FY17 RW FOA GRANT APPLICATION FINALV2.PDF

Phoenix EMA Ryan White HIV/AIDS Program Part A FY 2017 DUNS#077535144
Funding Opportunity Number: HRSA-17-30
i. Project Abstract
Project Title: Ryan White Part A, HIV Emergency Relief Grant Program
Applicant Organization: Maricopa County Employee Benefits and Health
Address: 301 West Jefferson Avenue, Suite 3200, Phoenix, Arizona 85003
Project Director: Rose Conner Contact Numbers: PH: (602)506-6181; FX:(602) 506-6300
Email Address: connerr001@mail.maricopa.gov Web Site: www.maricopa.gov
a) General Demographics of EMA: The Phoenix EMA is comprised of Maricopa and
Pinal Counties, located in Central Arizona. The two (2) counties had a population of
4,574,531 in 2015, up 2% from 4,489,109 in 2014, representing 67% of the state’s total
population. The EMA’s general population consists of 57% White, 5% Black/African
American, 4% Asian, 2% American Indian/Alaska Native and 2% Multi-Race. Hispanics
represent 31% of the EMA’s general population. Gender is 50% female and 50% male.
The population consists of 27% under the age of 18, 10% from 18 to 24, 31% from 25 to
44, 20% from 45 to 64, and 12% who were 65 years of age or older. The median age is
33 years.
b) Demographics of HIV/AIDS populations in EMA: Newly diagnosed HIV cases were
450 in 2015, a slight decrease from the reported 482 new HIV cases in 2014. New AIDS
cases were 115 in 2015, a slight decrease from the reported 125 in 2014. The majority of
new AIDS cases are among White and Hispanic MSM ages 20-44. New cases of
HIV/AIDS totaled 565 in 2015, a slight decrease from the 607 new HIV/AIDS cases
reported in 2014. Race/ethnic distribution is 36% White, 36% Hispanic, 18%
Black/African American, 5% Native American, 1% Asian/Pacific Islander and less than
1% (0.5%) Multi-race. Gender distribution of new HIV/AIDS cases in 2015 is: 87%
male and 13% female. Age groups of newly diagnosed with HIV/AIDS in 2015 include
0.2% under the age of 13, 2% from 13-19, 72% from ages 20-44 and 26% over the age of
45. The PLWHA population in 2015 consists of 12,906 persons, an increase of 3.5%
from 2014. PLWHA race/ethnicity is: 52% White, 28% Hispanic, 15% Black/African
American, 3% Native American, 2% Asian/Pacific Islander and 2% Multi-racial. Gender
ratios in 2015 are: 85% male, 15% female for PLWH and 87% male, 13% female for
PLWA and <.1% unknown.
c) Geography of the EMA with regard to communities affected by HIV/AIDS and
location of HIV/AIDS services in relation to those communities, including minority
populations served with MAI funds: The EMA’s land area is 15,000 square miles.
Arizona is the second fastest growing state in the nation and Maricopa County the fourth
most populous county in the nation. Pinal County is the 7th fastest growing county in the
nation among counties with populations over 10,000 persons. The EMA accounts for
74% of all prevalent cases and 74% of emergent cases of HIV/AIDS in Arizona in 2015.
92% of the EMA’s PLWHA live in Maricopa County and 8% in Pinal County. Minorities
served are represented by Hispanics at 28% of prevalent cases and 36% of newly
diagnosed HIV/AIDS cases, along with Black/African Americans representing 15% of
prevalent cases and 18% of newly diagnosed cases. HIV services are located in areas of
the EMA with high incident and prevalence of minority populations. MAI funds are
allocated to sub-recipients serving minority populations in the EMA.
d) Description of Comprehensive System of Care offered in the EMA: The Care
Continuum has evolved into a responsive medical model of HIV care and service
delivery. Outpatient Ambulatory Health Services is supported by substance abuse and
mental health treatment services, medical and non-medical case management, oral health,
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Phoenix EMA Ryan White HIV/AIDS Program Part A FY 2017 DUNS#077535144
Funding Opportunity Number: HRSA-17-30
transportation, and other services to provide PLWHA access to and retention in HIV
primary medical care. The EMA’s current HIV Care Continuum shows 12,906 PLWH/A,
with 63% or 8,149 linked to care; 51% or 6,601 retained in care; and 50% or 6,414
achieving viral suppression. However, it is important to note, the EMA’s Ryan White
Part A HIV Care Continuum shows dramatically better outcomes than the general HIV
population. The EMA’s RWPA 2015 Care Continuum shows 75% linked to care; 68%
retained in care and 63% achieving viral suppression. Unmet Need has decreased to
36.89% in 2015 from 37.9%, in 2014. The new methodology estimates Unmet Need at
31.55%.
e) Number of Years receiving Part A and MAI Funding: The Phoenix EMA has
received Ryan White Part A funding for 23 years, since 1993, and Minority AIDS
Initiative funds since 2007, for 9 years.
f) Changes to the RWHAP Part A Program as a result of the changing health care
landscape: Over the past two years, Arizona Ryan White recipients have collaborated on
an ACA outreach and enrollment program which resulted in 98% of all RWPA clients
being screened for ACA eligibility. The high screening rates can be attributed to the
dedication of the EMA’s subrecipient community, partners and the EMA’s systematic
approach to implementation of the Affordable Care Act. In 2015, one of the major health
insurance providers exited the marketplace which required a rigorous re-enrollment
outreach campaign. Over 400 PLWHA were re-enrolled in a new health insurance plan.
In 2017, more insurance plans will exit the marketplace, which will be a significant
barrier to care in the Phoenix EMA. The Arizona Ryan White recipients are working
closely together to identify alternate sources of health insurance for eligible Ryan White
clients.
g) Challenges and/or successes implementing the HIV Care Continuum. The HIV Care
Continuum has been a focus in the Phoenix EMA since 2012. The Planning Council has
been trained on reviewing and interpreting Care Continuum data. Each partnering
recipient shares Care Continuum data during preparation of the RWPA annual PSRA
session and during the Arizona Regional Quality Group quarterly meetings. In FY 2015,
RWPA began integrating quarterly updates on the EMA viral load suppression rate and
linkage to care timeframe during monthly Planning Council meetings. Planning Council
members, recipients and subrecipients receive training throughout the year on the HIV
Care Continuum. Due to the standardized definitions, Care Continuums can be
measured across all Ryan White recipients.
ii. Project Narrative
 INTRODUCTION - The purpose of this project is to provide direct financial assistance to
the Phoenix, Arizona Eligible Metropolitan Area (EMA) comprised of Maricopa and
Pinal Counties. Phoenix is the most populous state capital in the nation and the 6th most
populous city nationwide (US Census Bureau 2012). The following section will describe
the impact of the HIV epidemic in the Phoenix EMA and describe the significant need for
supplemental funding.
NEEDS ASSESSMENT--The Phoenix EMA conducts annual needs assessments to
identify needs, gaps and barriers to care. Since 2014, RWPA, RWPB and HIV Prevention
recipients have collaborated to conduct statewide needs assessments in order to identify
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Phoenix EMA Ryan White HIV/AIDS Program Part A FY 2017 DUNS#077535144
Funding Opportunity Number: HRSA-17-30
and address common needs, as identified in the State’s Integrated Comprehensive Plan.
In 2014, a Comprehensive Statewide Needs Assessment was conducted. In 2015, a
Statewide Needs Assessment for Newly Diagnosed and High Risk Negative Individuals
was completed, and in 2016 a Statewide Needs Assessment of Individuals who dropped
out of care in the past 12 months was completed. The data obtained from these needs
assessments was used to inform the FY 2016 plan, budget, allocations table and the
Integrated Comprehensive Plan. Based on this data, supplemental funding is urgently
needed to address the continued epidemic of HIV/AIDS in the Phoenix EMA for the
following reasons:
The Unmet Need for HIV-related services as determined by the Planning Council
process; Utilizing the current methodology, the Unmet Need for the EMA is estimated at
36.89% in 2015, a decrease from 37.9% in 2014. Utilizing the new methodology, the
EMA’s unmet need is estimated to be 31.55%. This decrease is attributed to aggressive
and targeted outreach efforts through the EMA’s Early Intervention Services. The EMA
has received funding increases over the past two years and the results outlined above
indicate the EMA is using the increased funding to deliver proven results.
An increasing need for HIV/AIDS related services, including relative rates of increase
in the number of living cases of HIV/AIDS; In 2015, the EMA had 565 new cases of
HIV/AIDS, a 21% increase since 2011. From 2011-2014, the EMA averaged 521 new
HIV/AIDS cases. Testing and linkage efforts have become more targeted (based on
Needs Assessment results) and thus, more individuals are being tested in high risk areas,
resulting in more individuals being linked to the Care Continuum. While testing and
linkage efforts are aligning with the National HIV/AIDS Strategy (NHAS), supplemental
funding is needed to continue the EMA’s progress towards achieving the goals outlined
in the NHAS.
The relative rates of increase in the number of living cases of HIV/AIDS within new or
emerging subpopulations; Significant disparities exist in the EMA among communities
of color. African Americans comprise 5% of the EMA’s general population but 20% of
emergent HIV cases and 12% of emergent AIDS cases. Hispanics comprise 31% of the
EMA’s general population but 36% of emergent HIV cases and 39% of emergent AIDS
cases. The emergent demographics include MSM ranging from 20-44 in age.
The current prevalence of HIV/AIDS; In 2015, the EMA’s PLWHA population
consisted of 12,906 persons, an increase of 3.3% from 2014. While emergent cases have
remained relatively stable, “in migration” to the EMA has resulted in higher prevalence
rates. In fact, most recent Needs Assessment data indicated 33% of respondents testing
positive outside of the EMA with former California residents comprising 11% of total
responses. Race/ethnicity is: 52% White, 28% Hispanic, 15% Black/African American,
3% Native American, 2% Asian/Pacific Islander and 2% Multi-racial. Gender ratios in
2015 are: 85% male, 15% female for PLWH and 87% male, 13% female for PLWA and
<.1% unknown. MSM is 62%.
Relative factors related to the cost of care and complexity of delivering healthcare to
individuals with HIV/AIDS in the eligible area; Co-morbidities and the escalating age of
PLWHA have contributed to the cost of HIV primary medical care and complexity of
care delivery with 22% of PLWHA responding to the 2014 Comprehensive Statewide
Needs Assessment in the EMA reporting a sexually transmitted infection within the last
year; 28% reporting Hepatitis A or B infection; 15% Hepatitis C co-infection; 30%
reporting high blood pressure and 25% citing high cholesterol. Over one-third of
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Phoenix EMA Ryan White HIV/AIDS Program Part A FY 2017 DUNS#077535144
Funding Opportunity Number: HRSA-17-30
respondents (36%) report mental health issues and 17% report substance use disorders.
Currently, 7% are homeless; 38% have been in jail and 14% have been in prison.
A. Epidemiologic Overview
1) The Phoenix EMA is comprised of Maricopa and Pinal Counties, located in
Central Arizona. The two (2) counties had a population of 4,574,531 in 2015,
up 2% from 4,489,109 in 2014, representing 67% of the state’s total
population. The EMA’s general population consists of: 57% White, 5%
Black/African American, 4% Asian, 2% American Indian/Alaska Native and
2% Multi-Race. Hispanics represent 31% of the EMA’s general population.
Gender is: 50% female and 50% male. The population consists of 27% under
the age of 18, 10% from 18 to 24, 31% from 25 to 44, 20% from 45 to 64, and
12% who were 65 years of age or older. The median age is 33 years. The
EMA comprises 74% of the state’s total HIV/AIDS prevalence and 74% of the
state’s emergent HIV cases. The map below identifies the Phoenix EMA in
relation to the State of Arizona.
2) The socio-demographic characteristics of persons newly diagnosed, PLWH, and
persons at higher risk for HIV infection in the geographical region are included
below.
a) Table 1 describes the Phoenix EMA’s incidence and prevalence of
HIV/AIDS for the past five (5) calendar years (2011-2015). A narrative
comparison of the five (5) year period from 2011 to 2015 is provided for
each of the four (4) categories included in Table 1: HIV incidence, AIDS
incidence, HIV prevalence and AIDS prevalence.
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Phoenix EMA Ryan White HIV/AIDS Program Part A FY 2017 DUNS#077535144
Funding Opportunity Number: HRSA-17-30
• HIV Incidence: The EMA identified a total of 2,044 new HIV cases in
the past five years. The largest number of new HIV cases was
identified in the White and Hispanic MSM population, and 80% of
new HIV cases were individuals in the 20-44 age group.
• AIDS Incidence: The EMA identified a total of 605 new AIDS cases
in the past five years. The largest number of new HIV cases was
identified in the White and Hispanic MSM population, and 56% of
new AIDS cases were in the 20-44% age group, and 44% in the 45+
age group.
• HIV Prevalence: The EMA has had an increase in HIV prevalence
every year since 2011. In 2015, the EMA had a 9.4% increase from
2014. White and Hispanic MSM were the majority of cases, with 49%
of the clients in the 20-45 age group, and 49% of the clients in the 45+
age group.
• AIDS Prevalence: The EMA has had an increase in AIDS prevalence
every year since 2011. In 2015, the EMA had a 9.8% increase from
2014. White and Hispanic MSM were the majority of cases, with 67%
of the clients in the 45+ age group.
TABLE 1.
2011-2015 HIV EPIDEMIC IN PHOENIX EMA COMPARED TO GENERAL POPULATION
Sources: Columns A-D: Arizona Department of Health Services, HIV/AIDS Surveillance, eHARS, as of December 31,
2015. Column E: U. S. Census Bureau, estimate for 2015 for Maricopa and Pinal Counties, AZ combined.
Column A Column B Column C Column D Column E
HIV Incidence AIDS Incidence HIV AIDS GENERAL
Prevalence Prevalence POPULATION
450- 2015 115- 2015 6,706-- 2015 6,200—2015 4,574,531-- 2015
486 – 2014 122 – 2014 6,345 – 2014 6,124 - 2014 4,489109 – 2014
383 – 2013 140 – 2013 5,932 – 2013 5,852 – 2013 4,398,762 – 2013
401 - 2012 108 - 2012 5,747 – 2012 5,681 – 2012 4,329,534 – 2012
324—2011 120-- 2011 5,471-- 2011 5,531-- 2011 4,281,899-- 2011
Race/ Ethnic (2015) Race/ Ethnic (2015) Race/ Ethnic (2015) Race/Ethnic (2015) Race/ Ethnic (2015)
35% White 38% White 52% White 55% White 57% White
36% Hispanic 39% Hispanic 27% Hispanic 27% Hispanic 31% Hispanic
20% Black 12% Black 15% Black 13% Black 5% Black
5% Native American 4% Native American 3% Native American 3% Native American 2% Native American
1% Asian/Pacific 6% Asian/Pacific 2% Asian/Pacific 1% Asian/Pacific 4% Asian/Pacific
Islander Islander Islander Islander Islander
2% Multi-Race 2% Multi-Race 1% Multi-Race 2% Multi-Race
Age Groups(2015) Age Groups (2015) Age Groups(2015) Age Groups (2015) Age Groups (2015)
0.4% 0-12 0.0% 0- 12 0.6% 0-12 0.11% 0-12 14% 0-12
3% 13‐19 0.0% 13-19 0.9% 13‐19 0.18% 13‐19 11% 13‐19
80% 20‐44 56% 20‐44 49% 20‐44 32% 20‐44 38% 20‐44
17% 45+ 44% 45+ 49% 45+ 67% 45+ 37% 45+
Gender (2015) Gender (2015) Gender (2015) Gender (2015) Gender (2015)
87% Male 88% Male 85% Male 87% Male 50% Male
13% Female 12% Female 15% Female 13% Female 50% Female
Transmission Transmission (2015) Transmission (2015) Transmission (2015)
(2015) 51% MSM 63% MSM 61% MSM
66% MSM 3% MSM/IDU 6% MSM/IDU 10% MSM/IDU
5% MSM/IDU 12% Heterosexual 11% Heterosexual 10.4% Heterosexual
6% Heterosexual 12% IDU 8% IDU 10% IDU
6% IDU 21% Not reported 12% Not reported 7.5% Not reported
17% Not reported
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Phoenix EMA Ryan White HIV/AIDS Program Part A FY 2017 DUNS#077535144
Funding Opportunity Number: HRSA-17-30
b) The following socioeconomic data was sourced from the United States
Census Bureau website and reflects 2014 data, unless otherwise stated. In
2014, the median household income in Arizona was $49,928. In Maricopa
County, the average annual pay was $53,689 and in Pinal County, it was
$50,248. Arizona ranks 42nd in the country for persons living below the
poverty level, with 18.2% of Arizona’s population living below the
poverty level. Maricopa and Pinal Counties are only slightly better than
across the State with 17.1% and 17.6% of the population, respectively,
living below the poverty level. According to the United States Census
Bureau, 27.1% of Arizona’s population of 25 years and older has a
bachelor’s degree or higher; and 85.9% of the same population is a high
school graduate or higher. In regards to employment, 59.7% of Arizona’s
population aged 16 years and older was employed. In Maricopa County,
this increases to 63.6%, but drops to 50.9% in the more rural Pinal County.
According to the United Health Foundation’s 2015 Annual Report,
Arizona ranks 46th in the nation with 28.5% of children under 18 years
living below poverty level. Additionally, the United Health Foundation
ranked Arizona 32nd in the nation based on all determinants. Arizona’s
strengths are a low rate of preventable hospitalizations with 40.1
discharges per 1,000 Medicare enrollees, and a low cancer death rate at
169.6 deaths per 100,000. Some of the challenges are low public health
funding with only $39.00 per person, ranking Arizona 49th in the nation in
public health funding. Arizona also had the lowest rate (50%) of adults
receiving the flu vaccine in the country. Arizona also ranks 42nd in primary
care physicians (99.7 per 100,000), 43rd in complete immunizations for
children (66.1% of children aged 19 to 35 months), and 41st in both drug
related deaths (18.1 per 100,000) and lack of health insurance (15.4%).
3) Table 2 describes the burden of HIV/AIDS and the characteristics of PLWH
in the Phoenix EMA.
TABLE 2 - Disproportionate Impact of HIV in the Phoenix EMA, 2015
Source: United States Census, 2015; ADHS 2015
% General Population v. HIV+ A B C D E
Group in 2 -County EMA General Population New HIV New AIDS PLWH PLWA
(Maricopa and Pinal)
Race/Ethnic Group
African American 5% 20% 12% 15% 13%
Asian/Pacific Islander 2% 1% 6% 2% 1%
Hispanic 31% 36% 39% 27% 27%
Native American 2% 5% 4% 3% 3%
White 57% 35% 38% 52% 55%
Multi-Racial 2% 2% 0% 2% 3%
Gender
Male 50% 87% 88% 85% 87%
Female 50% 13% 12% 15% 13%
Age Group
0-12 14% 0.4% 0% 0.6% 0.11%
13-19 11% 3% 0% 0.9% 0.18%
20-44 38% 80% 56% 49% 32%
45+ 37% 17% 44% 49% 67%
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Phoenix EMA Ryan White HIV/AIDS Program Part A FY 2017 DUNS#077535144
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3) Indicators of risk for HIV infection in the population covered by the Phoenix
EMA include:
a) Youth Risk Behavioral Surveillance System (YRBSS) data (2015) for Arizona
reports that 39% of youth have had sex and among those who were sexually
active 45% did not use a condom during last sexual intercourse. Arizona does
not use the YRBSS to survey youth about HIV, intravenous drug use or
partner violence through the YRBSS.
b) HIV surveillance data, including HIV testing program data, on the EMA’s
three target populations selected for the FY 2016 EIIHA Plan is included in
Tables 3 and 4.
Table 3 - NEWLY DIAGNOSED POSITIVE HIV TEST EVENTS FOR 1/1/2016 – 6/30/2016
Sources: Indicators A-F: Arizona Department of Health Services, HIV Prevention, Luther Database.
Indicator G.: Arizona Department of Health Services, HIV/AIDS Epidemiology program.
Lab Data extraction: 9/15/2016. Data is preliminary.
White Non- Hispanic Black/African
Indicator Hispanic MSM American
MSM Heterosexual
a. # of test events 961 745 690
b. # of newly diagnosed positive test events 39 30 6
c. # of newly diagnosed positive test events WITH 13 17 3
client linked to HIV medical care
d. # of newly diagnosed confirmed positive test events 24 27 3
e. # of newly diagnosed confirmed positive test events 19 23 3
WITH client interviewed for Partner Services
f. # of newly diagnosed confirmed positive test 21 26 3
events WITH client referred to prevention services
g. # of newly diagnosed confirmed positive test events 58 42 10
who received CD4 cell count and viral load testing
Table 4 - PREVIOUSLY DIAGNOSED POSITIVE HIV TEST EVENTS FOR 01/01/16- 06/30/16
Sources: Indicators A-F: Arizona Department of Health Services, HIV Prevention, Luther Database.
Indicator G.: Arizona Department of Health Services, HIV/AIDS Epidemiology program.
Lab Data extraction: 9/15/2016. Data is preliminary.
