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Assessment / Evaluation

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2004 - 2006 Comprehensive HIV Service Plan for the Sacramento EMA

Body

The Sacramento EMA HIV/AIDS Comprehensive Care Plan (Plan) presents a road map of the EMA’s response to the HIV/AIDS epidemic. It focuses on describing the journey made by the HIV Health Services Planning Council (Council) to address the epidemic, while presenting future routes anticipated in its mission of decreasing HIV/AIDS mortality and morbidity, improving the quality and availability of comprehensive HIV/AIDS-related services to needy individuals and families, collaborating with other HIV/AIDS services organizations to assess and identify emerging HIV/AIDS services delivery needs, and facilitating a coordinated and community-based viable regional voice for HIV-impacted populations.  A needs assessment that included a generalizable survey of PLWH/A plus focus groups, key informant interviews, and analysis of secondary epidemiological data informed the Comprehensive Plan.  An innovative use of templates shows the same indicators for each service and facilitates comparison of service needs.  The PowerPoint presentation of the Comprehensive Plan is shown below.  Links to the Executive Summary and full report are above the PowerPoint presentation.

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Sacramento EMA
2004 - 2006 COMPREHENSIVE HIV SERVICES PLAN
Prepared for
The Sacramento HIV Health Services Planning Council
August 2003
Submitted by:
Partnership for Community Health, Inc. 245 West 29th Street Suite 1202 New York, NY 10001
Project Team: Dr. Mitchell Cohen, Ms. Lucia Orellana, Ms. Irene Hung, and Ms. Carol Maytum Primary Contact: Mitchell Cohen, Ph.D. Executive Director Partnership for Community Health Telephone: 212.564.9790 X 26 Fax: 212.564.9781 Email: PCH@pchealth.org
© Sacramento EMA, August 2003
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TABLE OF CONTENTS ACKNOWLEDGEMENTS...........................................................................................................................i INTRODUCTION..................................................................................................................................... 1-1 Purpose of the Plan............................................................................................................................... 1-2 WHERE ARE WE NOW?........................................................................................................................ 1-3 HIV CONTINUUM OF SERVICES (HCS) IN THE SACRAMENTO EMA ..................................... 1-3 Goals of a HIV Continuum of Services (HCS) .................................................................................... 1-3 Objectives for a HCS ........................................................................................................................... 1-4 Process Outcomes of a HCS................................................................................................................. 1-5 Graphic Description of HIV Continuum of Services ........................................................................... 1-5 DEMOGRAPHICS PROFILE OF THE SACRAMENTO EMA ......................................................... 1-8 Regional Planning ................................................................................................................................ 1-8 HIV AND AIDS EPIDEMIOLOGICAL PROFILE & TRENDS......................................................... 1-9 Detailed Demographic Description .................................................................................................... 1-10 Progression from HIV to AIDS.......................................................................................................... 1-11 New AIDS Cases by District....................................................................................................... 1-12 New AIDS Cases by Ethnic Populations .................................................................................... 1-13 New AIDS Cases by Risk Group ................................................................................................ 1-13 Persons Living With HIV and AIDS.................................................................................................. 1-14 Gender......................................................................................................................................... 1-14 Ethnicity/Race and Mode of Transmission ................................................................................. 1-16 Age Distribution.......................................................................................................................... 1-17 Relationships............................................................................................................................... 1-18 Income ........................................................................................................................................ 1-18 Employment Status ..................................................................................................................... 1-19 OUT-OF-CARE....................................................................................................................................... 1-21 Estimated Number and Profile of Out-of-Care .................................................................................. 1-21 STAGE OF INFECTION AND OPPORTUNISTIC INFECTIONS.................................................. 1-22 ACCESS TO HEALTH CARE .............................................................................................................. 1-23 Where PLWH/A Go For Medical Care .............................................................................................. 1-23 Insurance Coverage............................................................................................................................ 1-25 Non-Insured ................................................................................................................................ 1-25 Insurance Profile ......................................................................................................................... 1-25 Non-insurance Entitlements and Benefits .......................................................................................... 1-27 VA and Public Health Services................................................................................................... 1-27 Drug Reimbursement .................................................................................................................. 1-27 Other Benefits ............................................................................................................................. 1-27 Disability..................................................................................................................................... 1-27 Supplementary Income ............................................................................................................... 1-28 OUTCOMES OF CARE SYSTEM ....................................................................................................... 1-30 Mortality............................................................................................................................................. 1-30 Physical And Emotional Health ......................................................................................................... 1-31 MEDICATION AND ADHERENCE .................................................................................................... 1-34 CO-MORBIDITIES ................................................................................................................................ 1-36 Homelessness ..................................................................................................................................... 1-36 Substance Use .................................................................................................................................... 1-37 STDs .................................................................................................................................................. 1-38 Mental Illness..................................................................................................................................... 1-38 RESOURCES FOR SERVICES ............................................................................................................ 1-40 Funding Sources for HIV/AIDS Services .......................................................................................... 1-40 History of Ryan White Funding ......................................................................................................... 1-42 Priorities and Allocations ................................................................................................................... 1-44 Allocations ......................................................................................................................................... 1-45
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Other Sources of Funding .................................................................................................................. 1-51 NEEDS, UNMET NEEDS, GAPS.......................................................................................................... 1-52 2003 Needs Assessment Methodology............................................................................................... 1-52 Consumer Survey........................................................................................................................ 1-52 Sample Design ............................................................................................................................ 1-53 Survey Analysis .......................................................................................................................... 1-53 Focus Groups and Key Informant Interviews ............................................................................. 1-54 Qualitative Analysis.................................................................................................................... 1-54 Service Categorization ................................................................................................................ 1-55 Top Needs: Council and PLWH/A..................................................................................................... 1-56 Service Demand and Utilization ........................................................................................................ 1-59 Service Gaps ...................................................................................................................................... 1-59 BARRIERS .............................................................................................................................................. 1-62 Existence of a Barrier......................................................................................................................... 1-62 Severity of a Problem......................................................................................................................... 1-63 SERVICE AND BARRIER TEMPLATES........................................................................................... 1-65 Outpatient Medical Care .................................................................................................................... 1-67 Medical Specialist .............................................................................................................................. 1-68 Complementary Care ......................................................................................................................... 1-69 Housing Information .......................................................................................................................... 1-70 Rental Assistance ............................................................................................................................... 1-71 Supportive Housing............................................................................................................................ 1-72 Case Management .............................................................................................................................. 1-73 Benefits Counseling ........................................................................................................................... 1-74 Intake Session .................................................................................................................................... 1-75 Vocational Referrals........................................................................................................................... 1-76 Food bank........................................................................................................................................... 1-77 Food vouchers .................................................................................................................................... 1-78 Delivered meals.................................................................................................................................. 1-79 Nutrition Supplement ......................................................................................................................... 1-80 Mental Health One on One................................................................................................................. 1-81 Family Counseling ............................................................................................................................. 1-82 Bereavement counseling .................................................................................................................... 1-83 Dental Care ........................................................................................................................................ 1-84 Substance abuse counseling ............................................................................................................... 1-85 Substance abuse assessment............................................................................................................... 1-86 Substance abuse one-on-one counseling ............................................................................................ 1-87 Substance Abuse Group ..................................................................................................................... 1-88 Substance abuse family counseling.................................................................................................... 1-89 Substance Abuse peer group .............................................................................................................. 1-90 Medication Reimbursement ............................................................................................................... 1-91 Residential Hospice Care ................................................................................................................... 1-92 Substance abuse services- Residential ............................................................................................... 1-93 Transportation .................................................................................................................................... 1-94 Taxi vouchers..................................................................................................................................... 1-95 Financial Assistance........................................................................................................................... 1-96 Child care services ............................................................................................................................. 1-97 Mental Health Group.......................................................................................................................... 1-98 Peer Counseling ................................................................................................................................. 1-99 Adherence Support........................................................................................................................... 1-100 Nutrition Counseling........................................................................................................................ 1-101 Home Health Care............................................................................................................................ 1-102 Insurance Assistance ........................................................................................................................ 1-103 Buddy emotional support ................................................................................................................. 1-104
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Buddy household tasks..................................................................................................................... 1-105 Buddy advocate................................................................................................................................ 1-106 Respite Services ............................................................................................................................... 1-107 Client Advocacy............................................................................................................................... 1-108 WHERE ARE WE GOING?.................................................................................................................... 2-1 SHARED VISION, AND VALUES FOR A CONTINUUM OF CARE FOR PLWH/A..................... 2-1 Vision ................................................................................................................................................... 2-1 Values .................................................................................................................................................. 2-1 CORE STRENGTHS AND WEAKNESSES .......................................................................................... 2-2 GOALS AND OBJECTIVES ................................................................................................................... 2-3 System-Wide........................................................................................................................................ 2-3 Core Services ....................................................................................................................................... 2-6 Primary Care ................................................................................................................................. 2-6 Oral Health.................................................................................................................................... 2-7 Substance Abuse Services – Residential....................................................................................... 2-8 Substance Abuse Services – Outpatient ........................................................................................ 2-8 Mental Heath................................................................................................................................. 2-9 Hospice Services ........................................................................................................................... 2-9 Primary Linking and Access Services.................................................................................................. 2-9 Case Management ......................................................................................................................... 2-9 Transportation ............................................................................................................................. 2-10 Insurance Continuation ............................................................................................................... 2-10 Support Services................................................................................................................................. 2-10 Emergency Financial Assistance................................................................................................. 2-10 Housing....................................................................................................................................... 2-11 Food ............................................................................................................................................ 2-11 Child Care ................................................................................................................................... 2-11 Psychosocial Support Services.................................................................................................... 2-11 Complementary Care .................................................................................................................. 2-12 Services to Providers.......................................................................................................................... 2-12 Program Administration Assessment and Evaluation ........................................................................ 2-13 Timeline ............................................................................................................................................. 2-14 HOW WILL WE MONITOR OUR PROGRESS AND RESULTS ..................................................... 3-1 System-Wide........................................................................................................................................ 3-1 Core Services ....................................................................................................................................... 3-3 Primary Care ................................................................................................................................. 3-3 Oral Health.................................................................................................................................... 3-5 Substance Abuse Services – Residential....................................................................................... 3-6 Substance Abuse Services – Outpatient ........................................................................................ 3-6 Mental Heath................................................................................................................................. 3-7 Hospice Services ........................................................................................................................... 3-7 Primary Linking and Access Services.................................................................................................. 3-8 Case Management ......................................................................................................................... 3-8 Transportation ............................................................................................................................... 3-8 Insurance Continuation ................................................................................................................. 3-9 Support Services................................................................................................................................... 3-9 Emergency Financial Assistance................................................................................................... 3-9 Housing......................................................................................................................................... 3-9 Food ............................................................................................................................................ 3-10 Child Care ................................................................................................................................... 3-10 Psychosocial Support Services.................................................................................................... 3-10 Complementary Care .................................................................................................................. 3-11 Services to Providers.......................................................................................................................... 3-11 Program Administration Assessment and Evaluation ........................................................................ 3-12
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ATTACHMENTS...................................................................................................................................... 4-1
TABLES Table 1-1 Objectives and Outcomes for HCS .................................................................................................... 1-4 Table 1-2 Demographic Profile .......................................................................................................................... 1-8 Table 1-3 Demos of General Population, PLWA and PLWH .......................................................................... 1-10 Table 1-4 Demographic Analysis (N=383)* .................................................................................................... 1-11 Table 5 2004-05 Priorities ................................................................................................................................ 1-44 Table 6 Priorities and Allocation - Projected 2004-05 ..................................................................................... 1-46 Table 1-7 Analysis Populations........................................................................................................................ 1-54 Table 1-8 Service Categories 2003 Priorities ................................................................................................... 1-55 Table 1-9 Types of Barriers.............................................................................................................................. 1-64 Table 2-1 Goals and Objectives- Who & When ................................................................................................. 2-3 Table 2-2 Timeline ........................................................................................................................................... 2-14 Table 3-1 Goal and Objectives - How & Indicators ........................................................................................... 3-1 FIGURES Figure 1-1 HIV Continuum of Services.............................................................................................................. 1-7 Figure 1-2 EMA Plus Sacramento Regional Districts ........................................................................................ 1-9 Figure 1-3 AIDS Cases by Year of Diagnosis by County ................................................................................ 1-12 Figure 1-4 AIDS Cases by Year of Diagnosis by District ................................................................................ 1-12 Figure 1-5 New AIDS Cases by Year of Diagnosis by Race ........................................................................... 1-13 Figure 1-6 AIDS Cases by Year of Diagnosis by Risk Group ......................................................................... 1-14 Figure 1-7 Gender by Ethnicity* ...................................................................................................................... 1-15 Figure 1-8 Gender by Mode and Stage of Infection* ....................................................................................... 1-16 Figure 1-9 Ethnicity by Mode of Transmission................................................................................................ 1-17 Figure 1-10 Age by Mode and Stage of Infection ............................................................................................ 1-17 Figure 1-11 Income by Gender and Mode........................................................................................................ 1-19 Figure 1-12 Income by Ethnicity...................................................................................................................... 1-19 Figure 1-13 Employment Status by Gender and Mode .................................................................................... 1-20 Figure 1-14 Employment Status by Ethnicity .................................................................................................. 1-20 Figure 1-15 Opportunistic Infections ............................................................................................................... 1-22 Figure 1-16 Medical Care Sites ........................................................................................................................ 1-24 Figure 1-17 Insurance Coverage – Gender and Exposure Category................................................................. 1-26 Figure 1-18 Insurance Coverage – Ethnicity and Stage of Disease.................................................................. 1-26 Figure 1-19 Supplemental Income – Gender and Exposure Category.............................................................. 1-28 Figure 1-20 Supplemental Income-- Ethnicity and Stage of Disease ............................................................... 1-29 Figure 1-21 HIV/AIDS Deaths by Ethnicity per 100,000 of Sacramento County Population ......................... 1-30 Figure 1-22 % Fatality Rate - Deceased by Year of Diagnosis ........................................................................ 1-31 Figure 1-23 Quality of Life – Physical Health ................................................................................................. 1-33 Figure 1-24 Quality of Life – Emotional Health .............................................................................................. 1-33 Figure 1-25 Medication by Stage of Infection.................................................................................................. 1-34 Figure 1-26 PLWH/A Who’ve Skipped Their Medications ............................................................................. 1-35 Figure 1-27 Reasons for Skipping or Stopping Medications by Gender and Ethnicity.................................... 1-35 Figure 1-28 Currently & History of Homelessness or Transitional Housing ................................................... 1-36 Figure 1-29 Substance Use Among PLWH/A*................................................................................................ 1-37 Figure 1-30 Distribution of $38.4 Million HIV/AIDS Funding – 2003 ........................................................... 1-40 Figure 1-31 Distribution of Funds in the HIV/AIDS Continuum of Services .................................................. 1-41 Figure 1-32 Ryan White Title I Allocations ..................................................................................................... 1-43 Figure 1-33 Ranked Service Needs .................................................................................................................. 1-58 Figure 1-34 Service Gaps* ............................................................................................................................... 1-61
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Abbreviations ADAP API ASO CDC Council EMA HARS HET HHSPC HRSA IDU LAC MSM NAC OI PAC PAG PCH PLWH/A RWCA SAPA SEMAS SSC STD TB TG VA Youth
AIDS Drug Assistance Program Asian / Pacific Islander AIDS Service Organization Center for Disease Control Ryan White Title I Planning Council Eligible Metropolitan Area HIV/AIDS Reporting System Heterosexual HIV Health Services Planning Council Health Resources and Services Administration Injecting drug user Los Angeles County Men-who-have-sex-with-men Needs Assessment Committee of the Council Opportunistic infection Priorities and Allocation Committee of the Council Planning Advisory Group Partnership for Community Health Person living w/ HIV/AIDS Ryan White Care Act Sacramento Alliance to Prevent AIDS Sacramento County Department of Health and. Human Services database Service Standards Committee of the Council Sexually transmitted disease Tuberculosis Transgender Veteran’s Assistance PLWH/A 24-years of age or younger
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ACKNOWLEDGEMENTS The 2003 Sacramento Eligible Metropolitan Area (EMA) HIV Care Comprehensive Plan was a collaborative effort among researchers, service providers, government officials, public health departments, consumers of services, and community members. This broad partnership has created a Comprehensive Plan with the input of many key players who provide and receive HIV/AIDS Care. The Partnership for Community Health (PCH) coordinated this effort, and we wish to acknowledge the many individuals, organizations, and institutions who assisted in the design, recruitment, execution, coordination, data analysis and writing of this Comprehensive Plan. Foremost, PCH would like to thank the nearly 400 PLWH/A who participated in the survey and focus groups and the many service providers and key informants who participated in the recruitment efforts and planning meetings. They were generous in their time and candid in their responses. The Plan presented in this report is their collective voices about their service needs, barriers and gaps, and about the future direction of HIV/AIDS care services in Sacramento. A special thanks to Alan Lange and Kay Merrill of the Community Services Planning Council. Alan coordinated our activities and meetings and the Council was generous in providing a desk and computer connection. Several persons at the Grantee, the County Department of Health and Human Services assisted us. Adrienne Rogers was an active participant in meetings and provided us access to the SEMAS database. She provided much of the raw data for the financial analysis and was helpful throughout the process. Alix Gillam, the epidemiologist at the Department of Health and Human Services assisted us in compiling the latest epidemiological data. Robert Nelson gave us excellent feedback throughout the process. Providers and Council members helped PCH access PLWH/A. Marty Keale, Peter Feeley, Jeff Cowen, Lisa Ashley, John Rambo and Lynn Zender, Kane Ortega, Katana Barnes, Ola Adams-Best, Alan Lange, Lisa DaValle, Julie Gallelo, Bill Puryear, and Craig Spatola were particularly helpful. Without the assistance of our Sacramento staff we would not have been able to organize the recruitment of the participants in the survey or focus groups. Ms. Carol Maytum provided coordination and assisted in the financial analysis. For recruitment of Non-CARES clients, Lynell Clancy and Monica Bernardo overcame significant obstacles in recruiting participants. At CARES, Socorro Padilla and Jesse Davis helped recruit participants. A special thanks to the individuals trained to conduct the survey in the field. Their enthusiastic participation and commitment to the many communities they represented made it possible to implement a complex survey instrument to a large number of people in a short period of time.
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We would like to thank Hugh Miller and Magda Cooling of Opinions, a professional focus group facility, who gave us a significant discount that enabled us to use their excellent facility. Their staff treated all participants with respect and was helpful in the logistics.
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INTRODUCTION The Sacramento EMA HIV/AIDS Comprehensive Care Plan (Plan) presents a road map of the EMA’s response to the HIV/AIDS epidemic. It focuses on describing the journey made by the HIV Health Services Planning Council (Council) to address the epidemic, while presenting future routes anticipated in its mission of decreasing HIV/AIDS mortality and morbidity, improving the quality and availability of comprehensive HIV/AIDS-related services to needy individuals and families, collaborating with other HIV/AIDS services organizations to assess and identify emerging HIV/AIDS services delivery needs, and facilitating a coordinated and community-based viable regional voice for HIV-impacted populations. The first section addresses the question of “where the epidemic is now”. It reviews the history of the HIV/AIDS epidemic in the Sacramento EMA while reviewing and assessing the current HIV/AIDS service delivery system. This section: • Reviews the existing HIV/AIDS Continuum of Care in the Sacramento EMA and suggests a revised continuum that is more concurrent with current HRSA directives to prioritize unmet need and prevention for positives. • Profiles the emerging demographic and economic trends and income and poverty for each planning area as well as trends in new infections including suggested planning within the five supervisory districts in Sacramento County, plus El Dorado and Placer Counties. • Summarizes the epidemiology of the HIV/AIDS epidemic in the Sacramento EMA and describes the positive outcomes of the care system by looking at declining death rates and estimates of the PLWH/A including their demographic and geographic profile. The epidemiology focuses on people living with HIV/AIDS, as this will be the population that must be served by the continuum of HIV/AIDS care. • Suggests who is out-of-care and estimates unmet need. • Discusses stages of Infection and OIs. • Reviews access to health care for PLWH/A including different insurance and assistance programs, including private insurance, COBRA, health insurance risk pool, Veteran’s Administration Medical Center, SSDI, Medical, SSI, TANF, CHIP, ADAP, HOPWA, and the non-insured. • Shows the positive outcomes of the care system. • Highlights the current state of medication adherence. • Describes HIV within a larger fabric of community needs, and discusses how the comorbidities of STDs, substance abuse, psychiatric need, and homelessness intersect and affect the HIV/AIDS service needs of PLWH/A. • Reviews the resources for HIV/AIDS Care throughout the Continuum of HIV Services. Additionally it discusses the process of priorities and allocations. This looks at the service integration gap analysis and resources available. It also considers trends in funding and non-RWCA funding sources.
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Summarizes the needs, unmet needs, service gaps, barriers, and disparities to services confronting PLWH/A based on the 2003 needs assessment survey, focus groups and supporting data from a variety of empirical studies and economic analyses. The needs of different ethnic and risk group subpopulations are presented, highlighting the needs and barriers of the target populations and those out-of-care. Included in this section are templates for each service that summarizes data presented in the Needs Assessment and includes financial information. Proposes how Ryan White CARE Act funds can fill critical gaps in the continuum of care or be used to build bridges to existing services within its capacity that may meet complementary needs of PLWH/A while looking at the geographical location of service providers. Describes the perceived barriers to care reported by PLWH/A. Summarizes each care service in a “template” that is a one-page summary of the epidemiology, funding, and perceived need for the services and gap in obtaining it.
The second section addresses the question “where are we going?” It reviews the overall context of the plan by describing the shared vision and values for a continuum of care and services. It outlines core competencies and weaknesses of the care services system as well as delineates the HIV/AIDS service system’s primary goals and objectives for the next three years, creating a timeline of tasks and responsibilities. The third and final section discusses how the Council will monitor the progress and outcomes of the Comprehensive Care Plan. For each objective, mechanisms to monitor the process and measure outcomes will be detailed. Both quantitative and qualitative measures are discussed. As work continues on the Plan, the Council should continue the development of data sources and indicators. Where current data is reliable, benchmarks are noted. Where data is not available, data that is needed for benchmarks and subsequent measurements of progress are identified. Purpose of the Plan The Plan is both a reference document for information collected and analyzed in the needs assessment and priority and allocation process, and a roadmap for planners to use in maintaining and developing services for PLWH/A. For consumers it documents the continuum of care and presents their voice in assessing the services. Further, it provides a guide to where HIV care services are evolving. Finally it is plan for which the consumers can assess the Council’s success. It allows consumers to hold the Council accountable and provides measures by which they can monitor the Council’s progress. It is a “living document” in the sense that it must be periodically modified to reflect new trends in the epidemic and new initiatives and directives implemented by the Council. Ideally it will be a reference and reminder to Council members of services they plan to provide and it will be used to reference consumer feedback on their needs, barriers, and gaps in services.
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1. WHERE ARE WE NOW? HIV CONTINUUM OF SERVICES (HCS) IN THE SACRAMENTO EMA An HCS represents a comprehensive range of HIV prevention and care services accessed by individuals, partners, and groups. They facilitate adopting safer drug use and sexual behaviors, accessing prevention and care services and maintaining care services that stabilize and improve the physical and mental health status of PLWH/A. This continuum incorporates the vision for HIV prevention and care that is based on creating specifying different services to meet goals and establishing eligibility and standards for each service. The HCS identifies: • Clear goals multiple measurable outcomes for the system. • An agreed upon array of coordinated care services for PLWH/A based on consumer need. • Clear eligibility and standards for services that are easily understood. • Quantifiable outcomes that can be measured. The HCS presented is the outcome of community planning in the Sacramento EMA. It broadens the existing continuum that categorizes services into: 1) core services, 2) primary linking and access services, 3) support services, and 4) community capacity building services by integrating prevention and care and recognizing the importance of public support. Through eligibility and standards of care, services are prioritized by need. As noted in the Needs Assessment, need varies by the socio-economic and experience with the system. The HCS is flexible to assure that those in them ore mature epidemic can access required medical care, monitoring, and adherence support while those newly entering the HCS can obtain the case management and wrap around services necessary to improve access to services. Goals of a HIV Continuum of Services (HCS) The HCS specifies and shows the linkages between a full range of cost-effective prevention and care services aimed at improving general public knowledge and support of HIV prevention and targeted to those at-risk for becoming infected, those who are likely to spread HIV infection, and those infected who need care services. It ensures that all persons at-risk for HIV and living with HIV, regardless of race, gender, or income, are served by a system that provides a comprehensive continuum of services that limits transmission, stabilizes, and improves the health status of PLWH/A. It assures that services are: • Available throughout communities at-risk for HIV infection.Accessible to those eligible for services.Affordable to those eligible for services.Appropriate to the cultural norms of the community, the cognitive abilities of the recipients of services, and the specific needs of those new to the service system and those who are familiar with the system.Accountable to the funders and consumers of services.
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Objectives for a HCS The objectives of the continuum of care are shown in Table 1-1. Table 1-1 Objectives and Outcomes for HCS OBJECTIVES OUTCOME A. Increasing public 1. Public support for prevention services. awareness of the risk of 2. Individual assessment of risk for HIV infection. HIV infection B. Outreach to at-risk 1. Knowledge of serostatus. populations 2. Knowledge of related co-morbidities. 3. Increased safer behaviors (condom and needle use). 4. Lower rates of STDs and TB. 5. Understanding about abstinence from sex / drug use. C. Prevention services to HIV 1. Maintain negative status. 2. Adopt and maintain safer sex and needle use activities. 3. Lower rates of STDs and TB. 4. Understanding of abstinence from sex / drug use. D. Care and prevention 1. Increased percentage of PLWH/A receive and maintain services to PLWH/A primary care. 2. Decreased gap between need and utilization of support services related to seeking medical care. 3. Maintain and improve health status of PLWH/A. 4. Maintain and improve the physical and emotional health status of PLWH/A. 5. Increased use of primary care by those who are out-ofcare. 6. Improved adherence to drug regimens. 7. Increased LOA for linkages and increased number of referrals to appropriate services. 8. Increased adoption and maintenance of safer behaviors. E. Prevention and care 1. New and implemented protocols for family support services to partners where services. one or both are HIV 2. Increased partner notification. positive 3. Increased number of mutual commitments to safer sex and needle use strategies. F. Training and technical 1. Increased capacity to provide effective care and assistance services to prevention services. providers G. Assessment and evaluation 1. Accountability of funds and services to consumers and of services by grantee funders. 2. Improved client satisfaction and reduction of barriers to care and prevention services. A comprehensive system:
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1. Emphasizes linkages to non-Ryan White funded programs such as TB and STD prevention, family planning, and substance abuse treatment programs, veteran’s benefits, reimbursed insurance and private treatment and medication services, HIV counseling and testing, law enforcement services directed toward illegal substance use1, and faith-based efforts to provide outreach to those infected but do not know their status and prevention and care to PLWH/A. 2. Builds feedback into the system for accountability, including consumer satisfaction, quality control, and planning through assessments, evaluations, and needs assessments. 3. Uses scientific and research findings, best practices, and accepted medical protocols in specifying services. 4. Establishes a dynamic system where movement of persons from one service to another and from one “track” to another is clear. Consumers access services depending on their needs. Process Outcomes of a HCS The process outcomes for a comprehensive coordinated HCS include that services be: 1. Community-centered: At-risk communities must have input into defining their needs, assessing services, and modifying/changing services to meet their needs. This is achieved by assuring the: 1.1. Participation of at-risk communities in the planning process. 1.2. Feedback from at-risk communities through needs assessments and consumer satisfaction surveys and an accessible grievance procedure. 2. Proactive: The HIV Care Councils, State and local Prevention Planning Groups (Sacramento Alliance to Prevent AIDS), and providers must anticipate the changing needs of communities at-risk. The HCS has to be flexible to meet new needs. Epidemiological surveillance and needs assessments are used to highlight trends such as the growing rates of infection among women, heterosexuals, and communities of color, the increase in “unknown” risk factors, and the decreased mortality and morbidity reflecting the need to increase services to communities of color and reach PLWH/A who remain sexually active with effective prevention-for-positives programs. 3. Inclusive of all services: In order to determine gaps in services it includes care services funded through County, State, and other federal programs, privately funded programs and prevention funded through CDC and other sources. Graphic Description of HIV Continuum of Services Based on the objectives shown in Figure 1-1, the HCS might be visualized as a seven-track system that identifies those at-risk, identifies those infected, provides care and support services to PLWH/A, and assures that the services are of high quality and accountable to funders and consumers. As shown in Figure 1-1, the tracks are defined by their starting point
1 The mention of law-enforcement services is not an endorsement of current policies. Rather it notes the potential role of law enforcement in controlling illegal substance use and providing referrals to those in need of substance abuse and HIV/AIDS services.
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– the objective. This is shown in the black bar on top on each section in Figure 1-1. Each track has outcomes that are measurable and those are shown in the gray bars beneath the black bars. The services offered to achieve the outcomes are shown in the lightly shaded boxes in Figure 1-1. The tracks represent the general type of services, some of which are funded by Ryan White Care Act, CDC, other federal, State, local, private and other sources. For the services provided to PLWH/A the major funding sources are insurance, including Medicaid, Medicare, and private insurance. One of the difficulties in determining gaps in services is determining the existing capacity of the system outside of the Ryan White Care Act funded services. Five of the tracks are for consumers: 1) public, 2) high-risk populations, 3) HIV negative, 4) HIV positive, and 5) partners where one or both are HIV positive. Another track is for providers and shows services that support prevention and care providers. Last, there is a track targeted to the grantee, Council and Prevention Planning Group, who are responsible for assessment and evaluation of services. Each track has eligibility criteria and a desired outcome. For example, those eligible for tracks four and five must be HIV positive or partnered with someone HIV positive, and those eligible for track three have to be engaged in high-risk behaviors or be members of high-risk communities (e.g. MSM, IDUs, “party-drug” users, bath-house patrons, heterosexuals with IDU partners, sexually active heterosexual in high incidence areas, incarcerated, and recently released). As shown by the arrow, only those who know their HIV status (through counseling and testing) are eligible for tracks three through five. Because infection is spread by activities of partners, certain prevention services are directed to negative, positive, and discordant couples that allow them to negotiate safer practices with the outcome being a commitment to use safe practices. In order to assure that services are effectively implemented, providers should be trained to identify and develop individualized service plans and have the organizational skills to provide services. Consequently, there are infrastructure development and training services to increase provider capacity to provide services. Listed next to services in parenthesis is the corresponding ranking as decided by the Council for 2004-2005. Finally, in any effective HCS there is a feedback mechanism for assuring the system is selfadjusting and dynamic. This involves the assessment and evaluation of services to assure that prevention services are accountable and to modify services to better meet the needs of consumers.
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Figure 1-1 HIV Continuum of Services
Track 1: Increasing Public Awareness Of The Risk Of HIV Infection Outcomes 1. Public Support 2. Personal Risk Assessment Services Place Advertisements / PSAs in mass and small media, billboards, brochures, and leaflets. Write articles & editorials advocating HIV/AID prevention. Circulate newsletters. Conduct group educational intervention such as HIV/AIDS prevention curriculum, drama or theater presentation, and World AIDS day presentation. Have a hotline or other type of information exchange, etc. Organize rallies, public meetings, write-in campaigns. Use advocacy / educational volunteers or interns. Provide advocacy / educational training. Solicit financial support for HIV/AIDS prevention advocacy. ì Track 2: Outreach To At-Risk Populations Outcomes: 1) Knowledge of serostatus Services: Offer HIV Testing and Counseling 2) Knowledge of co3) Increased safer 4) Abstinence from sex and morbidities and lower rate behaviors drug use of STDs Health education and risk reduction through targeted group and community level interventions including schools, street outreach, house parties, health fairs, public sex venues such as parks or bath houses, bars, STD and health care clinics, etc. Conduct 1-1 contact with high –risk individual. Operate a mobile van. Harm Reduction. Distribute bleach kits. Distribute condom. Offer STD testing. Offer TB testing. Offer Substance Abuse treatment, detox, and methadone maintenance. Offer 12-step and other abstinence. Offer care at neonatal and other women’s clinics. Offer family planning to populations at high risk for HIV infection. Track 4: Care and Prevention Services to PLWH/A
ì Track 3: Prevention Services To HIVOutcomes: Track 5: Prevention And Care Services To Partners Where One Or Both Are HIV Positive 1) Maintain negative status 1) Maintain and improve health status 2) Linkages to, initiating, and maintaining health care 3) Commitment to safer behaviors 1) Obtain STD treatments and lower rates of STDs 2) Abstinence from sex/drug use 3) Adopt and maintain safer behaviors (condom and needle use) 4) Maintain or improve quality of life Offer HIV/AIDS re-test Offer 1-1- counseling / prevention case management. Provide adherence Develop partner agreements. programs. Partner notification Provide partner Monitor HIV status. negotiation. Offer 1-1- counseling / Partner counseling and referral. prevention case management. Work with criminal justice system. Provide skill-building workshops (Condom use, needle cleaning, partner negotiation). Conduct behavioral modification programs. Provide peer education / support. Circulate newsletters. Offer support groups. Care Services (for HIV+ and Partners only) * Number in Parenthesis is 2004-5 priority. ** Not ranked Core: Ambulatory medical, specialty, care & labs (1)* Dental care (3) Substance abuse (residential) (7) Substance abuse services (outpatient, counseling) (9) Mental health services (individual and group) (5) Hospice and residential care (PLWA) (12) Adherence counseling (Pediatric) (14) Home health care** Primary Linking and Access Services Case Management (2) Benefits Counseling Advocacy Transportation (voucher and trips) (8) Insurance continuation (15) Outreach** Support Services Emergency financial asst (4) Medical reimbursement / medication (non-ADAP) ADAP co-pay assistance Food vouchers, utility assistance, other critical need Housing (Emergency housing, referrals, long term housing) (6) Food bank/home delivered meals (10) Psycho-social support services / groups (11) Nutritional counseling (non-nutritionist) Peer counseling Complementary (acupuncture, chiropractic, massage) Child care (13)
Prevention Services:
Track 6 Services To Providers OUTCOMES: Increase capacity to provide effective services Services: Training. Infrastructure support. Program development. Newsletters. Track 7 Program Assessment & Evaluation OUTCOMES: 1 Accountability to consumers and funders 2. Improvement of services Program Monitoring. Needs Assessment. Consumer Satisfaction.
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DEMOGRAPHICS PROFILE OF THE SACRAMENTO EMA The Sacramento EMA, located in central California, includes Sacramento, El Dorado, and Placer counties and has a population of 1,699,868. The EMA has both urban and rural characteristics and is geographically, racially, and ethnically diverse with variations in each county. As shown in Table 1-2, the EMA is 64% Anglo, 14% Latino, 9% Asian Pacific Islander, 8% African American, and about 5% other ethnicities including Native Americans and mixed races. Sacramento County is the most ethnically diverse county within the EMA with 58% Anglos, 16% Latinos, 10% African Americans, and about 16% all other ethnicities combined. The ethnic profiles of Placer and El Dorado have very similar ethnic profiles with about 84% Anglo, 9% to 10% Latino and under 1% African American. Table 1-2 also shows that the gender distribution is very similar across the EMA, with the majority (51%) of the residents being female. Table 1-2 Demographic Profile
El Dorado County Percent Number 162,586 9.6% 81,456 81,130 138,036 813 15,120 8,617 50.1% 49.9% 84.9% 0.5% 9.3% 5.3% Placer County Number Percent 268,512 15.8% 136,673 131,839 223,939 2,148 26,046 16,379 50.9% 49.1% 83.4% 0.8% 9.7% 6.1% Sacramento County Number Percent 1,268,770 74.6% 648,341 620,429 733,349 126,877 203,003 205,541 51.1% 48.9% 57.8% 10.0% 16.0% 16.2% Total Number Percent 1,699,868 100.0% 866,470 833,398 1,095,324 129,838 244,169 230,537 51.0% 49.0% 64.4% 7.6% 14.4% 13.6%
Total Population Gender Female Male Ethnicity/Race Anglo/white African American Latinos Other
Regional Planning Sacramento County is divided into five districts. The Board of Supervisors is the governing body of the County of Sacramento and each of the five members of the Board represent one of five districts. In addition, the EMA includes Placer County to the North East and El Dorado County to the East. The Council has decided to use the five supervisory districts in Sacramento County plus El Dorado County and Placer County to geographically distinguish the needs of PLWH/A in the Sacramento EMA. A map of Sacramento County’s five supervisor districts and El Dorado and Placer Counties is shown in Figure 1-2. Creating and supporting accessible services to all PLWH/A is an integral part of the Commission’s mission and values. HIV/AIDS services tend to be centrally located in Sacramento County, where there about 90% of the people living with HIV/AIDS reside in the EMA. Still there are over 100 PLWA and probably over 100 persons living with HIV in the rural areas of Placer and El Dorado counties that require services.
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Figure 1-2 EMA Plus Sacramento Regional Districts
Placer
El Dorado
1 3 4
Sacramento
2 5
HIV AND AIDS EPIDEMIOLOGICAL PROFILE & TRENDS When planning for HIV and AIDS services, knowing the number of persons living with HIV and AIDS, and the number currently accessing services, provides a theoretical referent for the number of PLWH/A who could seek services in the continuum of care and the number who have sought services in the past. The HIV/AIDS Reporting System (HARS) documents 1,435 people living with AIDS as of December 2002, nearly a 20% increase since 1997. There were 180 new AIDS diagnoses in the last two years, or 12% of living AIDS cases. Ninety-one percent (91%) of living AIDS cases is in Sacramento, with about five percent (5%) in Placer and four percent (4%) in El Dorado. Table 1-3 shows PLWA are disproportionately male, African American, and MSM. • MSM represent 58% of living AIDS cases in the Sacramento EMA. • MSM/IDU account for a larger share of the epidemic in the EMA than in most other parts of the country. They account for 12% of living AIDS cases, and over 40% of all injection-related HIV cases in the EMA, compared to only 6% of national cases.
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People of color represent about 31% of all AIDS cases prior to 1990, but account for 53% of new cases diagnosed in 2002.
Figure 1-3 indicates that there is an estimated 3,422 people living with HIV and AIDS in the Sacramento EMA who know their HIV status. At the end of 2002, there were about 1,435 PLWA and an estimated 1,987 people living with HIV (not AIDS) in the EMA (Department of Public Health, 2003). An estimated 95 HIV cases are in Placer and 86 HIV cases in El Dorado County. A disproportionate number of HIV/AIDS cases are among African Americans. They comprise only 8% of the Sacramento EMA’s population, yet 22% of living AIDS cases, 29% of estimated HIV infections, and 27% of people newly diagnosed with AIDS. According to the SEMAS database, there are over 1,770 PLWH/A accessing CARE-funded services. People of color make up 39% of clients receiving Title I-funded services (in contrast to representing about 36% of all PLWH/A), women make up about 18%, and IDUs represent about 16% of the PLWH/A in care. MSM continue to be the vast majority of people living with HIV/AIDS and the community most affected by the epidemic in the EMA. MSM includes both those men who identify as gay or bisexual and those who reported male same sex transmission of HIV. Table 1-3 Demos of General Population, PLWA and PLWH
Population Gender** Race Male Female African American Anglo Asian/Pacific Islander Latino Other Risk Group*** MSM MSM/IDU IDU HET GENERAL POP* 1,699,868 49% 51% 8% 64% 9% 14% 5% NA NA NA NA PLWA 2002** 1,435 86% 14% 22% 63% 1% 12% 2% 58% 12% 15% 15% PLWH + 2002 1,987 80% 20% 29% 58% 1% 10% 2% 53% 17% 10% 20% TOTAL PLWH/A 3,422 82% 18% 26% 61% 1% 10% 2% 54% 11% 16% 18%
* Census Bureau, 2002 ** HARS + RWCA Title I Application, 2004-2005
Detailed Demographic Description Figure 1-4 provides a detailed demographic profile of PLWH/A living in the Sacramento EMA2, based on the weighted consumer survey sample of 383 PLWH/A. Below are some demographic highlights of PLWH/A:
2
The data was weighed back to Placer and El Dorado County populations and therefore is not generalizable to those counties.
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• • • • •
82% are males, 18% are females. Women represent a far greater proportion of African Americans living with HIV/AIDS than other ethnic populations. The majority of the PLWH/A are non-Latino Anglo (61%), followed by African Americans (26%), Latinos (10%), and other ethnicities, including Asian Pacific Islanders and Native Americans at about 3%. People of color as a group, including African Americans, Latinos, Native Americans, and Asian/Pacific Islanders, represent 39% of PLWH/A. Among Anglos, 93% are male, and 68% percent of them are MSM. Twenty-five percent (25%) report a history of IDU, and 8% are heterosexual. African Americans PLWH/A are 44% female and 42% report being heterosexual. Thirty-five percent (35%) report a history of IDU, and 29% report being MSM. Latinos have a profile similar to Anglos: Mostly male (88%), about a quarter (23%) with IDU history, and 16% heterosexual. PLWA represent 58% of the sample and PLWH account for 42% of the sample. This distribution is actually the opposite of the breakdown presented in the Title I application. Notably in this sample, Anglos (representing majority MSM) are much more likely to have progressed to AIDS. This could reflect the greater likelihood of survey participants, who are recruited through care services, of being in later stages of HIV infection.
Table 1-4 Demographic Analysis (N=383)*
TOTAL N Gender
Male Female Risk group MSM MSM/IDU IDU Hetero Stage of Infection HIV asymptomatic HIV symptomatic AIDS asymptomatic 23% 19% 18% 17% 16% 19% 34% 26% 17% 30% 20% 20% 17% 0% 7% 55% 11% 16% 18% 68% 15% 10% 8% 23% 6% 29% 42% 62% 6% 17% 16% 66% 4% 14% 16%
TOTAL 383*
82% 18%
Anglo 232
93% 7%
African Am 100
57% 44%
Latino 40
88% 12%
API /Other 10
78% 22%
AIDS symptomatic 40% 48% 22% 30% 76% *Weighted sample from the Needs Assessment Survey. The total count may not sum to 383 due to weighting and rounding effect.
Progression from HIV to AIDS Early treatment of HIV disease has greatly reduced the progression of HIV to AIDS, and this trend is important in planning for care because of the more limited reimbursement of medical services for PLWH, combined with the need for early treatment.
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In 1997, 192 persons were diagnosed with AIDS in the Sacramento EMA, while in 2002, less than a quarter of that amount, 45 persons were diagnosed, representing a decline of about 77%. Figure 1-3 shows that for the past six years over 90% of the new cases have been in Sacramento County. While El Dorado accounts for a much smaller proportion of the total population in the EMA than Placer, both counties have about the same number of cases each year. Figure 1-3 AIDS Cases by Year of Diagnosis by County
200 180 160 140 # of Cases 120 100 80 60 40 20 0 S a c ram e nto P la c e r E l D o ra d o T o ta l E M A 1997 184 4 4 192 1998 144 1 8 153 1999 132 8 6 146 2000 114 5 5 124 2001 92 4 6 102 2002 41 3 1 45
New AIDS Cases by District Figure 1-4 displays the decline in AIDS cases reported yearly in the five supervisor districts in Sacramento County. Consistently, since 1997, District 1 has accounted for the largest proportion of all PLWH/A, with an average of about 48% of the cases over the past six years, followed by District 2 with an average of about 18% of the newly diagnosed cases over the past six years. In District 1, 97 AIDS cases were diagnosed in 1997 and 14 in 2002. Districts 1 and 4 have had fastest decline in newly diagnosed AIDS cases since 1997. Figure 1-4 AIDS Cases by Year of Diagnosis by District
120 100
# of Cases
80 60 40 20 0 District 1 District 2 District 3 District 4 District 5 1997 97 23 26 16 15 1998 79 27 15 8 11 1999 63 20 17 11 15 2000 53 16 15 9 12 2001 36 15 13 11 12 2002 14 10 8 3 4
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New AIDS Cases by Ethnic Populations Figure 1-5 shows that there has been a consistent decline in newly diagnosed cases from 1997 to 2002 among all ethnic populations. Since 1997, the decline in AIDS rate has been between 73% and 80% among Latinos, Anglos, and African Americans. Yet, while African Americans have experienced the greatest decline in AIDS rate (80%), in 2002, the AIDS rate among African Americans (9 per 100,000) was more than double that of Latinos (4) and three times the rate among Anglos (3). The growing Latino and African American populations in Sacramento are disproportionately impacted by AIDS. While Latinos account for about 14% of the population they account for 16% of the newly diagnosed AIDS cases. Similarly, African Americans represent 8% of the Sacramento population, yet, they account for more than a quarter (27%) of the newly diagnosed cases in 2002. In terms of absolute numbers, Anglos are not disproportionately impacted by AIDS, yet, they will continue to contribute the largest number of AIDS cases over the next several years accounting for nearly 60% of the new cases in 2002. Therefore in planning services for the newly diagnosed, the most units of service have to be allocated for the Anglos living with HIV and AIDS. At the same time, the system must prepare for the growing number of African Americans living with HIV and AIDS. Figure 1-5 New AIDS Cases by Year of Diagnosis by Race
120 100 80 60 40 20 0 Af Am Anglo Latino Other
# of Cases
1997 52 111 22 7
1998 49 83 18 3
1999 36 82 20 8
2000 36 73 11 4
2001 28 54 17 3
2002 12 26 7 0
New AIDS Cases by Risk Group Figure 1-6 shows an unequal decline in diagnosed AIDS cases for risk groups. MSM (men having sex with men) show a significant decline in number of AIDS cases diagnosed yearly from 1997 through 2002. Still, in 2002, MSM account for 40% of the newly diagnosed cases.
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The rate of decline in newly diagnosed AIDS cases among MSM in Sacramento is different than what is observed in other EMAs and other parts of California. While the national rate of newly diagnosed cases among MSM has leveled off and in some cases even increased, incidence of AIDS among MSM in Sacramento continues to decline. Since 1997, MSM/IDU have shown the largest decline in newly diagnosed AIDS cases. Similarly, the rate of new cases among IDUs has declined. Overall, there appears to be a shift in new infections toward heterosexuals in the epidemic where by 2002, heterosexuals account for 31% of the newly diagnosed AIDS cases. Heterosexuals show a decrease in incidence of about 41% since 1997, compared to over an 80% decrease among IDUs, MSM, and MSM/IDUs. Figure 1-6 AIDS Cases by Year of Diagnosis by Risk Group
120 100 80 # of Cases 60 40 20 0 MSM MSM/IDU IDU Het Not Classified
1997 105 20 33 24 4
1998 77 13 22 33 7
1999 61 23 25 27 6
2000 62 16 21 17 7
2001 42 7 16 29 7
2002 18 2 6 14 4
Persons Living With HIV and AIDS While the most reliable data is for PLWA, planning for services is for all PLWH/A. Consequently, the following graphs detail the demographics of several specific subpopulations living with HIV and AIDS based on the needs assessment survey. Because respondents were largely sampled from providers funded through Ryan White Care, it will over-represent those with lower incomes and those without private insurance. Gender Figure 1-7 shows that women represent 18% of the PLWH/A sample, yet among ethnic groups, women make up the largest percentage of the African American population at 44% and the smallest percent of the Anglo population at 7%.
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Figure 1-8 further shows that women represent 68% of the heterosexuals, and 36% of the IDUs. As newcomers to the HIV epidemic, women are more likely to be HIV positive without an AIDS diagnosis. In general, women are about evenly distributed among the asymptomatic and symptomatic PLWH/A. However, as shown in Figure 1-8 women living with HIV are more likely to be asymptomatic (40%) than symptomatic (29%), but women living with AIDS are much more likely to be symptomatic (21%) than asymptomatic (11%). The detailed demographic analysis in the needs assessment further reveals: • Women are more likely than men to postpone seeing a doctor after receiving their initial HIV diagnosis. Twenty percent (20%) of women have waited at least seven months to see a doctor compared to 15% of men. • Women (35%) are more likely than men (27%) to have lived with HIV less than six years. Less than one third of women have lived with HIV 12 years or more compared to over 41% of men. • Women are much less likely to live alone than men and are more likely to consider their home safe, habitable, and stable. • Women have a higher history of homelessness than men, with over 25% having lived in a homeless shelter over the last two years and almost 40% report having lived in the street or in a car. • Considering the high incidence of homelessness among women living with HIV/AIDS in Sacramento it is surprising that a lower percentage of women have been diagnosed with depression and anxiety than men. This may reflect their greater access to mental health therapy than men. For instance, 28% of women have received group counseling compared to 13% of men. Women are also far more likely than men to have received peer counseling, family counseling, and bereavement counseling. Figure 1-7 Gender by Ethnicity*
100% 80%
% of PLWH/A
60% 40% 20% 0% TOTAL Male Female 82.3% 17.7% Anglo 92.8% 7.2% African Am 56.4% 43.6%
Latino 87.7% 12.3%
Other 77.6% 22.4%
*Based on weighted sample.
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Figure 1-8 Gender by Mode and Stage of Infection*
100%
% of PLWH/A
80% 60% 40% 20% 0% Male Female IDU 64.1% 35.9% Hetero 32.3% 67.7% HIV 61.5% 38.5% HIV 63.6% 35.1% AIDS 81.5% 18.5% AIDS 80.9% 17.6%
*Based on weighted sample
Ethnicity/Race and Mode of Transmission Figure 1-9 shows the overall profile of PLWH/A in Sacramento. It is divided by race and risk group. For example, the first bar shows that in of all PLWH/A in Sacramento, 41% are MSM. Figure 1-9 indicates that: • Anglo MSM (41%) represent the largest number of PLWH/A, followed by African American heterosexuals (11%), and Anglo MSM/IDU (9%). • IDUs represent 16% of all PLWH/A and are distributed among African Americans (8%), Anglos (6%), and Latino (2%). The majority of MSM/IDU are Anglo (9%), while the majority of IDUs are African American (8%). • Heterosexuals represent 18% of all PLWH/A. They are mostly African Americans (11%), with about 5% Anglos, and 2% Latinos and other ethnicities. • MSM represents the largest proportion of PLWH/A in all ethnic groups, except among the African Americans. MSM represents over 60% of Anglos and Latinos living with HIV/AIDS, but they represent less than a quarter of the PLWH/A among African Americans. • African Americans show the widest distribution in exposure categories. 42% of African Americans report being heterosexual, 29% IDU, 23% MSM, and about six percent (6%) are MSM/IDU. • • Needs assessment data also reveals that: In nearly every ethnic group, the largest proportion of women report heterosexual exposure. Within the Anglos, 71% of women report heterosexual contact, the highest of all ethnic groups. Latinas report the largest IDU exposure with more than 38% reporting IDU as their mode of transmission.

