Ryan White newsletter summer 2018

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July 2018



Ryan White Program
Hennepin County Public Health Department
525 Portland Ave., 3rd Floor
Minneapolis, MN 55415 
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The Ryan White Provider Newsletter is issued semi-annually and provides information about HIV services planning, contract administration, quality management, CAREWare updates and training opportunities.  Your feedback and suggestions for future issues are appreciated. 

Contact Ryann Freeman

Happy summer

As we enjoy summer and revel in the year’s maximum sunlight, let’s take a moment to acknowledge how Minnesota’s HIV service providers maximize efforts to ensure that all Minnesotan’s living with HIV have access to high quality core medical and support services.

In 2017, infections in Minnesota declined for the third year in a row. In Hennepin County alone, new infections in 2017 dropped to 130 cases, 19 fewer than in 2016. Although it may be too early to conclude this decline in HIV incidence is a trend, the signs are encouraging. 

In 2017, 4,386 people living with HIV received services through our Ryan White system of care, an increase of four percent compared to 2016. Increasing the number of people living with HIV who are virally suppressed is our mission, which is key to getting to zero new infections. The work you do is the path to our collective success. With the eHARS to CAREWare project now fully operational, 83 percent of Ryan White Program service recipients now have viral load values in CAREWare and we are better able evaluate our future progress.

In this issue, you will read about Positively Hennepin’s first-year accomplishments and what we are focusing on in 2018. This summer the Minnesota Council for HIV/AIDS Care and Prevention will prioritize services, allocate Part A funds, and recommend Part B allocations to their priorities for fiscal years 2019 and 2020. You’ll also learn about the cost of the services we fund and some training activities planned for 2018.

Be sure to take some time to enjoy Minnesota’s glorious warm season.  

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Minnesota Council for HIV/AIDS Care and Prevention update

Minnesota Council for HIV/AIDS Care and Prevention

The Minnesota Council for HIV/AIDS Care and Prevention is busy setting their HIV-related service priorities, preparing to allocate Part A Ryan White HIV/AIDS Program and Part A Minority AIDS Initiative (MAI) funding, and make allocation recommendations for Part B federal Ryan White HIV/AIDS Program funding. The Planning and Allocations Committee, Needs Assessment and Evaluation Committee, and Disparities Elimination Committee designed a prioritization and allocation process that is fair and data driven. The Needs Assessment and Evaluation Committee created Service Area Review Summaries (SARS) for each service area that the council currently funds and presented the data to the council in May and June.

Using this data as well as additional data that was presented at previous council meetings, the council will use a paired comparison methodology to prioritize service areas. The council will also prioritize a group of service areas that the Disparities Elimination Committee believe will have the greatest impact on addressing and reducing disparities within underserved and disproportionately impacted populations. On August 7 the council will come together to review the list of core medical and support service priorities and receive presentations on the Part A and Part B allocation proposals. On August 14 the council will discuss ideas and evidence, determine Part A allocations, and recommend Part B allocations for the next two years. The final step is for the grant recipients to contract with service providers in accordance with the council’s priorities, allocations, directives, and recommendations.      

Please contact council staff or co-chairs if you have any questions about the prioritization and allocation process. All council and committee meetings are open to the public and a schedule of meetings is located at http://www.mnhivcouncil.org/calendar.html. We welcome your attendance and participation at our meetings to help us end the HIV/AIDS epidemic in Minnesota, and we extend an invitation to join the council as a community member or to submit an application for council membership.

Cultural responsiveness update

With the adoption of new cultural responsiveness standards in the Universal Standards of Care, Ryan White staff at the Minnesota Department of Human Services and Hennepin County are developing partnerships with local community-based organizations to offer relevant trainings. Through a collaboration with the Minneapolis YWCA, we are excited to offer a half-day training around confronting racism. As soon as we finalize the logistical details we will send out an invitation to all Ryan White providers.

As FY2018 Q1 comes to a close, we will be circulating a survey that providers can use to collect input from clients around culturally responsive service delivery. While providers are not required to utilize the survey we are providing, they are required to solicit feedback from clients around culturally responsive service delivery on an annual basis.