White Non- Hispanic Black/African
Indicator Hispanic MSM American
MSM Heterosexual
a. # of test events 961 745 690
b. # of newly diagnosed positive test events 18 18 4
c. # of newly diagnosed positive test events WITH 13 13 3
client linked to HIV medical care
d. # of newly diagnosed confirmed positive test events 18 18 3
e. # of newly diagnosed confirmed positive test events 11 11 3
WITH client interviewed for Partner Services
f. # of newly diagnosed confirmed positive test events 13 8 3
WITH client referred to prevention services
g. # of newly diagnosed confirmed positive test events 4 9 1
who received CD4 cell count and viral load testing
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Phoenix EMA Ryan White HIV/AIDS Program Part A FY 2017 DUNS#077535144
Funding Opportunity Number: HRSA-17-30
c) The RWPA Program utilizes data reported in CAREWare to determine risk factor
related disparities among the RWPA population. For instance, although African
Americans make up only 5% of general population within the EMA, they account
for 17% of the total population served by RWPA services. Additionally, MSM
account for 72% of the RWPA population and more than 80% live at or below
200% of the federal poverty level.
d) Other relevant demographic data, including Hepatitis B, Hepatitis C surveillance,
STD surveillance, tuberculosis surveillance, and substance use data are identified
in Attachment 5. Attachment 5 identifies other relevant data, including the
number of cases among the EMA’s general population and number of cases
among PLWH in the EMA.
e) In 2015, the Ryan White Part A, B and HIV Prevention programs conducted a
Statewide Newly Diagnosed Needs Assessment survey. RWPA identified 416
newly diagnosed clients. RWPA survey participants were 71% male, 29%
female, 35% aged 18 to 24, 39% 39 to 44, 17% 45 to 54, 9% 55+, 43% White,
35% Hispanic/Latino, 49% Men who have Sex with Men (MSM), 34%
Heterosexual, 6% Injection Drug User, 9% other, and 1% MSM and Injection
Drug User. The prevention survey interviewed 203 high risk individuals. Of the
MSM high risk respondents, 64% reported using web-based applications to find
sexual partners. Of those, 52% reported seeking sex encounters 5x per week,
24% 3-4x a week and 24% 1-2x a week. Overwhelmingly, participants reported
receiving their HIV information from their doctors and internet searches (Google,
Bing, etc.) with limited use of school and social medical resources. The data
collection process utilized a telephone survey instrument that adhered to the
topics that were determined and approved by Ryan White Part A, B and
Prevention. In this process, survey tools and scripts were created to evaluate the
patterns of where newly HIV diagnosed clients may socialize and social media
trends used to communicate and find sexual partners. These tools were
closely linked to elements utilized by Arizona HIV prevention staff as insights
into the community’s sexual habits, thus allowing HIV Prevention messages to be
more appropriately targeted to at risk groups sample results from the needs
assessment included:
• Before testing positive, had you heard HIV prevention messages?
o 68% responded Yes
o 31% responded No
o 1% responded Not Sure
• Before testing positive, did you discuss HIV transmission risks with
friends/social network?
o 34% responded Yes
o 65% responded No
o 1% responded Not Sure
• Where have you gotten your HIV information?
o 18% responded school
o 17% responded social network (Facebook, Twitter, Instagram, KiK,
Grindr, etc.)
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Phoenix EMA Ryan White HIV/AIDS Program Part A FY 2017 DUNS#077535144
Funding Opportunity Number: HRSA-17-30
o 52% responded Internet (Google, Bing, Yahoo, etc.)
o 14% responded family, friends, or acquaintances
o 88% responded medical provider (Doctor, nurse, health department)
o 3% responded Other: Library and Church youth group
• Where do you hang out with friends?
o Club/Bar
o Mall
o Church
o Friends’ house
o Parties
o Online
o School
o Work
f) Data from the Arizona Department of Health Services Office of Vital
Statistics related to HIV cases and deaths is shown in Table 5 below:
TABLE 5 – Vital Statistics related to HIV Cases and Deaths
Source: ADHS Office of Vital Statistics, 2015
2011 2012 2013 2014 2015 Total
NEW HIV 395 475 508 599 573 15002
NEW AIDS 171 158 195 161 160 7329
TOTAL NEW HIV/AIDS 566 633 703 760 733 22331
HIV Progressing to AIDS 187 149 153 149 136 6559
TOTAL AIDS 358 307 348 310 296 13888
HIV Death 1 0 38 39 29 631
AIDS Death 3 0 141 130 142 6324
g) The RWPA Program has strong working relationships with two of the biggest
Community Health Centers in Maricopa and Pinal Counties. One CHC is a
contracted RWPA sub-recipient. This CHC currently provides services to 30
non-RWPA clients, along with a smaller number of RWPA clients. The other
CHC has received technical assistance from the RWPA recipient on testing
criteria, and refers all clients that are identified as HIV positive to RWPA sub-
recipients.
B. HIV Care Continuum for FY2017
1) Below is a graph and description of the 2014 and 2015 Phoenix EMA’s HIV Care
Continuums:
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Phoenix EMA Ryan White HIV/AIDS Program Part A FY 2017 DUNS#077535144
Funding Opportunity Number: HRSA-17-30
The HIV Care Continuum was an instrumental tool in developing the Statewide
Integrated Plan for Arizona. The planning bodies agreed to utilize 2014
continuum data in order to have comparable data across all Ryan White recipients
and the ADHS HIV Surveillance. However, the RWPA recipient has a robust
system for generating continuum data and has decided to include both the 2014
Care Continuum and the 2015 Care Continuum in this section. The development
of the Phoenix EMA’s continua are based on data collected in CAREWare from
each sub-recipients, which is then extracted and imported into a highly specified
Access database which allows the RWPA recipient to produce many continua
based on total client population, sub-populations based on demographic data, such
as race, age group, gender, etc., and by specific sub-recipient agencies and service
categories.
The 2015 Care Continuum demonstrates decreases in percentages in each stage
across the continuum for the total RWPA population. This decrease is due to
several changes to the way data is collected. Prior to September 2015, viral load
data collected in CAREWare was not considered verifiable data, as much of the
data was of self-report by the clients to their case managers. Whether by
unintentional exaggeration or lack of knowledge of their actual viral load and the
importance of self-monitoring, it appeared that much of that data may have not
been accurate. In September of 2015, RWPA implemented a new requirement for
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Phoenix EMA Ryan White HIV/AIDS Program Part A FY 2017 DUNS#077535144
Funding Opportunity Number: HRSA-17-30
clients to submit viral load lab data at the time of eligibility. Additionally, in
early 2016, during the middle of the first cycle of viral load requirements at
eligibility, it appeared many agencies had become less diligent in entering lab
data and appointment information into CAREWare during the months in between
clients eligibility renewals. This resulted in many lab data only being reported at
the six month eligibility and may have affected the continuum results. It is
important to note that, with the greater importance the RWPA recipient has placed
on viral load monitoring and tracking, results across the continuum in 2016 have
been steadily rising throughout the year. The RWPA recipient projects the 2016
Care Continuum will surpass the results for both 2014 and 2015.
The Phoenix EMA’s RWPA program is using the Arizona Regional Quality
Group’s definitions for the HIV Care Continuum. In 2015, the Arizona Regional
Quality Group was awarded a National Quality Center Award for Cross Part
Collaboration for implementation of the quality group and development of
statewide definitions. The definitions were driven by the Arizona Department of
Health Services/HIV Surveillance, with input from all Ryan White recipients in
Arizona (Parts A, B, C, D and F), HIV Prevention and Epidemiology staff. Those
agreed upon definitions are, as follows:
a. HIV-Diagnosed – Numerator: Prevalent cases. Denominator: Prevalent
cases.
b. Linkage to Care – Numerator: Prevalent cases with a documented lab test,
doctor visit or medication use in the calendar year. Denominator: Prevalent
cases.
c. Retained in Care – Numerator: Prevalent cases with a documented lab test,
doctor visit or anti-retroviral (ARV) use in the first six (6) months of the
calendar year and the second six (6) months of the calendar year or one (1)
documented lab test, doctor visit or anti-retroviral (ARV) use in the calendar
year with a lab result indicating viral suppression status. Denominator:
Prevalent cases.
d. On Antiretroviral Use – Numerator: Prevalent cases with documented ARV
use or whose last viral load of the calendar year was undetectable. All
“Adherent/Suppressed” are in this category. Denominator: Prevalent cases.
e. Adherent/Suppressed – Numerator: Prevalent cases whose last viral load of
the calendar year was suppressed (<200 C/mL). Denominator: Prevalent
cases.
2) Graph and description of disparities in engagement among key populations:
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Phoenix EMA Ryan White HIV/AIDS Program Part A FY 2017 DUNS#077535144
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The above graph demonstrates the large disparaties across the stages of the
continuum experienced by YMSM, Transgender individuals, and those with
unstable housing or who are homeless. These three sub-populations continually
demonstrate the lowest rates of retention in care and viral suppression in the
Phoenix EMA.
a) Over the past two years, the HIV Care Continuum has been an important
component in planning and prioritizing services and funding to target
populations most in need within the Phoenix EMA. The RWPA Planning
Council is regularly informed on progress along the continuum stages and
uses the continuum data during their annual PSRA process to determine
appropriate funding for service categories. With this data, the Planning
Council began funding housing services in FY 2015 and has increased that
funding for FY 2016 and FY 2017. Similarly, the continuum data was
influential in adding three new EIS contracts in late 2015, one of those to
focus on linking newly diagnosed and out of care Youth and YMSM to care.
Finally, the RWPA recipient, in collaboration with the RWPB recipient and
HIV Prevention, will be conducting a needs assessment of Transgender clients
in the fall of 2016.
b) The HIV Care Continuum data is utilized for planning services through
periodic reports to the RWPA Planning Council on Unmet Need, Continuum
data, and EIIHA Strategies. The Planning Council also utilizes this data
during the PSRA process to ensure that services are funded according to
priority and needs in the community. Additionally, the Clinical Quality
Management Committee focuses its efforts around the data that can be
gleaned from the Care Continuum. An example of how the data has been
utilized for each stage of the continuum is, as follows:
Linked to HIV Care – In 2015, the RWPA Planning Council increased
funding for Early Intervention Services and three new contracts were awarded
to expand testing and linkage to care activities in the EMA. The data from the
Care Continuum and data related to linkage to care timeframes were
instrumental in supporting the Planning Council’s decision.
Retained in HIV Care – In 2015, the RWPA recipient determined the most
significant difference across our sub-recipient specific continua was between
the percentages for Linked to Care and Retained in Care. In an effort to shift
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focus to concentrate more heavily on retaining clients in care, the Clinical
Quality Management Committee made the decision to add retention in care to
the PDSA process. Provider agencies have begun to work on improvement
projections aimed towards retaining more clients in medical care.
Additionally, with the new requirement of the viral load data requirement,
eligible clients must have their labs drawn at least once within their 6 month
eligibility cycle.
On ARV Therapy – Over the past year, this stage of the continuum has
remained within one or two percentage points of the Retained in HIV Care
measure. This is due to increased data sharing between the RWPA recipient
and the RWPB and ADAP recipients.
Adherent/Suppressed – Early in 2016, the RWPA recipient developed a tool
for sub-recipients to determine which of their clients, by service category,
were reporting non-viral suppression. This tool has been utilized by several
sub-recipients to target those individuals and develop PDSAs around
improving care and treatment adherence. One sub-recipient, whose Medical
Case Management clients showed a 74% viral suppression rate, now reports a
95% viral suppression rate of current MCM clients.
c) During each quarterly meeting of the Clinical Quality Management Committee,
the committee reviews the updated RWPA Continuum and each sub-recipient is
provided an agency-specific continuum broken out by each service category for
which they receive funding. Additionally at each meeting, all sub-recipients are
required to complete, submit and present a PDSA or improvement project that
they are working on. Each PDSA or improvement project must focus on linkage
to care, retention in care, or viral load suppression rates. The RWPA recipient
reviews and provides feedback and direction, as necessary, to each sub-recipient.
d) Information related to the HIV Care Continua is disseminated to the community
in several fashions. The continuum data is presented to the Clinical Quality
Management Committee on a quarterly basis and through periodic reports
provided to the Planning Council. Additionally, information is disseminated
during Arizona’s Annual HIV Symposiums. Finally, the RWPA recipient is
planning to post the continuum data to our website, updated annually, and provide
up-to-date continuum information during the quality management portion of the
Quarterly Contractor calls with sub-recipients.
C. Demonstrated Need
1) Early Identification of Individuals with HIV/AIDS (EIIHA)
FY2017 EIIHA Plan
The overarching goal of the EMA’s EIIHA Plan is to reduce the number of
undiagnosed and late diagnosed individuals and to ensure they are accessing HIV
care and treatment. The total number of undiagnosed clients in the EMA is
estimated to be 1,807. This estimate is based on the CDC’s national unaware
estimate percentage.
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a) The EMA has collaborated with the Ryan White Parts B, C, D, F, and the
Arizona HIV and Surveillance programs to define the processes for
identifying high risk individuals as outlined in the EMA’s EIIHA plan. The
FY 2016 target populations for the Phoenix EMA EIIHA Plan include: White,
non-Hispanic MSM; Hispanic MSM; and Black/African American
Heterosexuals. One goal of the EIIHA Plan is to provide testing resources for
these individuals in multiple, culturally competent locations in order to
decrease barriers to testing. Locations were identified, in part through geo-
coding from the 2014 Comprehensive Statewide Needs Assessment survey
respondents. Ryan White, HIV Prevention and Surveillance Programs
collaborated on identifying and committing to multiple strategies to increase
resources for identification, testing, counseling and referring high risk
negative clients for testing in the 2017-2021 Statewide HIV Integrated Plan.
If high risk clients test negative, referrals are made for prevention counseling,
including PrEP education and possible referrals/linkage to PrEP providers. If
clients test positive, they are linked to Medical Care and Case Management
through the RWPA Central Eligibility system. The Phoenix EMA has
established a goal of linking newly diagnosed clients to medical care within
30 days. The accomplishment of this goal requires the collaborative efforts of
the EMA’s Early Intervention Service (EIS) sub-recipients, the Case
Management sub-recipients and Outpatient Ambulatory Health Services sub-
recipients. The Maricopa County Partner Services program works
collaboratively with the state’s Surveillance Program to complete partner
service investigations and rapidly follow-up after notification of a positive
diagnosis, and as part of the follow-up process, Partner Services’ staff
immediately links clients to Ryan White Part A Central Eligibility or private
physicians if the client has private insurance. The EMA’s Early Intervention
Services program, focused on testing and linkage activities, are currently
reporting 70% linked to care rate, with 63% being linked within 30 days.
Two of the EMA’s sub-recipients have CDC funding for testing, counseling
and linkage to care and these sub-recipients specifically focus on
identification of the EMA’s EIIHA target populations. In 2017, two sub-
recipients are applying for additional funding from CDC to increase their
testing, counseling and linkage to care for special populations.
b) The planned activities of the EMA for FY 2017 include the following:
(1) Primary activities include:
• Utilize data received through the 2016 implementation of the requirement
that all clients provide viral load data at six months eligibility renewals to
ensure complete and accurate Care Continuum data related to viral load
suppression. This project is a coordinated effort with Ryan White Part B
(RWPB), AIDS Drug Assistance Program (ADAP) and HIV Surveillance.
Integration of viral load reporting into CAREWare, which was completed
in 2016, now allows for more accurate health outcome reporting and leads
to increased client retention in care. Additionally, integration of viral load
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reporting further enhances the EMA’s HIV Care Continuum to target EIS
strategies and achieve suppression goals as outlined in the updated
National HIV/AIDS Strategy 2020. A retention specialist is available to
assist clients who may encounter barriers with obtaining the viral load data
if they are unable to complete this task on their own, and to ensure these
clients do not fall out of care due to any barriers the clients may incur as
part of this requirement.
• Routine testing and bilingual (English and Spanish) early intervention
services at Maricopa Integrated Health System’s (MIHS) Emergency
Department. This opt-out testing project includes partnership between
hospital staff, CDC funded HIV testing programs and Ryan White funded
Early Intervention Services (EIS) sub-recipients.
• Routine testing and early intervention services at the Maricopa County
Jails. This opt-out testing project includes partnership between Maricopa
County Correctional Health staff, CDC funded HIV testing programs and
Ryan White funded EIS sub-recipients.
• Routine testing and early intervention services in Federally Qualified
Healthcare Center (FQHC) Look Alike Urgent Care Clinic in low-income
communities of South Phoenix. This routine testing program, funded with
RWPA EIS funds, has resulted in 3,791 tests completed in 2015, with 13
new infections (0.34 %) positivity rate identified.
• Maricopa County Partner Services and RWPA Linkage Improvement
Project are designed to decrease linkage times, and to develop linkage
training materials for Partner Services staff.
• Ryan White Parts A and B will collaborate with HIV Prevention in 2017 to
complete a coordinated Comprehensive Statewide Needs Assessment
Survey to identify factors impacting movement through the continuum for
newly diagnosed and high risk individuals.
• Early Intervention Services at the refugee clinic encourage linkage and
retention in care in two (2) distinct groups with more than five (5)
different languages. Includes partnership with MIHS Refugee Women’s
Health Clinic.
• Continue partnership with Maricopa County Public Health Partner
Services to contact newly diagnosed individuals and identify potential
partners, providing HIV-focused health education, and addressing stigma
related concerns while emphasizing the importance of being linked to HIV
medical care. Through funding provided by HIV Prevention Services,
Maricopa County Public Health Partner Services will provide counseling
and referrals to high risk negative individuals for PReP.
• Referrals for Primary Medical Care, ADAP, Housing, Mental Health,
Substance Abuse Treatment and other support services. Referrals are
based on risk acuity assessments and provide the ability for case managers
to expedite referrals based on the clients’ acuity assessment.
• Linkage agreements and Memorandums of Understanding with key points
of entry such as the Maricopa County Hospital’s Emergency Room
Department, Maricopa County Jails, and Ryan White Sub-recipients.
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• Utilization of high- and low-tech linkage materials such as the single page
linkage flyer, which outlines access steps for insurance (private, Medicaid,
and RWPA) and HIVAZ.org, which allows users to search for HIV friendly
services throughout the EMA. HIVAZ.org provides direct links to the
RWPA Program’s website and to the RWPA eligibility sub-recipient. In
2017, HIVAZ.org will be available in both English and Spanish.
• The RWPA Clinical Quality Management Committee (CQM) and the
RWPA subrecipients Clinical Quality Improvement (CQI) activities
strongly focus on reducing linkage to care timeframes and increasing
retention in care and viral load suppression rates for EIIHA
subpopulations. The additional level of analysis for these subpopulations
has demonstrated that Hispanic MSM and White MSM are showing higher
percentages across the continuum than the overall population, and Black
Heterosexuals are showing higher percentages than the total Black
population in the EMA. Please see the Care Continuum below for more
information.
• Presentation and analysis of continuum and newly diagnosed data by
race/ethnicity and risk factor at the Arizona Regional Quality Group (all
Ryan White Recipients, HIV Surveillance and HIV Prevention) and at the
RWPA Clinical Quality Management Committee. In 2016, the Arizona
Regional Quality Group began utilizing tools to provide a more thorough
analysis of the data available to programs through the Continuum of Care.
This analysis has identified common health disparities among programs
which will assist the group in developing statewide strategies to address
health disparities in 2017.
• Establishment of new partnerships and linkage education for community
based organizations. Maricopa County and Maricopa Integrated Health
System have been approved for a five year grant to address health literacy
and connection to community based services for youth who are involved
in the Criminal Justice System. The RWPA Program will participate in
this grant by identifying youth who are newly diagnosed in the Jail
through the RWPA Jail Testing Project, and by referring HIV positive
youth that enter the Justice System through this program for health literacy
and community referrals for social support services.
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• Regular EIIHA reporting at Planning Council meetings and Clinical
Quality Management meetings. Many key stakeholders from collaborating
agencies (all Ryan White Recipients and ADAP, Maricopa County Public
Health Department, Arizona Department of Health Services (ADHS), HIV
Prevention and communities of color) participate in the Phoenix EMA
Planning Council. EIIHA topics have been integrated into the full
Planning Council meeting agendas. This time is used to present EIIHA
strategy progress and pertinent data related to the EIIHA target
populations.
(2) The Phoenix EMA’s EIIHA plans collaboration with the following programs
and agencies:
• Emergency Department Routine Testing: Key partners include RWPA
(HRSA) for EIS staff which is available/on call 24 hours/day for newly
diagnosed individuals, HIV Prevention (CDC) for HIV tests, RWPC and
Maricopa County Partner Services to conduct follow up investigations
with identified individuals.
• Maricopa County Jail Routine Testing: Key partners include RWPA
(HRSA) in provision of Early Intervention Staff and testing supplies,
Maricopa County Jail staff who draw blood for the HIV tests, Maricopa
County Public Health Department who run the HIV tests and conduct
follow up with positively identified inmates in the jail.
• Integrating Prevention Services with RWPA Services. The new 2017-2021
Arizona Statewide HIV Integrated Plan identifies multiple strategies and
action steps which will be achieved through the Ryan White and
Prevention Programs working together to integrate services that identify
newly diagnosed individuals, provide counseling and ensure rapid linkage
to care. Some of these action steps include coordinating media campaigns,
maximizing resources through coordinating funding, and providing
collaborative opportunities for learning through the annual Statewide HIV
Symposium.
• Collaboration with State Surveillance and HIV Prevention: The EIIHA
and HIV Care Continuum data could not be compiled without strong
support from HIV Surveillance and the ADHS HIV Prevention Program.
A data sharing agreement is in place between RWPA and HIV
Surveillance, and viral load data will be shared with RWPB and HIV
Surveillance. The new viral load data will be used for health outcome
reporting and supplement state data systems.
• Other Ryan White Recipients: RWPA and RWPB support the use of case
managers to build personal connections with urban and rural clinicians.