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Figure 1-9 Ethnicity by Mode of Transmission
100% 80% 60% 40% 20% 0% MSM MSMIDU IDU Hetero Anglo 41.0% 8.9% 6.1% 4.7% African Am 6.1% 1.6% 7.5% 11.0% Latino 6.4% 0.6% 1.8% 1.6% API and other 1.7% 0.1% 0.3% 0.4%
Age Distribution The average age of PLWH/A who participated in the survey is 43 years. Four percent (4%) are under 30, 84% are between 30 and 50, and 13% are over 50.3 Latinos and African Americans are slightly younger, indicating their later entry into the epidemic. In the SEMAS database, about 7% of PLWH/A are between 18 and 30. Figure 1-10 shows the average age by mode and stage of HIV infection. The data indicates: • Amongst risk groups, IDUs are the oldest, averaging 45 years of age. • Reflecting the progression of HIV to AIDS, PLWA are older than those living with HIV. Figure 1-10 Age by Mode and Stage of Infection
50
% of PLWH/A
40
Age in Years
30
20
10
0 TOTAL Average age 42.5 MSM 42.1 MSMIDU 42.2 IDU 44.6 Hetero 42.2
HIV asymp 41.9
HIV symp 41.1
AIDS asymp 41.0
AIDS symp 43.8
3 Based on the epidemiology of PLWA at the end of 2002, the sample is slightly younger but, since it includes PLWH, it is likely to approximate the population. Using that same estimate, approximately 95 cases would be found in Placer and 86 cases in El Dorado. Therefore, there would be approximately 2,162 estimated cases of PLWH in the Sacramento EMA.
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Relationships In determining the care needs of PLWH/A, the support system of a PLWH/A can play a significant role in providing their care, or if other family members are HIV positive, can indicate situations where additional care is needed. PLWH/A who are married or living with partners often have a caregiver, but may also have larger financial needs if the partner is not working or disabled. PLWH/A with families also have particular needs, including day care and services for children when seeking care. • 11% PLWH/A reported living with children in the same household. African Americans (25%) are more likely than Latinos (19%) and Anglos (5%) to live with children. • 35% of PLWH/A report living alone. Men are more likely (39%) to live alone than women (19%). Sixteen percent (16%) of PLWH/A live with an HIV positive partner. Income In order to receive Ryan White and state supported benefits, the current HIV/AIDS care system has income restrictions depending on the service provided. For instance, in order to qualify for the AIDS Drug Assistance Program (ADAP) or other state-funded medication reimbursement programs, PLWH/A are eligible if they don’t surpass 400% of the Federal poverty levels (between $33,000 and $34,000 a year for a single person). The sample drawn from Ryan White funded providers is likely to over-represent persons living at or near the poverty level. Still, only 2% of the sample report making over $35,000, making the vast majority eligible for Ryan White care services including ADAP. Figure 1-11 shows income levels by gender and mode. It indicates that: • In general, those participating in the survey have low incomes, with about 87% reporting earning less than $16,500 and approximately 48% reporting earning less than $8,600. • Women report significantly lower income than men. Seventy-two percent (72%) of women report an annual income of $8,600 or less. • Among risk groups, the vast majority of IDUs (98%) and heterosexuals (96%) have incomes of $16,500 or less per year. MSM have the highest income with 18% making more than $16,500 followed by MSM/IDU (16%). While MSM living with HIV/AIDS are at every income level, heterosexuals and IDUs tend to be very poor or have incomes above $16,500. However, even among MSM and MSM/IDU, less than 4% report earning more then $35,000 – the usual limit to qualify for ADAP. Figure 1-12 shows income by ethnicity. This graphic indicates that: • Over half the Latinos and African Americans report earning $8,600 per year or less. • Anglos report the highest income of any group, with 17% earning $16,500 or more per year. Needs assessment data further indicates that:
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Over 80% of the homeless and recently incarcerated report earning less than $11,600 a year with over 60% report earning less than $8,600 a year. PLWH report the lowest income, suggesting that the newly infected are from the lowest socio-economic brackets, and are coming into the epidemic with a high level of need of social and medical services.
Figure 1-11 Income by Gender and Mode
100% 80%
% of PLWH/A
60% 40% 20% 0%
Total 3.5% 0.9% 8.5% 12.3% 26.2% 48.6%
Male 4.0% 0.8% 9.9% 13.5% 28.0% 43.7%
Female 1.3% 1.3% 2.0% 6.3% 17.5% 71.6%
MSM 5.0% 0.2% 13.1% 16.3% 28.9% 36.5%
MSMIDU 3.2% 4.8% 8.0% 7.6% 23.2% 53.2%
IDU 1.4% 0.0% 0.9% 8.3% 25.2% 64.2%
Hetero 1.3% 1.3% 1.1% 6.2% 20.6% 69.5%
Greater than $26,001 $23,201 - $26,000 $16,501 - $23,200 $11,601 - $16,500 $8,601 - $11,600 $8,600 or less
Figure 1-12 Income by Ethnicity
100% 80%
% of PLWH/A
60% 40% 20% 0%
TOTAL 3.5% 0.9% 8.5% 12.3% 26.2% 48.6%
Anglo 4.7% 1.3% 10.7% 14.4% 29.5% 39.4%
African Am 0.9% 0.5% 2.6% 9.9% 20.4% 65.7%
Latino 4.3% 0.0% 6.4% 6.9% 24.7% 57.7%
API and other 0.0% 0.0% 26.7% 7.5% 10.7% 55.1%
Greater than $26,001 $23,201 - $26,000 $16,501 - $23,200 $11,601 - $16,500 $8,601 - $11,600 $8,600 or less
Employment Status Figure 1-13 and Figure 1-14 shows employment status by gender and mode and by ethnicity. The figures show the following: • The majority of PLWH/A are not currently working (89%). Seventeen percent (17%) of those not working are actively looking for work, 7% are students or homemakers, 6% are
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• •
retired, and 59% are not looking for work. About 10% are either employed part- or fulltime. Men and women are equally likely to not be working, however, more women (20%) report looking for work than men (17%), and slightly more women are employed full time (7.3%) compared to men (5.6%). Among risk groups, MSM/IDU have the highest percent of persons employed full-time (9%), followed by heterosexuals (7%), MSM and IDUs at 5%. Among ethnic populations, Latinos have the highest percent of PLWH/A who are currently employed full-time at 11%. More Latinos (23%) and African Americans (21%) report looking for work than any other ethnic group.
100% 80%
% of PLWH/A
Figure 1-13 Employment Status by Gender and Mode
60% 40% 20% 0%
Total 5.8% 58.8% 7.4% 17.2% 3.8% 5.9%
Male 6.5% 58.2% 7.5% 16.6% 4.1% 5.6%
Female 2.4% 61.5% 6.8% 19.7% 2.2% 7.3%
MSM 7.4% 58.4% 8.4% 15.6% 3.3% 5.4%
MSMIDU 4.8% 59.2% 5.6% 20.0% 1.3% 8.8%
IDU 4.4% 61.3% 10.9% 13.8% 5.2% 4.5%
Hetero 2.5% 57.3% 2.2% 23.4% 5.7% 6.7%
Retired Not w orking/not looking for w ork Not w orking - student/ homemaker Not w orking/looking for w ork Employed part-time Employed full-time
Figure 1-14 Employment Status by Ethnicity
100% 80%
% of PLWH/A
60% 40% 20% 0%
Total 5.8% 58.8% 7.4% 17.2% 3.8% 5.9%
Anglo 7.0% 62.5% 6.7% 15.4% 1.7% 4.7%
African Am 5.9% 55.3% 6.6% 20.7% 5.1% 6.5%
Latino 0.0% 41.9% 14.7% 22.7% 9.8% 10.9%
API and other 0.0% 74.1% 0.0% 0.0% 15.6% 8.8%
Retired Not w orking/not looking for w ork Not w orking - student/ homemaker Not w orking/looking for w ork Employed part-time Employed full-time
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OUT-OF-CARE HRSA and CDC have placed emphasis on identifying those with unmet need (those out-ofcare) and bringing them into medical services. For planning, it is helpful to know the number of PLWH/A who are out-of-care and, if the system is successful in identifying them and brining them into care, the impact on the needed services and capacity of the continuum of care. Estimated Number and Profile of Out-of-Care When talking about out-of-care it is useful to divide the populations into three segments: • A pattern of starting care after a period of delay and continuing care, • Those who have started care and stopped, and • Those who have an inconsistent pattern of starting and stopping care. Earlier it was noted that there are an estimated 3,422 PLWH/A who know their status in the Sacramento EMA and they would be the individuals that have a possibility of seeking AIDS services. The SEMAS system shows about 1,770 clients receive services funded by Ryan White Care. For all services that would suggest that about half of PLWH/A who know their status and have an income of 300% of the federal poverty level are not receiving Ryan White funded services (although they may be accessing services through other sources). Using the recommended CDC estimate that 25% of all those infected don’t know their status, there would be an estimated 4,600 PLWH/A in the EMA. Based on the estimate that 96% of the PLWH/A accessing Ryan White Care services are at or below 300% poverty level, nearly 4,400 would be eligible for Ryan White funded services, and as outreach expands to reach those out of service, the system will have to accommodate new clients in the care system. Given the number of men who are infected, there are more men and MSM out-of-care. However, women are disproportionately represented among delayed care seekers. Proportionately, African Americans are much more likely to delay care, access care inconsistently, and stop care. Delayed care seeking is related to education, and the data indicate that those with less education are more likely to name lack of knowledge as a barrier to seeking care. Low literacy and Spanish language campaigns to inform person about where and when to seek care could make a significant impact. Delayed care seekers and those out-of-care are much more likely to have been recently incarcerated, and there is ample evidence to show that care in jails is not adequate. Those currently out of care are much more likely to say that reasons for not going to care is some problem with a provider and a feeling that there are few alternatives. Where there are few alternatives for where to access care, providers need to assure that there is an accessible grievance procedure.
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Those unconnected to care name structural problems with getting into the system as greater barriers, and it is clear from the data that basic home and food needs trump HIV/AIDS care services as necessities. STAGE OF INFECTION AND OPPORTUNISTIC INFECTIONS Based on the Table 1-3, 41% of the PLWH/A have been diagnosed with AIDS and 58% have HIV and have not progressed to AIDS. (Notably, a majority of the sample of PLWH/A used in the needs assessment survey report having AIDS, suggesting a slight over-representation of those at more advanced HIV disease.) Based on the survey data, using accepted medical criteria, it is estimated that 68% of PLWH/A are likely to need medical treatment for their infection. And for those in early stages of HIV, there is considerable support for early intervention; about 20% of the participants reported becoming infected in the last three years, and a significant part of that population is likely to be eligible for early intervention. Consistent with the length of time of infection and the trend in the epidemic, currently Anglos (47%), MSM (47%), and men (42%) are more likely than other populations to have T-cell counts below 350 cells/uL. As shown in Figure 1-15: • Almost 60% of the people reporting OIs said they had herpes or shingles. Latinos and heterosexuals report herpes and shingles more frequently. • Just over 50% of all PLWH/A who report OIs, and 75% of MSM/IDU say they have had thrush or Candidiasis. • Over a quarter of those who have had an OI report a history of PCP or pneumonia. It is surprising to see that it is most frequently reported by those newest to the epidemic, heterosexuals and African Americans. It is much greater among women (not shown in the figures), although this finding may not be reliable due to small sample sizes. Figure 1-15 Opportunistic Infections
200% 150% % Reporting OI 100% 50% 0% MSM Wasting Thrush PCP Herpes 28.2% 54.3% 22.7% 54.8% MSM/IDU 12.7% 84.3% 20.4% 54.2% IDU 20.3% 35.1% 32.0% 63.6% Hetero 22.9% 12.1% 53.9% 71.1% Anglo 28.4% 57.4% 23.8% 57.8% African Am 19.5% 30.3% 45.1% 47.9% Latino 14.7% 29.5% 29.3% 82.3% Total 24.9% 51.9% 26.5% 57.3%
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ACCESS TO HEALTH CARE Where PLWH/A Go For Medical Care Ryan White Care Act has an objective of 100% access to care for all persons living with HIV/AIDS, regardless of ability to pay. Because Ryan White Care Act funds are to be used as a last resort, it is important to know how many persons have different types of benefits and what those benefits cover. The vast majority of PLWH/A, whether insured or not, access medical care through a number of clinics and community organizations in Sacramento. By far the largest medical provider to PLWH/A is the community clinic at CARES but UC Davis, private doctors, VA, Kaiser, ER, and other clinics offer HIV/AIDS care as well. In the survey participants were asked where they received their medical care most often. Of the 383 participants, all but twelve (3%) noted a place of care. About two-thirds reported one place for medical care, 17% report two, and 8% report three. Figure 1-16 displays the sites for the total sample, sex/gender subpopulations, race/ethnicity, and risk group. They are not mutually exclusive – as noted above over a quarter of the PLWH/A reported more than one site where they usually receive their medical care. Overall: • The vast majority (71%) of PLWH/A receive medical care from community clinics such as CARES and County Clinics. • While community clinics are the most common site for all populations, Latinos (88%) are more likely than other populations to use community clinics for their care. • Men living with HIV and AIDS use community clinics, private hospitals, and the VA more than women living with HIV/AIDS, while women use all the other care facilities slightly more than men. • About 20% of PLWH/A report using UC Davis Medical Center, with women, IDUs, African Americans, and Latinos being more likely to use this site for medical care. • Slightly more than 11% of the PLWH/A say they use a private doctor or private clinics. Women, heterosexuals, and Anglos are more likely to use private facilities. Because the sample was recruited through community-based providers this may be an underestimate. • Emergency rooms are visited by about 11% of PLWH/A. Women and MSM/IDU are more likely to go to the emergency room than other subpopulations. • About 11% of PLWH/A receive their medical care from alternative treatment facilities (not the ER, hospital, doctor’s office or clinic). Alternative treatments are used more by women than by men. Of those reporting alternative care, most also report receiving clinic based medical care. About 30% say they use UC Davis, and about 22% use private doctors, clinics or hospitals. • About 8% of PLWH/A report using Mercy Hospital and Kaiser Permanente Hospital System. • About three percent (3%) of PLWH/A report using the VA. Not surprisingly men are much more likely to report using the VA than women. IDUs are also more likely to use the VA for medical care than other populations.
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Figure 1-16 Medical Care Sites
100% 80%
% of PLWH/A
60%
40%
20%
0%
Comm/ Nghbor Clinic 72.7% 65.0% 71.3%
UC Davis 18.9% 26.2% 20.2%
Private Doctor's Office/Clini 11.0% 13.3% 11.4%
ER 10.3% 16.0% 11.3%
Alt. Treatment 9.9% 13.5% 10.6%
Kaiser 6.0% 9.5% 6.6%
Mercy 4.5% 5.8% 4.7%
Private Hospital 3.3% 1.1% 2.9%
VA 3.1% 0.4% 2.6%
Male Female TOTAL
100% 80% % of PLWH/A 60% 40% 20% 0%
Comm/ Nghbor Clinic 72.4% 75.3% 72.7% 64.2% 71.3%
UC Davis 17.1% 19.2% 25.9% 25.1% 20.2%
Private Doctor's Office/Clini 13.5% 5.1% 3.8% 15.5% 11.4%
ER 9.1% 19.2% 9.1% 15.1% 11.3%
Alt. Treatment 9.9% 10.8% 11.7% 11.5% 10.6%
Kaiser 6.8% 10.0% 1.8% 7.9% 6.6%
Mercy 4.4% 6.0% 6.0% 3.7% 4.7%
Private Hospital 2.8% 7.2% 1.0% 2.4% 2.9%
VA 1.7% 4.8% 7.1% 0.0% 2.6%
MSM MSMIDU IDU Hetero TOTAL
100% 80% % of PLWH/A 60% 40% 20% 0%
Comm/ Nghbor Clinic 69.3% 68.8% 88.2% 71.3%
Private UC Davis Doctor's Office/Cli 16.6% 26.7% 26.6% 20.2% 13.4% 10.1% 5.4% 11.4%
ER 11.5% 11.7% 11.7% 11.3%
Alt. Treatme nt 10.9% 10.7% 9.2% 10.6%
Kaiser 7.6% 6.7% 0.5% 6.6%
Mercy
Private Hospital 3.0% 2.7% 4.2% 2.9%
VA 2.9% 2.6% 0.0% 2.6%
Anglo African Am Latino TOTAL
4.4% 6.1% 4.2% 4.7%
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Insurance Coverage Non-Insured In the survey participants were asked to report if they had insurance and, if so, the various forms of health insurance coverage they have. Twenty percent (20%) of the PLWH/A who were surveyed reported having no form of insurance. • Despite that fact that poor women often have more insurance options than men, women (23%) and MSM/IDU (26%) are more likely to report not having insurance than other populations of PLWH/A. However, about 87% of the women with at least one child report having insurance. Latinos are more likely than any of the other ethnic populations to not be insured. People with HIV are slightly more likely to be non-insured, and those that are HIV asymptomatic are much more likely to be noninsured.
• •
In other EMAs women are more insured than men. In California, they have greater access to insurance though various sources including Medi-Cal, and Healthy Families (SCHIP) and California Children’s Services (CCS) and have access to care and benefits through programs related to WIC and TANF. While a greater percentage of women in Sacramento receive WIC and TANF than men, a substantially lower percentage report receiving SSI, SSDI, or Medi-Cal/Medicaid. Insurance Profile About 80% of the PLWH/A interviewed report some type of insurance. There appears to be an impact of counseling in obtaining benefits as HIV disease progresses; about two-thirds of HIV asymptomatic participants have insurance. Confirming that insurance is a barrier to obtaining care, only 56% of those out-of-care report having insurance (this may be an unstable estimate due to the small sample size (N=23). While the level of insurance is not dramatically different by subpopulations, the types of insurance vary by life experience. As expected, Anglos and MSM, due to their generally higher incomes and past work experience, and greater likelihood of having AIDS, are more likely to be eligible for Medi-Cal and/or Medicare. Interestingly, IDUs (83%) are more likely to be insured than other risk groups, while MSM/IDU (74%) are least likely to report having any form of health insurance. As shown in Figure 1-17 and Figure 1-18 several types of insurance are reported by PLWH/A. Figure 1-17 and Figure 1-18 indicate that the different types of coverage vary by population.
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Medi-Cal/ Medicaid are by far the most common form of insurance for all populations infected with HIV/AIDS in the Sacramento area, with men, Anglos, and PLWA being the groups most likely to have this type of insurance. Medicare is the second most common form of insurance for PLWH/A in Sacramento. Overall, more than one quarter of PLWH/A report receiving Medicare. However, a much lower percentage of IDUs, Latinos, and asymptomatic PLWH report receiving Medicare than other groups. Overall, a much lower percentage of PLWH/A (10%) report having private insurance than Medi-Cal or Medicare. However, women, heterosexuals, and Latinos report the highest private insurance coverage. This is consistent with their reported higher level of employment.
Figure 1-17 Insurance Coverage – Gender and Exposure Category
80% 70% 60% 50%
% of PLWH/A
40% 30% 20% 10% 0% Total 9.8% 26.5% 63.3% Male 9.1% 27.6% 66.9% Female 12.9% 21.4% 46.5% MSM 8.7% 29.5% 66.1% MSMIDU 8.4% 32.8% 64.8% IDU 9.1% 17.9% 63.0% Hetero 14.7% 21.0% 54.2%
Private/COBRA Medicare Medi-Cal / Medicaid
Figure 1-18 Insurance Coverage – Ethnicity and Stage of Disease
80% 70% 60% 50%
% of PLWH/A
40% 30% 20% 10% 0% Total Anglo 8.2% African HIV Latino Am asymp 10.6% 13.4% HIV symp AIDS asymp AIDS symp 6.2%
Private/COBRA Medicare
9.8%
12.2% 11.2% 12.1%
26.5% 28.7% 25.2% 15.7%
16.0% 18.3% 16.5% 39.6% 43.7% 62.4% 71.2% 73.2%
Medi-Cal / Medicaid 63.3% 69.7% 54.9% 54.0%
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Non-insurance Entitlements and Benefits PLWH/A access health care through non-insurance benefits, including Veteran’s Assistance (VA), public health services, WIC, and through drug reimbursement programs, like ADAP. VA and Public Health Services About three percent (3%) of the PLWH/A report VA benefits and an additional one percent (1%) report receiving CHAMPUS, a form of VA for non-military personnel. Among the recipients of VA benefits, about 12% report having no insurance. Less than one percent of the PLWH/A report receiving public health services or Bureau of Indian Affair benefits. Which is consistent with the small percentage of Native Americans who participated in the needs assessment survey. Drug Reimbursement The data suggest that PLWH/A do not have a clear sense of how their medication is purchased. While up to 22% and 44% of the PLWH/A report that ADAP or MediCal/Medicaid paid for their medications, respectively, more than 30% do not know the amount of prescriptions paid for by any of their sources of drug reimbursement. In addition, 6% of the PLWH/A report that their medication was reimbursed by private insurance, 7% of PLWH/A reports out-of-pocket medication cost, and about two percent (2%) report receiving VA benefits to cover their medications. Other Benefits PLWH/A receive other benefits, such as food, housing, and financial assistance that are funded through a variety of sources. These entitlement and benefits are triggered by low income and disability. When PLWH/A are asked if they qualify for benefits, eight percent (8%) report not being eligible for benefits with an additional six percent (6%) not knowing whether they qualify or not. Disability About 24% of PLWH/A report being on long term disability. As expected the rate of disability is higher among those infected earlier, such as males, Anglos, MSM, MSM/IDU, and symptomatic PLWA. Latinos, heterosexuals, women and PLWH are the least likely to receive long term disabilities.
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Supplementary Income Income supplements include Supplemental Security Income (SSI), Temporary Assistance to Needy Families (TANF), emergency financial assistance, rent assistance, food stamps, and long-term and short-term disability payments. SSI and TANF are based on family income and SSI also required a status of disability. Those on SSI usually qualify for MediCal/Medicaid. Emergency assistance paid for by Ryan White usually covers rent, utilities, food, or medication reimbursements. Access to emergency financial assistance is through a case manager. The proportion of PLWH/A reporting supplemental sources of income is shown in Figure 1-19 and Figure 1-20. The data show that: • Indicative of the low income of PLWH/A, more than one-third (39%) report receiving SSI and 17% report receiving housing subsidies. IDUs, heterosexuals, African Americans, and symptomatic PLWH are more likely to receive SSI. With the exception of IDUs, these are basically the same groups that receive rental subsidies. In addition, women are much more likely than men to receive rent supplements. About 9% of the PLWH/A report receiving direct emergency financial assistance (DEFA), usually used for utilities, rent, or emergency medical treatment. However, women, African Americans, heterosexuals, IDUs, and asymptomatic PLWH are the least likely to receive DEFA. Surprisingly, only 9% report receiving food stamps and three percent (3%) report receiving TANF/CalWorks. However, women (21%), heterosexuals (22%), and African Americans (15%) are much more likely to receive food stamps than any other group. Not surprisingly, women (13%) are much more likely to receive TANF/CalWorks than men.