Please reach out to Ryann Freeman at ryann.freeman@hennepin.us with any questions.

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A case study of continuous improvement: new methodology for determining efficiency measure targets

Hennepin County emphasizes our core values of employee engagement, workforce development, diversity and inclusion, customer service, and continuous improvement. To zero in on the fifth value, Hennepin County Public Health, which includes the Ryan White HIV/AIDS Program (RWHAP), places a strong emphasis on continuous improvement. In this spirit, our team sought to improve the efficiency measure targets for FY2018.

Efficiency measures are the quantity of services provided (i.e., clients to be served, units to be provided, HIV tests to be performed). This contrasts with effectiveness measures that look at quality (i.e., retention in care, referrals for those out of HIV medical care, viral suppression, care plans documented in CAREWare). Historically, efficiency measures have been calculated by using providers’ historical performance. Over the years this methodology has led to a high variance of cost per client in some services across multiple providers. In FY2018, the RWHAP analyzed cost per client across providers for each service area and then determined the efficiency measure for the provider using the methodology summarized below:

  1. What is the average cost per client for the past three fiscal years?
  2. Are there differences in units per client (for applicable services)?
  3. If a provider is above the average cost per client without higher units per client, the cost per client for FY2018 was adjusted to the average.

As implied in the units per clients step, variance in cost is not always negative. You would expect there to be some differences in cost depending on populations being served. A clear example is medical transportation services; a client in greater Minnesota would be more expensive than a client in the metro area. However, in most service areas, particularly for providers’ Part A funded services where all clients reside in the 13-county metro area, the RWHAP wants to reduce the variance in cost across providers. The rationale for this is straightforward: by setting efficiency measure targets for historically higher cost providers at the average cost per client, more clients can be reached.

Reaching these targets depends on the commitment of providers to continuously improve their service delivery. The RWHAP wants to be clear: you are not on an island. You are our partner in improving the lives of people living with HIV and ending the HIV epidemic.

Continuous improvement involves the Plan-Do-Check-Act cycle. If you want technical assistance on this process, please contact our quality coordinator Anika Kaleewoun at anika.kaleewoun@hennepin.us. 

Additionally, the RWHAP wants to increase peer-to-peer technical assistance. Please do not hesitate to reach out to your fellow providers to ask how they are approaching service delivery. You can also reach out to your contract manager, and they would be happy to get you connected with a peer provider.

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Positively Hennepin update

Positively Hennepin

In April 2018, the first progress report on Positively Hennepin, Hennepin County’s ambitious, comprehensive strategy to end our HIV epidemic was released. The report details:

  • Baseline evaluation of Positively Hennepin’s ten milestones, which measure progress on our journey to ending the HIV epidemic
  • Steps that Positively Hennepin has taken — in partnership with the Ryan White Program, programs across Hennepin County Government, state and city governments, HIV-service providers, and community leaders — to coordinate our response to the HIV epidemic
  • Strategies moving forward that build upon the successes of the last year and draw increased attention to communities that HIV hits hardest

Through the county’s HIV strategy, Hennepin County Public Health also became the second county government in the United States to join the U=U campaign. This campaign means that undetectable HIV is untransmittable through sex. Built on a solid foundation of scientific evidence, nearly 700 organizations from 82 countries have signed on to share the U=U message with their communities.

Baseline evaluation shows that we are in a solid position to achieve many of the strategy’s ten milestones by 2019. However, the milestones also indicate that more progress is needed to achieve health equity among the black and Latino communities.