RWPC and RWPA provide collaborative funding for the routine
emergency department testing program. A RWPA funded EIS Linkage
Specialist assists with referring newly diagnosed individuals to RWPA
and community resources after they are diagnosed in the Emergency
Department. RWPA and RWPD case managers are co-located at the
largest HIV clinic in Maricopa County. These case managers make
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referrals to RWPA funded community agencies to support client retention
and treatment adherence.
• Opportunities for input from all Ryan White recipients, ADAP, the
Maricopa County Health Department and HIV Prevention, as well as
diverse community members and general public exist through the RWPA
Planning Council meetings. The RWPA Planning Council members
provide formal input and collaboration through the PSRA process.
(3) The Phoenix EMA plan anticipates three (3) outcomes for overall EIIHA
strategy. The EIIHA strategy recognizes the increased importance of viral
load suppression in efforts to prevent new infections. The following three (3)
goals are designed to support the stages of the EMA’s HIV Care Continuum
and lead to increased viral load suppression among newly diagnosed
individuals.
1. By December, 2017, increase by 3% the number of newly diagnosed
clients who are linked to clinical care and achieve viral suppression
within 180 days of diagnosis. RWPA will be working to achieve the
updated National HIV/AIDS Strategy (NHAS) goal of having a minimum
of 80% of all diagnosed individuals virally suppressed. The RWPA
program has developed policies, systems and EIS programs to expedite
linkage to care and is partnering in state lead discussions on reducing
linkage to care time for Maricopa County. Case Managers have started
entering client viral load data and electronic submission systems have
been established to transfer viral load data to ADAP via RWPA/B’s data
sharing agreement.
2. By December, 2017, increase by 3% the number of people living with HIV
who will know their serostatus after participating in routine and targeted
testing programs within the EMA. RWPA funding will supplement not
supplant existing funding sources. This goal will be achieved by
continued support and growth of the jail opt-out testing project, the routine
emergency department and urgent care opt-out testing projects, and
increased capacity in RWPA subrecipients for funded EIS testing.
3. By December, 2017, increase to 85% the number of newly diagnosed
clients linked to medical care within thirty (30) days as reflected in the
National HIV/AIDS strategy. This goal will be accomplished by
continued PDSA projects which focus on improving linkage to care
timeframes and implementing successful evidence based strategies to
decrease linkage to care timeframes.
c) The EMA’s planned FY 2017 outcomes mirror goals which have been updated to
reflect the updated National HIV/AIDS 2020 strategy.
(1) The EIIHA target populations are disproportionately affected by HIV/AIDS
within the Phoenix EMA, which reflects the updated NHAS 2020 focus of
reducing HIV-related disparities and health inequities. The EIS activities are
designed to contribute to improving health outcomes along the EMA’s
continuum of care. The activities are aligned to best practices. Routine testing
services are paired with Early Intervention Services. Since the
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implementation of this EIIHA Strategy, the number of tests conducted within
the EMA has increased by almost 40,000 annually, which contributes to the
National HIV/AIDS Strategy 2020 goal of increasing the number of people
aware of their HIV status. In FY 2015, two hundred and seventy-four (274)
newly diagnosed clients entered RWPA services in the EMA as a result of the
EMA’s expanded testing initiatives. The EIS model has annually connected
two hundred and twenty-one (221) individuals into medical care. This
improvement supports the NHAS goal of increasing the proportion of newly
diagnosed individuals linked to clinical care. Linkage-to-care calculators and
aggregators have been built into the CAREWare systems to support
monitoring and improvement of linkage to care timeframes. The Phoenix
EMA has a strong ACA plan which supports clients in transitioning to and
understanding insurance and preventive care. This plan aligns to the
recommendations from the White House HIV Care Continuum Initiative
related to access to care. Following the Initiative’s recommendations of
tackling misconceptions, stigma, and discrimination to break down barriers to
care, RWPA has and will continue to partner with HIV Prevention in the
“Know Your Numbers Campaign.” This campaign is centered on normalizing
the messages around HIV, and creating media which is less focused on fear-
based advertisement and more on the ability of HIV+ individuals to live long,
healthy lives. As recommended by the Initiative, the plan works to strengthen
data collection, coordination and use of data to improve health outcomes, and
monitors the use of federal resources. An EMA specific HIV Care Continuum
plan has been drafted, which provides the program’s partners a better
understanding of existing interventions which strategically utilize resources to
impact different indicators within the continuum.
(2) The three (3) innovative approaches used in the Phoenix EMA EIIHA plan to
address barriers to assessing testing and treatment which contribute to the HIV
Care Continuum include:
• Focus on routine HIV testing strategies. The ADHS HIV Prevention
Program often funds targeted testing; however, routine testing, through the
opt-out jail, emergency department and urgent care projects, has identified
multiple individuals who would not have qualified under the specialized
guidelines for targeted testing. The routine testing programs must meet the
CDC’s recommendation of 0.1% positivity rate to support ongoing testing.
All current routine testing programs funded by RWPA exceed the
benchmark by 0.1% to 0.4%.
• Leveraging data systems and data sharing to support health outcome
reporting, monitoring and improvement. Data quality is of utmost concern
for measuring progress towards ending the EMA’s HIV epidemic. The
Phoenix EMA embraces several principles to achieving successful data
projects:
i. Use existing data (from RWPA or RWPB) when possible, creating
reports or additional functions to create desired metrics, with minimal
additional work required from sub-recipients. This step supports
sustainability.
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ii. Engage key stakeholders early when requiring additional data or data
elements. The rationale and importance should be clearly defined and
stakeholders given opportunity for suggestion. The end user’s expert
opinion must be solicited.
iii. Pilot changes in a small setting before expanding change requirements
across the entire EMA.
iv. Allocate recipient staff time for follow up of the project to ensure any
required changes are successfully deployed to all RWPA agencies.
v. Actively focus on achieving excellence in two areas of continuum
instead of modest improvements across the board. This approach does
not preclude improvements to the other areas of the continuum.
RWPA, along with other prevention and care partners, is focused on
the goal of ending the EMA’s HIV epidemic. Two (2) of the most
important outcomes identified by the Phoenix EMA are improving
linkage to care timeframes to under 30 days and increasing viral load
suppression of RWPA clients to 95% by 2021. This focus is identified
in the RWPA Clinical Quality Management meeting minutes and has
been incorporated into Maricopa County’s Managing for Results
program, which reports the County’s success in achieving critical
performance measures. These two (2) outcomes drive collaborations
with traditional and non-traditional stakeholders and provide a narrow,
measurable focus for sub-recipients.
(3) The Phoenix EMA will continue to pursue collaborations as a part of the
EIIHA plan within the community and with other public health stakeholders
to strengthen outcomes across the HIV Care Continuum. The RWPA and
RWPB leadership teams have established parallel EIIHA plans, which will
provide a statewide EIIHA Plan which will be included in the Statewide
Integrated Plan. Data is currently being collected by all of the recipients, and
Community (subrecipient and client) input on goals, strategies and activities is
routinely scheduled during Planning Council and Statewide Advisory Group
meeting, and during the annual Statewide HIV Care Continuum Symposium.
The expected outcome of these collaborative efforts is ensure community
input is incorporated into the comprehensive goals, objectives, strategies and
action steps which are identified in the Statewide HIV Integrated Plan.
Monthly meetings with participation of leaders from all recipients provide
opportunities to monitor progress and identify process improvement needs.
EIIHA Outcomes will be monitored and discussed by the Arizona Regional
Quality Group, Statewide Advisory Group, and the RWPA Planning Council.
Among the RWPA subrecipients, the CQM Committee structure has been
revised to include representation from all RWPA sub-recipients, and the
agenda for these meetings includes quarterly reporting on viral load
suppression, retention in care rates and linkage to care outcomes.
(4) The Phoenix EMA is utilizing EIIHA data to analyze and address gaps along
the HIV Care Continuum. In 2015, the Arizona Regional Quality Group met
with biostatisticians from ADHS and MIHS to better understand statistical
significance and essential first steps to analyzing and interpreting data. This
important step positioned recipients from across the state to begin
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understanding health disparities. In 2016, the Regional Quality Group
expanded this data analysis through a Deep Dive Data process. This process
helped the group identify common disparities and populations who have
challenges across the continuum of care, and the Regional Quality Group is
continuing to meet to address these issues on a local and statewide basis. As
part of this process, the Regional Quality Group identified significant
disparities in retention in care and viral load suppression in the state’s youth
and transgender populations, and the group will be working collaboratively to
identify strategies to address these disparities.
d) Based on the 2017 Unmet Need estimate calculations, the RWPA’s unmet need
for MSM clients is 30%. This indicates inroads are being made with the local
MSM populations. As MSM is the largest noted risk factor, MSM (White and
Latino) continue to be a focus of the EIIHA strategies. The unmet need estimate
for African-Americans is 39%, in comparison to Whites at 31% and Latinos at
27%. The local African-American community is a high priority because the HIV
infection rates continue to show the highest disparities in the EMA. The RWPA
Unmet 2014 Comprehensive Statewide Needs Assessment Survey indicated
clients who took longer than 90 days to enter care often experienced client-centric
barriers such as substance abuse issues or not being ready to address the
disease. EIIHA strategies continue providing support to the aware and not in care
population through provision of health education and literacy and Early
Intervention Services. Additionally, assistance with client enrollment in
Medicaid connects clients to inpatient substance abuse services. Part of the
EIIHA Plan is to ensure there are clearly established pathways to care for use
once the client is ready to enter services. Strategies include:
• Development of a single page linkage flyer which outlines access steps and
contact information for private insurance, Medicaid and RWPA.
• Ongoing publication (in paper and online) of the RWPA brochure of services.
• Establishment of new partnerships and linkage education for community
based organizations such as the People of Color Network and Community
Health Centers.
e) In 2016, the RWPA EIIHA Strategy was considered a key component in the
Statewide HIV Integrated Planning process. The 2016 EIIHA plan was heavily
influenced by research on how viral load suppression can prevent transmission of
HIV in couples, and the ability to use treatment as prevention. This resulted in an
EIIHA goal shift from linking ‘newly diagnosed clients to the medical care within
90 days’ to ‘viral load suppression within 180 of new diagnosis.’ As an outcome
of the successful implementation of the Affordable Care Act within the EMA, less
than one-third (1/3) of RWPA clients will be enrolled in RWPA funded medical
care. Recognizing the importance of viral load suppression, the RWPA Program
began to require viral load reporting as a component of RWPA eligibility in FY
2016. This information is also integrated into Medical Case Management health
outcome reporting and provides a clearer picture of how RWPA services are
improving the health of our clients. In addition, this data supports HIV
Surveillance reporting at the county and state level. In January 2016, the state’s
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second annual HIV Symposium was held, with participation from over 150 sub-
recipients, planning body members and consumers from across the state. This
symposium provided updates on HIV Prevention and Care best practices, and
included a strategic planning session which provided input from all participants
into the development of the goals, objectives, strategies and action steps for the
Statewide HIV Integrated Plan. The outcomes of this meeting were provided to
the RWPA Planning Council’s Community Health Strategies and Planning
Committee (CHPS) and the Statewide Advisory Group (SWAG), and provided
the basis for the final strategies to be incorporated into the Integrated Plan. The
2017 EIIHA Plan has been developed utilizing the data and the input from these
group processes, and it is expected that the EIIHA Plan and the Integrated Plan
will both contribute to successful health outcomes in the EMA’s EIIHA
populations.
f) Arizona may be the last state in the country that does not legally mandate the
reporting of virally suppressed HIV labs. The Arizona Surveillance program is
working closely with the Arizona State Rule-Writing Committee and anticipates a
public comment period soon and implementation in 2017. The program currently
receives almost all of the reports because an inclusive batch process has been
preferred by the partnering lab companies. Although Arizona does not have any
legal barriers or regulations regarding who may test and how to offer counseling,
the testing of pregnant women continues to be opt-in, which requires additional
steps on the part of the tester and tested. Arizona Ryan White Part D Program
staff helped 18 of 21 hospitals throughout Maricopa and Pinal Counties establish
protocols for testing high risk pregnant women and treatment for any found
positives. The Ryan White Part C Program in Maricopa County conducted a
multi-part campaign to educate the community when HIV testing in the Maricopa
County Hospital Emergency Department transitioned to an opt-out model. The
Ryan White Parts A and B recipients have collaborated with the ADHS Border
Health Office, the Arizona Mexico Commission and the Maricopa County
Sheriff’s Department to identify community needs around access to and retention
in care of HIV positive undocumented individuals. As a result of these efforts, a
HIV indication has been integrated into the US-Mexico health plan.
g) The Phoenix EMA has selected the following three (3) distinct target populations
for the FY 2017 EIIHA Plan:
White MSM
Selection: The White MSM target population for the EIIHA plan has been
selected based on epidemiological data from the ADHS HIV Epidemiology
Program’s 2015 Annual Report and community input. MSM continue to have the
largest incidence of HIV within the EMA at 62% of all new cases between 2011
and 2015, while White non-Hispanics compose 48% of all new cases.
Challenges and Opportunities: The Phoenix EMA’s epidemic is predominantly
White MSM. According to geospatial analysis, the majority of the White MSM
population is located in the Central Phoenix area. Some challenges include
complacency, fear of knowing HIV status, and a sense the clients do not need
services as noted in the 2014 Comprehensive Statewide Needs Assessment.
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Targeted activities which have been implemented have the potential to reduce
transmissions in the White MSM population. Arizona’s Medicaid expansion,
which began in January 2014, has provided many clients access to comprehensive
medical care. Additionally, RWPA has been engaging with non-Ryan White
funded clinicians, who see a large number of White MSM patients, to inform
them about the resources available through the healthcare law changes and to
learn about linkage to care issues appearing in their practices.
Activities: RWPA, RWPB, and HIV Prevention participated in an advertising
campaign entitled, “Know Your Numbers” which encouraged clients to become
knowledgeable of their CD4 and viral load numbers. The 2015 Newly Diagnosed
Needs Assessment conducted by RWPA and RWPB, had a special focus on
newly diagnosed individuals and was designed to assess their level of knowledge
of their CD4 and viral load numbers.
White MSM Objectives:
Identify: By July 2021, Arizona will reduce the number of new White MSM
diagnoses by at least 25%. Responsible Parties: ADHS, Maricopa County
Department of Public Health, RWPA, and Community Partners. MIHS’s
Emergency Department and the Maricopa County jails will continue offering
routine testing. Partner Services will continue testing, notification, and reporting
activities. Community based organizations will continue testing, notification, and
reporting efforts. Additional funds will be awarded in EIS services to increase the
number of tests completed for white MSM individuals.
Inform: By July 2021, Arizona will have increased the percentage of White MSM
living with HIV who know their serostatus to at least 90%. Responsible Parties:
RWPA (EIS), RWPC and Maricopa County Jail clinicians will inform HIV+
individuals identified at their routine testing sites. Maricopa County Partner
Services will inform clients who tested positive at county testing locations.
Refer: By July 2021, Arizona will reduce disparities in the rate of new White
MSM diagnoses by at least 15%. Responsible Parties: RWPA and RWPC EIS
staff will refer newly diagnosed or previously diagnosed clients to medical care.
Community agencies will refer rural HIV+ clients to rural HIV focused primary
medical care subrecipient. Rural Labor and Delivery staff will refer HIV+ to HIV
focused medical clinics. RWPA will oversee the newly implemented CAREWare
electronic data/referral system, which facilitates referrals to all service categories
and ADAP.
Link to Care: By July 2021, Arizona will increase the percentage of newly
diagnosed White MSM people linked to HIV medical care within one month of
their HIV diagnosis to at least 85%. Responsible Parties: RWPA and RWPB case
management agencies will continue connecting clients to medical and ADAP
services. EIS funded navigators will connect clients identified through routine
testing sites to medical care and continue distribution of all RWPA Service Sub-
recipient brochures through Maricopa County Department of Public Health and
Planning Council website. RWPA will oversee enhanced referrals, which
document linkage to medical care.
White MSM Planned Outcome: By July 2021, 90% of White MSM LWHA will
be retained in care and 90% will be virally suppressed.
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African-American Heterosexuals
Selection: The African-American Heterosexual target population for the EIIHA
plan has been selected based on epidemiological data from the ADHS HIV
Epidemiology Program’s 2015 Annual Report and community input. African-
Americans experience HIV/AIDS rates which are three (3) times higher than
other race/ethnicity groups, with the greatest disparity among emerging cases of
HIV in African-American Heterosexuals.
Challenges and Opportunities: Challenges include general stigma, fear of dying
in the hospital, beliefs that the disease only impacts gay men and fear of
discrimination. Targeted activities have the potential to reduce transmissions in
African-American Heterosexuals. Arizona’s Medicaid expansion which began
January 1, 2014, continues to allow more of these clients to access comprehensive
medical care.
Activities: RWPA partnered with University of Arizona to develop and implement
cultural competency training for service subrecipients. RWPA participates in the
advisory group for HIV Prevention’s new media campaign (It’s Only Dangerous
If You Don’t Know), which began in 2015. As part of the 2016 EIIHA Plan, the
media campaign was expanded to focus on African Americans. The EMA’s
Minority AIDS Initiative (MAI) sub-recipient funded for Medical and Non-
Medical Case Management Services for African-Americans has increased their
capacity for testing and support groups though a new CDC Prevention grant.
Women of color support groups have been implemented at the MAI funded sub-
recipient. RWPA funds patient navigators at the HIV Refugee Clinic to assist
clients in navigating the medical system and retaining these clients in care.
African-American Heterosexuals Objectives:
Identify: By July 2021, Arizona will reduce the number of new African
Americans diagnoses by at least 25%. Responsible Parties: ADHS, RWPA,
Community Partners. Emergency Departments and Maricopa County jails will
continue offering routine testing. Maricopa County Partner Services will continue
testing, notification, and reporting activities. Community based organizations will
continue testing, notification and reporting efforts.
Inform: By July 2021, Arizona will have increased the percentage of African
Americans living with HIV who know their serostatus to at least 90%.
Responsible Parties: Local partners who inform pregnant women in Labor and
Delivery units, RWPA (EIS), RWPC, and Maricopa County Jail clinicians will
inform HIV+ individuals identified at their routine testing sites. Maricopa County
Partner Services will inform clients who tested positive at county testing
locations.
Refer: By July 2021, Arizona will reduce disparities in the rate of new African
Americans diagnoses by at least 15%. Responsible Parties: RWPA and RWPC
EIS staff will refer newly diagnosed or previously diagnosed clients to medical
care. Community agencies will refer rural HIV+ clients to rural HIV focused
primary medical care subrecipient. Rural Labor and Delivery staff will refer HIV+
African-American Heterosexuals to HIV focused medical clinics. RWPA will
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oversee the newly implemented CAREWare electronic data/referral system,
which facilitates referrals to all service categories and ADAP.
Link to Care: By July 2021, Arizona will increase the percentage of newly
diagnosed African Americans people linked to HIV medical care within one
month of their HIV diagnosis to at least 85%. Responsible Parties: RWPA and
RWPB case management agencies will continue connecting clients to medical and
ADAP services. EIS funded navigators will connect clients identified through
routine testing sites to medical care. Linkage Specialists at the Refugee Women’s
Clinic will ensure linkage and retention in care. Distribution of all RWPA Service
Sub-recipient brochures will continue through Maricopa County Department of
Public Health and Planning Council website. RWPA will oversee enhanced
referrals, with document linkage to medical care.
African-American Heterosexual Planned Outcomes: By July 2021, 90% of
African Americans living with HIV will be retained in care and 90% will be
virally suppressed.
Latino MSM
Selection: The Latino MSM target population for the EIIHA plan has been
selected based on epidemiological data from the ADHS HIV Epidemiology
Program’s 2015 Annual Report and community input. MSM continues to have
the largest incidence of HIV within the EMA at 62% of all new cases between
2011 and 2015. Latinos form the second largest race/ethnicity group with 35% of
all new cases.
Challenges and Opportunities: Challenges include distrust of doctors, stigma,
specifically homophobia, and cyclical resistance to seeking governmental aid due
to fear of deportation. Fortunately, the community can see local government
policy changes are not resulting in increased deportation, and participation rates in
RWPA services have increased after initial dips in 2010 when deportation fears
were increased due to legislation passed by the Arizona Legislature. Many of the
provisions of this legislation have been overturned, and many Latino clients that
had expressed concern about accessing core medical and support services have
returned to care. Community input indicates gay Latino men also face increased
levels of stigma related to HIV and homosexuality. Targeted activities have the
potential to reduce transmissions in the Latino MSM population. Arizona’s
Medicaid expansion in January 2014 allowed some of these clients to access
comprehensive medical care.
Activities: RWPA sub recipients have Bilingual (English and Spanish) staff in all
service categories to assist monolingual clients in accessing services. RWPA
partnered with University of Arizona to develop and implement cultural
competency training for service subrecipients. The MAI agency funded for
Medical and Non-Medical Case Management Services for Latinos leverages
positive client relationships (as documented in consumer survey findings) to link
clients to on-site mental health and substance abuse services which can help
clients overcome stigma and reduce barriers to care.
Latino MSM Objectives:
Identify: By July 2021, Arizona will reduce the number of new Latinos diagnoses
by at least 25%. Responsible Parties: ADHS, RWPA, and Community Partners.
Emergency departments and Maricopa County jails will continue offering routine
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testing. Maricopa County Partner Services will continue testing, notification, and
reporting activities. Community based organizations will continue testing,
notification, and reporting efforts.