Figure 1-19 Supplemental Income – Gender and Exposure Category
60% 50%
% of PLWH/A
40% 30% 20% 10% 0% TOTAL 9.1% 38.6% 17.1% 9.3% 3.3% Male 6.5% 38.4% 15.2% 10.2% 1.1% Female 21.1% 39.2% 26.0% 5.5% 13.4% MSM 4.0% 33.0% 15.9% 13.3% 1.4% MSMIDU 13.3% 37.9% 13.9% 9.2% 0.8% IDU 9.4% 52.9% 15.7% 1.3% 3.9% Hetero 21.6% 43.5% 24.4% 4.4% 9.9%
Food stamps SSI Subsidized housing DEFA TANF / CalWorks
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Figure 1-20 Supplemental Income-- Ethnicity and Stage of Disease
50% 40%
% of PLWH/A
30% 20% 10% 0% TOTAL Anglo 4.8% 35.6% 15.2% 12.5% 2.0% African Latino Am 15.4% 44.6% 23.0% 2.7% 6.3% 14.2% 41.4% 17.4% 10.2% 1.3% HIV asymp 18.3% 28.1% 12.9% 6.0% 4.6% HIV symp 8.5% 45.0% 28.1% 12.7% 4.3% AIDS asymp 8.2% 43.8% 10.3% 10.1% 0.4% AIDS symp 4.9% 37.9% 18.3% 9.8% 2.9%
Food stamps SSI Subsidized housing DEFA TANF / CalWorks
9.1% 38.6% 17.1% 9.3% 3.3%
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OUTCOMES OF CARE SYSTEM Mortality To assess the success of a continuum of care, medical and social outcomes must be measured and tracked. Basic outcomes for the HIV/AIDS continuum of care are mortality, morbidity, and quality of life. The continuum of care is having the expected positive impact on mortality and morbidity. There has been a sharp decline in death rates of all PLWH/A. However, as shown in Figure 1-21, the death rate among the African American population has remained higher than that of the Anglo and Latino populations. At the end of 2002, the death rate among African Americans was almost twice as high as that of Anglos and Latinos. Figure 1-21 HIV/AIDS Deaths by Ethnicity per 100,000 of Sacramento County Population
20
15 Death rate per 100,000
10
5
0 African Am Anglo Latino
1997 13.2 6.7 4.0
1998 13.8 4.2 2.6
1999 10.9 6.5 6.4
2000 17.1 4.9 3.1
2001 7.2 2.3 1.8
2002 5.4 2.8 2.9
This large discrepancy between African Americans and other ethnic populations is somewhat moderated by the case fatality rates shown in Figure 1-22. The “case fatality rate” measures the death rate among a cohort diagnosed with AIDS during a certain calendar year and tracked to determine year of death. When a cohort of those in care are tracked, African Americans do better, suggesting that once in care, they have similar outcomes to other ethnic populations.
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Figure 1-22 % Fatality Rate - Deceased by Year of Diagnosis
100%
% Known Dead of AIDS Cohort
80%
60%
40%
20%
0% Af Am Latino Anglo
1997 25.0% 27.3% 24.3%
1998 32.7% 5.6% 25.3%
1999 19.4% 15.0% 22.0%
2000 13.9% 36.4% 21.9%
2001 14.3% 5.9% 3.7%
2002 8.3% 0.0% 7.7%
Physical And Emotional Health While there is no trend data, it would be expected that a successful continuum of care would continue to keep persons in good physical health, including those with AIDS. Overall, based on improvement in both physical and emotional health, the care system is making an impact. Well over half of PLWH/A report that their physical and emotional health are the same or better. HIV symptomatic populations report having the worst outcomes. Figure 1-23 and Figure 1-24 report the current and perceived change in physical health and emotional health. It is divided into three independent groups: 1) PLWH who are asymptomatic 2) PLWH who are symptomatic, and 3) those who report being diagnosed with AIDS (69% symptomatic and 31% asymptomatic. When available, physical and emotional health is compared to similar data collected in the San Francisco EMA. Physical Health of PLWH With No Symptoms • Over 60% of asymptomatic PLWH rate their physical health as good or excellent. • Nearly half (47%) say that their physical health is better now as compared to when they first sought treatment and another 42% say their health is the same. Physical Health of PLWH With Symptoms • In contrast, far fewer symptomatic PLWH (39%) report that their health is good or excellent. About 52% report their physical health as fair. • While about the same percentage of symptomatic PLWH as asymptomatic PLWH say their health is a little better now than when they first sought treatment. The biggest
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difference between the asymptomatic and the symptomatic PLWH is that far more symptomatic PLWH (43%) say that their health is worse than before they sought treatment. Physical Health of PLWA • Not surprisingly, PLWA have a higher percentage than PLWH reporting poor health (16%). Still, about 40% say they have good to excellent health. Not surprisingly, they report the least improvement in health compared to those at other stages of infection since they started treatment (43%). In comparison to symptomatic PLWH, symptomatic PLWA are currently doing slightly better with 41% reporting good to excellent health compared to 39% of the symptomatic PLWH. • Women, heterosexuals, and African Americans report the best physical health with about 20% reporting excellent health. Emotional Health of PLWH With No Symptoms The emotional health of PLWH is a little worse than their physical health. Symptomatic PLWH in particular report the worst emotional health of those in any stage of infection, but they say that their emotional health has gotten better since they started treatment. • Nearly half of the asymptomatic PLWH in Sacramento report good to excellent emotional health, and 44% say it is better now than when they started treatment. Emotional Health of PLWH With Symptoms • Compared to both asymptomatic PLWH and PLWA, a larger percentage of symptomatic PLWH report poor (19%) or fair (52%) emotional health. This may be connected to concern of their recent diagnosis. But a majority (57%) reports better emotional health than their initial diagnosis. • In contrast, about the same number of symptomatic PLWH say their emotional health is good or excellent, and significantly fewer say their emotional health is better now than when they first started treatment. Emotional Health of PLWA • About 47% of PLWA report excellent or good emotional health, and over 56% report an improvement in health since they started treatment. • While more than half of PLWH/A report an improvement in their mental health, MSM/IDU (44%) report the poorest improvement in emotional health.
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Figure 1-23 Quality of Life – Physical Health
CURRENT PHYSICAL HEALTH CHANGES IN PHYSICAL HEALTH
AIDS
better 43%
worse 40%
same 17% HIV+ Symptomatic better 48% same 9% worse 11% 0% 10% 20% 30% 40% 50% 60% better 47% worse 43%
HIV+ Asymptomatic
Poor
Fair
Good
Excellent
same 42%
Figure 1-24 Quality of Life – Emotional Health
CURRENT EMOTIONAL HEALTH CHANGES IN EMOTIONAL HEALTH worse 29% AIDS better better 56%
same 15%
HIV+ Symptomatic better 57%
worse 33%
same 10% HIV+ Asymptomatic worse 20% better better 44% 44% same 36%
0%
10%
20%
30%
40%
50%
60%
Poor Fair Poor Fair
Good Goo
Excellent Excelle
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MEDICATION AND ADHERENCE An objective of the care system is to increase adherence to medical regimens. Lack of adherence can limit the effectiveness of medication and create resistant strains of HIV. In the needs assessment survey of PLWH/A: • Eighty-five percent (85%) of all PLWH/A report taking medicines to treat their HIV infection, and there is a linear relationship with stage of disease, starting with 67% of asymptomatic PLWH taking medication to 99% of symptomatic PLWA taking medication (Figure 1-25). • PLWH/A with a longer history of HIV disease are more likely to have taken HIV medications. For instance, nearly 90% of men, MSM, and Anglos report having taken medications. On the other hand, women (70%) and heterosexuals (63%) are the least likely to have taken HIV medications – most likely as a function of their newer HIV status. • Forty-two percent (42%) of PLWH/A report never skipping their medications, and at the other extreme, ten percent (10%) have stopped taking their medicines. Women are significantly more likely to stop their medication than men (Figure 1-26). • Notably, symptomatic PLWA are more likely to skip taking their medication than asymptomatic PLWH/A or symptomatic PLWH. • Among all groups, forgetting to take them (49%) is typically the major reason for skipping medication, with IDU (67%) and MSM/IDU (56%) being the most likely to forget (Figure 1-27). • PLWH who are symptomatic and PLWA who are asymptomatic also have higher rates of forgetting than asymptomatic PLWH and symptomatic PLWA. • The next two most common reasons cited for skipping doses were side effects of medications (39%) and the difficult medication schedules (27%). MSM/IDU (46%) and Anglos (44%) appear to have a greater problem with side effects than other groups. MSM/IDU (40%) also report the most trouble with the medication schedule. • The three least cited reasons for skipping medications include not understanding the instructions (less than one percent), not wanting others to see taking medications (6%) and the feeling that medicines were no longer needed (6%). Figure 1-25 Medication by Stage of Infection
% of PLWH/A Taking HIV Meds
100% 80% 60% 40% 20% 0% PLWH/A on Meds
HIV asymp 66.5%
HIV symp 72.5%
AIDS asymp 91.3%
AIDS symp 98.7%
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Figure 1-26 PLWH/A Who’ve Skipped Their Medications
70% 60% 50% 40% 30% 20% 10% 0% TOTAL Ever Last w eek 58.3% 13.0% Male 56.6% 12.1% Female 67.1% 17.8% MSM 58.0% 10.8% MSMIDU 59.8% 14.9% IDU 62.1% 20.5% Hetero 53.9% 12.2% Anglo 56.4% 10.9% African Latino Am 59.3% 15.4% 58.1% 20.6%
Figure 1-27 Reasons for Skipping or Stopping Medications by Gender and Ethnicity
60% 50%
% of PLWH/A
40% 30% 20% 10% 0% Forgot Side effects 38.8% 36.8% 43.9% 28.6% 25.0% 38.5% hard to Didn't Doctor Felt meds Difficult Affordabi coord. w / w ant to advised Homeless didn't sched lity food take them to stop w ork 27.7% 20.4% 29.2% 19.4% 28.3% 26.5% 21.4% 14.1% 22.5% 13.8% 20.7% 20.2% 19.9% 21.4% 24.5% 13.6% 14.0% 20.1% 19.3% 20.7% 22.0% 16.3% 16.9% 19.6% 11.1% 13.7% 10.9% 16.2% 4.7% 11.5% 9.1% 7.9% 9.9% 6.1% 8.5% 8.9% 7.3% 2.6% 8.0% 3.0% 7.6% 6.5%
Male Female Anglo African Am Latino TOTAL
49.8% 44.6% 46.9% 50.2% 49.9% 49.0%
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CO-MORBIDITIES Effective treatment and prevention of HIV can mean treating different serious co-morbidities of PLWH/A. The co-morbidities of homelessness, mental illness, and STDs and drug use are discussed in this section. Homelessness Stable housing is often a prerequisite for a PLWH/A who is trying to adhere to a difficult medical regimen and improve their quality of life. Living in shelters with inconsistent access to food and proper nutrition, or sharing living spaces with strangers further aggravates the difficulty in adhering to medications. As shown in Figure 1-28: • Nearly 17% of those interviewed currently report currently being homeless or living in transitional housing. Thirty-one percent (31%) of PLWH/A interviewed have been homeless in the past two years (not shown), and nearly 40% indicate unstable housing in the last two years. • Men are less likely to be currently homeless or have a history of homelessness or living in transitional housing than women. • African Americans are more likely to be currently homeless and have a history of homelessness and living in transitional housing than other ethnic groups. • Recently incarcerated have the highest rate of homelessness and unstable housing (not shown). Figure 1-28 Currently & History of Homelessness or Transitional Housing
70% 60% % of PLWH/A 50% 40% 30% 20% 10% 0% Total Male Female Anglo African Latino Am API and other
MSM 9.2%
MSM/ IDU
IDU
Hetero
Currently hmless 16.7% 15.1% 23.8% 11.3% 28.5% 16.1% 25.9% Hist homeless
24.3% 24.4% 28.2%
39.3% 36.3% 53.0% 32.6% 59.5% 24.8% 49.8% 24.7% 59.5% 58.1% 55.0%
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Substance Use Drug use is significantly correlated with symptomatic HIV, suggesting that those who use opiates such as heroin or crack and frequent users of marijuana and alcohol may not be seeking adequate prophylactic treatment and that drug use may be related to the manifestation of symptoms. Based on the survey, those self-medicating with crystal meth or speed show little impact on stage of infection, but heavy use of crystal meth or speed can be harmful by encouraging higher risk behaviors, having negative health consequences, and adding a considerable expense to persons already in or near the poverty level. Figure 1-29 indicates Sacramento has relatively high drug use, particularly for opiates, crystal meth, and party drugs. Fifty-five percent (55%) of the PLWH/A report using crack/cocaine in the past with 14% of those who have used it in the past saying they used it in the last six months. Twenty-three percent (23%) report using heroin sometime in their life, and 12% of those have used it in the last 6 months. Figure 1-29 Substance Use Among PLWH/A*
100% 80% % of PLWH/A
60%
40% 20%
0% Alcohol Ever Used (EU) %EU who Currently Use 82.7% 51.4% Marijuana 71.0% 42.6% Crack 54.6% 13.7%
Crystal meth 46.2% 21.9%
Poppers 35.7% 19.2%
Heroin 22.9% 11.9%
Pills 20.2% 16.6%
Speedball 17.5% 9.2%
Ecstasy 16.9% 9.1%
GHB 8.2% 9.9%
*The black bar represents the % of those who ever used and are currently users. For example, for GHB, 8.2% have ever used GHP, and of those 8.2%, 9.9% currently use it.
In addition: • Recently incarcerated are among the most frequent abusers of drugs. • “Party drugs” include poppers, ecstasy, and Gamma Hydroxybutyrate (GHB). More than one third (36%) of the PLWH/A report using poppers, with about 20% of those saying they used in the last six months. Party drugs are much more commonly used by men, Anglos and MSM with as much as three quarters of the MSM/IDU and 43% of the MSM reporting having used poppers in their lives. More than a quarter of MSM/IDU and about six percent (6%) of MSM have used GHB. A very small percentage of heterosexuals (3%) report using ecstasy compared to seventeen percent (17%) of all PLWH/A.
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STDs
Sexually transmitted diseases (STDs) have a dual impact on PLWH/A and those at risk for HIV infection. Individuals with a history of STDs are likely to have a compromised immune system and are more likely to contract opportunistic infections (OIs). Also, manifestations of STDs such as open sores and genital ulcers make a person more vulnerable to HIV infection or re-infection. From an epidemiological perspective, a rise in STD rates, particularly gonorrhea and syphilis, indicate a rise in unprotected sexual intercourse that can lead to higher infection rates. Hepatitis, particularly hepatitis C, is associated with needle sharing and is an indication of risk of HIV infection among IDUs. As expected, a history of STDs is a significant co-morbidity among PLWH/A. What is surprising, however, is that Latinos report one of the highest levels of STDs. This may be a function of the small sample size, but it does suggest that these high levels of STDs among Latinos be further investigated. • Nearly one quarter of the PLWH/A report having been diagnosed with hepatitis C in the last year. Predictably, the incidence of hepatitis is significantly higher among IDUs (65%) and MSM/IDU (37%). • Among ethnic communities, the incidence of hepatitis C is highest among Latinos (37%). The data shows that Latinos (23%) report a lower use of intravenous drugs than African Americans (35%) and Anglos (25%), suggesting that they are under-reporting IDU or have other routes of transmission. • Next highest incidence of STDs is hepatitis A or B (23%). It is significantly higher among men (26%), Anglos (29%) and Latinos (23%). Among the risk groups, heterosexuals (8%) report the lowest incidence of hepatitis A or B.
Mental Illness
Mental illness covers a broad array of mental disabilities. Many people living with HIV and AIDS, particularly substance users, have had mental disabilities prior to becoming infected. For others, the diagnosis of HIV infection or its manifestations has led to mental health service needs. For many mental disabilities can negatively impact seeking and maintaining treatment. For the purpose of this needs assessment mental illness was defined as having a self-reported diagnosis of anxiety, dementia, or depression. More than two thirds of PLWH/A (69%) reported having been diagnosed with one of these conditions. • Depression has been diagnosed among 61% of PLWH/A in the past two years, and it is the most frequently diagnosed mental illness reported by PLWH/A. It tends to be highest among men (62%), Anglos (62%), symptomatic PLWA (71%), and MSM/IDU (72%). • Asymptomatic PLWH (41%), heterosexuals (45%), women (58%), and African Americans (54%), recently incarcerated (58%) and PLWH/A with a history of homelessness (59%) report less than the average incidence of depression. While the lower incidence rates among these populations may suggest greater access to support
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systems, it may also reflect a lower likelihood of seeking mental health professionals for a diagnosis. Forty–three percent (43%) of PLWH/A report a diagnosis of anxiety in the past two years. Anglos (51%) and MSM/IDU (53%) tend to have received a diagnosis of anxiety more than any of the other race and risk groups. There is a significant relationship between substance use and reported mental health problems. PLWH/A who report any type of drug use are also more likely to report substance use. Those using crack/cocaine and crystal meth are much more likely to report mental heath problems.
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RESOURCES FOR SERVICES4
The purpose of this section is to show the relative importance of Ryan White Title I funded services in the overall funding of the continuum of care, and to provide some history about the mechanics of the disbursement of funding. This information is particularly useful in the priorities and allocation process when one of the key elements is providing resources for key services that are inadequately funded elsewhere.
Funding Sources for HIV/AIDS Services
The Sacramento EMA had about $38.4 million in public funding for HIV/AIDS care in 2003. Based on the epidemiological estimate of 4,600 PLWH/A that would mean there is about $8,400 per capita for their care and secondary prevention. This is likely to be low as it does not include those with private insurance, and includes those who are not in-care. While the number served is greater than the approximately 1,700 in the SEMAS database, it will not be all PLWH/A. If the actual number served by the $38.4 million is closer to 2,000, it suggests that there is an actual average per capita expense of over $19,000. Figure 1-30 shows the distribution of Federal funds, State funds (including ADAP), Federal Ryan White Title I funds, and Federal, non-Ryan White Title I funds. Medi-Cal accounts for over $16 million and is the largest single source of funding for the HIV/AIDS Services Continuum. State funds, including ADAP (the Ryan White Title II pass-through), accounts for $14.2 million. ADAP alone contributes 21% to the HIV/AIDS Continuum of services. Ryan White Title I funds represent about $3 million, or about 8% of all funding. Federal, non Ryan White Title I funds, including Titles II (non ADAP) and III, HOPWA and HUD account for 6.7% of the funding. Local and Country Funds, including special DHHS grants and CARES local funds account for about 6.4% of the funds.
Figure 1-30 Distribution of $38.4 Million HIV/AIDS Funding – 2003
Local / Country 6.4% Fed Non RW TI 6.7% Fed RWTI 8% Medi-Cal 41.8%
State (incl ADAP) 37.1%
A more detailed accounting of these funds are shown in Figure 1-31. The bar graph on the right is a visual presentation of the distribution of funds and shows the magnitude of MediCal and ADAP in funding the system, and the relative contribution of Ryan White Title I funds.
4 The information presented below was largely provided by the Grantee for Title I and through published material or grant applications. Information in this section was previously submitted to the Priorities and Allocation Committee and used as part of their deliberations. Ms. Carol Maytum assisted with the collection and presentation of the information in this section.
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It further shows some emphasis on Early Intervention programs, and there are several smaller funding sources for education and information, including prevention.
Figure 1-31 Distribution of Funds in the HIV/AIDS Continuum of Services
100% HIPP (Tobacco) Medical Court Ordered AIDS Testing (Viral Load Test Vouchers) (Recent Release) El Dorado (AIDS testing, prevention) DHHS (PCRS) Education (Breaking Barriers) Harm Reduction-Outreach/Testing EIP (CARES) Ca. Child Services (UCD) AAIDS Master Grant-no EIP Substance Abuse (CDC) ADAP (through RWTII) State $20,000 $25,000 $29,156 $37,500 $181,193 $191,235 $314,832 $326,600 $337,112 $412,855 $644,590 $1,647,942 $1,710,757 $8,358,574 $14,237,346 0.1% 0.1% 0.1% 0.1% 0.5% 0.5% 0.8% 0.9% 0.9% 1.1% 1.7% 4.3% 4.5% 21.8% 37.1%
CCS 1.7% AAIDS Master Gnt 4.3% Sub Abuse CDC 4.5%
90%
80%
ADAP 21.8%
70% Grantee Admin Harm Reduction-Outreach/Testing Case Mgmt (Calif Endowment-outreach research) Indigent & Mental DHHS (CARES - local) Local /County Grantee Admin, Prog Suppt RWTI Federal Ryan White Title I Grantee Admin HUD RW Title III DHHS RW Titles II HOPWA Federal Non-Ryan White Title I $17,270 $10,000 $54,571 $116,000 $472,000 $553,753 $1,229,033 $2,452,627 $487,110 $2,604,532 $3,091,642 $61,927 $219,495 $365,134 $472,373 $599,473 $850,500 $2,568,902 0.0% 0.0% 0.1% 0.3% 1.2% 1.4% 3.2%
6.4%
State 60% Local
CARES local 3.2%
50%
RWT I
RW TI 6.8%
1.3% 6.8%
8.0%
Oth Fed 40%
HOPWA .2.2%
0.2% 0.6% 1.0% 1.2% 1.6% 2.2%
6.7
30%
MediCal .41.8%
20%
MediCal 41.8%
10%
MediCal
$16,068,581
41.8%
0%
MediCal Distribution of HIV/AIDS Care Funds
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History of Ryan White Funding
This plan focuses on the use of the Ryan White Title I funds, and how they can best be configured to complement other funding sources to fill service needs and any gaps in services, and to overcome any barriers to services. On June 18, 1996, the Director of the Department of Health and Human Services (DHHS) accepted funding from the United States Department of Health and Human Services (USDHHS) for the Ryan White CARE Act (RWCA) Title I and Title II Grant. On April 25, 1997, the State Department of Health Services (DHS), in concurrence with the Rural Counties' Department Directors, Health Officers, and respective Boards of Supervisors designated Sacramento County to act as fiscal agent for El Dorado and Placer Counties for Title II funding. Sacramento County's designation as the "Fiscal Agent" authorizes the Department to subcontract with various vendors to provide planning council staff support, program support and direct services to the community. The USDHHS grant conditions limit the administrative expenditures for the Fiscal Agent and Quality Management to 10% the amount awarded. The responsibility for planning and distributing the funds rests with the Sacramento HIV Health Services Planning Council, a volunteer body that represents the community of PLWH/A. The HIV Health Services Planning Council is a 30-member community advisory body with the primary responsibility for assessment of need for direct medical psychosocial and support services for persons living with HIV/AIDS in El Dorado, Placer and Sacramento Counties. Additionally, the Council must establish appropriate service priorities and allocate approximately $3.5 million in federal grant funding, as provided under Titles I and II of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, to providers of HIV/AIDS services within the region of continuum of care. Council support is subcontracted to the Community Services Planning Council, a not-forprofit organization in Sacramento. Through monthly meetings and various subcommittee meetings the Council establishes priorities and allocations for the Title I funds and has the responsibility to set service standards and provide directives to providers for the appropriate use of the funds. More detail about the organizational structure of the Council can be found on http://www.communitycouncil.org. Within Title I, the planned 2003 allocation of the projected $2.7 million in RWTI funds for each service is shown in Figure 1-32. By far, case management has the largest allocation, 32% ($943,263). It is followed by outpatient medical care with an allocation of 10% ($311,389) and mental health services, with an allocation of 9%. Notably, almost $600,000 is added to the outpatient medical care category from Ryan White Title II funds. After that dental care and residential or in-home hospice care were each allocated 5%. Food, transportation, and outpatient substance abuse were each allocated 3%
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Figure 1-32 Ryan White Title I Allocations
*LESS THAN 1% Home Health Care Day/Respite Care for Adults Nutritional Counseling Medication Adherence Services Other Support Services Health Insurance
Quality Management 5% Fiscal Administrative Agency 5% Ambulatory /Outpatient Medical 10% Planning Council Support 5%
Program Support 5%
Housing Assistance 1%
Client Advocacy 2% Buddy/Companion Services 1% Outreach Services 1% Psychosocial Support Services 1% Child Care Services 1% Emergency Financial Assistance 1% Transportation Services 3% Residential Substance Abuse Services – 2%
*
Case Management Services 32%
Residential or In-Home Hospice 5% Food Bank/Home Delivered Meals 3%
Drug Reimbursement Program 1% Substance Abuse Services – Outpatient 3% Oral Health Care 5% Mental Health Services 9%
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Priorities and Allocations
The priority setting and resource allocation processes take place annually and traditionally over a period of months. The processes involve community meetings, trainings and data review sessions. The Priorities and Allocation Committee (PAC) leads the priority setting and allocation determination process. The Fiscal Agent is engaged throughout the process as they are responsible for the monitoring of expenditures throughout each fiscal year. As necessary, the PAC establishes ad hoc committees inclusive of consumers and community members to ensure the contribution of diverse perspectives. Epidemiological data, service utilization data, needs assessment data, community input and CARE Act requirements should guide both the priority setting process and the resource allocation process. Analysis of service utilization based on units of service rather than solely unduplicated client counts is a key information component. This allows for a more detailed understanding of utilization patterns and a closer estimate of the costs associated with various services. Based on this process and recommended continuum of HIV services, priorities were recommended for 2004-5 that are shown in Table 5. The logic behind these new priorities was to cluster groups of core services and wrap-around services. The priorities recognize the greatest need of outpatient care and gaps in services in oral health, emergency financial assistance, food, and housing. Table 5 2004-05 Priorities
1 2 Ambulatory/Outpatient Medical Care Case Management Services Case Management Childcare Minority AIDS Initiative Office-based Services Field/In-Home Services Oral Health Care Emergency Financial Assistance Food Vouchers Utility Assistance Other Critical Need Drug Reimbursement (Non-ADAP) ADAP Co-Pay Assistance Mental Health Services Housing Assistance Substance Abuse Services – Residential Transportation Services Substance Abuse Services - Outpatient Food Bank/Home-Delivered Meals Food Bank Meals Nutritional Supplements Psychosocial Support Services HIV Support Group(s) Nutritional Counseling (non-licensed) Acupuncture/Chiropractic/Massage Services Acupuncture Services (substance abuse) Residential or In-Home Hospice Care Child Care Services Treatment Adherence Services Pediatric Services Health Insurance Continuation
3 4
5 6 7 8 9 10
11
12 13 14 15
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Allocations
Based on these priorities, allocations were derived which supported the existing distribution of funds, with minor increase to allow for inflation. Before allocations are determined for any service category, the PAC agrees to use percentages to determine the allocations to categories so that when the award is received from HRSA, allocations will be adjusted according to the percentage. The rationale for this decision is that the process used for the original allocation is a sound, data driven process and the Planning Council should not duplicate its work when the actual award amount is received. Allocations for services should be determined by using a formula that considered the following factors for each service category: 1. Number of unduplicated clients in the previous year (FY2002). 2. Increase in clients accessing services from FY2001 to FY2002. 3. Projected number of clients to be served in upcoming fiscal year FY2004. 4. Average number of units of service or encounters per client in FY2002. 5. Total expenditures in the previous year (FY2002). 6. Average cost per unit of service or encounter (based on total expenditure). Once the final award from HRSA, or DHS has been received the Fiscal Agent re-calculates the available allocations within each service priority. The available allocations are published in the Fiscal Agent’s Request for Proposals (RFP) process that solicits providers of HIV services once every three years. The procurement process solicits a variety on information, including financial information on the “unit cost of service”. At the end of the procurement process the Provider and Fiscal Agent negotiate a reimbursement rate. Therefore, from the provider’s perspective, understanding their operating cost and full cost (and other payment sources) is a critical element to a successful negotiation. These allocations are shown in Table 6. This table is based on a worksheet that permits the PAC to change parameters for expected unduplicated counts of clients, unit costs, or average number of unit costs, and therefore model and project different scenarios.
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Table 6 Priorities and Allocation - Projected 2004-05
System Change UDC 2004-05 Proj System Change in UDC Proj 2004-05 Average Est New Units UDC Percent Allocation
Fiscal Year 2001 – 2002 Service Category: Ambulatory Care Service Type
Expended 2003-4 UOS
UDC
av # units
Exp / UOS
Proj Unit Cost
Est New Units
Est New Cost
20 min visit w/HCP* 20 min specialty care 1 medication adherence session
Cost per client
$769,950 $17,368 $6,757 $53,448 $9,994
5,310 171 188 48,589 443
757 27 27 111 27
7.01 6.33 6.96 437.74 16.41
$145.00 $101.57 $35.94 1013 $1.10 $22.56
-0.4% -10.0% -26.0% -74.0%
0.0% 0.0% 0.0% Totals 0.0% 0.0%
$149.35 $104.62 $37.02 144.27 $1.10 $23.24 1.2941530 6
7.01 6.38 6.96 6.78 330.12 16.41
757 27 27 784 111 27
5310 $793,049 172 188 50050 443 $18,009 $6,960 $55,055 $10,290
28.53% 0.65% 0.25% 24.93% 1.98% 0.37%
5670 $818,018
1 vendor paid alter/comp therapy dollar 1 acupuncture visit
Total Alternative Therapy
Totals
Service Category: Oral Health Care (Dental) Annual Expenditures:
365.89
138
50493
$65,345
1.99%
Service Type 1 dental visit
Service Category: Home Health Care: $0 Service Category: Mental Health Counseling Annual Expenditures:
$155,963
1,514
305
4.96
$103.00
11.7%
0.0%
$106.10
4.96
341
1692 $179,479
5.47%
Service Type 1 hour adult psychological - ind. 1 hour child psychological - ind. 1 hour ind. Family 30 min.'s ind. Psychiatric (adult) 30 min.'s ind. Psychiatric (child) $105,315 $2,290 $8,722 $121,204 $990 1,716 34 197 1,616 12 299 4 1 255 1 5.74 8.42 197.00 6.34 12.00 $61.37 $68.00 $44.27 $75.00 $82.50 -19.6% -20.0% 0.0% -10.8% #VALUE! 0.0% 0.0% 0.0% 0.0% 0.0% $61.37 $68.00 $44.27 $75.00 $82.50 5.74 8.42 197.00 6.34 12.00 299 4 1 255 1 1716 $105,315 34 197 12 $2,290 $8,722 $990 3.79% 0.08% 0.31% 4.36% 0.04%