Over the next year, Positively Hennepin has five areas of focus:

  • Preparing for an HIV outbreak among people who inject drugs
  • Building an integrated public response to HIV
  • Developing new data methodologies
  • Focusing on black and Latino communities
  • Engaging American Indian and transgender communities

To learn more about Positively Hennepin’s accomplishments and its focus areas over the next year, visit the Positively Hennepin website or contact its coordinator Jake Maxon at jake.maxon@hennepin.us

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West African HIV Task Force

Emma Boyce, an intern with Hennepin County Public Health’s Ryan White Program, partnered with African-born communities to host an HIV forum to increase HIV awareness. This forum was a culturally competent way to address the disparities that plague African communities. The forum was well received by community members, with over 200 attendees and over 45 people tested for HIV. Individuals involved in the planning of the forum were asked to continue this effort and create initiatives to educate the community, and increase testing, preventative measures, and HIV service utilization. Thus, the West African HIV Taskforce was formed.

Through partnership with Hennepin County’s Ryan White Program and Positively Hennepin, the task force will create culturally specific evidence-based interventions to increase HIV testing, prevention, and care among African-born communities. We have partnered with the Minnesota Department of Health to provide HIV testing kits to this disproportionately affected community. We have engaged over 15 different community organizations, social groups, and religious institutions to highlight HIV-related disparities and task them to be companions in our fight against HIV.

One June 21, 2018, an HIV awareness campaign was held through a Facebook Live event, where over 35,000 people watched within Minnesota, across the nation, and globally. Through social media, we have educated over 70,000 people about HIV. We have partnered with Clinic 555 to develop a culturally specific sexual and reproductive health/HIV education curriculum in order to train African-born women to be peer educators and recruit others for testing. 

Our next event focused on protecting your health for African-born women will take place on July 14, 2018. Testing will also be offered at the event. The task force will also provide testing at different community events throughout the summer.

Please contact Emma Boyce at emma.boyce@hennepin.us to register for an event or learn more about the task force.

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MCHACP Council update

Community Voices Committee

Members of the Minnesota Council for HIV/AIDS Care and Prevention have identified the revitalization of the Community Voices Committee (CVC) as an integral element in ongoing efforts to improve consumer engagement and outreach. So, after a hiatus, the CVC reconvened on March 20, 2018. The meeting was well attended and included a robust contingent of consumers from Greater Minnesota. Many consumers returned to the CVC’s April meeting, where they prioritized HRSA allowable service areas.

The CVC met again on May 23, with 27 consumers from both the TGA and Greater Minnesota in attendance. At this meeting, members elected two co-chairs, Destiny Holiday and Joann Vertetis. Consultants Mark Fischer and Steven Vargas, from Jon Snow Inc., attended the meeting to discuss the history and value of consumer advocacy. Mark and Steven also educated members on how the CVC can influence the council’s work.  

Future meetings will offer an opportunity for consumers to share what their ongoing needs are, as well as provide a forum to provide feedback on service delivery and needs. CVC meetings will also include an educational component for consumers. The next CVC meeting will be scheduled for later this summer; further information will be provided about this meeting and providers are encouraged to inform their clients about the council and the CVC.

Technical Assistance from HRSA

In May 2017, the council formally requested Technical Assistance (TA) from HRSA’s HIV AIDS Bureau (HAB) to improve the council’s consumer engagement and outreach efforts. This request was made at the behest of council members who noted that many Ryan White consumers are unfamiliar with the council’s work and impact on the HIV/AIDS community. In February of this year, two consultants from Jon Snow Inc. began providing this requested TA. Mark Fischer and Steven Vargas conducted extensive interviews with various stakeholders -- including providers, consumers, and government representatives -- to better understand how consumers currently engage with the council. In addition, Mark and Steven held several onsite meetings with a diverse group of stakeholders from May 23-25, 2018.

Based upon feedback gathered from these efforts, Mark and Steven developed a report on their findings, as well as a series of actionable items that the council can take to improve consumer involvement with the council’s committees and activities. Some of these items will need coordination with providers to be successful. For example, one of the actionable items is to implement new ways of sharing information with and securing input from consumers, eligible consumers, service providers, and others who support or are served by the council.

The council’s Executive Committee is currently reviewing the actionable items and will determine which to prioritize first. Providers will play an integral role in improving the council’s consumer engagement and are encouraged to attend council and/or committee meetings (the council’s calendar is available here). 