Inform: By July 2021, Arizona will have increased the percentage of Latinos
living with HIV who know their serostatus to at least 90%. Responsible Parties:
RWPA (EIS), RWPC, and Maricopa County Jail clinicians will inform HIV+
individuals identified at their routine testing sites. Maricopa County Partner
Services will inform clients who tested positive at county testing locations.
Refer: By July 2021, Arizona will reduce disparities in the rate of new Latinos
diagnoses by at least 15%. Responsible Parties: RWPA and RWPC EIS staff will
refer newly diagnosed or previously diagnosed clients to medical care.
Community agencies will refer rural HIV+ clients to rural HIV focused primary
medical care subrecipient. RWPA will oversee the newly implemented
CAREWare electronic data/referral system, which facilitates referrals to all
service categories and ADAP.
Link to Care: By July 2021, Arizona will increase the percentage of newly
diagnosed Latino people linked to HIV medical care within one month of their
HIV diagnosis to at least 85%. Responsible Parties: RWPA and RWPB case
management agencies will continue connecting clients to medical and ADAP
services. Bilingual (English and Spanish) EIS funded navigators will connect
clients identified through routine testing sites to medical care. Distribution of all
RWPA Service subrecipient brochures through Maricopa County Department of
Public Health and Planning Council website will continue. RWPA will oversee
enhanced referrals, which document linkage to medical care.
Latino MSM Planned Outcomes: By July 2021, 90% of Latinos living with HIV
will be retained in care and 90% will be virally suppressed.
h) EIIHA presentations are often combined with HIV Care Continuum updates.
Regular updates are shared at RWPA Planning Council meetings and RWPA
Clinical Quality Management Committee meetings. The EIIHA data is presented
as part of the annual PSRA Data Session and considered as part of the overall
PSRA planning process.
i) The EMA conducts quarterly contractor calls with all sub-recipients that include
an opportunity to identify challenges and successes that they are experiencing
with their clients and services. The sub-recipients are provided their specific
service continua prior to the call for them to review and highlight how their
strategies are impacting the EIIHA populations they serve. The subrecipients also
have the opportunity to report on their efforts and dialogue with public members
of the CQM Committee during the quarterly CQM Committee meetings.
j) The Planning Council receives an annual presentation on the EMA’s EIIHA Plan,
including information on how the EIIHA populations are selected, how the data is
gathered, compiled and analyzed, how the EIIHA strategies are developed and
implemented, and the outcomes that are achieved in each of the strategies. Many
of the EMA’s EIIHA strategies are included in the 2017-2021 Statewide HIV
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Integrated Plan activities, and both the Planning Council and the Statewide
Advisory Group will receive an annual report on the status of all of the activities
in the plan.
2) Unmet Need: Unmet Need is defined as the need for HIV primary medical care
among individuals who are aware of their HIV status and are not in care.
• The current methodology using the Unmet Need Framework to calculate Unmet
Need for 2017, using CY 2015 data calculates the Phoenix EMA unmet need at
36.89%.
• The new methodology using the HIV Care Continuum Framework to calculate an
Unmet Need estimate for 2017, using CY 2015 data calculates the Phoenix EMA
unmet need at 31.55%. See Attachment 4 for the 2015 Unmet Need Framework
for the Phoenix EMA. Table 6 provides a brief overview of the Unmet Need
estimates.
Table 6- Comparison of Unmet Need Estimates
Source: Arizona Department of Health Services, HIV Surveillance and RWPA CAREWare,
2016
CY2013 CY2014 CY2015 CY 2015 - New Method
Unmet Need Unmet Need Unmet Need Diagnosed (4314) –
Relative Proportion: Relative Proportion: Relative Proportion: Retained (2953) = 1361
40.16% 37.89% 36.89% Unmet Need (1361)
Unmet Need Relative
Proportion: 31.55%
Current Methodology: Unmet Need Framework Estimate
a) Provided below is an Unmet Need narrative description of the FY 2017 estimation
methods based on an assessment of the EMA’s Unmet Need:
(1) Estimation methods: The Current Methodology is based on jurisdictional data
and estimates. Utilizing this approach allows for the RWPA Program to base
decisions on the overall need in the Phoenix EMA because it is developed
using data that includes all PLWHA in the service area, and not simply those
individuals who are receiving services from the RWPA program. This is both
a benefit and a limitation. This methodology allows the RWPA Program to
analyze the overall health outcomes of RWPA’s service delivery system and
make plans to address the needs not being met in the greater community.
However, there are several limitations with this data. First, it is only reported
on an annual basis and therefore cannot be reviewed on a more regular basis.
Additionally, with the use of the continuum, the RWPA program has the
ability to further analyze the unmet need based on several different
demographic data, separately and simultaneously. Since the current method is
based on surveillance data and the RWPA is not granted access to client-level
data for these figures, this cannot be completed at the same level of accuracy
using the current method. The RWPA program is currently working with the
local Ryan White Part C Program to identify whether or not newly diagnosed
individuals who appear to have not been linked to care, have been seen at their
clinic utilizing a payer source other than Ryan White. By doing so, this will
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allow for a more accurate picture of the EMA’s unmet need among newly
diagnosed clients.
(2) Assessment of Unmet Need: The Current Methodology using the Unmet Need
Framework calculates Unmet Need for 2017 at 36.89%. The following
provides a summary on the: (a) demographics and geographic location of
those with an unmet need; (b) a description of the estimate trends of the past
five years; and (c) an assessment of service needs, gaps, and barriers to care
for those not in care:
(a) As stated previously, ADHS HIV Surveillance provides the data on an
annual basis which allows the RWPA program to calculate the unmet need
percentage for the entire EMA. Unfortunately, the 2015 data provided for
the EMA does not include a breakdown based on demographic
information. Similarly, the geographic location is only detailed by
specific regions, the Phoenix EMA being one of those regions. With the
development of the Statewide Integrated Plan, the RWPA Program will be
able to request more detailed information regarding these data
deficiencies.
(b) In 2011, the unmet need for the Phoenix EMA was calculated to be
25.33%. There was a sizeable increase the following year to 42.26%
unmet need. In 2012, there was a change to qualifications for Medicaid in
Arizona and single males without dependent children were dis-enrolled
from coverage. As the predominant HIV/AIDS population in the EMA is
MSM and even though many were covered by RWPA for medical
services, this may account for many of individuals falling out of care.
Since 2012, the EMA has seen a steady decrease in the unmet need
estimates each year due to improved linkage techniques, expanded wrap
around services, improved data collection methods, and the expansion of
Medicaid in 2014 due to the ACA.
(c) The 2014 Statewide Comprehensive Needs Assessment highlighted
several service needs, gaps, and barriers; the most prominent of these
being housing, transportation and food/nutrition services. Due to this
needs assessment, the RWPA Planning Council expanded funding for
transportation and nutrition services, along with allocating funding for
housing and food services. In the subsequent years, the Planning Council
has continued to increase funding in each of these service categories to
meet the need of the clients. In 2017, the RWPA program, along with
RWPB and HIV Prevention are planning follow-up comprehensive needs
assessment focused on updating information on service needs, gaps, and
barriers.
New Methodology: Unmet Need Estimate based on the HIV Care Continuum
Framework
In comparing and contrasting the FY 2017 unmet need estimates derived from the
Current Unmet Need Framework and the new HIV Care Continuum Framework there
is several factors to consider:
a) Variance in Unmet Need estimates is evidenced by a 5% decrease in the estimated
unmet need when using the HIV Care Continuum Framework, as opposed to the
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current methodology. This is largely due to the fact that the data for the new
method is gathered from the RWPA Care Continuum for the EMA and does not
include the greater EMA data. Early in 2016, the RWPA program completed its
initial cycle of requiring viral load data at eligibility renewal times. This will only
serve to improve our data collection and increase our retained in care numbers,
thus giving us an even more accurate estimate of the unmet need going forward.
The new data element requirement will further enhance the outcomes in the
RWPA Program.
b) When comparing the Unmet Need estimates using the new methodology for FY
2016 and FY 2017, the estimate has changed from 25% for FY 2016 to 32% for
FY 2017, an increase of 7%. While the estimate is closer to that of the current
methodology than previously, there are several factors which may have
contributed to this. To start, there have been an ever increasing number of clients
being served by RWPA. From 2014 to 2015, this was demonstrated by an
increase of 9.3% in clients served. Additionally, in early 2016, during the middle
of the first cycle of viral load requirements at eligibility, it appeared that many
agencies had become less diligent in entering lab data and appointment
information into CAREWare. This resulted in many lab data only being reported
at the six-month eligibility thus impacting the care continuum results. Training
and instruction was provided to each case management sub-recipient on how to
properly report lab data outside of eligibility timeframes and has resulted in
improved reporting throughout the year.
c) The data used to determine the Unmet Need using the HIV Care Continuum
framework methodology for the RWPA Program is extracted directly from
CAREWare. A report is generated quarterly from CAREWare to include all
clients who had at least one service or was eligible for services at any time in the
measurement year. This report is loaded in to a customized Access database and
generates a set of data that provides the figures across the continuum.
d) The Arizona Regional Quality Group, which includes representation from all
Ryan White Parts in Arizona, HIV Prevention, and HIV Surveillance, developed
definitions across the continuum to allow for more accurate and comparable
results throughout the state. This collaborative effort was awarded a 2015
National Quality Center Award for Cross-Part Improvement Efforts. The agreed
upon statewide definition of Retained in Care is prevalent cases with a
documented lab test, doctor visit or anti-retroviral (ARV) used in the first 6
months and the second 6 months of the measurement year or one documented lab
test, doctor visit or ARV use during the measurement year with a corresponding
lab result indicating viral suppression status.
e) The major challenge of using the Retained in Care measure to calculate Unmet
Need has been data collection. Since approximately 83% of all RWPA clients
had other pay sources during 2015, medical visits and lab data were not
consistently reported in CAREWare. This makes calculating the Retained in Care
measure more difficult, as clients do not fall under the prevue of RWPA.
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However, with the implementation of the viral load lab data requirement for
eligibility in the fall of 2015 and the revised definition of Retained in Care, the
RWPA Program has seen a steady increase in the data reported via CAREWare
and the Retained in Care numbers. The projections and improvements in data
collections indicate that the 2016 Continuum of Care will show a significantly
lower Unmet Need in the Phoenix EMA. This will allow the RWPA Program to
more accurately demonstrate our Unmet Need for the FY 2018 estimate.
f) The HIV Care Continuum Framework method of estimating the Unmet Need
impacts our approach to the unmet need estimate by allowing the (1) use of more
accurate data produced by our robust Care Continuums, allowing the RWPA
Program to more easily (2) identify key characteristics and sub-populations to
target with new (3) strategies.
(1) Utilizing this new methodology allows the RWPA Program to more closely
identify sub-populations within the RWPA Program. The continuum data is
such that a continuum can be built by single or multiple demographic
characteristics (i.e., race, housing status, income level, age group, risk factor,
etc.). Additionally, the RWPA, along with partners in the Arizona Regional
Quality Group, has begun to look at disparities and health equity utilizing the
Deep Dive Data methodology.
(2) Both of these tools have provided significant information on which
populations of RWPA clients have the highest levels of need. Youth,
specifically MSM Youth and MSM Youth of Color, have consistently shown
to have some of the highest levels of Unmet Need. In 2015, continuum data
showed that Youth had a 49% Unmet Need, with MSM Youth even higher at
50%. Additionally, the Transgender population, served by RWPA, showed
44% Unmet Need. Housing status however, has shown the characteristic
which demonstrates the highest Unmet Need population. Whereas those with
stable housing have only an estimated 28% Unmet Need, the estimate for
those with unstable housing increases significantly to 57%.
(3) With the expansion of Early Intervention Services in late 2015 and early 2016,
the RWPA Program awarded three subrecipient contracts for testing and
linkage of newly diagnosed individuals, along with assisting previously
diagnosed but out-of-care individuals in linking back to services. EIS staff is
encouraged to follow the client’s progress for six months, with the express
intent of helping clients remain in care. One of the three subrecipients is
specifically focused on Youth. Additionally, two of the RWPA Program’s
Medical Case Management subrecipients are currently applying for an
additional CDC grant which focuses on Youth and Transgender individuals.
Finally, the RWPA Planning Council is fully committed to ensuring wrap-
around support services, such as housing, transportation and health education,
are fully funded and available to those in need. The addition of housing
services has greatly affected the Care Continuum. Individuals accessing
housing services have an unmet need of 26%, down from 57% from those
unstably housed. Individuals who have accessed housing services report 71%
viral suppression as opposed to the 38% who are unstably housed.
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g) The Unmet Need estimate is utilized for planning services through periodic
reports to the RWPA Planning Council on Unmet Need, Continuum data, and
EIIHA Strategies. The Planning Council also utilizes this data during the annual
PSRA process to ensure services are funded according to priority and needs in the
community.
h) During each quarterly meeting of the Clinical Quality Management Committee,
the committee reviews the updated RWPA Care Continuum and each sub-
recipient is provided a sub-recipient-specific continuum broken out by each
service category for which they receive funding. Additionally at each meeting, all
sub-recipients are required to complete, submit and present a PDSA or
improvement project which they are working on. Each PDSA or improvement
project must focus on linkage to care, retention in care, or viral load suppression
rates. The RWPA Program reviews and provides feedback and direction, as
necessary, to each provider.
i) Information related to the Unmet Need estimate is disseminated to the community
in several fashions. As stated previously, the continuum data is presented to the
Clinical Quality Management Committee on a quarterly basis and through
periodic reports provided to the RWPA Planning Council. Additionally,
information is disseminated during Arizona’s Annual HIV Symposium. Finally,
the RWPA program is planning to post the continuum data to the RWPA website,
updated annually, and provide up-to-date Unmet Need estimates during the
quality management portion of the Quarterly Contractor calls with sub-recipients.
3) Service Gaps
a) In 2014, RWPA partnered with RWPB and HIV Prevention Services to conduct a
Statewide 2014 Comprehensive Statewide Needs Assessment to identify service
gaps within the State of Arizona and the Phoenix EMA. A total of 416 RWPA
clients were surveyed. Service gaps, which were identified during the 2014
Comprehensive Statewide Needs Assessment, are listed in Table 7. In 2014, the
Planning Council increased funding in identified service gap areas and in 2015
and 2016, the Planning Council evaluated continuing needs and allocated
additional funds as needed. In 2015, the RWPA Program collaborated with
RWPB and HIV Prevention Services to conduct a Needs Assessment on newly
diagnosed clients. Newly diagnosed was defined as any individual receiving a
confirmed positive HIV test result within the last 18 months. The results of this
needs assessment identified 52% of clients were tested in a clinic or HIV testing
facility, 22% were tested at a doctor’s office and 20% were tested in an
emergency department or hospital. These statistics help support additional
funding allocations to Early Intervention Services. In 2015, funds were allocated
for additional testing in emergency departments, based in part on the 2015 Newly
Diagnosed Needs Assessment results. In 2016, a linkage specialist was placed at
non-RWPA doctors’ offices that specialize in HIV care to identify newly
diagnosed and helps link them to care. Collectively, these two private medical
facilities serve roughly 2,300 PLWHA. Additionally, in 2016, funds were
allocated to increase testing opportunities at several provider subrecipients. In
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2016, the RWPA and RWPB programs collaborated on a Needs Assessment of
clients who had dropped out of RW services to identify barriers and gaps which
may have contributed to these clients failing to renew their RW eligibility.
Approximately 100 clients were interviewed as part of this needs assessment and
30 RWPA clients identified barriers that could be resolved with Ryan White
assistance. The 30 clients were connected to a linkage to care specialist and 10
clients re-engaged in care within 1 month of being assigned to the linkage to care
specialist which translates into a 33% re-engagement success rate. This is the first
time in the EMA’s history that needs assessment survey respondents were “re-
linked” to care. The EMA plans to continue this survey methodology for future
assessments.
b) The Planning Council reviewed utilization data in all service categories to identify
any gaps in service and used the data from the past three years of needs
assessments to increase funding as needed for FY 2017. As the EMA continues
to fund fewer individuals under primary medical care, more funding can be
allocated to other service categories where gaps in service have been identified. A
new Comprehensive Needs Assessment will be completed in 2017 to identify any
changes in service gaps and new strategies will be developed based on data
collected during the assessment.
c) The Planning Council voted during the recent 2017 Planning Service and
Resource Allocation session to continue to allocate additional funds to service
categories that were identified as gaps in service.
TABLE 7 - SERVICE GAPS
Source: 2014 Arizona Statewide 2014 Comprehensive Statewide Needs Assessment
Source: 2015 Newly Diagnosed 2015 Comprehensive Statewide Needs Assessment
# Service Gap RWPA Planning Council Response to
Addressing Identified Service Gaps
1 Medical The Planning Council approved an expansion of taxi services
Transportation with specific criteria to include individuals up to 400%
Services Federal Poverty Level (up from 200% FPL). In addition, the
Planning Council approved a pilot project which would waive
certain criteria for taxi vouchers to allow Native American
clients improved access to dental services. The medical sub-
recipient demonstrated that many of these clients had a barrier
to oral health services due to limited ability to receive taxi
services to a RWPA dental sub-recipient close to the
reservation. This program will allow an increased number of
Native American clients to access dental services.
**MSM, Hispanic, Blacks/African American, Native
American and Youth subpopulations identified
Transportation as gap in service.
2 Housing Services The Planning Council approved funding for Housing Support
services in late FY 2014 and RWPA was able to serve 15
clients. In FY 2015, 119 clients were served through housing
services. The Planning Council continued to fund services in
FY 2016 and has allocated funding for FY 2017. Based on
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Care Continuum data, stable housing is a huge influencer on
greater outcomes of retention in care and viral suppression. In
CY 2015, data showed a 29% difference in Retained in Care
and Viral Load Suppression rates between those in stable
housing and those in unstable housing or who are homeless.
**MSM and Native American subpopulations identified
Housing as a service gap.
3 Medical In FY 2014, the Planning Council approved food vouchers as
Nutritional part of the Food Bank/Home Delivered Meals service category
Therapy and Food in partnership with Medical Nutrition Therapy. In 2014,
Bank/Home RWPA served 244 clients through the Food Voucher program
Delivered Meals with 714 visits overseen by the registered dietitian. In FY
2015, the number served increased to 389 clients and
approximately 2,479 encounters overseen by the registered
dietitian. This service category has shown great outcomes
with clients eventually graduating from the food program once
they have met their nutritional goals. The Planning Council
has continued to allocate funding in FY 16 and 17.
**Newly diagnosed and Native American subpopulations
identified Nutrition as a service gap.
4 Oral Health In FY 2015, the Planning Council raised the maximum dental
Services benefit from $1,500 to $2,500 with additional funding on a
case by case basis. After this year of allowing requests for
additional funds above the benefit maximum, RWPA
identified that 95% of clients’ needs could be met with a
benefit maximum of $3,500. In FY 2016, the Planning
Council approved expanding the maximum benefit to $3,500
with additional funding up to $5,000 total on a case by case
basis. Oral Health services continue to be a top priority for the
Phoenix EMA.
**Newly diagnosed, Blacks/African Americans and Native
Americans identified Oral Health as a service gap.
5 Early Intervention At the end of FY 15, the Planning Council approved three
Services additional funding for Early Intervention Services. RWPA
allocated funds to two additional EIS sub-recipients to expand
testing and provide linkage to care services to specific
populations including Hispanic MSM and the seriously
mentally ill. In addition, RWPA allocated resources to a
linkage to care specialist to be placed in non-RWPA HIV
doctors’ offices not funded by RWPA to support linkage to
care for newly diagnosed clients who are identified in these
locations.
4) Minority AIDS Initiative
The purpose of the Part A MAI is to improve “HIV-related health outcomes to reduce
existing racial and ethnic health disparities.” The MAI program, at the heart of its
mission, is to address health disparities and health inequities among minority
communities. MAI funds are to be used to deliver services designed to address the
unique barriers and challenges faced by hard to reach, disproportionately impacted
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minorities within the EMA. The services have to be consistent with the epidemiologic
data, needs of that community, and be culturally appropriate.
According to the demographic characteristics presented in the Epidemiologic
Overview, African Americans and Hispanic/Latino populations are the most
disproportionately impacted by HIV in the Phoenix EMA. The Black/African
American population account for 5% of the total population, but accounted for 20%
of all new HIV cases and 12% of all new AIDS cases in 2015. The Hispanic/Latino
population account for 31% of the general population, yet accounted for 36% of all
new HIV cases and 39% of new AIDS cases in 2015. In addition to race/ethnicity
disproportionate rates, individuals between the ages of 20-44 account for 38% of the
general population but account for 80% of new HIV infections and 56% of new AIDS
cases.
a) Based on the demographic characteristics presented in the Epidemiologic
Overview, below are two Care Continuums illustrating significant health
disparities experienced by minority populations. The Care Continuums shown
below provide data on race and youth percentages across the continuum.
CAREWare data for 2015 data shows that Black/African American populations
have the lowest percentages across the entire continuum and all youth categories
show significantly lower percentages across the continuum.
b) For each MAI population identified:
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(1) The planning process for determining the needs of African American and
Hispanic MAI populations include annual needs assessments which provide
data by specific populations and the gaps and service needs of these
populations. The needs assessments are analyzed and an overview is provided
to the members of the Planning Council to include as a part of their decisions
during PSRA. We also communicate regularly with existing MAI funded
subrecipients to identify client needs in these special populations and what can
be done to influence positive outcomes along the continuum. An example of
this communication resulted in re-funding Psychosocial Support Services,
specifically at these MAI agencies through Part A funding at the request of
clients who identified these support groups as beneficial to dealing with their
HIV diagnosis and having support from peers.