1616 $121,204
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Fiscal Year 2001 – 2002
Expended 2003-4 UOS
UDC
av # units
Exp / UOS
System Change UDC
2004-05 Proj System Change in UDC
Proj Unit Cost
Proj 2004-05 Average Est New Units UDC
Est New Units
Est New Cost
Percent Allocation
Each adult attending group Each child attending group
Totals Cost per client Service Category: Outpatient Case Management Annual Expenditures:
$1,680 $30
56 1
11 1
509.00
5.09 1.00
$30.00 $30.00 542
-26.7% 0.0%
0.0% 0.0%
$30.00 $30.00
55.8771
5.09 1.00 9.99
11 1 509
56 1
$1,680 $30
0.06% 0.00% 8.66%
5085 $284,154
Service Type 15 min face 2 face encounter 15 min other encounter 15 min CBC/MAI face2 face 15 min CBC/MAI other
Totals Cost per client Service Category: Residential Hospice Annual Expenditures:
$414,557 $169,974 $67,507 $46,275
25,581 9,584 3,645 2,177
777 303 24 23
32.92 31.63 151.88 94.65
$16.21 $17.74 $18.52 $21.26
-2.5% -49.6% -84.8% -58.2%
0.0% 0.0% 0.0% 0.0%
$16.21 $17.74 $18.52 $21.26 19
32.92 31.63 151.88 94.65 43.45
777 303 24 23 954
25581 $414,557 9584 $169,974 3645 2177 $67,507 $46,275
14.91% 6.12% 2.43% 1.66% 24.00%
41451 $787,576
Service Type 24 hours of hospice care
Totals Cost per client Service Category: Substance Abuse Treatment-residential Annual Expenditures:
$141,837
1,747
18
97.06
$81.19
0.0%
0.0%
$83.63
103.41
18
1861 $155,669
4.74%
Service Type 1 hour residential treatment 1 hour residential treatment-detox $56,063 $28,209 21,156 4,872 26 19 813.69 256.42 $2.65 $5.79 -18.8% -32.1% 0.0% 0.0% $2.73 $5.96 813.69 256.42 22 19 25805 4872 $70,434 $29,055 2.53% 1.05%
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Fiscal Year 2001 – 2002 Totals Service Category: Substance Abuse Treatment-Outpatient
Expended 2003-4 UOS
UDC
av # units
Exp / UOS
System Change UDC
2004-05 Proj System Change in UDC
Proj Unit Cost
Proj 2004-05 Average Est New Units UDC
Est New Units
Est New Cost
Percent Allocation
3.34
727.00
41
29815
$99,494
3.03%
Service Type 1 addiction assessment 1 physical assessment 1 hour outpatient counseling 1 hour /client /group counseling 1 hour family counseling 90 min's family group counseling/person 15 min's other staff encounter
Totals Service Category: Supportive Services
$6,210 $1,822 $18,180 $18,056 $135 $7,533 $31,155
100 35 404 559 3 233 1,915
63 31 61 41 1 17 67
1.59 1.13 6.62 13.63 3.00 13.71 28.58
$62.10 $52.06 $45.00 $32.30 $45.00 $32.33 $16.27
-40.6% -50.0% -26.5% -12.8% -66.7% -15.0% -23.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
$62.10 $52.06 $45.00 $32.30 $45.00 $32.33 $16.27 $26.87
1.59 1.13 6.62 13.63 3.00 13.71 28.58 34.00
63 31 61 41 1 17 67 95
100 35 404 559 3 233 1915 3230
$6,210 $1,822 $18,180 $18,056 $135 $7,533 $31,155 $86,793
0.22% 0.07% 0.65% 0.65% 0.00% 0.27% 1.12% 2.64%
Service Type Buddy Companion 1 hour emotional support 1 hour volunteer support
Total Buddy/Companion Housing
$13,377 $20,408
637 1,029
49 91
13.00 11.31
$21.00 $19.83
11.4% -49.4%
0.0% 0.0%
$21.00 $19.83 0
13.00 11.31 0.00 249.86 391.65 314.00
49 91 0 72 31 99
637 1029 0 17990 12141 31055
$13,377 $20,408 $0 $19,789 $13,355 $34,160
0.48% 0.73% 0.00% 0.71% 0.48% 1.04%
1 vendor rent dollar 1 vendor lodging dollar
Total Housing
$19,789 $13,355
17,990 12,141
72 31
249.86 391.65
$1.10 $1.10
-13.3% -45.6%
0.0% 0.0%
$1.10 $1.10 1.1
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Fiscal Year 2001 – 2002 Food/Nutrition
Expended 2003-4 UOS
UDC
av # units
Exp / UOS
System Change UDC
2004-05 Proj System Change in UDC
Proj Unit Cost
Proj 2004-05 Average Est New Units UDC
Est New Units
Est New Cost
Percent Allocation
1 vendor food dollar 1 vendor vitamin/herb dollar 1 nutritional supplement pack 1 home delivered meal 1 food bag
Total Food/Nutrition Emergency Financial Assistance
$5,723 $6,864 $6,989 $6,652
5,202 156 694 732
4 31 92 97
1300.50 5.03 7.54 7.55
$1.10 $44.00 $10.07 $9.09
-50.0% -18.4% -22.7% -31.2%
0.0% 0.0% 0.0% 0.0%
$1.10 $44.00 $10.07 $9.09 3.98
1300.50 5.03 7.54 7.55 24.00 99.15 153.69 164.45 136.00 22.39 31.44 42.00 613.90
4 31 92 97 220 506 206 11 723 157 449 421 31
5202 156 694 732 5315 50168 31661 1809
$5,723 $6,864 $6,989 $6,652 $21,153 $55,184 $34,827 $1,990
0.21% 0.25% 0.25% 0.24% 0.64% 1.99% 1.25% 0.07% 3.30% 1.27% 0.56% 1.60% 0.64%
$55,184 1 vendor utility dollar 1 other critical need dollar
Total Emergency Financial Transportation
50,168 31,661 1,809
506 206 11
99.15 153.69 164.45
$1.10 $1.10 $1.10
-6.8% -2.4% -75.0%
0.0% 0.0% 0.0%
$1.10 $1.10 $1.10 1.1
$34,827 $1,990
98338 $108,172 3516 14116 17632 19031 $35,340 $15,643 $52,513 $20,935
1 one way trip 1 vendor transportation dollar
Total Transportation Child/Respite Care
$35,340 $15,643
3,516 14,116
157 449
22.39 31.44
$10.05 $1.11
-32.6% 28.3%
0.0% 0.0%
$10.05 $1.11 2.98
1 vendor child care dollar
Total Child Care Treatment Adherence
$47,169
47,169
23
2050.83
$1.00
-20.7%
0.0%
$1.10
1 medication adherence session
Total Treatment Adherence Psychosocial Support Services
$8,030
44
18
2.44
$182.50
-40.0%
0.0%
$187.97
7.05
18
127
$23,854
0.73%
1 nutritional counseling visit 1 hour individual support group
$10,250 $8,386
5,652 136
117 62
48.31 2.19
$1.81 $61.66
41.0% -20.5%
0.0% 0.0%
$1.81 $61.66
48.31 2.19
117 62
5652 136
$10,250 $8,386
0.37% 0.30%
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Fiscal Year 2001 – 2002 Total PSSS Drug Reimbursement
Expended 2003-4 UOS
UDC
av # units
Exp / UOS
System Change UDC
2004-05 Proj System Change in UDC
Proj Unit Cost
Proj 2004-05 Average Est New Units UDC
Est New Units
Est New Cost
Percent Allocation
3.32 $18,802 17,093 59 289.71 $1.10 -13.2% 0.0% $1.10
31.00 298.00
219 59
6878 17605
$22,804 $19,366
0.69% 0.59%
1 vendor paid medication dollar
Total Drug Reimbursement Client Advocate
15 min's face 2 face advocate encounter 15 min's other advocate encounter
Total Client Advocate Outreach Services
$16,660 $37,255
389 777
23 35
16.91 22.20
$42.83 $47.95
-48.9% -35.2%
0.0% 0.0%
$42.83 $47.95 0
16.91 22.20 0.00 9.36 0.00
23 35 0 84 0
389 777 0 786 0
$16,660 $37,255 $0 $19,691 $0 $2,779,48 4
0.60% 1.34% 0.00% 0.71% 0.00% 84.70%
1 hour of outreach
Total Outreach Services
$19,691
786
84
9.36
$25.05
211.1%
0.0%
$25.05 0
$2,663,60 Totals 9 Cost per client
El Dorado County Placer County Sub-Total Direct Service Allocations Quality Management Planning Council Support Fiscal Agent-Administration Program Support
GRAND TOTAL FY 04 ALLOCATIONS
$219,865 $282,215 $3,281,56 4 $163,159 $163,159 $222,065 $22,300 $3,852,24 7
6.70% 8.60% 100.00%
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As noted in the Table 6 above, there is a unit cost that when multiplied by the number of units of service expected, results in the overall funding levels. While the client database system is designed to establish unit costs, and most services are paid on a unit cost basis there are notable exceptions, such as outpatient medical care for adults. The reasons for this are complex, but the end result is that the reimbursement for medical care is based on a cost-reimbursement basis with most of the discretion of cost left with the provider. This system lacks the checks and balances inherent in the unit-costing structure. Moving to a more transparent unit-cost system for all services would add transparency to the system.
Other Sources of Funding
At this time there is not a good understanding of other sources of existing funding. For example, the VA is likely to add about 3% to 5% to the resources for outpatient care, and the impact of private (non MediCal / Medicare) is unknown. The contribution to care of drug trial and pharmaceutical compassionate drug distribution programs are not known. When planning for services, there is a need to determine the contribution of other sources of care. There is also no coordinated Council plan in place to exploit other funding sources, including other Ryan White Titles. There are applications for Title IV (for CARES) and Title III (CARES) and SPNS applications, but efforts are not tracked or coordinated.
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NEEDS, UNMET NEEDS, GAPS 2003 Needs Assessment Methodology
A brief summary of the methodology is found below. A more completed description of the development of survey, focus group, and key informant instruments, sampling, fielding and analysis can be found in the 2003 Needs Assessment Report (June 2003). Three data collection methods were used by PCH for the Sacramento EMA HIV/AIDS Care Needs Assessment: 1. Secondary analysis of existing needs assessments and epidemiological information in order to estimate incidence and prevalence of HIV and AIDS, develop a sampling plan, and obtain mortality and morbidity data as outcome measures for the continuum of care. 2. A consumer survey was conducted among 383 PLWH/A to determine their HIV/AIDS care needs, unmet needs, barriers, and relevant behaviors, such as adherence to medical regimens, drug use, and quality of life. 3. A series of eight focus groups among target populations permitted in-depth discussion of needs and barriers to services that allow a greater depth of analysis by providing support and exceptions to quantitative findings from the survey. In addition, one-on-one interviews were conducted with parents or guardians of HIV positive children and youth. As part of the process several discussions were held with providers. A Project Advisory Group (PAG) was formed to provide oversight to the needs assessment process and feedback on survey and focus group tools and draft reports. Decisions regarding content and length were approved by the PAG and they continued to be consulted throughout the project. The names of those on the task force are shown in Attachment 1. Consumer Survey
Questionnaire
The consumer survey was an interviewer-assisted questionnaire, with trained interviewers available at all sites where the survey was administered to provide guidance and assistance to participants. The survey instrument was designed and approved on March 14, 2003. The process included a draft submitted by PCH and several rounds of revisions based on comments and specifications of the HHSPC and PAG. The survey was available in English and Spanish. The survey measured key demographics, insurance and benefits, level of care, stage of infection, medication and adherence, and quality of life, and the awareness, current need, demand, and utilization of services. At the end of each major service category, PLWH/A had an opportunity to say what problems s/he had in obtaining the services.
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Following the measurement of service need, PLWH/A ranked different barriers to care. The barriers assessed were based on prior needs assessments conducted by the research team using a multidimensional schema discussed in the Barriers Section in the Needs Assessment. The final questions in the survey measured drug-use and residency status. Sample Design The recruitment strategies for the consumer survey were based on a stratified quota sample based on race and risk group. It purposely oversampled specific subpopulations in order to have adequate sample sizes for females, heterosexuals, Latinos and other difficult-to-reach populations. Because the oversampled subpopulations were known, they were weighted back to their populations-proportionate-to-size in the analysis of all PLWH/A. Survey Analysis The survey data permits the analysis of needs, unmet needs, and barriers among different key populations. It also permits the estimates of co-morbidities including homelessness, substance use, STDs, mental illness, and tuberculosis among PLWH/A. The survey included measures of quality of life and adherence to medication as additional outcomes of the care system. For the total sample analysis, oversampled subpopulations are weighed back to their proportion in the estimated HIV population. When subpopulations are compared, the weighted sample is used. However, when special populations are analyzed unweighted data is used to take full advantage of the oversamples. The survey was analyzed using the statistical package Statistical Program for Social Sciences (SPSS). Analysis of the data was done by the “total sample” and key demographic, geographic, and stage of infection subpopulations. These are shown along with the unweighted sample size, and weighted and unweighted sample proportions in Table 1-7:
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Table 1-7 Analysis Populations
Analysis Subpopulation 1. Total 2. Gender 2.1 Male 2.2 Female 2.3 Transgender 3. Mode of Transmission 3.1 MSM 3.2 MSM/IDU 3.3 IDU 3.4 Heterosexual 4. Race 4.1 African American 4.2 Anglo 4.4 Latino 4.5 API and other ethnicities, including Native Americans 5. Medical Visit 5.1 Within last six months (< 6 mos.) 5.2 Six months or longer (>= 6 mos.) 6. Stage of Infection 6.1 HIV, asymptomatic 6.2 HIV, symptomatic 6.3 AIDS, asymptomatic 6.4 AIDS, symptomatic Unweighted N
383 278 102 3 132 68 100 82 159 152 59 13 354 21 104 77 65 131
Unweighted %
100% 73% 27% 1% 35% 18% 26% 21% 42% 40% 15% 3% 94% 6% 28% 20% 17% 35%
Weighted %
100% 82% 18% 0% 55% 11% 16% 18% 26% 61% 11% 3% 95% 5% 23% 19% 18% 40%
Focus Groups and Key Informant Interviews The purpose of the focus groups and key informant interviews was to gain greater insight into the perception of needs, gaps, and barriers of selected key populations. They supplement the quantitative findings of the consumer survey and, for populations where sample sizes are too small such as immigrants and migrants, they provide the main information for the report. The key informant interviews for the parents or guardians of children living with HIV/AIDS addresses a key population not included in the survey. Eight focus groups among MSM, MSM of color, recently incarcerated men, women with children and adolescents with HIV, heterosexuals, recently incarcerated women, rural men and women, immigrants/migrants. Seven key informant interviews (1-1) were conducted among parents of children living with HIV/AIDS, adolescents, and the staff of providers. Parents and adolescents were obtained through referrals from a provider who contacted clients to determine their interest in participating in the survey. Qualitative Analysis Focus groups were audio taped, transcribed, and entered into a database. PCH staff coded comments by basic demographics and the service and/or barrier they referred to using a
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systematic coding scheme (for greater detail see 2003 Needs Assessment Report), and team members sorted these comments based on services and barriers and they were selected for inclusion in the report based on the comment’s ability to substantiate and add depth to the quantitative findings or show a view of consumers that is contradictory or different from the quantitative findings. Service Categorization Consumers were asked to rank their awareness, need, demand, and utilization for forty-two services, representing twenty-three service categories shown Table 1-8. The twenty-three service categories are shown in order of the Council’s 2003 service priorities.
Table 1-8 Service Categories 2003 Priorities
2003 Priority Service 1 Ambulatory Outpatient Medical Care Outpatient medical care Medical Specialist Complementary care 2 Housing Assistance Housing info Rental asst Supportive housing Case Management Services CM help w/ benefits Benefits counseling Intake session Vocational referrals Food Bank / Home Delivered Meals Food bank Food vouchers Delivered meals Nutrition supplement Mental Health Services MH 1-1 Family counseling Bereavement counseling Oral Health Care Dental care Substance Abuse Services - Outpatient Subst abuse counseling Subst abuse assessment Subst abuse 1-1 counseling Subst abuse Grp Subst abuse family counseling Subst abuse peer group Drug Reimbursement Medication Reimbursement Residential or In-home Hospice Care Residential Hospice Care Substance Abuse Services - Residential
Sub Abuse Serv – Residential
11 Transportation Services Transportation Taxi vouchers Emergency Financial Assistance Financial asst Child Care Services Child care Psychosocial Support Services MH group Peer counseling Medication Adherence Services Adherence support Other Support Services Nutrition Counseling Nutrition counseling Home Health Care Home health care Health Insurance Insurance Asst Outreach Services Buddy/Companion Services Buddy emotional support Buddy household tasks Buddy advocate Day/Respite Care for Adults Adult day care Client Advocacy Client Advocacy
12 13 14
3
15 16 17 18 19 20 21
4
5
6 7
22 23
8 9 10
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Top Needs: Council and PLWH/A
Each year the Council ranks services by priority as part of the Ryan White Title I application. The Figure 1-33 graphs services in the order of the 2003 Service priorities of the Council. The Council rankings reflect several criteria such as the consumer’s perceived need, epidemiological trends, and other data. The numbers on top of some bars represent the ranking of the top twelve sub-services by consumers and the bars represent the percentage of PLWH/A who report they needed the service in the past year. Consumer rankings, represented by the bars, are the percentage who says they needed the service in the past year. In general, consumer rankings match the Council’s priority rankings. However there are significant differences. The Council ranks housing 2nd, but the consumers place it relatively lower on their list of needed services. Given reports of high levels of homelessness and difficulty finding stable housing other factors then the consumers’ perceived need is reflected in the Council’s ranking. Another difference is the approach to case management. Consumers understand that their access to services is often through their case manager, and it is not surprising that they rank it among their most needed service. That is followed by food and outpatient care. The Council perceives case management as a means to access service, so ranked it lower than direct medical services. From the consumers’ point of view, however, because they perceive case managers as the gatekeepers to care, it is logical that their need for it would be very high. Figure 1-33 further shows that: • Three of the top ten highest priorities are in the case management category, and two of the top ten are in outpatient medical care and food. The top two most needed services5 are not within health care: 1) case management and 2) food vouchers. Notably in 2003, case management received the greatest RWTI allocation. • Outpatient care is the top rank of the Council and is needed by the third largest number of PLWH/A. • Dental care is among the top services needed by PLWH/A. • Taxi vouchers and transportation are important, but in the second tier needs by both PLWH/A and the Council. • Notably, the perceived need by PLWH/A for substance abuse treatment is relatively low even among drug users. While ranked higher among IDUs, it is not a top need, with far more saying they need outpatient medical care, food pantry, rental assistance, and case management. It was perceived as more important by the Council, and that is justified by the high non-IDU drug use and strong relation to poor adherence and high service needs. • Nearly 54% of PLWH/A reported they needed one-on-one mental health counseling. Still it was not among the top services needed by all PLWH/A, and the other mental health services, family counseling and bereavement counseling, were needed by under 20% of PLWH/A. However, the Council is likely to have responded to the very high
5 “Most needed” refers to aggregate ranking of consumers who say they needed each service; it is not the report of individual rankings or sorting of services.
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incidence of depression, anxiety, and other emotional problems reported by PLWH/A, in giving mental health services a ranking of 5 out of 21 services. In a subgroup analysis: • Men perceive a greater need for medical care, and women perceive a greater need for support services. For example, among the top perceived needs, women report a much greater need than men for transportation and mental health services. For the most part, men and women have about the same rankings for other top services. • Most of the largest differences in perceived need between men and women are among the services with lower overall need. As might be expected there is a greater perceived need among women for childcare. However, there is also a greater perceived need for bereavement counseling, adult day-care and respite care, and emotional support from buddies. • Anglos and then Latinos perceive a higher need for medical services, including dental care. Anglos perceive a higher need than Latinos or African Americans for mental health services and complementary care. • African Americans perceive a higher need for most support services, particularly substance abuse services, including assessment and group sessions, and transportation services. Reflecting the disproportionate number of African American women infected, they also have a higher need for childcare and family counseling.
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Figure 1-33 Ranked Service Needs
100% 90% 80% 70% 3 Outpatient Care 6 Housing 11 Case Managem ent 1 5 8 Food 2 7
% PLWH/A
60% 50% 40% 30% 20% 10% 0%
Outpatient medical 78.8% M edical Specialist 64.5% Co mplem Ho using entary info care 44.9% 49.1 % Rental asst 56.3% Suppo rtive ho using 25.6% CM help w/ benefits 83.5% B enefits cnsling 68.7% Intake sessio n 59.1 % Vo catio n Fo o d al vo uchers referrals 1 8.8% 81 .0% Fo o d bank 62.9% Nutritio n Delivered supmeals plement 48.1 % 27.0%
P LWH/A
Hospice 100% 90% 80% 70% Mental Health Dental 4 Substance Abuse Services Medication 10
Transportation Res Sub Ab 12
% PLWH/A
60% 50% 40% 30% 20% 10% 0%
MH 1 -1 P LWH/A 53.7% Family cnsling 1 9.3% B ereavement cnsling 1 2.9% Dental care 71 .7% SA cnsling 24.3% SA peer grp 1 9.9% SA SA family assessm cnsling nt 1 % 6.1 9.1 % M eds Reimb 57.2% Ho spice Care 7.3% SA - ResiTaxi Transdential vo uchers po rtatio n 1 3.0% 54.3% 38.2%
SA Grp 23.0%
SA 1 -1 21 .0%
100% 90% 80% 70% % PLWH/A 60% 50% 40% 30% 20% 10% 0%
Financial Asst Child Care Psychosocial
Adherence Nutritional Cnsling
Home Health Care Insurance Asst
Buddy/Companion
Client Advocacy Adult Day Care
9
Financial asst PLWH/A 59.1%
Child care 5.4%
MH group 26.2%
Peer cnsling 25.2%
Adherence suppt 22.9%
Nutrition cnsling 43.2%
Home health care 28.5%
Insurance Asst 19.5%
Buddy emtl supprt 23.0%
Buddy household 23.0%
Buddy Adult day Client Adadvocate care vocacy 15.8% 10.4% 37.8%
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Service Demand and Utilization
Participants in the survey reported whether they had asked for each of the 42 services in the past year, and whether they received the service: • With the exception of outpatient medical care, perceived need is higher than either the reported demand or utilization for each service. • Demand is usually greater than utilization, with the exception of outpatient medical care, intake, and adherence support, where they are about the same. • The demand for services follows reported need, with the exception of food vouchers and financial assistance where PLWH/A are considerably less likely to ask for them than other top ranked services. • Among services with less perceived need, PLWH/A are considerably less likely to ask for nutritional supplements, counseling, complementary care, and insurance assistance.
Service Gaps
This report highlights three gap measures: 1) what services are needed by PLWH/A but not asked for, 2) what services are asked but not received, and 3) what services are known, but not asked for. In the first instance the reason may reflect the consumer knowledge that they are not eligible, that the service is not available in the continuum of care, or it may indicate a lack of knowledge. Figure 1-34 focuses on services where there was a large difference between PLWH/A who have needed but not asked for, and asked for but not received services. It is ranked by the “need-asked” for gap. The need-ask gap reflects an expectation on the part of the consumer that the service is available, but that the system was unable to provide it. The “aware-ask” gap shows that consumers say they need but do not report asking for the service. • For the most part, consumers know what services they are eligible for. The biggest “need – ask” gap is for food services, particularly nutritional supplements, and food bank and delivered meals. • Other services with relatively large need-ask gaps are complementary care, client advocacy, benefits counseling, dental care, transportation, financial assistance and rental assistance. • For the “ask – receive” gap (services consumers ask for but do not receive), housing has by far the largest gap. More consumers ask for but do not receive housing information and rental assistance, and financial assistance. After that food vouchers and food bank have a greater than 5% gap. • The largest “know-ask” gaps are for substance abuse and mental health counseling. As noted earlier, even among IDUs, the perceived need for substance abuse services is low, and this provides further evidence that the barrier is not lack of knowledge. • Many PLWH/A who perceive a need for complementary care, do not ask for it. However, once asked for, they are fairly likely to receive it.
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There is over a 10% gap between those consumers who perceive a need but do not ask for client advocacy, benefit counseling, dental care, and transportation. In each of these instances, once consumers ask for the service most report receiving them. The opposite pattern is found for housing services. There is a substantial gap between those who ask for but do not receive housing information and rental assistance, but a smaller gap between those who need it and ask for it. Four percent (4%) of PLWH/A received outpatient medical care without asking for it, whereas three percent (3%) of them expressed a need for outpatient medical care but did not ask for it. One explanation for this discrepancy is the fact that most PLWH/A automatically seek out medical care with the knowledge they are eligible for service.
Consumers sometimes may be aware of a service, but do not ask for it. • Case management is ranked as the most needed service, yet 18% of PLWH/A who were aware of it did not ask for it. • The two services with the highest “need-ask” gap are nutritional supplements and food bank services. For nutritional supplements, 48% say they need it and 28% say they asked for it. For food bank services, 63% of PLWH/A indicated that the food bank is a need but only 49% have asked for it. Complementary care, client advocacy, delivered meals, and dental care and benefit counseling have similar “need-ask” gaps. • Certain services such as dental care and financial assistance for housing, utilities, and/or insurance premiums, although known and needed by PLWH/A, were not asked for by PLWH/A. This is likely due to eligibility constraints.
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Figure 1-34 Service Gaps*
Out-patient medical Housing info Intake session Vocational ref Insurance Asst Buddy hshld tsks Food vouchers Buddy emtll suppt Nutrition cnsling Rental asst Taxi vouchers Financial asst Transportation Benefits cnsling Dental care Delivered meals Client Advocacy Complementary care Food bank Nutrl Suppl -5% 0% 5% 10% 15% 20%
Co m p l Clien t DelivBen e- Tr an s Fin an c Taxi Nu t r it Bu d d y Fo o d Bu d d y In su r - Vo cat i In t ake Ho u s- Ou t Ren t al Den t al Nu t r l Fo o d vo u on em t ll vo u ch h sh ld an ce o n al sessio n in g p at ien f it s p o r t at ial em en Ad vo c er ed asst car e Su p p l b an k ar y asst ch er s cn slin su p p t er s t sks Asst acy m eals r ef cn slin o n in f o m ed i Ask - Receive Need - Ask 3.7% 19.9 6.2% 13.6 3.9% 13.6 0.6% 12.0 4.9% 12.0 3.5% 11.1 3.1 11.1 4.1 10.1 9.3% 10.0 5.5% 15.8 9.8% 9.8% 3.2% 9.7% 2.8% 9.4% 7.1 9.2% 3.2% 9.1 0.8% 7.9% 2.4% -2.4% 18.9 7.5% 7.5% 7.3% -3.8% 3.2%
*Services with insignificant or no perceived gaps include case management help w/ benefits, supportive housing, mental health group, Peer counseling, family counseling, medication reimbursement, home health, medical specialist, buddy advocate, Adult day care, mental health one-on-one, bereavement counseling, adherence support, substance abuse group, Residential Hospice, substance abuse counseling, substance abuse residential, Child care, substance abuse 1-1counseling, substance abuse family counseling, substance abuse assessment, substance abuse peer group.
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BARRIERS
PLWH/A were asked to rank problems on a scale ranging from “not a problem” to a “very big problem”. They ranked thirty potential problems. In Table 1-9, two analyses are presented. First is the percent who have a problem. Second, is the size of the problem. The barriers are classified into the more general categories of “organizational”, “structural, or “individual” barriers. Individual barriers are those that the PLWH/A attribute to themselves and they can hope to control it. Organizational barriers tend to be rooted in the practices and attitudes of the providers such as their procedures or the attitudes and sensitivity of their staff. Structural barriers tend to be those that are controlled through the legislative and administrative dictates of the government or other regulatory bodies.
Existence of a Barrier
As seen in Table 1-9, the largest percentage of PLWH/A report individual barriers. Over 60% of PLWH/A said that not knowing about treatment and their own state-of-mind were barriers. The size of these barriers was moderate. • Over 55% said that not knowing who to ask for services was a barrier. Among those, it was a moderately high barrier. • About 46% said that the lack of knowledge of needed services was a barrier, and for them it was a moderately high barrier. • Among structural barriers, over 50% of PLWH/A have some problem with “waiting for appointments or to see someone” and transportation. Between 40% and 50% have a problem with navigating the care system, the amount of red-tape, rules and regulations, including eligibility rules, and availability of a specialist. • On average, among structural rules and regulation barriers, none were ranked as a big barrier. Yet, for those having a problem with the lack of adequate insurance, cost, eligibility, and rules and regulations represented moderate barriers. • For the 50% of PLWH/A who noted that transportation was a problem, over forty percent (40%) said it was a big problem. The need for transportation was consistently voiced in the focus groups. • Fifty percent (50%) of PLWH/A said that waiting and navigating the system was a problem, and for them, over a third said it was a big problem. • Among organizational barriers, sensitivity of the organization, feeling like a number, and provider expertise are reported as a barrier by over 50% of PLWH/A. Among those naming these barriers, provider sensitivity is reported to be a moderate barrier. This topic was frequently discussed in the focus groups. A number of participants noted that they received excellent care from staff, particularly from physicians. However, it should be noted that there were a number of negative comments about case managers in the focus groups. • Lack of referrals and fear of losing confidentiality were also perceived as moderately high among those naming them as barriers.
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Forty percent (40%) of PLWH/A named discrimination by “the persons or organizations providing services” as a barrier and ranked it as a relatively high barrier. Sixteen percent (16%) of those with a problem said it was a big problem. In focus groups, person of color and IDUs were most likely to mention discrimination.
Severity of a Problem
Although the highest average barrier was rated as a moderate barrier, different populations reported considerably higher barriers. Important differences are highlighted below.




