemented as framework for addressing chronic conditions including obesity and smoking and chronic diseases such as asthma, cancer, cardiovascular disease, diabetes and sleep disorders Model may look different for HIV/AIDS based on socio-demographics despite advances in treatment

17. Health Care Reform Greatest danger is lack of perceived need and reduced constituency for safety net services As the perception of “full coverage” occurred in Massachusetts, lawmakers reduced funding for STI, TB, Family Planning, Sexual Assault and Health Promotion programs ADAP will be a major concern

18. Health Care Reform (cont’d) Barriers under health care reform include: –Co-pays; deductibles; premiums; other out-of-pocket costs –Shortage of primary care providers –Lack of support for case managers, interpreters, patient navigators Equity remains a challenge: ethnic minorities, non- English speaking, immigrants (legal and not), low income still experience disparities People who are newly insured experience unique challenges (Fairchild, 2009)

19. Acknowledgments Kevin Cranston, Director, Bureau of Infectious Diseases (BID), Massachusetts Department of Public Health (MDPH) Dawn Fukuda, Director, Office of HIV/AIDS, BID, MDPH Pat Fairchild and Lisa Hirschhorn, JSI

20. Bibliography Bradford, J. et al., (2007) HIV System Navigation: An Emerging Model to Improve HIV Care Access, AIDS Patient Care and STDs, 21(s1): S-49-S-58. doi:10.1089/apc.2007.9987. Fairchild, P. (2009) Care Beyond Coverage, Report to The Boston Foundation Hirschhorn, L. et al., (2009) Reported care quality in federal Ryan White HIV/AIDS Program supported networks of HIV/AIDS care. AIDS Care, 21(6), 799- 807 Landon, B.E. et al., (2004) Effects of a quality improvement collaborative on the outcome of care of patients with HIV infection: the EQHIV study. Annals of Internal Medicine, 140(11), 887-896.

21. Bibliograpy (cont’d) McKinney, Martha M. (1993) "Consortium approaches to the delivery of HIV services under the Ryan White CARE Act," AIDS and Public Policy Journal 8(3): 115125 Mor, V. et al., (1993) “Developing AIDS Community Service Consortia,” Health Affairs 12, no. 1: 186-99 Roy, B. et al., (1995) “Building Community Networks to Increase Access to Services for Women, Children, Youth and Families,” HIV Infected Women Conference 22-24, p.72