(2) The subrecipients receiving MAI funds have strong cultural connections to the
communities they serve. The team of staff appropriately represents the
targeted population which reduces barriers associated with stigma for
individuals seeking HIV care and services. In addition to the staff being a
reflection of the communities they serve, each agency exceeds in Culturally
and Linguistically Appropriate Services (CLAS) to improve the quality of
care for their clients and eliminate disparities. In addition to the appropriately
represented staff, the MAI funded agencies provide medical case management
by a licensed registered nurse (RN) who offer enhanced medical case
management based on their clinical background. Our minority populations
experience higher rates of acuity risks and therefore having this enhanced
clinical overview in case management has greatly influenced the outcomes of
the clients at these agencies. Due to the strong culturally competent staff and
high level case management, both MAI agencies are leading the rest of the
RWPA Phoenix EMA program in higher rates of linkage, retention and
suppression. Table 8 below compares these three bars of the continuum for
each targeted population and the overall RWPA Program.
TABLE 8 – MAI Subrecipient Linked, Retained and Suppressed
Source: 2015 Phoenix EMA Care Continuum Data from CAREWare Database
Group Linked Retained Suppressed
Ryan White Part A 75% 68% 63%
MAI Medical Case Management Sub-recipient 77% 71% 66%
targeting Black/African American population
MAI Medical Case Management Sub recipient 89% 80% 74%
targeting Hispanic/Latino population
(3) The impact of MAI funded programs and/or activities are instrumental in
improving the HIV health outcomes among minority populations within the
Phoenix EMA. It is through the use of MAI funding that the Phoenix EMA
reduces stigma and barriers to care by funding agencies which are culturally
sensitive and reflective of the individuals they serve. Each MAI agency is
responsible for a Plan, Do, Study, Act (PDSA) quality improvement project
that is reported quarterly to the Phoenix EMA’s Clinical Quality Management
Committee. Each agency has focused on linkage to or retention in care over
the past two years, and the impact is demonstrated by the increased
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percentages in the linkage and retention in care continuums in both agencies
over the past two years, as well as increases in viral suppression in both
populations. The RWPA recipient submitted nominations to the National
Quality Center for consideration of the agency’s Quality Awards in 2016, and
there is a plan to highlight improved health outcomes for these populations at
the 3rd Annual Statewide Symposium in 2017.
5) Special Populations and Complexity of Providing Care
a. Emerging Communities – New/emerging populations not reported in last year’s
application where significant changes were noted in service delivery are in the
EMA’s youth and transgender populations. In 2016, the Arizona Regional
Quality Group began utilizing a “Deep Dive Data” approach to analyzing each
region’s Care Continuum data, with the goal of identifying emerging trends and
establishing strategies to address disparities. This “deep dive” tool evaluates the
statistical significance of various factors and translated the likelihood of retention
and viral load suppression into statements such as “Youth are 1.75 times less
likely to be retained in care than the average Ryan White client”, or “Clients with
Ryan White as a primary payer are 3.4 times more likely to be retained and two
times more likely to be virally suppressed than the average Ryan White client”.
The tool identifies the p-value for each data element, and odds ratio. By utilizing
the deep dive data approach, the EMA identified Youth and Transgender
populations as having the most significant health disparities, specifically related
to their retention in care and viral load suppression. Youth were identified to be
1.75 times less likely to be retained and two times less likely to be suppressed,
and transgender individuals were identified to be two times less likely to be
retained and two times less likely to be virally suppressed. These two populations
were also identified by the other Ryan White recipients as being the most
significantly impacted groups, and the Regional Quality Group is working
together to identify strategies that can be implemented across the state to address
these disparities in 2017.
b. Under-represented Populations – Transgender Individuals are under-represented
in the EMA’s care system, with 51 transgender clients enrolled in the RWPA
Program. Through the Deep Dive Data analysis completed in 2016, it has been
identified that transgender clients receiving medical care through the RWPA
Program are two times less likely to be retained in care and two times less likely
to be virally suppressed. The Arizona Prevention and Care Programs are receiving
CDC-provided technical assistance to design a transgender training program for
sub-recipients, and are developing a transgender needs assessment to be
conducted in 2017.
c. Co-morbidities – See Attachment 5 for information related to:
(1) Hepatitis C Virus
(2) STI rates
(3) Prevalence of homelessness
(4) Formerly incarcerated
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(5) Mental illness
(6) Substance abuse
The Phoenix EMA, consisting of the large, urban population in Maricopa County
and the smaller, rural Pinal County present interesting co-morbidities separate
from the behavioral risks associated with HIV infection disease. Co-morbid
conditions including high rates of substance use, mental illness, homelessness,
and other infectious diseases including tuberculosis and hepatitis are prevalent in
this urban environment. Environmental factors placing PLWHA at risk of further
complicating their condition include Valley Fever or coccidioidomycosis. Valley
Fever, unique to the Phoenix EMA, is a lung infection resulting from a fungus
which becomes airborne when dust is transported around construction areas and
agricultural areas. It normally takes between one and four weeks following
inhalation of spores to become sick. It is estimated roughly one third of the
residents in the lower desert areas of Arizona have had Valley Fever at some
point. There are about 100,000 new cases of Valley Fever each year. Once
infected, certain groups have more instances of it spreading to other parts of their
bodies. Men are more likely than women to get Valley Fever as are African
Americans and Filipinos. People with compromised immune systems are also at
risk. In the two-county EMA, over 4,500 of the state’s total Valley Fever cases
occurred in 2014 for a rate of 105.9 per 100,000 for Maricopa County and 103.5
per 100,000 for Pinal County. Among PLWHA, the figure documented was 1,097
or 997.9 per 100,000 when case rates were much higher in the EMA (over
10,000). Treatment can be expensive if lung cavities appear, particularly among
the old and immune-compromised. These may result in lung surgery. Cost of
treatment is typically low, at under $200 for a fungal medication regimen but can
escalate to $20,000 or more if complications ensue. The high correlation of
Sexually Transmitted Infections (STIs) to HIV risk and co-infection with both
diseases has been documented in the Phoenix EMA. STIs are listed in Table 9
for the three (3) major STIs, Primary and Secondary Syphilis, Gonorrhea and
Chlamydia, with cases and rates per thousand referenced for the general
population in the EMA and number of cases among PLWH in the EMA.
Table 9: Other Relevant Demographic Data, Phoenix EMA, 2015
Number of Cases Among Number of Cases Among
Co-morbidity General Population in EMA PLWH in EMA
Total # of Cases EMA: 21,576 2,589
Chlamydia 472 per 100,000 20% of total 12,906
PLWHA living in the EMA
Total # of Cases EMA: 5,944 1248
Gonorrhea 135 per 100,000 10% of total 12,906
PLWHA living in the EMA
Total # of Cases EMA: 409 86
Syphilis
Includes Primary, 10 per 100,000 .6% of total 12,906
Secondary and PLWHA living in the EMA
Latent 7,126 per 100,000
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d) In 2014, a total of 39,919 cases of STDs were reported in Arizona. The majority
of the cases were reported from Maricopa (64.4%) and Pinal (4.1%) counties. Of
the total 39,919 total cases, 4,315 (10.8%) were investigated cases, 98.4 (22.8%)
of those were identified in men who have sex with men (MSM). (Arizona
Department of Health Services, 2014). Of these cases, 80% are reported among
young adults, ages 15 to 29 years, evidencing high levels of unprotected sex.
Youth Risk Behavioral Surveillance System (YRBSS) data (2015) for Arizona
reports 39% of youth have had sex and among those who were sexually active
45% did not use a condom during last sexual intercourse. There is a clear
disparity when comparing chlamydia rates by race/ethnicity. American
Indians/Alaskan Natives (AI/AN) and Blacks continue to maintain the highest
rates of chlamydia (Arizona Department of Health Services, 2014). Maricopa
County ranked 7th among counties/independent cities in the U.S. for reported
gonorrhea cases in 2013, which underscores the impact this population has on
statewide and nationwide trends. (Arizona Department of Health Services, 2014).
The US/Arizona Healthy People 2020 target for responsible sexual behavior for P
& S Syphilis is to reduce incidence to 1.4; Maricopa’s rate is 5.3 (Arizona
Department of Health Services, 2014). In the 2014 Comprehensive Statewide
Needs Assessment, 22% of respondents (n=125) reported having been diagnosed
with syphilis; 21% (n=124) with gonorrhea and 12% (n=71) with chlamydia.
Testing for STIs can range from $79 to $249. Intangible costs are related to the
pain and suffering associated with STIs like miscarriage and infertility (Pratini N.
“The Cost of STIs: Gonorrhea, Chlamydia and Syphilis”. Diseases, Personal Health
Finance, October 29, 2014). The estimated cost per case to treat P&S Syphilis is $444
per person (Harrell W. Chesson, John M. Blandford, Thomas L. Gift, Guoyu Tao and
Kathleen L. Irwin, Perspectives on Reproductive Health, January/February 2011).
Estimated costs per gonorrhea case range from $36 to $69; however this cost does not
include any additional costs for treatment with complications such as PID (Harrell W.
Chesson, John M. Blandford, Thomas L. Gift, Guoyu Tao and Kathleen L. Irwin,
Perspectives on Reproductive Health, January/February 2011). The estimated costs per
chlamydia case are $73 per person for early disease treatment (Harrell W. Chesson, John
M. Blandford, Thomas L. Gift, Guoyu Tao and Kathleen L. Irwin, Perspectives on
Reproductive Health, January/February 2011).
6) AIDS Pharmaceutical Assistance (i.e., Local Pharmaceutical Assistance
Program) –This section does not apply to the Phoenix EMA.
 METHODOLOGY
A. Impact of Funding
1) Impact and Response to Reduction in RWHAP Formula Funding – This section
does not apply as the Phoenix EMA did not receive a reduction in RWHAP Part A
formula funding last year.
2) Impact of the Changing health Care Landscape
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a) Uninsured and poverty: Table 10 provides data on PLWH who are uninsured
and living in poverty including the number and percentage of persons enrolled in
Medicaid, Medicare or marketplace exchanges, private or public health care
coverage and living at or below 138% and 400% of the 2015 FPL in the Phoenix
EMA.
TABLE 10 - UNINSURED AND FPL LEVEL OF RWPA CLIENTS
Source: RWPA FY 2015 CAREWare Data
Insurance A. Persons Enrolled in B. Persons C. Persons living at/below and 400% of the
Type Medicare, Medicaid without Insurance FPL by insurance type
and Marketplace
Below 138% 138 -300% 301-400
# % # % # % # % # %
Medicaid 1942 44% - - 1746 39% 169 4% 27 1%
Medicare 781 18% - - 377 9% 373 8% 31 1%
Marketplace 368 8% - - 112 3% 207 5% 49 1%
Other (VA, 450 10% - - 87 2% 262 6% 101 2%
IHS, Private
Employer)
None 882 20% 882 20% 710 16% 131 3% 41 1%
TOTAL 4423 100% 882 20% 3032 69% 1142 26% 249 6%
C. Total Count: 4423 C. Total Percent: 100%
b) Impact of health insurance expansion: The greatest impact of health insurance
expansion on RWPA has been Arizona’s expansion of Medicaid services to
childless adults under 138% of the federal poverty level. Due to Medicaid
expansion and the Affordable Care Act, 1,147 individuals were able to be enrolled
in Medicaid in 2015 and 368 were enrolled in Federally Facilitated Marketplace
health plans. By expanding Medicaid and the FFM options, the RWPA program
was able to redirect much needed resources, approximately $3,128,475, to other
service categories that significantly impacted the EMA’s Care Continuum. In
addition, several support service categories which had been defunded in previous
years due to budget constraints have been refunded. Two (2) new support service
categories were funded for the first time in 2015, addressing service needs which
were unable to be addressed in previous grant years. In providing additional
funding to these service categories, the Planning Council focused on how this
funding reallocation improved outcomes along the EMA’s HIV Care Continuum.
The changing health care landscape affects the following:
(1) Service provision and the complexity of providing care to PLWH in the
EMA/TGA. RWPA has expanded core medical and support services such as
Oral Health Services, Medical Nutritional Therapy, Food Bank/Home
Delivered Meals, Psychosocial Support Services, Medical Transportation,
Housing Services, Treatment Adherence Services and Health Education and
Risk Reduction Services to all eligible RWPA clients. Effective September 1,
2015, all clients who re-enroll in RWPA services are required to provide viral
load data as part of their eligibility renewal process. This requirement helps
identify viral load data for clients who are not receiving medical services
through RWPA. This information assists the Planning Council in prioritizing
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services which are needed to support all RWPA clients, regardless of their
health insurance coverage.
(2) Changes in allocations, including activities related to health insurance
premium assistance. With Arizona’s changing healthcare landscape changes
in Planning Council allocations have resulted in providing more funding in
other core and support services. The RWPB Program provides health
insurance premium assistance and medication copays for all FFM clients and
RWPA pays for up to $4,000 per year for medical copays for HIV-related
outpatient primary medical care.
(3) Costs including services costs, cost-sharing, cost-savings, etc.
Table 11 below illustrates the changing costs as a result of the ACA and
health insurance expansion. RWPA primary medical care costs have
decreased by 37% since the expansion of health insurance while the number
of clients accessing RWPA primary medical care has been reduced by 50%. In
addition to primary medical care, mental health and substance abuse costs
have also decreased as these services are now being covered either by ACA
plans or state Medicaid insurance plans. The number of clients being
provided health insurance premium and cost sharing assistance has increased
from 99 clients in the first year of the ACA cost sharing program to 747
clients in 2015. Since 2014, RWPB has covered all health insurance
premiums for clients in the Marketplace, while RWPA covers medical co-
pays and deductibles. This allows RWPA to serve more clients through
Health Insurance Premium and Cost Sharing Assistance.
Table 11: SERVICE COSTS, COST SAVINGS SINCE IMPLEMENTATION OF ACA AND
HEALTHCARE EXPANSION, 2013-2015
Source: CAREWare Data, 2015
2013 2014 2015
Service Category # Dollars # Dollars # Dollars
clients Expended clients Expended clients Expended
Primary Medical Care 1,295 $2,144,357 770 $1,054,915 647 $1,335,357
Health Insurance
Premium Cost Sharing 99 $340,958 566 $231,000 747 $302,744
Assistance
Mental Health 290 $263,876 146 $124,583 121 $115,900
Substance Abuse 82 $120,876 26 $9,973 14 $5,812
c) Outreach and enrollment:
In Open Enrollment 3, the EMA experienced a dramatic change in the availability
of Marketplace health plans. Two days prior to Open Enrollment 3 in 2015, the
plan that covered the majority of Ryan White clients was suspended by the
Arizona Department of Insurance. This change required subrecipients to assist
over 400 clients in transitioning to new health plans in less than two months. Due
to the successful collaboration of all the Ryan White partners, in this short period,
98% of RWPA clients were transitioned to new health plans.
(1) RWPA subrecipients met weekly to establish and monitor enrollment
protocols for eligible clients. The RWPA Program modified existing data
systems to categorize all existing clients into groups based on their federal
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poverty level, existing insurance coverage and action needed to complete
ACA enrollment. The data systems were used to track and report progress.
The recipient and sub-recipients have access to this shared data through the
CAREWare system. Each eligible client was contacted by their case manager
and medical providers and informed of their choices for transitioning into
available insurance plans and were provided a clear, simple message on taking
action to complete new enrollment. Clients were referred to certified assistors,
who remained engaged with clients through the enrollment process until
clients were successful in transitioning to their new insurance plan. At the end
of Open Enrollment 3, 98% of all clients were successfully enrolled in a
Marketplace plan.
(2) Through Open Enrollment 3, all RWPA subrecipients collaborated to ensure
clients were identified, informed, educated and enrolled into appropriate
insurance coverage. This was accomplished through weekly meetings of all
subrecipients, coordinated data sharing and coordinated payment of premium
and cost sharing assistance. The EMA’s Central Eligibility office screened for
ACA enrollment at time of renewal and contacted any client who was listed as
eligible for a Marketplace health plan option. In addition, case managers were
able to assist and support clients during ACA enrollment. Open Enrollment 4
begins in November 1, 2016. The Phoenix EMA faces multiple challenges for
enrolling clients in ACA plans for 2017, including a decrease in ACA health
plans available in Maricopa and Pinal Counties, and limited network options
for HIV Care. The RWPA Program will coordinate efforts of all subrecipients
to ensure clients receive enrollment assistance during open enrollment and to
ensure clients are provided information on the current options available to
them under the ACA.
(3) The following list of challenges during outreach and enrollment efforts
include:
• Challenge 1: The suspension of the major insurance plan from the
Marketplace covering the majority of Ryan White clients two days prior to
Open Enrollment 3 in 2015. This required RWPA to transition over 400
clients to new health insurance coverage within 60 days and required an
increase in health literacy programs to ensure clients understood the
changes in health plan coverage. Despite this challenge, RWPA
transitioned 98% of all eligible clients to appropriate health insurance
programs by Jan. 1, 2016.
• Challenge 2: The exit of multiple health plans from the ACA in Arizona
for Open Enrollment 4. In 2017, there will be only one ACA Health Plan
available in both Maricopa and Pinal Counties. In Maricopa County, the
available health plan is new to Arizona, and this will require all 400 of the
current RWPA clients to transfer to the new health plan prior January 1,
2017. This change will require intense collaboration between RWPA,
RWPB, RWPC and their subrecipients to ensure clients are informed of
their options and are enrolled in the best option for each client. Partners
are currently meeting weekly to address this challenge and are awaiting
further information about possible other options from the Arizona
Department of Insurance. This information will be available in mid-
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October, 2016 and the partners will begin enrollment activities by
November 1st.
• Challenge 3: Lack of compliance with Essential Community Provider
provision of the ACA by ACA Health plans. In 2016, only one ACA health
plan in Maricopa County complied with the Essential Community
Provider provision of the ACA, which requires health plans to contract
with a RWPA provider for HIV services. In 2017, this health plan will not
be participating in the ACA in Arizona. The only health plan that will be
available in 2017 in Maricopa County does not currently have a contract
with the RWPA provider, and is planning a limited network of providers.
At the time of submission of this application, it is unknown what HIV
specialists will be contracted in the sole health plan’s network. The
RWPC recipient is currently in negotiations with the new health plan to
determine if a contract can be executed for HIV care. Arizona Ryan
White partners are reviewing other potential options, including
researching the availability of Off-Marketplace plans for clients. The
programs are keeping HRSA and CMS updated on this challenge and will
continue to pursue options to ensure clients have access to appropriate
healthcare choices.
(4) The three major facilitators in our outreach and enrollment efforts include:
Facilitator 1: Consistent messaging to all recipients and sub-recipients to
ensure clients received accurate messages on enrollment. The Ryan White
recipients develop messages collaboratively and agree to the content and
design as part of the collaborative efforts to meet enrollment goals.
Facilitator 2: A shared data system that allows all recipients to identify and
track client enrollment status throughout the ACA open enrollment period.
RWPA and RWPB are able to share enrollment data through enhanced
CAREWare functions, which allows both programs to monitor enrollment
activities in real time.
Facilitator 3: Partnership with RWPB to pay for premiums for Marketplace
clients. The collaborative efforts of RWPA and RWPB to ensure all clients
have access to premium payments has been instrumental in the RWPA and
RWPB efforts to enroll clients in ACA health plans and to retaining these
clients in medical care.
d) Marketplace options: For Open Enrollment 3, there were a total of eight (8)
health plans available to Ryan White clients. As of October 1, 2016, there is only
one health plan offering ACA coverage in Maricopa County and one heath plan
offering ACA coverage in Pinal County. Both of these health plans will only offer
HMO options for clients, and at the time of the submission of this application
there is limited information regarding the network adequacy of these plans,
especially related to the availability of HIV specialists. All Ryan White
recipients are meeting weekly to discuss all available options to enroll clients in
appropriate coverage. This may include Off-Marketplace plans if the new ACA
plans do not have adequate network availability of HIV specialists for the 400
currently enrolled ACA clients that will need to transition to a new health plan.
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The recipients are keeping HRSA apprised of the changing environment and the
options that are available to clients beginning November 1, 2016.
(1) The following challenges regarding how current plans available affect
provider accessibility:
Challenge 1: The only current health plan providing ACA coverage in
Maricopa County during Open Enrollment 4 does not have a contract with a
Ryan White Part A essential community provider at the time this application
was submitted. Over 350 of the current ACA covered clients are cared for by
this RWPA subrecipient primary medical care provider. The RWPA sub-
recipient is in discussions with the health plan to identify possible contract
options. The Ryan White recipients have been in contact with HRSA, CMS
and the Department of Insurance to identify possible resolution to this
challenge.
Challenge 2: The only available health plan in Maricopa County has limited
HIV specialists currently identified in their limited HMO network. This
health plan is seeking additional providers to provide HIV care to existing
clients. It is anticipated this health plan may not have adequate provider
coverage to serve all Ryan White clients who choose to transfer into this plan
unless a contract is executed with the current RWPA medical provider.
Challenge 3: Non Ryan White HIV specialists in Maricopa County may be
impacted due to not being in the HMO network of the new ACA health plan.
The clients currently receiving care in these practices would be required to
leave their medical home and transfer to other providers who are in the HMO
network. This would be a difficult transition for clients, as it is unknown at
this time whether there will be adequate number of providers to accept clients
who will need to transfer to other primary care practices. This is a significant
challenge that could impact continuity of care, retention in care and viral
suppression.