Overall, males were more likely to report barriers than females, but among women who reported barriers they rated them as slightly bigger than men. Men were significantly more likely to report structural problems than women, particularly red tape, rules and regulations, eligibility, and navigating the system. They were also more likely to report individual-level problems than women, including knowledge about service treatment, their own state-of-mind and physical health. Among risk groups, IDUs tended to report more problems than other risk groups, particularly individual and organizational barriers. MSM are more likely to report structural barriers particularly waiting for an appointment, red tape, and rules and regulations. Heterosexuals are less likely to report barriers than other risk groups. For those reporting barriers, MSM/IDU tend to report bigger barriers, particularly related to problems with the justice system (along with IDUs), confidentiality, insurance, and transportation. IDUs tend to report that getting along with their provider is a bigger barrier than for other risk groups. African Americans, while less likely to mention barriers, generally reported higher barriers than other ethnic populations when they were mentioned, particularly regarding individual and organizational barriers.
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Table 1-9 Types of Barriers
STRUCTURAL 0= Not a Problem, 1=Very small, 2=Small, 3=Moderate, 4=Big, 5=Very big Rules and Regulations 1. The amount of time I had to wait to get an appointment or to see someone. 2. My ability to find my way through the system. 3. There was too much paperwork or red tape. 4. There are too many rules and regulations. 5. I was not eligible for the service. 6. My lack of, or inadequate, insurance coverage. 7. I can’t afford one or more of the services. Access 8. There was no specialist who could provide the care I needed. 9. No transportation. 10. I have been denied or have been afraid to seek services due to a criminal justice matter. 11. I have been terminated or suspended from seeking services. 12. No childcare. ORGANIZATIONAL Provider Sensitivity 13. Sensitivity of the organization and person providing services to me regarding my issues and concerns. 14. The organization providing the service made me feel like a number. 15. The people providing services to me are not helpful. 16. Fear of my HIV or AIDS status being found out by others – lack of confidentiality. 17. Discrimination I experienced by the persons or organization providing the services. 18. Fear that I would be reported to immigration or other authorities. Provider Expertise 19. Experience or expertise of the person providing services to me. 20. The organization did not provide the right referrals to the services I need. 21. I do not get along with the people providing services. INDIVIDUAL Knowledge 22. Not knowing that a service or treatment was available to me. 23. Not knowing the location of the service(s). 24. Not knowing who to ask for help. 25. Not knowing what medical services I need to treat my HIV infection or AIDS. 26. Not understanding instructions for obtaining service or treatment. 27. My ability to communicate or interact with the service provider. Well-Being 28. My state of mind or mental ability to deal with the treatment. 29. My physical health has not allowed me to get to the place where the service is provided. 30. I do not believe HIV/AIDS is a problem for me that requires assistance (denial). % WITH PROBLEM % WITH BIG PROBLEM AVERAGE BARRIER SCORE
63.3% 50.1% 48.7% 45.9% 42.0% 38.8% 41.8% 42.5% 50.0% 23.8% 20.5% 16.6%
35.8% 35.2% 32.4% 35.6% 32.9% 38.1% 36.4% 26.9% 42.2% 32.7% 26.3% 18.2%
3.0 2.9 2.8 3.0 3.0 3.1 3.1 2.8 3.2 2.8 2.5 2.1
51.8% 52.5% 43.4% 42.4% 43.0% 16.0% 51.2% 41.9% 39.1%
35.1% 29.1% 24.2% 39.4% 34.2% 23.8% 26.5% 32.4% 22.3%
3.1 2.8 2.6 2.9 2.8 2.3 2.8 2.9 2.5
61.2% 56.3% 55.7% 45.9% 51.0% 35.9% 55.8% 52.7% 61.2%
38.5% 34.6% 43.2% 38.0% 25.8% 18.1% 35.6% 24.0% 34.2%
3.1 2.9 3.2 3.0 2.6 2.4 3.0 2.6 3.0
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SERVICE AND BARRIER TEMPLATES
This next section provides thumbnail representations of each service and is particularly useful for making decisions about priorities and allocations. Readers may go to the service of interest (page numbers are in the Table of Contents) and quickly review the unit of measurement and eligibility for a specific service. Each service is shown using the same page layout. At the top of each template is the name of the service followed by the total estimated PLWH/A. The estimate of 3,360 PLWH/A is used throughout these templates based on the epidemiological projections noted earlier. The next measure is the unit of service that is reported in the SEMAS system or used by the council for priorities and allocations. Following the unit of service is a description of any system-wide eligibility criteria for receiving the service. Notably, different providers may have their own additional eligibility criteria. This information is useful in understanding the continuum of care and specifically what services are provided. In future needs assessments, in order to gauge the need for the service and availability of the service, more system wide eligibility criteria might be considered. The box titled “Funding 2002-2003” is a summary of the founding sources and amounts reported during fiscal year 2002 –2003. The adjacent box, “EXPENDED AND PROJECTED,” presents the total units of service provided during 2002-2003 and the amounts projected through 2004 –2005. Because 2003-2004 information is not available, and allocation decisions have to be made for 2004-2005, those making decisions have only 2002-2003 data available. Again, some of this information was not available for the specified year and therefore spaces are left blank. Notably, this information is generally available at the overall service category level and not at the sub service level. Given the limited amount of information available at the sub-service level regarding units of service funded, provided, and projected it is not possible to present a full description of the service delivery system nor calculate its capacity. However, in all instances spaces are left for this information, so these templates can be completed as information becomes available. Below these top boxes are three graphs, and to their right a summary of the gaps measure. The graphs show the level of awareness, perceive need, reported demand, and reported utilization of different key populations of PLWH/A. The top graph shows these measures for sex/gender and ethnic/race groups. The second graph shows the four measures by risk group and the third graph shows them by stage of infection, homeless, and recently incarcerated populations. The boxes to the right of the graphs display summary gap measures based on the survey. . The “need-ask gap” is the difference between the percentage who perceive they need the service and the percentage who actually demand the service. The larger the “need-ask” gap the more likely the person was to need a service and not ask for it. This may be because the
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consumer is aware that they are not eligible for the service or it may reflect a frustration in trying to receive a service. The “ask-receive gap” is the difference between the percentage of PLWH/A who asked for the service and received it. It is a useful in determining how well the system processes PLWH/A who ask for services and how well PLWH/A understand the eligibility criteria. Following the gap tables there is a box with the summary of the top barriers reported for each subservice. Finally, at the right bottom corner of each template there is box highlighting specific notes and considerations for each sub-service. This space is left for readers to add notes and observations that may be useful of them in assessing the service needs, gaps, and barriers.
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Outpatient Medical Care
Service Unit and Eligibility
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 20 minute visit Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific.
EXPENDED AND PROJECTED EXPENDED PROJECTED UNITS 2002-2003 2004-2005 Number duplicated 5,310 Number unduplicated 757 Average Used 7 Expenditure $769,950
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00% 80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 94.2% 92.0% 96.0% 89.8% 89.9% 93.8% NEED 80.2% 72.4% 80.5% 72.6% 81.5% 78.8%
AMOUNT FUNDED
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
ASK 77.2% 68.4% 80.0% 65.4% 75.9% 75.6%
RECEIVE 80.7% 73.6% 81.9% 73.0% 82.2% 79.4%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • • • • •
3.2% 3.1% 4.0% 2.8% 2.0% 3.7% 4.7% 0.5% 7.2% 5.6% 5.2% 6.5% 4.6% 4.6% 5.4% 8.6%
-3.8% -3.5% -5.2% -3.4% -2.4% -6.5% -3.5% -1.9% -7.6% -6.3% 62.1% 74.0% 70.8% 80.9% 73.5% 64.5%
1 00% 80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 96.6% 89.7% 91.6% 89.4% 93.8% NEED 81.1% 76.8% 80.0% 72.1% 78.8% ASK 78.3% 74.8% 76.3% 67.3% 75.6% RECEIVE 81.6% 77.2% 82.9% 70.8% 79.4%
3 out of 42
Not knowing about service Not provided proper referrals Length of time for an appointment Individual physical or mental health Cost of service/ inadequate insurance
1 00% 80% 60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 90.4% 93.5% 93.8% 90.8% 87.8% 89.2% 93.8% NEED 67.3% 80.5% 75.4% 85.5% 78.9% 73.1% 78.8% ASK 62.1% 74.0% 70.8% 80.9% 73.5% 64.5% 75.6% RECEIVE 69.9% 68.3% 76.6% 75.4% 88.9% 73.9% 79.4%
Notes
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Medical Specialist
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 20 minute visit Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific.
EXPENDED AND PROJECTED EXPENDED PROJECTED UNITS 2002-2003 2004-2005
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
Number duplicated Number unduplicated Average Used Expenditure
171 27 6 $17,368
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 84.2% 73.5% 84.9% 74.7% 81 .8% 82.3% NEED 67.1 % 53.9% 71.0% 51.5% 63.4% 64.8% ASK 62.2% 46.6% 67.0% 44.0% 58.5% 59.4% RECEIVE 59.7% 51.5% 62.5% 48.4% 60.2% 58.3%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • •
5.3% 4.9% 7.3% 5.1% 5.2% 2.3% 8.3% 4.0% 7.5% 4.9% 5.8% 5.9% 6.2% 5.6% 5.2% 10.8%
1.2% 2.5% -4.9% 2.9% -1.2% -1.9% 0.1% 4.5% -4.5% -1.7% 3.5% 12.5% 3.2% 15.1% -25.6% -24.2%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 90.6% 72.7% 69.1 % 74.2% 82.3% NEED 75.9% 52.0% 49.1% 52.1% 64.8% ASK 70.8% 46.7% 46.8% 43.8% 59.4% RECEIVE 67.8% 47.9% 48.7% 43.6% 58.3%
6 out of 42
Not knowing about service Not provided proper referrals
1 00%