If you are a provider and would like additional information on TA efforts, or want to learn more about how you and/or your agency can get involved, please reach out to the council’s coordinator Carissa Weisdorf at carissa.weisdorf@hennepin.us.

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2017 HRSA/HAB Part A site visit findings

As many of you learned at our Hennepin County Ryan White Program contracted providers meeting in April, we had a number of findings from our 2017 site visit conducted by HRSA’s HIV/AIDS Bureau. These findings are typical of many Part A grant recipients across the country. The ones most relevant to our providers relate to charges for services, program income, and reviewing standards of care annually. Over the next several months, we will be providing training on the legislative requirements related to these findings and working with you to help develop policies and procedures to meet the requirements.

Sliding fee scale and caps on charges

The Ryan White HIV/AIDS Program legislation requires all subrecipients (funded service providers) to have policies and procedures in place to ensure that charges for services do not exceed caps based on client income. These policies and procedures include having a sliding fee scale, informing clients of fees for services and caps on charges, and having a procedure for tracking client charges so their expenses for HIV services do not exceed the caps. The caps on charges based on client income are as follows:

  • < 100% of FPG – no charge
  • 101 - 200% FPG – not more than 5% of annual gross income
  • 201 - 300% FPG – not more than 7% of annual gross income
  • > 300% FPG – not more than 10% of annual gross income

The legislation allows grant recipients (Hennepin County) to approve nominal fees for services and prohibits providers from denying client services if they are unable to pay the charges.

Program income

All Ryan White HIV/AIDS Program providers must track and report program income. Program income is most commonly generated by charging for services and receiving payment from third-party reimbursement such as Medicaid and private insurance. 

The template Hennepin County provides for reporting your annual revenue and expenses includes lines to specify the source and amount of program income you receive. Please work with your Hennepin County contract manager to ensure that you understand this requirement and are reporting any program income that you receive accurately. All program income that is directly generated by a supported activity or earned as a result of your Ryan White grant award must go back into the program to support your Ryan White Program activities.

Annual standards of care review

Over the past several years, many of you have participated in our provider input meetings. Your on-the-ground expertise is integral to developing standards of care that ensure the delivery of highly effective HIV care services. We are working with DHS to develop a process for reviewing standards of care annually and updating them as needed. We anticipate that there will be two general tracks of review: one track for services that only require minor updates and one track for services that warrant more extensive review. We appreciate your participation in this important process. 

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Quality management update: PDSA cycle

Step one. Identify an area you want to or need to improve.

Write out your goal as a SMART (specific, measurable, achievable, relevant, and time-bound). 

Priorities should focus on improving health outcomes for clients, aligning outcomes with the National HIV/AIDS Strategy, and reducing disparities in services and outcomes.

Step two. Identify how you will measure your goal and progress towards it. 

Ensure you know where you are at now (your baseline) and where you want to go (your target). Make sure your team is clear on how to measure your progress, how the progress will be tracked, and how progress will be communicated and with whom.

Step three. Make an initial plan. 

This is where you make a hypothesis and write out one initial intervention or experiment. Try to change only one thing at a time; this helps know whether this change is helping you reach your goal.

Step four. Do. 

Test your hypothesis, meaning try out your plan or idea. 

Do it small scale for a short period of time. Maybe test for the next 10 clients or two weeks, just enough time to make some observations and collect data. Make sure you are tracking results during your test period.

Step five. Study

Analyze the results of your trial. Did it work like you thought it would work? Did things improve or get worse? What did you observe? What important lessons will you take away from this experiment?

Step six. Act. 

Based on your analysis, will you adopt what you tried, make it the standard way you do things, and scale it up for all clients? Will you adapt it and make a tweak to your intervention to make it more effective? Or will you abandon this hypothesis and try a new intervention?

This is the end of your first PDSA cycle. Then you repeat, starting with step one, until you achieve your desired goal. Learn more at the Target Center’s Quality Academy.

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Ryan White table of services by provider and funding stream – Hennepin County contracts

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