(2) Challenges experienced based on how health plans affect care and
medications for PLWH include:
Challenge 1: At the time of the submission of the grant, the provider networks
and formularies for the health plans that will provide ACA coverage in
Maricopa and Pinal Counties are not available. As this information is
available, the RPWA and ADAP programs will develop messages that will be
communicated to the clients related to options for care and medication
coverage.
Challenge 2: With the new limited network of physicians and formularies,
clients may need to transition both their provider and their medications in
order to meet the requirements of the health plan coverage. This could have
an impact on the clients’ medical home, retention in care and viral
suppression. The RWPA and ADAP programs will work with clients to
minimize the impact on the client’s continuity of care.
Challenge 3: The instability of the ACA Marketplace in Arizona, with
significant changes in the number of health plans available, and the requisite
transition of clients to new health plans three times in four years creates
significant challenges to clients, specifically in the areas of understanding how
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their coverage changes impact their access to care and medications. This
situation has increased the importance of RWPA’s funding of Health Literacy
programs for all clients who are impacted by these changes.
3) Planning and Resource Allocation
a) Description of the Community Input Process
(1) The Phoenix EMA Planning Council is composed of a culturally diverse
group of institutional, sub-recipient, and consumer members who provide
guidance to the program on policy and priorities for all service categories. The
consumer members who serve on the Planning Council take an active role in
identifying priorities on behalf of the community and participate in informing
and educating the community on health issues.
The community participates in regular need assessments to identify priorities
for the Phoenix EMA. The most recent 2016 Statewide Needs Assessment
focused on individuals who had dropped out of care, and identified strategies
to re-engage these clients back in care. A total of 100 clients participated in
this needs assessment, which represented 10% of all clients statewide who had
previously received medical case management services prior to 2015 and then
did not receive any case management services in 2015.
The EMA receives community input through consumer surveys and integrates
the information from these surveys into the priority setting process. The
RWPA Program collaborates with RWPB/C/D to share information gathered
through their Community Advisory Boards and consumer surveys and
incorporates this input into the planning process.
(2) All Planning Council Priority Setting and Resource Allocation (PSRA)
decisions are guided by the Planning Council’s Guiding Principles for
Decision-Making. The Guiding Principles provide specific considerations
which must be addressed during any Planning Council funding decision,
including: eligible PLWHA should not be denied access to Ryan White‐
funded primary medical care services; funding for higher prioritized service
categories should be preserved at the expense of lower prioritized service
categories; and regardless of the amount of available federal funds or demands
on services, core service categories must be fully funded to meet identified
needs. These services include Outpatient Ambulatory Health Services, Oral
Health Services, Medical Case Management, Early Intervention Services,
Mental Health Services, Substance Abuse Services and Medical Nutrition
Therapy. A total of 35 participants, including 20 Planning Council members
and 15 staff and community members took part in the FY 2017 PSRA process.
From those who participated, ten (10) were consumers of Ryan White Part A
services. Priorities and allocations determined during the PSRA process
emphasize the identification of persons unaware of their HIV status, and
ensure the availability of HRSA-defined core services to meet anticipated
need. The implementation of the Affordable Care Act was an important
consideration in establishing priorities and allocations and impacted the
decisions made for 2017. The process for PSRA includes the following steps:
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• Determination of data needs –The Planning Council identifies data
which is needed for the PSRA process, and Planning Council Support
staff request this data one month in advance of the PSRA data session
from the programs. Each recipient of Ryan White funding (including
Parts A, B, C and D) and HIV Prevention is responsible for providing
the requested data.
• PSRA process review for PC member – Planning Council Support
staff presents information on the process for PSRA. This includes a
review of the Guiding Principles mentioned previously and Planning
Council member expectations.
• Presentation of data –Ryan White Parts A, B, C, D, and HIV
Prevention present all data to the Planning Council at the data session
prior to PSRA.
• Determination of priorities – Based on data presented, the Planning
Council determines the priority for each service category to be funded.
• Resource allocation: Based on the data presented and the assigned
priority, the Planning Council determines how much funding should be
allocated to each service category.
• Final approval – The Planning Council votes to approve the final
priorities and allocation of funds for each service category.
• Evaluation of PSRA activities – Once the PSRA is complete the
Planning Council is given the opportunity to provide feedback on the
entire PRSA process. A survey is conducted requesting feedback and
input for the next year’s process. The survey results related to the
2017 PSRA session indicated the Planning Council is highly satisfied
with the current PRSA methodology.
As a part of the PSRA process, the focus of the Planning Council is to link
each service category funded to the EMA’s HIV Care Continuum. Priorities
and allocations determined during the PSRA process emphasize the need for
all allocations to support the HIV Care Continuum, including identifying
individuals unaware of their HIV status, linking these individuals to care, and
helping clients achieve viral suppression. The Planning Council has been
trained to review and interpret HIV Care Continuum data. All data
presentations prior to the PSRA contain HIV Care Continuum data as
preparation for the PSRA session. Sub-recipients of RWPA, RWPB, and HIV
Prevention, along with members of the RWPA Planning Council, received
formal Continuum training in 2016. The prioritization and allocation process
include the following:
(a) The Planning Council considers the needs of PLWH not retained in care
(unmet need), persons unaware of their HIV status (EIIHA) and the
historically underserved populations: PLWHA not retained in care
(Unmet Need): The Planning Council has identified a priority to identify
individuals who are aware of their HIV status and not in care, and
facilitate their re-entry into care. Funding was increased in 2016 to include
health literacy training to assist consumers in understanding how to stay in
care. Additionally, the EMA increased funding to Non-Medical Case
Management to improve retention in care for clients who have been linked
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to care, but have dropped out of care in the past year. Persons unaware of
their HV status (EIIHA): The Planning Council has established a
priority to identify individuals who are unaware of their HIV status and
not in primary medical care, and facilitate their entry into care. In late
2014, the Planning Council directed the RWPA recipient to increase Early
Intervention Services to address persons unaware of their HIV status. An
RFP was released and contracts were awarded in 2015 and the EMA now
has six subrecipients providing Early Intervention Services. The sub-
recipients target specific populations including the formerly incarcerated
and recently released, seriously mentally ill and homeless youth. The
Planning Council is knowledgeable of the EMA’s EIIHA strategy and
places high priority on funding services which address the need to identify
unaware individuals in these special populations. The 2015 Newly
Diagnosed Statewide Needs Assessment showed 28.3% of all respondents
stated they tested positive for the first time during an emergency room
visit, with the predominant respondents being 50% MSM or 35%
Hispanic. This finding supports continued funding of Early Intervention
Services targeting emergency rooms and linkage to HIV Primary Medical
Care. Historically underserved populations: The Planning Council has
established a priority to develop and implement strategies to increase
access to care by eliminating barriers to care and bridging gaps in care.
The EMA has identified the formerly incarcerated and recently released
population as one of the most underserved populations. A component of
the EMA’s EIS Program, a RN medical case manager is co-located within
several county jails to assist with the identification of those incarcerated
inmates that are HIV positive while facilitating their release into the
community and linkage to primary medical care. This facilitation includes
making referrals to specific community based agencies who have agreed
to help facilitate rapid linkage to care. The total number of clients served
in 2015 who were incarcerated was 145, with 74 (51%) of those clients
identified as being either Black/African American or Hispanic. These
clients are linked to MAI sub-recipients which then help facilitate their
linkage to care and retention in care by reducing barriers such as stigma,
homelessness and mental illness.
(b) The Community Health Planning and Strategies (CHPS) Committee of the
Planning Council is a public meeting which meets at least quarterly where
consumers are able to provide input to the planning process. The CHPS
committee is the planning body responsible for identifying the RWPA
strategies that will be completed as part of the Statewide Integrated Plan,
and has involved consumers and stakeholders from both traditional and
non-traditional partners in this process. Planning Council members also
participate in community events to solicit community input. For example,
Planning Council members and staff have attended events at consumer
agencies in an effort to identify needs and priorities of the community.
(c) Due to successful enrollment of clients into Medicaid and ACA health
plans, additional funding was available for reallocation from OAMC to
other core medical and support services. Prior to the 2017 PSRA, the
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CHPS Committee and the Planning Council reviewed the 2015 Newly Diagnosed
Needs Assessment and incorporated the data identified in the needs assessment
into the PSRA decision making process. Based on recommendations from the
CHPS Committee, the Planning Council increased funding for Housing Services,
Medical Nutrition Therapy and Early Intervention Services. The Planning
Council recommended an overall 5% increase scenario for 2017 and will conduct
an additional PSRA session if necessary when the 2017 grant award is received.
The 2017 allocations meet the RWPA requirement to allocate 75% of direct
funds to core services and 25% to support services;
(d) For FY 2016, MAI funding was allocated to Early Intervention Services,
Medical and Non-Medical Case Management to assist minority
populations with linkage to care and facilitate their retention in care by
decreasing health disparities and barriers to care. Based on 2015
epidemiology data provided by Arizona Department of Health Services,
Hispanics (Latinos) accounted for 36% of new HIV diagnoses and 39% of
new AIDS cases respectively, yet only make up 31% of the general
population. African-Americans account for 5% of the general population
yet totaled 20% of new HIV infections and 12% of AIDS cases,
respectively.
(e) Planning Council members receive detailed information about client
need/barriers/gaps and utilization of core and support services throughout
the grant year. Data sources referenced during the PSRA process include:
a 2014 Comprehensive Statewide Needs Assessments specific to each
special population within the EMA and a 2015 Statewide Needs
Assessment on Newly Diagnosed and High Risk Negative Individuals.
Unmet Need and Epidemiological data information was presented by
RWPA/B/C/D during the PSRA data session, as well as information
shared by Medicaid. Non-Ryan White HIV health care and social service
sub-recipients provided presentations on health disparities during the 2015
grant year for the Planning Council to consider during PSRA. The
Planning Council considers data related to client needs, utilization barriers
and gaps in care as cited in the 2014 Comprehensive Statewide Needs
Assessment and the 2015 Statewide Needs Assessment of Newly
Diagnosed and High Risk Negative Individuals. This data guides the
planning process for how MAI funding is allocated and to designate funds
to specific service categories which will enhance access to services for
disproportionately impacted minority populations and sub-groups. Funds
allocated to MAI are specifically designed to address the unique needs of
the EMA’s minority populations. Funding is provided to community-
based agencies who have long-term relationships in the African American,
Hispanic, and Refugee communities. Cultural Competency is a key
component in linking and retaining clients in care and staff are well
connected to the communities they serve. The MAI sub-recipients
continue to utilize a nurse medical case management model which has
shown a positive impact on client retention in care in the EMA’s minority
populations.
(f) During the FY 2017 PSRA Data Session, all of the recipients, including
RWPA/B/C/D, and HIV Prevention provided epidemiology data related to
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the populations served by each recipient and in relation to the HIV Care
Continuum. From 2014 to 2015, the Phoenix EMA saw an increase in the
number of PLWH/A from 12,469 to 12,906, for an increase of 403 (3.5%).
RWPA provided data which identified increasing service utilization in
Youth, Hispanics, and Black/African Americans. Based on review of the
epidemiological data, the Planning Council recommended an increase in in
several service categories such as Early Intervention Services, Housing
Services and Medical Nutrition Therapy;
(g) At the PSRA Data Session, the RWPA recipient provided detailed
utilization summaries and financial reports for each service category for
the prior grant year. These documents offered a comprehensive analysis of
the costs associated with providing services, detailed by race, ethnicity,
gender, transmission mode, and age. Since service costs can substantially
differ based on these factors, this information was compared against the
current and historical epidemiology of the EMA to develop population-
based cost estimates. Costs were averaged to develop an overall cost per
client for each service category. Representatives of other Ryan White
recipients and sub-recipients discussed trends related to the cost of service
delivery, such as rising prices for nutritional products, public
transportation fees, and the impact of decreased funds from other federal,
state and private sources. The Planning Council used a formula to
determine resource allocations for each service category, the total number
of projected FY 2017 clients were multiplied by the anticipated overall
cost per client. Then, additional funding was added as needed to
implement approved Planning Council directives which guide service
delivery;
(h) Data from other federally funded programs were reviewed at the Planning
Council Data Session. RWPB/C/D, HIV Prevention and Medicaid
provided information on what funds are available and how they are being
used so the Planning Council had complete information in order to make
decisions with regard to other funding available in the EMA;
(i) During 2016, the Planning Council reviewed monthly ACA enrollment
updates and enrollment impact on RWPA services. As funds were
identified as being available due to successful enrollment of clients into
ACA plans, funds were reallocated to other services such as Early
Intervention Services, Housing Services and Medical Nutrition Therapy.
During the 2017 PSRA, the Planning Council made projections for the 4th
year of ACA enrollment and recommended priorities and allocations
consistent with these projections;
(j) Since January 2015, RWPA has collaborated with other Ryan White
recipients as well as HIV Prevention to develop the Arizona Statewide
HIV Integrated Plan. Two annual symposiums have been held (2015,
2016) to provide all stakeholders an opportunity to participate in the
planning and development of the Statewide Integrated Plan. The RWPA
Planning Council and the Statewide Advisory Group have combined
efforts to ensure the Statewide HIV Integrated Plan includes strategies
which will maximize high quality care and treatment, as well as increase
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prevention efforts to prevent new infections. In 2015, the RWPA/B
recipients collaborated with the state’s HIV Prevention Program to
conduct a statewide needs assessment for newly diagnosed and high risk
negatives individuals. This Needs Assessment was completed in
December 2015 and the data was presented to both planning groups and
used to help inform the overall goals for the Statewide HIV Integrated
Plan. Implementation of the Statewide HIV Integrated Plan will begin in
2017, and all partners are committed to working together for successful
completion of the established goals and objectives as outlined in the plan.
b) Letter of Assurance from Planning Council Chair(s) or Letter of
Concurrence from Planning Bodies – See Attachment 6 for Letter of Assurance
from the Phoenix EMA Planning Council Chair.
c) Coordination of Services and Funding Streams
(1) Financial and Human Resources Inventory
(a) See Attachment 7 – Funding Sources Table for a jurisdictional HIV
resources inventory.
(b) The Arizona recipients of RWPA/B/C/D/F and HIV Prevention Services
funding participate in monthly conference calls to discuss issues and
collaborate on projects, which include program updates, grant issues and
funding priorities. This regular meeting provides an opportunity for all
recipients to share information on issues which may require assistance
from the other Arizona programs. The RWPB program has availability of
rebate funds through the AIDS Drug Assistance Program (ADAP), and
has established mechanisms for other Arizona recipients to request these
funds for HIV services which are needed, but not currently funded through
grant funding. The RWPA and RWPB program have an Intergovernmental
Agreement in place that provides a mechanism for the programs to
collaborate on Statewide Needs Assessments. This IGA is in the process
of being amended to increase the scope of collaboration between both
programs. All of the grant recipients participate in the Arizona Regional
Quality Group, which analyzes statewide and regional data. This
collaboration has resulted in identification of gaps in service that may
need to be resolved through additional funding. The RWPA/B/C/D, HIV
Prevention and AHCCCS (Medicaid) have representation on the RWPA
Planning Council, and these representatives participate in the annual
Priority Setting and Resource Allocations process that directs the funding
for the RWPA program. Additionally, the RWPB and HIV Prevention
programs collaborate with the Las Vegas TGA Planning Council, which is
responsible for funding RWPA HIV services in Mohave County in
northwest Arizona, to ensure adequate funding is available for the needs of
people living with HIV/AIDS in this region of the state.
(c) The Financial and HIV Workforce Capacity Inventories identified the
following resources which are needed to meet the statewide goal of
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Ending the HIV Epidemic by 2021. The Arizona recipients and sub
recipients will evaluate progress on improvement in each of these
identified areas of need on an annual basis. This monitoring and
evaluation process will be conducted as part of the Integrated Plan.
Table 12: RESOURCES NEEDED TO MEET STATEWIDE GOAL OF ENDING
THE HIV EPIDEMIC BY 2021
Identified Need Steps to Secure Resources Timeline
Additional HIV Medical Training and Preceptorship by 2016-2021
Providers AETC
Increased Federal Funding for Annual Needs Assessment to 2016-2021
HIV Prevention identify priorities
Increased Federal Funding for Annual Priority and Resource 2016-2021
HIV Services Setting Allocation process to
identify priorities and funding
levels
Improved Reimbursement Rate Continued discussion with 2016-2021
by Medicaid Medicaid on establishing rates
specific for HIV care and
services
HIV Prevention and Service Update needs assessment every 2016-2021
Needs Assessments 2 years
Increased Partner Services HIV Prevention Services to 2016-2021
identify if there are any
resources that could be allocated
to increase partner services
Increased number of test sites RWPA, RWPB and HIV 2016-2021
Prevention will review options
for increased funding to increase
number of test sites annually
Improved health literacy RWPA, RWPB, RWPC, RWPD 2016-2021
will collaborate on health
literacy projects
Improved treatment adherence Quality Management projects 2016-2021
will evaluate the success of
funded treatment adherence
projects and determine best
practices to be implemented
Increased resources for housing RWPA and RWPB will 2016-2021
collaborate to determine
increased funding opportunities
to increase stable housing for
homeless clients
Education/Awareness campaigns Review best practice 2016-2021
for underserved populations education/Awareness campaigns
and collaborate with other RW
and HIV programs to implement
Provide services in more Collaborate with AETC and 2016-2021
culturally competent manner other RW and HIV programs to
implement best practices
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 WORK PLAN –
A. Funding for Core and Support Services
1) FY 2017 Service Category Plan
a) Service Category Plan Table
See Attachment 8 for the Phoenix EMA’s Service Category Plan Table which
illustrates how Part A and MAI Core Medical and Support Services are funded in
the EMA. The table includes: 1) service categories; 2) priority number; 3)
funding amount; 4) unduplicated clients served; 5) service unit definition; 6)
service units; and 7) MAI target populations for a three-year period (2015-2017).
b) Service Category Plan Narrative
(1) All prioritized Core Medical Services were funded at the level identified by
the Planning Council to meet the expected utilization for each of these
services. Each prioritized Core Medical Service has been allocated funding for
FY 2017. The majority of Outpatient Ambulatory Health Services will be
funded through other funding sources due to Medicaid expansion and the
ACA. RWPA will fund this service category only for those individuals with
no other payer for medical care due to being categorically ineligible.
(2) Phoenix EMA clients reside in both urban and rural settings, and there is a
need to provide services which are accessible to clients regardless of where
they reside in the EMA. In the urban areas, all services are accessible by
public transportation, and the EMA supports transportation through the use of
bus vouchers for clients to access up to 10 HIV-related services per month.
Taxi services are provided on a case-by-case basis for clients who are eligible.
In rural communities, RWPA funds a sub-recipient which has a medical home
model with both medical and behavioral health services. This FQHC partners
with one of the EMA’s Case Management sub-recipients to have a case
manager located on site to provide case management services. Case managers
from all of the EMA’s case management agencies perform home visits, as
needed. In Pinal County, the area which accounts for the majority of the
EMA’s rural population, a high percentage (89%) of the 112 clients accessing
RWPA services have other coverage (Medicaid, Medicare, or private
insurance) for medical care. Clients in rural areas can also access oral health
services in their own communities through the use of the RWPA Dental
Insurance Program, which provides a robust provider network through Delta
Dental. In Pinal County, there are more than 340 dentists who accept Delta
Dental insurance provided through the Dental Program. The 2014
Comprehensive Statewide Needs Assessment in rural Pinal County indicated
that according to the Arizona Department of Corrections 30% of prevalent
cases and 60% of the emergent cases of HIV/AIDS in Pinal County are
attributed to the incarcerated population residing in the Florence prison, which
is the county seat for Pinal County;
(3) As part of their contract, all sub-recipients are required to annually provide
their staff with Culturally and Linguistically Appropriate Services (CLAS)
training. Every sub-recipient in the Phoenix EMA is able to provide bilingual
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services (English and Spanish) and has access to the language line for
interpretation of other languages, as needed. One sub-recipient provides
services in several languages such as Swahili and Burmese for the refugee
population receiving services in the refugee clinic through MAI funding.
(4) The Phoenix EMA has experienced significant changes in the funding needed
to provide medical services in the EMA. The primary factors include the
expansion of Medicaid and the implementation of ACA. In FY15, a total of
1,942 clients were covered through Medicaid and 368 clients were covered
though the Federally Facilitated Marketplace insurance plans. This transition
has provided the EMA the funding to increase other core and support services,
including increased case management, oral health, nutrition, psychosocial
services, and health education and risk reduction services. Additionally, the
EMA has increased funding to focus on identifying more individuals who are
unaware of their HIV status, and to link these clients to medical care through
the EMA’s Early Intervention Services programs.
(5) RWPA works in close collaboration with RWPD to monitor services to
women, infants, children and youth. RWPA attends quarterly RWPC and
RWPD meetings to address and monitor any needs within the WICY
population. Collaborative services are offered at Phoenix Children’s Hospital,
the Women’s Refugee Clinic and at the weekly Women’s Day Clinic at
Maricopa Integrated Health System’s McDowell Healthcare Clinic. The
Phoenix EMA consistently meets the percentages mandated by the WICY
requirements.
(6) In 2017, additional funding has been allocated to the EIS service category
based on the increased number of newly diagnosed individuals in 2015 and
2016. Additional funds have also been allocated to transportation, housing and
medical nutrition based on the 2015 Needs Assessment findings.
c) Core Medical Services Waiver (if applicable – not scored)
This section does not apply to the Phoenix EMA. No Attachment 9 submitted.