Notes
% of PLWH/A
80% 60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 68.3% 75.3% 83.1 % 83.2% 67.3% 64.5% 82.3% NEED 39.4% 53.9% 60.0% 73.1 % 46.3% 38.7% 64.8% ASK 33.7% 48.1% 53.8% 67.4% 41 .1% 28.0% 59.4% RECEIVE 30.1% 35.6% 50.6% 52.3% 66.7% 52.2% 58.3%
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Complementary Care
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility: 3,360 vendor paid therapy dollar Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific; Distribution among maximum number of clients; First come, first serve with limited availability; Limitations may be established.
EXPENDED AND PROJECTED EXPENDED PROJECTED UNITS 2002-2003 2004-2005 Number duplicated 49,032 37,087 Number unduplicated 138 138 Average Used 355 269 Expenditure $63,442 $50,602
FUNDING 2002-2003
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED $47,296
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo African Am Lat ino Tot al AWARE 57.0% 58.5% 58.4% 59.7% 46.0% 57.2% NEED 45.6% 41.6% 51.6% 36.5% 25.7% 44.9% ASK 31.7% 29.6% 34.4% 28.9% 21.4% 31.3% RECEIVE 26.8% 30.6% 30.3% 27.8% 15.1 % 27.4%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • • • • •
13.6% 13.9% 11.9% 16.4% 7.5% 8.7% 12.6% 17.2% 7.7% 4.3% 4.8% 11.7% 9.2% 17.3% 12.2% 8.6%
3.9% 4.9% -1.0% 6.4% 3.2% 2.4% -2.2% 4.1% 1.1% 6.3% 1.7% 6.1% 10.7% -1.5% 9.3% -7.9%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM /IDU IDU Hetero Total AWARE 59.4% 60.5% 49.9% 55.0% 57.2% NEED 52.1% 39.5% 38.3% 31.7% 44.9% ASK 35.6% 32.0% 29.6% 1 9.1% 31.3% RECEIVE 29.2% 28.8% 27.2% 21.3% 27.4%
16 out of 42
Not knowing about service Length of time for an appointment Red tape Lack of funding for service Variable need
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp A IDS asymp A IDS symp Homeless Rec Inc Tot al AWARE 58.7% 53.2% 60.0% 53.8% 51 .0% 57.0% 57.2% NEED 26.9% 39.0% 44.6% 48.1 % 32.7% 31.2% 44.9% ASK 22.1% 27.3% 35.4% 30.8% 20.4% 22.6% 31.3% RECEIVE 20.4% 21 .2% 24.7% 32.3% 11 % .1 30.4% 27.4%
Notes
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Housing Information
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific.
EXPENDED AND PROJECTED
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
UNITS Number duplicated Number unduplicated Average Used Expenditure
EXPENDED PROJECTED 2002-2003 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 69.2% 74.5% 70.0% 71 .6% 64.2% 70.1 % NEED 48.9% 49.4% 45.2% 56.4% 54.2% 49.0% ASK 40.4% 47.4% 41 % .1 48.1 % 36.9% 41 .7% RECEIVE 1 9.8% 36.8% 1 9.8% 33.4% 1 7.4% 22.8%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank Barriers
• • • • •
7.3% 8.5% 2.0% 4.2% 10.3% 10.9% 11.8% 4.1% 8.3% 17.3% 10.6% 7.8% 6.2% 10.7% 9.5% 11.8%
18.9% 20.6% 10.6% 22.4% 26.1% 12.6% 8.8% 21.3% 14.7% 19.5% 8.5% 29.2% -0.7% 24.2% 42.0% 16.8%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 70.7% 77.5% 65.6% 67.4% 70.1% NEED 45.3% 53.5% 56.4% 51 .0% 49.0% ASK 41 .0% 43.2% 45.5% 39.2% 41 .7% RECEIVE 1 8.6% 1 7.1% 32.9% 30.4% 22.8%
14 out of 42
Not knowing about service Long waiting list for housing Service is unavailable – cannot find housing Service providers not helpful Eligibility criteria – e.g., citizenship, income
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 72.1 % 77.9% 70.8% 69.5% 72.1 % 71 .0% 70.1 % NEED 48.1 % 61.0% 43.1 % 61.1 % 62.6% 63.4% 49.0% ASK 37.5% 53.2% 36.9% 50.4% 53.1% 51.6% 41 .7% RECEIVE 29.0% 24.0% 37.7% 26.2% 11 .1% 34.8% 22.8%
• Individual, physical or mental health Notes
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Rental Assistance
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 Vendor rent dollar Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific.
EXPENDED AND PROJECTED EXPENDED PROJECTED UNITS 2002-2003 2004-2005 Number duplicated $17,990
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
Number unduplicated Average Used Expenditure
72 250 $19,789
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 75.3% 72.8% 74.9% 67.3% 89.9% 74.8% NEED 56.9% 53.0% 51.9% 63.8% 58.8% 56.2% ASK 46.0% 48.1% 44.7% 50.7% 46.6% 46.4% RECEIVE 29.2% 37.5% 27.0% 38.3% 36.0% 30.7%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated
9.8% 10.8% 4.9% 7.7% 13.4% 10.7% 13.0% 7.2% 13.1% 12.2% 8.7% 9.1% 7.7% 13.7% 11.6% 14.0%
15.8% 16.9% 10.6% 19.4% 14.5% 11.8% 8.7% 17.8% 12.4% 10.6% 19.2% 20.6% 4.8% 12.7% 37.2% -15.7%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 78.1% 75.2% 70.3% 68.5% 74.8% NEED 55.0% 61.1% 64.0% 49.8% 56.2% ASK 47.3% 47.6% 53.3% 36.7% 46.4% RECEIVE 27.9% 33.2% 41.5% 28.1% 30.7%
Consumer Rank
Barriers •
11 out of 42
Not knowing about service Insufficient funding available for service Eligibility criteria, e.g., income restrictions
1 00% 80%
• •
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 71.2% 77.9% 70.8% 77.9% 68.7% 66.7% 74.8% NEED 55.8% 62.3% 55.4% 63.4% 59.9% 54.8% 56.2% ASK 47.1% 53.2% 47.7% 49.6% 48.3% 40.9% 46.4% RECEIVE 28.0% 32.7% 42.9% 36.9% 1 1.1% 56.5% 30.7%
Notes
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Supportive Housing
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility: 3,360 Vendor lodging dollar Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific.
EXPENDED AND PROJECTED EXPENDED PROJECTED UNITS 2002-2003 2004-2005 Number duplicated 12,141 Number unduplicated 31 Average Used 392 Expenditure $13,355
FUNDING 2002-2003
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Latino Total AWARE 59.6% 64.7% 64.1% 59.3% 41.7% 60.5% NEED 23.7% 35.7% 21.8% 35.6% 20.4% 25.8% ASK 16.0% 31.8% 15.2% 28.1 % 17.4% 18.8% RECEIVE 13.5% 27.7% 12.5% 23.8% 16.9% 16.0%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
7.0% 7.7% 3.9% 7.6% 8.4% 8.8% 2.8% 6.7% 7.6% 3.0% 5.8% 3.9% 4.6% 9.9% 8.8% 7.5%
2.8% 2.5% 4.2% 1.4% 10.0% -0.5% 5.5% 2.7% 4.3% 0.5% 5.9% 16.5% -14.2% 2.9% 32.0% -8.9%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 62.5% 67.1% 57.1% 53.2% 60.5% NEED 22.1 % 33.2% 27.1 % 31.3% 25.8% ASK 14.6% 24.8% 18.4% 28.5% 18.8% RECEIVE 13.2% 14.8% 18.8% 23.0% 16.0%
23 out of 42
Barriers • •
Not knowing about service Not interested in this type of housing
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 60.6% 62.3% 63.1% 59.5% 53.7% 49.5% 60.5% NEED 28.8% 37.7% 21 .5% 29.8% 40.8% 29.0% 25.8% ASK 23.1% 33.8% 16.9% 19.8% 32.0% 21 .5% 18.8% RECEIVE 17.2% 17.3% 31.2% 16.9% 0.0% 30.4% 16.0%
Notes
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Case Management
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 15 minute interval Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific.
EXPENDED AND PROJECTED EXPENDED PROJECTED UNITS 2002-2003 2004-2005 Number duplicated 40,987 Number unduplicated 879 Average Used 78 Expenditure $698,313
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 95.6% 89.7% 97.6% 86.8% 94.9% 94.5% NEED 84.1% 80.8% 87.3% 76.6% 82.7% 83.5% ASK 76.7% 74.6% 80.6% 68.8% 76.4% 76.3% RECEIVE 73.1% 71.9% 75.1% 69.0% 73.0% 72.9%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank Barriers
• • •
7.2% 7.5% 6.1% 7.9% 7.2% 8.9% 3.6% 6.7% 7.9% 6.3% 11.5% 3.9% 3.1% 5.3% 4.1% 7.5% 1 out of 42
3.4% 3.6% 2.7% 4.6% -0.5% 1.3% 4.2% 5.5% -0.3% 3.4% -9.5% 14.2% -4.8% 14.7% -11.3% -6.2%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 97.7% 94.8% 90.5% 88.1% 94.5% NEED 86.3% 84.3% 79.5% 77.9% 83.5% ASK 78.4% 77.1% 70.5% 74.3% 76.3% RECEIVE 73.8% 77.6% 69.2% 70.1% 72.9%
Case managers are not helpful, they are rude or insensitive Eligibility criteria, i.e., income restrictions Not enough funding for needed benefits, e.g., bus passes, food vouchers Staff turnover – lack of continuity Hard to navigate system Not knowing about service
1 00% 80%
• • •
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 88.3% 90.9% 92.3% 96.9% 90.4% 94.6% 94.5% NEED 74.0% 84.4% 72.3% 89.3% 81.6% 79.6% 83.5% ASK 62.5% 80.5% 69.2% 84.0% 77.6% 72.0% 76.3% RECEIVE 72.0% 66.3% 74.0% 69.2% 88.9% 78.3% 72.9%