B. FY 2017 HIV Care Continuum Work Plan
See the 2017 HIV Care Continuum Work Plan in Attachment 10.
RWPA is using the Arizona Regional Quality Group’s definitions for the HIV Care
Continuum. In 2015, the Arizona Regional Quality Group was awarded a National
Quality Center Award for Cross Part Collaboration for implementation of the quality
group and development of statewide definitions. The definitions were driven by the
Arizona Department of Health Services HIV Surveillance, with input from all Ryan
White recipients in Arizona and HIV Prevention and Epidemiology staff. All of the
statewide definitions and those utilized by RWPA were previously outlined in the 2017
HIV Care Continuum section of this application. The 2017 HIV Care Continuum Work
Plan (Attachment 10) shows which service categories will be utilized by RWPA to
achieve the targeted outcomes for each stage along the HIV Care Continuum
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 RESOLUTION OF CHALLENGES –
Table 13 outlines the challenges and resolutions in which the Phoenix EMA has
encountered in both the larger context of implementing the Part A Program and in
integrating the HIV Care Continuum into the planning and implementing of the Part A
Program.
Table 13- RESOLUTION OF CHALLENGES
Challenge Resolution Outcome Status
Part A Program
Dissection of The Phoenix EMA has HIV Surveillance has Future
Epidemiological Data requested that the HIV requested additional staff
by EIIHA Surveillance add this to accommodate this
Subpopulations additional data analysis. request.
Multiple Renewal RWPA and RWPB This resulted in a Ongoing – The
Dates for Ryan White aligned enrollments to decreased number of second phase of the
Services for Clients every six months clients being dis-enrolled joint application
(birthday and ½ from RWPA and ADAP, process began in
birthdays) and developed as well as, dropping out 2016 and will
a joint application. of care on a monthly continue in 2017.
basis.
HIV Care Continuum
Calculating Linkage to Establish workgroup to The EMA’s Early Future
Care Timeframes develop reporting Intervention Services
mechanism and standard program, focused on
procedures for EIS sub- testing and linkage
recipients on reporting activities, are currently
linkage data in reporting 70% linked to
CAREWare and to the care rate, with 63% being
RWPA program. linked within 30 days.
Increasing Retention The CQM Committee Implementation began in Ongoing – The
in Care Rate of those shifted their focus to February 2016 and earlier CQM Committee
linked to care. address Retention in results are showing a 13% will continue to
Care through quality improvement from 2014. monitor this closely
improvement/PDSA and develop new
projects, noting a methods of
significant drop between retaining clients in
linked and retained care.
across the continuum.
Collection of Viral Instituted new policy in Implementation has Ongoing – The
Load Lab Data 2015 requiring viral load caused an initial decrease implementation will
lab data to be submitted in the viral suppression complete its first
with RWPA eligibility rate from 2014 to 2015 year in late October
application. due to: 1) viral load data 2016 and training is
is more accurate and not being provided on
based on client self- an ongoing basis to
report; and 2) Case increase data
Management sub- reporting outside
recipients discontinued eligibility times.
entering lab data in
between eligibility due
dates which made for a
lack of real time data.
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 EVALUATION AND TECHNICAL SUPPORT CAPACITY
A. Clinical Quality Management (CQM)
1) Description of CQM Program Infrastructure:
a) There are 3.75 FTEs assigned to the EMA’s CQM function.
b) The CQM program staff roles and responsibilities include:
Program Manager: (0.5 FTE) Provides administrative oversight and support to
the Quality Management Program. The Program Manager is a Registered Nurse
and provides clinical expertise to the CQM team.
Grants/Contracts Administrator: (0.25 FTE) Develops goals and strategies for
the HIV Care Continuum Plan, development and implementation of metrics,
interventions and partnerships for administration and CQM. Implements best
practices for the improvement of clinical health outcomes. Monitors sub-recipient
compliance and reviews instruments to ensure required data is collected consistent
with sub-recipient contracts.
Contract Supervisor: (1.0 FTE) Assists in the development of program goals
and strategies relative to CQM activities. Completes quarterly sub-recipient
reviews and assists with annual site visits to ensure contract and sub-recipient
compliance.
Trainer: (0.5 FTE) Completes training assessments for all sub-recipients,
develops and provides technical assistance as needed; assists in chart reviews
during annual site visits, assists in the collection and analysis of client satisfaction
data; coordinates the review and resolution of client complaints according to the
RWPA Grievance Policies and Procedures.
Care Continuum Coordinator: (1.0 FTE) Responsible for developing goals,
monitoring outcomes, and reporting on progress across the EMA as it relates to
the HIV Care Continuum and the RWPA EIIHA Strategies. Manages the data
systems for RWPA and provides technical assistance to sub-recipients related to
data collection, analysis and reporting.
Management Analyst: (.25 FTE) Provides data management support to CQM
Team and assists with CQM meeting and site visit preparation, review and
reporting.
Program Assistant: (0.25 FTE) Provides administrative support to CQM team as
needed for CQM meeting coordination and site visit preparation, review and
reporting.
c) The RWPA program contracts with TriYoung & Associates, the contracted
programmer for the RWPA CAREWare system. This contractor provides support
in developing automated processes from CAREWare to pull data reports on CQM
for each RWPA sub-recipient. Additionally, RWPA contracts with Collaborative
Research to conduct the annual Comprehensive Statewide Needs Assessments
and also provides clinical chart review support during annual sub-recipient site
visits.
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d) The RWPA Quality Management Team coordinates CQM activities with all
Arizona Ryan White recipients and HIV Prevention Services in the Arizona
Regional Quality Group. This group meets quarterly to discuss quality issues
which impact all recipients, and establishes quality improvement goals which can
be measured across all programs. The RWPA CQM Committee includes
representation from RWPB/C/D and HIV Prevention Services, and these partners
contribute their expertise in evaluating the RWPA quality improvement projects.
The Regional Quality Group is currently working together to identify health
disparities across programs, utilizing a Deep Dive Data approach, and will
develop collaborative strategies to implement in 2017.
2) Description of CQM Program Performance Measures:
a) Each of the service categories funded in the Phoenix EMA have been linked to a
HIV/AIDS Bureau (HAB) Performance Measure. Table 14 specifies which
HRSA/HAB performance measure is being monitored in each service.
Table 14 - PHOENIX EMA FUNDED SERVICE CATEGORY AND HRSA/HAB
PERFORMANCE MEASURES
Source: HRSA/HAB Performance Measures
Service Category HRSA/HAB Performance Measure
Outpatient Ambulatory Health Services Viral Load Suppression
Medical Case Management Viral Load Suppression
Oral Health Oral Health Services: Periodontal Screening or Examination
Early Intervention Services Linkage to HIV Medical Care
Mental Health Viral Load Suppression
Health Insurance Premium & Cost Viral Load Suppression
Sharing Assistance Sharing Services
Substance Abuse- Outpatient Viral Load Suppression
Medical Nutrition Services Retention in HIV Medical Care
Non-Medical Case Management Viral Load Suppression
Medical Transportation Services Retention in HIV Medical Care
Psychosocial Support Viral Load Suppression
Food Bank/Home Delivered Meals Retention in HIV Medical Care
Treatment Adherence Services Viral Load Suppression
Housing Services Viral Load Suppression
Health Education and Risk Reduction Viral Load Suppression
b) Performance measure data is collected from sub-recipients throughout the grant
year. At the beginning of the grant year, sub-recipients submit their projected
units of service and anticipated number of clients during the initial condition of
award submission. Additionally, RWPA requires this information with the
submission of every sub-recipient’s budget request. Monthly performance
measures are submitted with billing data and are reviewed with each sub-recipient
during quarterly sub-recipient calls. Variance reports automatically calculate
quarterly reports of utilization expenditures and any variances or issues
influencing quality outcomes are provided and reviewed with sub-recipients
during the quarterly monitoring call. Annual performance measure data is
reviewed with the organizational assessment tool which is completed during the
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annual sub-recipient site visits. Finally, all sub-recipients report on their Plan,
Do, Study, Act (PDSA) projects during the quarterly CQM meetings.
c) The Phoenix EMA Outpatient Ambulatory Health Services sub-recipients are
tracking the percentage of RWPA clients linked to care. In 2015, this percentage
was 75%. The Phoenix EMA Medical Case Management Sub-recipients are
tracking the percentage of clients receiving medical case management services
who are retained in care. In 2015, this percentage was 68%. These sub-recipients
are also tracking client viral loads. In 2015, viral suppression was 63%. Utilizing
the data from 2015, the EMA has identified a concerning trend related to youth
who are not retained in care. In 2015, 47% of Black/African American MSM
youth, and 49% of the EMA’s total youth population were not retained in care. As
a result of this data, the RWPA Program, with direction from the Planning
Council, increased funding to Early Intervention Services and directed MAI
funding to target the EMA’s Black/African American MSM youth and youth sub-
populations. These sub-populations will continue to be monitored in 2016, with
specific subrecipient strategies identified to address this trend. Since 2015,
RWPA requires all clients to provide their viral load lab values as part of their
RWPA eligibility process. This provides the EMA better tracking of viral load
suppression, especially for clients who receive their medical care from non-
RWPA funded sub-recipients.
d) Performance measure data is analyzed and utilized in multiple ways to determine
the effectiveness of the EMA’s CQM activities, identify disparities and develop
strategies to eliminate those disparities. In 2015, the EMA developed data
systems which can stratify the HIV Care Continuum data by sub-recipient,
race/ethnicity, age, and service category. This data is available to all sub-
recipients and is discussed during the quarterly sub-recipient meetings, the
quarterly CQM meetings, and Planning Council Standards Committee meetings.
The analysis of this data contributed to the EMA’s MAI Medical Case
Management sub-recipients’ decision to support a RN case management model
which provides for an increased level of assessment for clients who have high
acuity for case management services. In 2016, the Arizona Regional Quality
Group began a project that utilizes a “Deep Dive Data” methodology to review
health disparities across all Ryan White Programs in Arizona. This process has
provided data which will be analyzed for youth and transgender populations to
determine possible barriers to care and methods to improve retention in care and
viral suppression.
e) During a statewide meeting facilitated by the National Quality Center held in
January 2014, Arizona’s Ryan White recipients, along with the RWPA Planning
Council, RWPA and RWPB sub-recipients and HIV Prevention partners agreed
on a Statewide AIM Statement which guides the selection of performance
measures. The Phoenix EMA is continuing to build on the 2014-2015 AIM
Statement in 2016-2017, which has provided a successful framework to engage
stakeholders, sub-recipients, consumers, the RWPA Planning Council and other
RWHAP recipients in the selection of performance measures. Activities which
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contributed to the successful integration of partners into this process are described
below:
Arizona RWPA 2016-2017 AIM Statement
Ryan White Recipients across all HIV/AIDS Bureau funding streams in Arizona
work jointly to improve its HIV Care Continuum and advance care for individuals
living with HIV. We will focus on all aspects of the Care Continuum to ultimately
improve the viral load suppression within the population we serve. Our efforts
will be evidenced by:
1. A statewide conference in 2016 and 2017 with HIV sub-recipients across
Arizona to address the Care Continuum and implement strategies to identified
in the Arizona Statewide HIV Integrated Plan.
Results: Achieved in 2016. Over 100 stakeholders participated in this
collaborative planning process. A Second Annual Symposium was held in
March 2016 to continue the statewide efforts to develop the Statewide
Integrated Plan. A Third Annual Symposium will be held in 2017 to begin
implementation of the Statewide Integrated Plan activities.
2. 100% of RWPA sub-recipients have access to statewide and regional HIV
Care Continuums. Continuums are updated quarterly to assist the sub-
recipients in implementing their Quality Improvement projects.
Results: All RWPA sub-recipients receive agency and contract specific Care
Continuums and develop PDSAs based on needs identified in their individual
Care Continuums.
3. At least 90% of sub-recipients have individualized aim statements which focus
on agency-specific aspects of the HIV Care Continuum.
Results: Achieved in 2016. All Sub-recipients included an individualized aim
statement in the agency’s Quality Management plan. Sub-recipients also
utilize their agency HIV Care Continuum to measure their progress towards
meeting their goals and report on their PDSAs addressing these goals
quarterly.
4. At least 80% of patients meet the linkage NHAS targets in 2016.
Results: In early 2016, based on the Linked to HIV care – Prevalent statewide
definition, 80% of the EMA’s clients were linked to care.
5. At least 74% of patients meet the retention NHAS targets in 2015.
Results: In early 2016, 74% of the EMA’s clients met the NHAS targets.
6. At least 70% of patients meet the viral load suppression NHAS targets in
2015.
Results: In early 2016, 68% of the EMA’s clients met the NHAS targets.
3) Description of CQM Program Quality Improvement:
a) The RWPA Quality Management Team meets with each subrecipient’s Quality
Management Team during the annual site visit to review their quality
management process improvement initiatives. A review of each sub-recipient’s
Organizational Quality Assessment Tool is also completed at the site visit with
a discussion on improvements for the next year. Each sub-recipient is required
to submit their agency Quality Management Plan at the beginning of each grant
year, and during annual site visits, the quality management plan is reviewed
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with each sub-recipient for updates/modifications. The information identified
during the annual site visit is utilized to identify priorities to be addressed
during the next grant year. The agencies notify RWPA of at least two quality
improvement priorities which will be addressed during the annual Condition of
Award submission process at the beginning of each grant year. In 2016, the
RWPA Clinical Quality Management Committee was expanded to include
additional members from each sub-recipient and the committee meets monthly
to review the EMA’s progress towards quality improvement goals. Each sub-
recipient presents information on their PDSAs, which focus on linkage,
retention and viral load suppression improvement across the HIV Care
Continuum. In 2015, one direct dental sub-recipient and one medical case
management sub-recipient collaborated to address barriers to the Native American
sub-population. The PDSA identified transportation as a barrier since the majority
of the Native American sub-population lives on reservations and find it difficult to
get to a dentist appointment. The medical transportation sub-recipient was also
able to join in this quality improvement initiative by allowing transportation
services for clients who are seeking dental services and in need transportation.
The PDSA has evolved into an ongoing project to improve the quality of care and
access to dental services between these agencies. This collaboration reduced
barriers and increased access to oral health care services for the Native American
sub-population. In 2016, another Medical Case Management sub-recipient
conducted a PDSA on the effect of targeted treatment adherence activities and
viral suppression rates. On a weekly basis, sub-recipient staff contacted clients
with a higher viral load to discuss their treatment adherence and increased the
amount of education regarding adherence and the importance of viral suppression.
The outcome has shown an increase in the viral suppression rate of their clients to
95%, with those not suppressed being new clients to the sub-recipient or recently
diagnosed individuals. In 2016, the Centralized Eligibility sub-recipient
conducted a quality improvement project with newly diagnosed individuals to
determine if scheduling a medical appointment at the time of eligibility intake,
rather than at first appointment with the Medical Case Manager, improved linkage
to care. Results showed that those with scheduled medical appointments at
eligibility intake were successfully linked a rate of 9% higher than those not
scheduled for an appointment. Furthermore, 96 % of those individuals were
linked in less than 30 days, whereas only 76% of those without scheduled
appointment were linked in the same timeframe. The RWPA Quality
Management Team participates in the quarterly sub-recipient calls which provide
an opportunity for sub-recipients and the RWPA staff to review data and progress
towards meeting their quality improvement goals. This quarterly meeting assists
the RWPA Quality Management team in identifying any technical assistance
which may be needed, and assists the sub-recipients in communicating their
progress towards meeting their annual goals.
b) Several initiatives have been implemented in 2015 and 2016 to improve HIV viral
suppression within the EMA:
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1. The Arizona Regional Quality Group agreed on common definitions for the
HIV Care Continuum, resulting in consistent measurement of viral
suppression.
2. The RWPA/B programs collaborated on a joint Ryan White eligibility
application, which has decreased the number of client applications required
for Ryan White eligibility. This has decreased the timeframes for linkage to
care and decreased the number of clients dropping off of ADAP. This
collaboration has also reduced clients’ paperwork requirements.
3. The RWPA/B programs have implemented aligned timeframes for Ryan
White eligibility renewals. Clients re-enroll in all Ryan White services during
their birthday and half-birthday months, which has decreased the number of
clients who failed to renew in either program.
4. The RWPA/B Programs have established data sharing processes which update
data nightly for both programs. This data sharing has increased the
information available to RWPA related to viral suppression for clients who
are ADAP eligible, but do not receive medical care through RWPA.
5. In 2015, RWPA began requiring all clients to provide viral load reports as part
of their renewal for RWPA every six (6) months. This viral load information
is now available in CAREWare, and allows the client’s case manager access
to this information as they assist clients in developing viral suppression goals.
c) CQM data is provided to the Planning Council Standards Committee. In 2015, the
Standards Committee utilized CQM data as part of their complete review and
update of the EMA’s Service Standards. CQM data is presented to the Planning
Council as part of the Council’s consideration of data for the Priority Setting and
Resource Allocation process. During the 2017 PSRA session, this data
contributed to decisions to increase funding for several service categories
including Medical Nutrition Therapy, Food Bank/Home Delivered Meals, Early
Intervention Services and Housing Services.
d) Stakeholders including RWPA sub-recipients, consumers, community members
and other Ryan White recipients serve on the RWPA Clinical Quality
Management (CQM) Committee. The committee meets quarterly to review
quality data and recommend quality improvement activities. The CQM
Committee annually reviews the RWPA Program’s Organizational Assessment,
and the EMA’s Quality Plan. Data related to Quality Improvement activities is
reported regularly at RWPA Quarterly sub-recipient meetings, Planning Council
Standards Committee, Arizona Regional Quality Group, and RWPA Planning
Council. In 2016, all of these stakeholders participated in the Statewide HIV
Integrated Plan development process which resulted in the creation of the Arizona
Statewide HIV Integrated Plan. The plan outlines strategies, including quality
improvement activities, to help achieve the integrated plan’s goals and objectives.
4) Data for Program Reporting
(a) The following table lists the Phoenix EMA’s information/data systems used for
data collection and reporting operations.
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TABLE 15 - PHOENIX EMA-MANAGEMENT INFORMATION SYSTEMS-2015
Management Information Purpose Agency(s)
System(s)
EMA CAREWare v. 5 Build 881 EMA wide data and billing All sub-recipients
eCW Data and billing Southwest Center
CAREWare v. 5 Build 839 Data MIHS
CareWare (internal) v . 5 594
Epic Electronic Medical Record EMR MIHS
IHS Patient Management Electronic Health Record (HER) MIHS
System (RPMS)
Dentrix Dental EMR MIHS, ASDOH
InteGreat E.H.R. 6.5.1.3. S2 Electronic Medical Record EMR SLHC
Microsoft Access Service Data Entry Tool RWPA Office
Medsis Lab Reporting Data Repository State Surveillance
Luther Evaluation Web Services Testing Data System which feeds into HIV Prevention
CDC reporting systems
Partner Services Web Partner Services and Partner Elicitation Maricopa County
Information which is fed into CDC Public Health
reporting systems
(b) Data collection for the RSR is accomplished through the networked Phoenix
EMA CAREWare database. This provides connectivity to the individual sub-
recipients, allowing for unduplicated client counts, and utilization data reporting
by service category used by the grant recipient and Planning Council for planning
and resource allocation purposes. In FY 2015, 100% of RWPA sub-recipients
completed all required client level data reporting in the RSR. The RWPA staff
work closely with the sub-recipients throughout the year to ensure the data is
complete and valid, and all reports are submitted within the required timeline.
 ORGANIZATIONAL INFORMATION –
A. Grant Administration
1) Program Organization
a) The EMA’s Ryan White Part A and MAI Programs are administered by the
Ryan White Part A Division of the Employee Benefits and Health Department
of Maricopa County. This administrative model allows the EMA to effectively
communicate with the Chief Elected Officials (Maricopa County Board of
Supervisors) and Healthcare Executives of Maricopa County, thus facilitating
improved understanding while meeting the needs of the HIV/AIDS community
within Maricopa and Pinal Counties. The Ryan White Part A and MAI Program
(Administrative Agency) has a staffing level of 11.0 FTE (7.25 Administration
and 3.75 Clinical Quality Management) to administer the funds of the Ryan
White Part A grant. At the time of application, three full-time vacant positions
existed. The Grants/Contracts Administrator, Management Analyst and Trainer
positions are currently vacant, and are expected to be filled in January, 2017.
Efforts to fill these positions are coordinated through the County’s Human
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Resources Department’s recruitment and hiring process. Planning Council
functions are currently being filled by a contracted consultant and the EMA will
continue this contract in 2017.The EMA’s staffing structure provides oversight
for all required areas of the grant. The Program Manager provides
administrative oversight for all grant administration, quality management, and
fiscal operations. The Program Manager directly supervises the
Grants/Contracts Administrator, the Quality Management Supervisor and the
Financial Administrator. The Grants/Contracts Administrator oversees
administrative and quality management functions of all sub-recipients. This
position supervises the Management Analyst and Program Assistant. The
Quality Management Supervisor manages all quality management functions
related to subrecipient contracts, including MAI sub-recipients, and supervises
the program’s Care Continuum Coordinator and Trainer. The Trainer is
responsible for identifying both administrative and quality management training
needs of subrecipients and provides technical assistance as needed. The Trainer
also participates in annual sub-recipient site visits and provides guidance to sub-
recipients as they implement corrective action plans related to site visit findings.