Notes
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Benefits Counseling
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific.
EXPENDED AND PROJECTED
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00% 80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 80.7% 72.6% 81.9% 73.5% 75.9% 79.3% NEED 69.3% 66.0% 69.3% 64.7% 74.7% 68.7%
AMOUNT FUNDED
UNITS Number duplicated Number unduplicated Average Used Expenditure
EXPENDED 2002-2003
PROJECT ED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.) Ask Receiv Need – ed Population Ask Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • •
ASK 59.0% 51.7% 59.3% 50.9% 65.7% 57.7%
RECEIVE 54.7% 54.4% 53.6% 53.1% 65.7% 54.6%
11.1% 10.4% 14.3% 10.3% 8.8% 14.8% 11.5% 10.0% 13.8% 9.0% 14.4% 7.8% 9.2% 14.5% 10.2% 17.2%
3.1% 4.3% -2.6% 4.6% 2.9% -1.1% 2.2% 5.7% -2.1% 0.0% 0.9% 7.8% -1.2% 9.5% -0.5% 10.4%
1 00% 80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 83.7% 78.3% 68.9% 75.3% 79.3% NEED 72.1% 58.0% 64.5% 69.0% 68.7% ASK 61.7% 49.2% 49.7% 57.5% 57.7% RECEIVE 57.2% 46.3% 50.8% 55.3% 54.6%
5 out of 42
Not knowing about service Counselors do not volunteer information
1 00% 80% 60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 72.1% 72.7% 73.4% 83.2% 73.5% 73.1% 79.3% NEED 61.5% 63.6% 60.0% 73.3% 65.3% 62.4% 68.7% ASK 47.1% 55.8% 50.8% 58.8% 55.1% 45.2% 57.7% RECEIVE 46.2% 48.1% 51.9% 49.2% 55.6% 34.8% 54.6%