The HIV Care Continuum Coordinator is responsible for data analysis and
reporting related to the HIV Care Continuum, and leads the program’s efforts to
improve the EMA’s HIV Care Continuum. The Financial Administrator is
responsible for the monitoring of all financial requirements of the grant, and
supervises one (1) Management Assistant, and two (2) Finance/Business
Analysts. Additionally, Maricopa County’s Department of Finance has provided
an in-kind Business Official to support the RWPA Program as needed to
provide guidance in the areas of finance and fiscal reporting requirements. The
RWPA administrative and fiscal staff meets with the Department of Finance
regularly to discuss issues that require support from the County’s finance team.
The Planning Council and its sub-committees provide support and evaluation to
and for the Administrative Agency (AA) as outlined in related guidance. See
Attachment 11 for the Phoenix EMA organizational chart.
b) To avoid duplication of services between RWPA/B/C/D/F funding, the RWPA
recipient has developed policies, procedures and contract requirements to ensure
the sub-recipients funded through multiple Ryan White programs are able to
distinguish the clients to be served under these funding streams, and provide
data to the RWPA Program on the number of clients served by each Ryan White
program. Policies, procedures, and contract requirements include, but are not
limited to: use of CAREWare and Centralized Eligibility for client eligibility
and service data collection and entry, monthly eligibility monitoring for any
third party payer, including Medicaid, Medicare, Federal Marketplace Health
Insurance and other private insurance prior to sub-recipient reimbursement, sub-
recipient policies and procedures on payer of last resort, disclosure of other
revenue streams (including all Ryan White parts), separation of revenues and
expenses by funding streams documented in financial systems and software, and
client chart reviews to verify services were billed to Part A only after
exhausting other payer sources. The Grants/Contracts Administrator, Quality
Management Supervisor and Financial Administrator oversee annual, quarterly
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and monthly monitoring of these mechanisms to assure these requirements are
met by all subrecipients. RWPA/B has consolidated each program’s client
databases into a statewide centralized CAREWare database which provides both
programs information about client eligibility and payer sources. This new
database system is an instrumental component of the Ryan White grantees’
statewide efforts to transition every eligible Ryan White client in the state to
appropriate payer sources.
2) Grant Recipient Accountability
a) Program Oversight
(1) The HRSA National Monitoring Standards were updated in 2012. All
Phoenix EMA policies and procedures are reviewed annually to ensure
compliance with the National Monitoring Standards. Sub-recipients are
notified of any changes or clarifications issued by HRSA or programmatic
policy changes via a clarification notice. All policies and procedures and
any updates or clarifications are emailed to all sub-recipients and posted to
the RWPA website at www.maricopa.gov/rwpa. Technical assistance is
provided to any sub-recipient needing assistance in implementing the
National Monitoring Standards. Compliance on the National Monitoring
Standards and program Policies and Procedures are reviewed and checked
during annual sub-recipient site visits. The EMA will provide technical
assistance and training on new National Monitoring Standards when HRSA
releases new National Monitoring Standards later this year;
(2) The RWPA Program conducts program monitoring through several
mechanisms throughout the grant year. Each sub-recipient is required to
submit documentation to demonstrate compliance with all HRSA
Conditions of Award at the beginning of each grant year. Monthly review
of expenditures and quarterly performance reviews are conducted, and year
end reconciliation and closeout of all sub-recipient contract expenditures are
completed each year. Quarterly Contractor Meetings are held with all sub-
recipients to address any issues related to administrative and fiscal issues,
and a Quarterly Clinical Quality Improvement Meeting is held to address
quality management issues. Annual fiscal, administrative, and clinical
quality site visits are conducted for all sub-recipients. Site visits, overseen
by the Grants/Contracts Administrator, Quality Management Supervisor and
Fiscal Administrators, assure allowable and reasonable expenses are charged
to Ryan White, clinical quality service standards are met in service delivery,
services are billed only for eligible clients with no other payer source, and
contractual requirements are met. The Financial Administrator reviews
source documents such as timesheets, general ledgers, invoices and receipts
for the sample period and determines whether expenditures are allowable.
The Grants/Contracts Administrator and Quality Management staff review
client charts to check for contract and service standard compliance.
Contractual interviews, including the collection of required policies, are also
conducted. All data collected at site visits is entered into the site visit
monitoring tool, a Microsoft Access database developed specifically for the
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EMA, and corrective action plans are provided to the sub-recipients based
on the findings identified during the site visit;
(3) In FY 2015, annual fiscal, administrative and quality management site visits
were conducted for 11 subrecipients, which was a complete review of all
sub-recipients in the Phoenix EMA. Each sub-recipient is provided a report
of all findings and a corrective action plan for any findings. The
Administrative Agent has scheduled twelve (12) site visits for grant year
2016, which includes all RWPA subrecipients. Annual Site visits for grant
year 2016 will begin in November, 2016 to be completed by February, 2017.
(4) Following all annual site visits, a preliminary site visit summation report is
provided to subrecipients and printed, customized reports within thirty (30)
days from completion of the site visit. Within ten (10) business days of each
report, final corrective action plans are submitted to sub-recipients and sub-
recipients are allowed 30-45 days to respond with an action plan for
correction and improvement. The corrective action report indicates the
findings, relevant contractual language, necessary action, and correction
deadlines. Corrective actions range from procedural changes, to compliance
with grant and contract requirements, to recovery of funds deemed
unallowable. Actions are monitored and followed up until the deadline is
met and the site visit is officially closed. Any findings which identify the
need to repay funds due to unallowable expenditures in 2016 will require
repayment of sub-recipient funds before the end of the grant year. Funds
which are recouped will be reallocated to other service areas as identified
through Planning Council directives. Sub-recipients may be scheduled for
targeted site visits based on issues identified during the grant year.
(5) Table 16 below lists the number of subrecipients who have received
technical assistance during GY 2016 to date:
TABLE 16 - 2015 TECHNICAL ASSISTANCE (TA)
TYPE OF TA SCOPE OF TA TIMELINE SUB-RECIPIENT TYPE
Admin/Fiscal Secure File Transfer Portal (FTP) Ongoing All
Support
QM New Provider Staff Orientation & Ongoing All
Training
QM VPN Connection Setup Ongoing All
Admin/Fiscal/Q Grant Opening Review 03/02/2016 All
M
Case Management, Mental
Admin/QM Site Visit Review 03/03/2016 Health, Medical Nutrition
Therapy
Admin Contract Issues 03/03/2016 OAHS/Oral Health
Fiscal Billing Requirements 03/15/2016 Oral Health
Fiscal Cost Reimbursement Assistance 03/18/2016 Case Management, Mental
Health
Fiscal Billing Requirements 03/23/2016 EIS
Admin/Fiscal Billing Requirements 03/23/2016 Oral Health
Admin/QM MCM Policy and Standards 03/29/2016 Case Management
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Admin/QM Dental Policy and Standards 03/30/2016 Oral Health
QM Eligibility and Referral Processes 04/01/2016 EIS
Budget Development and Case Management, Mental
Fiscal Requirements 04/05/2016 Health, Medical Nutrition
Therapy
QM Group Rapid Service Entry 04/07/2016 Case Management,
Psychosocial Services
QM Custom Report Assistance 04/07/2016 All
QM Unit Entry 05/05/2016 EIS
Admin/QM Service Documentation 05/25/2016 Case Management
Requirements
QM Site Visit Review 6/3/2016 EIS
Fiscal/QM Billing Requirements 6/6/2016 OAHS
QM Unit Entry and Reporting 6/27/2016 EIS
QM Referral Requirements 7/7/2016 Case Management
Admin Contract Clarification 7/15/2016 EIS
Budget Development and Case Management, Mental
Admin/Fiscal Requirements 7/19/2016 Health, Medical Nutrition
Therapy
Admin/QM Billing, Documentation, and Unit 7/28/2016 Medical Nutrition Therapy
Entry
Admin/QM Contract Clarification, Continuum 7/28/2016 Case Management
Reporting
Admin Eligibility Clarification 8/12/2016 Case Management
QM CAREWare Reporting and PDSA 9/8/2016 Case Management
Instruction
Admin Site Visit Prep 10/5/2016 All
b) Fiscal Oversight
(1) The Program Manager oversees operations of the grant and assures all
contractual and fiscal requirements of the grant are met. Working under the
Program Manager, the Financial Administrator oversees all financial
requirements of the grant, including budgeting, billing, reimbursement,
fiscal monitoring and fiscal reporting. The Finance Management Assistant
provides assistance with program and fiscal monitoring, billing analysis and
payment. The Finance Business Analyst(s) perform fiscal monitoring and
reconciliation activities. Under the direction of the Financial
Administrator, the Finance Business Analyst(s) reconcile all task orders,
grant masters, purchase orders, and payment vouchers on a quarterly basis
and performs the sub-recipient compliance review of all sub-recipient
variance reports to identify spending and service trends. On a weekly basis,
the Management Assistant is responsible for billing, analyzing and
processing bills for payment and reporting the status of sub-recipient
payments to the Financial Administrator. On a monthly basis, the
Management Assistant and Financial Business Analyst(s) are responsible for
assisting with all other grant fiscal monitoring activities, reconciling and
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reporting internal administrative expenditures. The Financial Administrator
reviews the reconciliation process and outcomes to assure spending is
properly recorded and tracked in all internal systems. Various meetings take
place within the RWPA Program’s office to assure both programmatic and
fiscal parties are informed and closely monitor grant expenditures,
unobligated balances, and program income. The Financial Administrator
meets weekly with the fiscal team to discuss billing and reimbursement
concerns. Each month, after sub-recipients invoices have been received and
logged, the Program Manager, Grants Administrator, and Financial
Administrator meet to review sub-recipient expenditures in order to make
recommendations for reallocations, as needed to the Planning Council’s
Allocation Committee to assure unobligated formula and supplemental
funds are properly expended. As needed, the Program Manager, Grants
Administrator, and Financial Administrator meet with the program and
fiscal teams to discuss shared contract compliance and billing concerns.
Weekly, all Recipient management staff members meet to review and
discuss contractual and financial issues. Fund balance reports are generated
monthly by the County’s Finance department and compared with the
Recipient’s internal monitoring systems to confirm financial accuracy.
Finally, the Program Manager and Financial Administrator meet monthly
with the Director of Maricopa County Employee Benefits and Health
Department to review and report on the status of grant expenditures and
performance measures;
(2) The Recipient internally monitors and tracks Part A and MAI formula,
supplemental, unobligated, and carry-over funds utilized per service
category and service sub-recipients through an internal database-driven
Grants Management System (GMS). This system, which maintains and
reports all sub-recipient, Administrative and Quality Management
allocations and utilization, allows the AA to effectively administer, monitor,
and redistribute grant funds from receipt of the grant to the sub-recipient
level. The GMS is electronically linked to Advantage, the County’s
financial tracking and reimbursement software program. Comprehensive
financial analysis and reconciliation by Recipient staff and automatic
electronic routines occur daily, monthly, and quarterly to assure the funds
and utilization are tracked separately. The Recipient has transitioned all
business process documentation to OnBase, an electronic workflow system.
All financial transactions, including allocations, budget approvals, monthly
billing, reimbursement, and document archiving are done through this
electronic process;
(3) The RWPA team has created an internal administrative network system
which provides Maricopa County the confidence that RWPA funds are
being disbursed quickly to ensure services are provided as rapidly as
possible. The funds are monitored closely to ensure unobligated funds are
limited, and Ryan White is the payer of last resort. Fiscal monitoring occurs
monthly, quarterly and annually. Sub-recipients are required to submit a
monthly billing packet which includes a general ledger, expense reports, and
other billing information which supports reimbursement. Quarterly variance
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reports are reviewed by the Financial Business Analysts and Financial
Administrator to identify spending and service trends. The Recipient
monitors funding utilization within the RWPA Grant Management System
database monthly and quarterly by using customized, year-to-date
forecasting reports. These reports are used to provide utilization information
to the Planning Council at their regular monthly meetings. This reporting
system allows the Planning Council to monitor the use of formula,
supplemental, unobligated, and carry-over funds, and utilization for each
service category. Based on this information, the Planning Council’s
Allocations Committee recommends reallocations to the Planning Council at
least quarterly to ensure unexpended funds are rapidly reallocated based on
current needs and other relevant data. In addition to quarterly reallocations,
the Planning Council may allow the Recipient the authority to reallocate
funds across service categories during the last quarter of the grant year
without Planning Council prior approval. The Recipient informs the
Planning Council of all reallocations that occurred during the 4th quarter of
the grant year;
(4) Effective December 26, 2014, a sub-recipient, non-Federal, entity which
expends $750,000 or more during the non-Federal entity’s fiscal year in
Federal awards must have a single audit conducted in accordance with
§75.514. Internal Audit reviews the findings and notifies the recipient of
these findings and any items which require attention. Prior to the
implementation of the Uniform Guidance, single audits were required of
non-federal entity’s expending $500,000 or more. Single Audit reviews
were conducted for 7 of 9 (78%) sub-recipients who provided services in
grant year 2015. One sub-recipient who did not receive a single audit is a
federal agency (IHS), and as such, is not required to undergo a single audit.
The other sub-recipient is a new service provider and began providing
services in January 2016. Internal Audit noted all FY2015 sub-recipients
falling under the Single Audit Act requirements were accounted for during
this review and complied with Single Audit Requirements.
(5) Internal Audit noted all sub-recipients included in the FY2015 review
complied with Single Audit Requirements. Internal audit identified a
deficiency with one (1) sub-recipient. The finding was not related to RWPA
funding. The Recipient provided a specific corrective action plan to
improve the noted deficiencies and a timeline to respond to the corrective
action plan. The identified deficiencies have been addressed by the sub-
recipient and substantiated with written and oral communication.
(6) Sub-recipients are required to submit monthly invoices for each service
category to the Recipient no later than the fifteenth (15th) day (or other day
designated by the AA) of the month following the month services were
provided. All billing materials must be submitted securely through the
Secure File Transfer Process (FTP). Sub-recipients are responsible for
submitting invoices which only include eligible clients, services and units.
Upon receipt of the monthly invoices, the billing documents are scanned
into OnBase, the electronic Billing workflow system and the billed amounts
are recorded in the Grants Management System to track the amounts billed
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by each sub-recipient by service category. Overnight, OnBase runs a review
for Client Eligibility (CE) against the CAREWare database. Ineligible
clients/services reports are sent to sub-recipients to review and to remove
any ineligible clients/services before the invoices are processed for payment.
Completed invoices without CE issues are routed to the Management
Assistant to be reviewed for completeness and accuracy. Sub-recipients are
contacted and informed of any missing documentation or information. Once
the invoice has been determined to be complete and accurate by the
Management Assistant, the invoice undergoes a second review by the
Finance Business Analyst before it is routed to the Program Manager for
final review and approval for reimbursement. The approved invoice is
routed electronically to the Maricopa County Accounts Payable OnBase
workflow system and the Management Assistant integrates the OnBase
billing document with the Maricopa County Advantage Financial System.
The RWPA Financial Administrator provides the final step of the billing
approval process, which includes verification of appropriate funding, and
the invoice is routed to the Maricopa County Finance/Accounts Payable
department for payment. Upon payment, financial transactions are saved in
the Advantage financial system. This expenditure data is electronically
imported into the Grants Management System (GMS), weekly, to record the
payment and payment date.
3) Administrative Assessment
a) On September 22nd, 2016, the Planning Council’s Executive Committee and
Planning Council approved the 2015 Administrative Assessment. Data supplied
by the Grantee indicated timely allocation/contracting of funds and payment to
contractors. Payments to contractors averaged 18 days. On February 18th, 2015,
the EMA received notification of grant award for partial funding. Based on the
partial grant award, providers were notified on February 26th, 2016 of their
partial awards. Provider contracts were executed on average eight days after
contractors received their award letters. All contracts had a start date of March
1st, 2014. On May 28th, 2015, the EMA received its full Notice of Grant Award.
Provider contract amendments were issued on June 2nd, 2015. Provider contract
amendments were executed on average five days after contractors received their
contract amendments. In 2015, the Phoenix EMA expended 98.6% of available
Ryan White Part A funds.
b) No deficiencies were identified by the Phoenix EMA Planning Council.
4) Third Party Reimbursement
a) In the Phoenix EMA, third party payer sources include Medicaid’s Arizona
Health Care Cost Containment System (AHCCCS), State Children’s Health
Insurance Programs, Medicare, private insurance, and the Federal Marketplace
Insurance Plans. Sub-recipients providing Medicaid eligible services are
Medicaid certified and this certification is verified at the start of each grant year
as a part of the sub-recipients’ Condition of Award. The Recipient has clear
policies in place to ensure sub-recipients are screening clients for third-party
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payers before the Ryan White program is billed. County contracts and program
policies require sub-recipients to maintain policies addressing the screening
mechanism, frequency and documentation for third party payers. These policies
are reviewed and compared to actual practice during annual sub-recipient site
visits. Additionally, monthly CAREWare monitoring reports for Federal
Marketplace Insurance Plan eligible clients as identified by the State of
Arizona’s Ryan White ADAP and Part B Program are generated so the clients
receiving benefits under the Marketplace Plans maintain their eligibility in
ADAP and these client’s medical expenses are not billed to RWPA.
b) The EMA has a Centralized Eligibility system requiring all clients to apply and
renew for RWPA benefits through one sub-recipient. All eligibility documents
are archived in the CAREWare database, and all RWPA sub-recipients have
real time access to client eligibility information through the centralized
CAREWare database. Monitoring of these screening and billing practices takes
place at the annual sub-recipient site visit by reviewing client charts for
documentation which clients were screened for other payers, and by reviewing
the sub-recipient accounting records for billing and reimbursements received,
including program income and expenditure of that income. Sub-recipients
providing Medicaid/Medicare, Federally Facilitated Marketplace Insurance, or
private insurance plan services use CAREWare, and statewide and national third
party payer software programs to determine eligibility at the time of each visit.
Corrective action and repayment of funds is required if clients eligible under
other payer sources were not exhausted before billing RWPA. Through these
processes, the Recipient ensures RWPA is the payer of last resort.
c) The recipient reviews program income reported by sub-recipients on a monthly
basis on invoices submitted, and at annual sub-recipient site visits to ensure
program income is utilized appropriately for program needs. Program income is
not generated at the Recipient level.
B. Maintenance of Effort (MOE)
1) Table 17 (below) and Attachment 12 identify the MOE budget elements and the
amount of expenditures related to HIV/AIDS core medical and support services for
the two most recently completed fiscal years prior to the application’s deadline;
TABLE 17 - MAINTENANCE OF EFFORT REPORTING
Sources: Maricopa County Correctional Health Service Report on Maintenance of Effort September,
2016
ITEM DESCRIPTION ENTITY FY2014 FY2015
# EXPENDITURES EXPENDITURES
1. Primary Medical Care CHS $417,186.04 $ 436,464.00
2. Outpatient Ambulatory Health CHS $43,770.92 $ 65,604.90
Services, including Specialty
Services
3. Pharmaceuticals CHS $1,072,735.70 $1,081,144.31
4. Dental CHS $ 3,303.50 $ 4,000.00
5. Mental Health/Substance Abuse CHS $160,614.37 $ 198,645.00
6. Labs CHS $ 56,370.48 $ 55,699.29
7. Other CHS $ 7,351.95 $0
Totals: $1,761,332.75 $$1,841,557.50
68

Phoenix EMA Ryan White HIV/AIDS Program Part A FY 2017 DUNS#077535144
Funding Opportunity Number: HRSA-17-30
2) The Phoenix EMA currently has two (2) political subdivisions which provide services
for people living with HIV/AIDS within the Phoenix EMA. These entities are
Maricopa Integrated Health System (MIHS) and Maricopa County Correctional
Health Services (CHS). In FY 2016, the EMA anticipates that the Maintenance of
Effort will be maintained, based on the number of inmates being treated for HIV in
the Maricopa County Jail system. The following core medical and support services
provided by these two (2) entities will be consistently tracked and reported to the
EMA:
a. Outpatient Ambulatory Health Services
b. HIV Specialty Services provided by specialists outside of Correctional Health
Services
c. Pharmaceuticals
d. Dental Services
e. Mental Health/Substance Abuse
f. Labs
g. Other
3) CHS Methodology: Maricopa County’s Correctional Health Services utilizes an
electronic medical record system (TECHCARE) which provides electronic
documentation of patient medical records, billing, and encounter data. This system
allows the CHS finance team to identify clients treated by the sub-recipient within
CHS and by outside referrals, and to calculate the costs associated with the medical
services, and the cost of medications provided to HIV positive inmates. In 2015, CHS
provided medical services to 449 HIV positive inmates, a decrease of 9.6% from
2014. The cost per client increased from $3,771.59 in 2014 to $4,107.46 in 2015.
The CHS finance team completes the analysis of this data and submits the summary
data to RWPA by Sept. 15th each year.
MIHS Methodology: MIHS has notified the Recipient there are no expenditures to
be reported in core medical and support services for FY 2014 and FY 2015, due to the
fact all expenditures incurred by MIHS for HIV-related services in these fiscal years
were expenditures related to inpatient hospitalizations or emergency department
visits. The Recipient will request MIHS to continue tracking any core medical and
support services expenditures which are incurred in 2016, and will continue to track
these expenditures in the future. The 2014 and 2015 Maintenance of Effort
expenditures for these two (2) governmental entities are identified in Attachment 12.
iii. Budget
See SF 424 A
iv. Budget Narrative
See Attachment 14 GY17 Application Budget Narrative
69