Notes
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Intake Session
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
Number unduplicated Average Used Expenditure GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Latino Total AWARE 87.6% 76.0% 89.3% 78.1 % 82.7% 85.5% NEED 58.4% 62.9% 58.2% 58.9% 63.7% 59.2% ASK 51.8% 51.5% 51.2% 51.3% 54.7% 51.8% RECEIVE 53.2% 58.3% 52.7% 54.2% 59.1% 54.1%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
7.5% 6.6% 11.4% 6.8% 9.3% 6.0% 9.6% 7.1% 7.6% 9.0% 10.6% 10.4% 1.5% 9.9% 8.2% 9.7%
-2.4% -1.4% -6.8% -0.9% -3.8% -4.1% -4.4% -1.5% -2.9% -4.3% -10.6% 1.9% 0.8% -1.2% -8.8% -8.2%
00% 1
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 89.6% 89.1% 80.2% 75.4% 85.5% NEED 59.3% 59.5% 54.5% 62.9% 59.2% ASK 52.5% 50.2% 48.5% 53.4% 51.8% RECEIVE 53.4% 54.0% 52.7% 57.7% 54.1%
8 out of 42
Barriers •
Not knowing about service Not provided proper referrals
1 00% 80%

% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 78.8% 80.5% 92.3% 87.8% 81.6% 83.9% 85.5% NEED 54.8% 62.3% 56.9% 67.2% 66.0% 62.4% 59.2% ASK 44.2% 51.9% 55.4% 57.3% 57.8% 52.7% 51.8% RECEIVE 54.8% 50.0% 54.5% 58.5% 66.7% 60.9% 54.1 %
Notes
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Vocational Referrals
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific.
EXPENDED AND PROJECTED EXPENDED PROJECTED UNITS 2002-2003 2004-2005 Number duplicated Number unduplicated Average Used Expenditure
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo African Am Lat ino Tot al AWARE 40.5% 41.8% 44.3% 41.4% 22.9% 40.7% NEED 18.0% 22.4% 18.4% 20.9% 19.0% 18.8% ASK 10.5% 14.9% 10.5% 14.1% 10.1% 11.3% RECEIVE 7.6% 1 4.8% 7.3% 1 2.9% 8.4% 8.8%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • • •
7.5% 7.5% 7.5% 8.1% 7.6% 6.6% 6.6% 7.9% 6.9% 8.9% 2.9% 16.7% 7.7% 6.1% 7.4% 5.4%
2.4% 2.9% 0.2% 4.2% -1.2% 0.2% 1.3% 3.2% 1.2% 1.6% 2.2% 1.9% -0.9% -2.4% 13.7% -5.5%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Hetero Total AWARE 41.9% 41 .7% 34.7% 42.1% 40.7% NEED 18.5% 13.2% 18.3% 23.9% 18.8% ASK 1 0.4% 5.6% 11.7% 1 7.3% 1 1.3% RECEIVE 6.2% 6.8% 11 .6% 16.0% 8.8%
34 out of 42
Not knowing about service Do not need service Physical health – disabled
1 00% 80%

Notes
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 45.2% 33.8% 46.2% 37.4% 37.4% 34.4% 40.7% NEED 11 .5% 27.3% 18.5% 17.6% 21 .1% 12.9% 18.8% ASK 8.7% 10.5% 1 0.8% 11.5% 13.7% 7.5% 11.3% RECEIVE 6.5% 8.7% 1 1.7% 13.8% 0.0% 13.0% 8.8%
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Food bank
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility: 3,360 1 food bag Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific; To be distributed among the maximum number of most at-risk clients.
EXPENDED AND PROJECTED EXPENDED PROJECTED UNITS 2002-2003 2004-2005 Number duplicated 732 Number unduplicated 97 Average Used 8 Expenditure $6,652
FUNDING 2002-2003
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo African Am Latino Tot al AWARE 79.1% 84.9% 81.8% 77.6% 73.9% 80.1% NEED 62.5% 66.0% 65.0% 62.7% 56.5% 63.1 % ASK 48.4% 54.6% 48.7% 52.9% 45.9% 49.5% RECEIVE 41.3% 52.2% 43.0% 48.1 % 31.1 % 43.3%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank Barriers
• • • • •
13.6% 14.1% 11.4% 16.9% 11.1% 9.5% 8.8% 16.4% 9.8% 10.6% 10.6% 10.4% 10.8% 9.5% 10.5% 12.4%
6.2% 7.1% 2.4% 7.7% 5.7% 4.8% 3.5% 5.6% 4.8% 14.8% 5.1% 14.2% -3.4% 13.1% 4.0% -5.4%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Hetero Total AWARE 78.6% 81.6% 79.7% 84.1% 80.1% NEED 66.4% 43.7% 65.2% 63.3% 63.1 % ASK 49.5% 32.6% 55.7% 54.5% 49.5% RECEIVE 41 .9% 26.9% 50.9% 51 .0% 43.3%
7 out of 42
Not knowing about service Transportation to food bank Lack of funding for service Poor quality of food Eligibility criteria
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 77.7% 80.5% 84.6% 80.2% 79.6% 83.9% 80.1 % NEED 54.8% 64.9% 55.4% 65.6% 70.1% 59.1% 63.1% ASK 44.2% 54.5% 44.6% 56.2% 59.6% 46.7% 49.5% RECEIVE 39.1 % 40.4% 48.1 % 43.1 % 55.6% 52.2% 43.3%

Notes
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Food vouchers
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility: 3,360 Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific; To be distributed among the maximum number of most at-risk clients; No purchase of alcohol, tobacco, or game of chance.
EXPENDED AND PROJECTED EXPENDED PROJECTED UNITS 2002-2003 2004-2005 Number duplicated Number unduplicated Average Used Expenditure
FUNDING 2002-2003
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo African Am Latino Tot al AWARE 90.0% 91.5% 94.8% 81.9% 86.7% 90.3% NEED 80.2% 84.8% 83.2% 79.7% 77.2% 81.0% ASK 70.7% 76.9% 73.8% 70.3% 67.1% 71.8% RECEIVE 63.1% 71.7% 67.1% 63.5% 58.7% 64.7%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • • • •
9.2% 9.5% 7.9% 7.7% 15.3% 8.5% 10.8% 9.4% 9.3% 10.1% 8.9% 15.6% 6.2% 7.7% 9.7% 11.8%
7.1% 7.6% 5.2% 7.6% 4.3% 9.4% 5.4% 6.7% 6.8% 8.5% 5.7% 2.5% -0.1% 13.1% 20.5% 4.7%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM /IDU IDU Hetero Total AWARE 90.4% 93.2% 87.0% 90.7% 90.3% NEED 79.5% 81.1% 82.3% 84.7% 81.0% ASK 71.8% 65.8% 73.7% 73.9% 71.8% RECEIVE 64.2% 61.5% 64.3% 68.5% 64.7%
2 out of 42
Do not know where to go for the service Limited availability of food vouchers Not enough funding for service Too many rules and regulations
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 85.6% 83.1% 92.3% 90.1% 88.4% 90.3% 90.3% NEED 79.8% 84.4% 69.2% 82.3% 85.7% 81.7% 81.0% ASK 70.9% 68.8% 63.1% 74.6% 76.0% 69.9% 71.8% RECEIVE 65.2% 66.3% 63.2% 61.5% 55.6% 65.2% 64.7%

Notes
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Delivered meals
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 1 home delivered meal Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific; To be distributed among the maximum number of most at-risk clients.
EXPENDED AND PROJECTED EXPENDED PROJECTED UNITS 2002-2003 2004-2005 Number duplicated 694 Number unduplicated 92 Average Used 8 Expenditure $6,989
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo African Am Lat ino Tot al AWARE 50.7% 55.5% 54.2% 45.7% 48.9% 51.5% NEED 25.9% 30.6% 26.6% 27.7% 29.4% 26.8% ASK 14.4% 16.4% 13.7% 16.4% 18.2% 14.7% RECEIVE 8.2% 1 % 7.1 7.3% 1 % 5.1 1 1.4% 9.8%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • • •
12.0% 11.6% 14.2% 11.4% 8.7% 14.5% 13.7% 12.9% 11.4% 11.2% 6.7% 18.2% 6.2% 13.7% 15.0% 7.5%
4.9% 6.1% -0.7% 7.1% 0.4% 3.6% 2.4% 6.4% 1.3% 6.8% 8.3% 3.7% 0.9% 6.0% 3.9% -10.9%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Hetero Total AWARE 47.2% 59.5% 45.9% 65.2% 51.5% NEED 24.7% 24.4% 25.3% 36.1 % 26.8% ASK 1 3.2% 1 5.6% 1 0.9% 22.3% 1 4.7% RECEIVE 6.2% 15.2% 7.3% 20.0% 9.8%
21 out of 42
Not knowing about service Not eligible Language barrier
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 51 .5% 42.9% 63.1 % 53.4% 47.3% 48.4% 51 .5% NEED 18.3% 32.5% 20.0% 30.5% 29.9% 14.0% 26.8% ASK 11.5% 1 4.3% 1 3.8% 1 6.8% 1 5.0% 6.5% 1 4.7% RECEIVE 3.2% 10.6% 13.0% 10.8% 1 1.1% 17.4% 9.8%
Notes
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Nutrition Supplement
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 1 nutritional supplement pack Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific; To be distributed among the maximum number of most at-risk clients
EXPENDED AND PROJECTED EXPENDED PROJECTED UNITS 2002-2003 2004-2005 Number duplicated 156 Number unduplicated 31 Average Used 5 Expenditure $6,864
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Latino Total AWARE 50.0% 56.3% 51.9% 52.1 % 50.2% 51.1 % NEED 48.3% 47.4% 50.1 % 44.3% 53.8% 48.1 % ASK 27.2% 33.2% 26.5% 31.6% 34.6% 28.2% RECEIVE 23.4% 30.0% 23.0% 27.3% 30.2% 24.5%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • • •
19.9% 21.1% 14.2% 22.2% 19.1% 16.2% 16.5% 23.6% 12.6% 19.2% 14.4% 17.8% 9.2% 18.8% 13.4% 11.6%
3.7% 3.8% 3.2% 4.2% -1.4% 4.3% 4.7% 3.5% 4.3% 4.4% 5.4% 6.8% 1.7% 4.6% 10.0% -13.0%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 47.2% 59.3% 48.9% 59.9% 51.1% NEED 48.2% 40.8% 50.0% 50.8% 48.1 % ASK 26.0% 21.7% 33.8% 34.3% 28.2% RECEIVE 21.8% 23.1% 29.5% 29.6% 24.5%
14 out of 42
Not knowing about service Not eligible – service not provided Quality of supplements
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 54.8% 42.9% 63.1% 52.7% 51 .0% 52.7% 51.1% NEED 41.3% 46.8% 36.9% 51 .1% 45.6% 33.3% 48.1% ASK 26.9% 28.9% 27.7% 32.3% 32.2% 21.7% 28.2% RECEIVE 21.5% 22.1 % 26.0% 27.7% 22.2% 34.8% 24.5%
Notes
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Mental Health One on One
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility: 3,360 1 hour (psychological) Diagnosis of HIV infection or family member of, EMA resident, no income to 300% of Federal Poverty Level, Agency specific; RW to be used only as a last resort on a limited, goal-focused basis.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 1,716 Number unduplicated 299 Average Used 6 Expenditure $105,315
FUNDING 2002-2003
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 84.9% 75.0% 88.4% 71.8% 79.3% 83.2% NEED 52.7% 59.4% 59.8% 44.3% 46.0% 53.9% ASK 49.6% 51.9% 56.6% 39.4% 41.8% 50.0% RECEIVE 48.4% 46.9% 56.5% 34.8% 32.1% 48.1%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • • • •
3.9% 3.1% 7.5% 3.4% 8.7% 3.3% 3.2% 3.2% 4.9% 4.2% 4.8% 7.8% 0.0% 5.8% 5.4% 4.3%
1.8% 1.2% 4.9% 0.3% 0.8% 7.6% 2.1% 0.0% 4.6% 9.7% -2.5% 12.1% 3.8% 7.3% 1.1% 19.1%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 88.9% 77.9% 72.7% 78.0% 83.2% NEED 54.2% 65.8% 49.7% 49.0% 53.9% ASK 50.9% 57.1% 46.4% 45.8% 50.0% RECEIVE 50.5% 56.3% 38.8% 43.7% 48.1%
13 out of 42
Not knowing about service Length of time for appointment -overbooked No Spanish services available Red tape
1 00% 80%
% of PLWH/A

Notes
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al
AWARE 73.1% 75.3% 81.5% 84.0% 74.8% 68.8% 83.2%
NEED 44.2% 54.5% 49.2% 57.7% 51.0% 49.5% 53.9%
ASK 39.4% 46.8% 49.2% 51.9% 45.6% 45.2% 50.0%
RECEIVE 41.9% 34.6% 45.5% 44.6% 44.4% 26.1% 48.1%
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Family Counseling
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility: 3,360 1 hour (family) Diagnosis of HIV infection or family member of, EMA resident, no income to 300% of Federal Poverty Level, Agency specific; RW to be used only as a last resort on a limited, goal-focused basis.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 197 Number unduplicated 1 Average Used 197 Expenditure $8,722
FUNDING 2002-2003
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo African Am Latino Tot al AWARE 56.5% 57.7% 60.6% 53.1% 47.6% 56.7% NEED 16.7% 30.0% 19.2% 21.4% 13.4% 19.1 % ASK 11.6% 22.1% 1 3.9% 1 5.4% 5.8% 1 3.5% RECEIVE 8.5% 21.0% 10.4% 14.0% 3.7% 10.8%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
5.6% 5.1% 7.9% 5.5% 5.6% 6.4% 5.2% 5.3% 6.0% 7.6% 2.9% 13.2% -1.5% 7.6% 6.8% 7.6%
2.7% 3.1% 1.1% 3.3% 6.4% 1.3% 0.0% 3.5% 1.4% 2.1% 7.1% 0.2% 9.5% -3.9% 4.0% 5.4%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Hetero Total AWARE 59.8% 49.6% 47.4% 60.0% 56.7% NEED 16.7% 25.7% 18.6% 22.7% 19.1 % ASK 1 1.2% 20.1% 1 2.2% 1 7.5% 1 3.5% RECEIVE 7.9% 13.7% 10.9% 17.5% 10.8%
33 out of 42
Barriers • •
Not knowing about service Hours of operation
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 52.4% 46.8% 64.6% 54.2% 45.9% 42.4% 56.7% NEED 16.5% 25.0% 18.5% 19.1% 21 .9% 17.4% 19.1% ASK 1 3.6% 11.8% 20.0% 11.5% 15.1% 9.8% 13.5% RECEIVE 6.5% 1 1.7% 1 0.5% 1 5.4% 1 % 1.1 4.3% 10.8%
Notes
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Bereavement counseling
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility: 3,360 Diagnosis of HIV infection or family member of, EMA resident, no income to 300% of Federal Poverty Level, Agency specific; RW to be used only as a last resort on a limited, goalfocused basis.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated
FUNDING 2002-2003
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
Number unduplicated Average Used Expenditure GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo African Am Lat ino Tot al AWARE 45.6% 46.6% 47.9% 46.4% 35.4% 45.8% NEED 10.0% 26.4% 10.3% 20.1 % 1 1.3% 12.9% ASK 7.2% 17.5% 7.7% 12.7% 8.0% 9.0% RECEIVE 4.6% 1 7.5% 5.1 % 1 2.4% 3.8% 6.9%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
3.9% 2.8% 8.9% 2.1% 5.6% 7.0% 5.5% 2.6% 7.4% 3.3% 1.0% 9.1% 3.1% 6.1% 3.4% 4.3%
2.1% 2.6% 0.0% 3.7% 0.8% 0.0% 0.0% 2.6% 0.3% 4.2% 4.0% -1.5% 4.5% -2.4% -0.2% 3.2%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Hetero Total AWARE 46.2% 39.6% 36.3% 56.9% 45.8% NEED 9.2% 13.2% 14.5% 22.6% 12.9% ASK 7.2% 7.6% 7.6% 1 7.0% 9.0% RECEIVE 3.5% 6.8% 7.6% 17.0% 6.9%
38 out of 42
Barriers •
Not knowing about service
1 00% 80%

Notes
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 51.0% 33.8% 52.3% 38.9% 35.4% 35.5% 45.8% NEED 12.5% 18.2% 15.4% 13.0% 14.3% 11 .8% 12.9% ASK 11.5% 9.1% 1 2.3% 6.9% 1 0.9% 7.5% 9.0% RECEIVE 7.5% 10.6% 7.8% 9.2% 1 % 1.1 4.3% 6.9%
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Dental Care
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 Encounter Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 1,514 Number unduplicated 305 Average Used 5 Expenditure $155,963
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED $166,171
PROJECTED 2004-2005 1692 341 5 $179,479
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Total AWARE 84.9% 82.0% 86.7% 78.0% 85.3% 84.4% NEED 75.7% 53.3% 75.8% 59.6% 72.3% 71.7% ASK 62.6% 51 .1% 64.6% 51 .5% 61 .4% 60.6% RECEIVE 59.2% 47.3% 62.3% 47.9% 52.3% 57.1 %
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • • • •
11.1% 13.0% 2.2% 13.0% 19.4% 7.4% 3.2% 11.2% 8.0% 10.9% 10.2% 7.8% 9.2% 14.9% 9.2% 9.7% 4 out of 42
3.5% 3.4% 3.8% 0.8% 8.5% 8.9% 4.1% 2.4% 3.6% 9.1% -1.3% 8.1% 16.3% 2.0% -2.5% 14.6%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM /IDU IDU Het ero Tot al AWARE 89.1 % 76.0% 80.2% 78.6% 84.4% NEED 80.2% 69.7% 67.0% 51.1% 71.7% ASK 67.1% 50.3% 59.6% 47.9% 60.6% RECEIVE 66.4% 41 .8% 50.7% 43.8% 57.1%
Length of time for an appointment Insufficient coverage Transportation Not knowing about service
1 00% 80%
% of PLWH/A

Notes
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 79.6% 79.2% 87.7% 82.2% 74.7% 79.6% 84.4% NEED 57.3% 58.4% 72.3% 76.9% 62.3% 63.4% 71.7% ASK 47.1 % 50.6% 63.1 % 62.0% 53.1 % 53.8% 60.6% RECEIVE 48.4% 42.6% 46.8% 60.0% 55.6% 39.1% 57.1%
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Substance abuse counseling
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 1 hour outpatient counseling Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 404 Number unduplicated 61 Average Used 7 Expenditure $18,180
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Total AWARE 79.9% 77.3% 82.6% 73.6% 73.1% 79.5% NEED 22.5% 32.4% 22.1 % 31 .2% 17.1 % 24.3% ASK 20.7% 30.1% 20.4% 29.5% 1 7.0% 22.4% RECEIVE 20.7% 30.6% 20.1% 29.7% 1 5.3% 22.5%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • • • • •
1.9% 1.8% 2.3% 1.2% 4.8% 1.0% 3.0% 1.7% 1.7% 0.1% 2.9% 5.2% -1.5% 0.8% 4.8% 7.5% 25 out of 42
-0.1% 0.0% -0.4% -0.1% 2.0% -1.6% 0.0% 0.3% -0.1% 1.8% -12.5% 6.3% -7.9% 2.1% 28.3% 17.0%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Hetero Total AWARE 79.4% 88.5% 76.9% 76.0% 79.5% NEED 1 6.7% 36.8% 37.3% 28.5% 24.3% ASK 15.5% 32.0% 36.3% 25.5% 22.4% RECEIVE 1 5.6% 30.0% 37.9% 25.5% 22.5%
Do not need service - sober Not knowing about service Limited availability of detox beds Discrimination toward PLWH/A Lack of trust, fear of loss of confidentiality
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 77.7% 71 .4% 80.0% 83.1 % 78.2% 77.4% 79.5% NEED 29.1% 37.7% 23.1% 27.5% 44.2% 46.2% 24.3% ASK 26.2% 32.5% 24.6% 26.7% 39.5% 38.7% 22.4% RECEIVE 38.7% 26.2% 32.5% 24.6% 11 .1% 21 .7% 22.5%
Notes
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Substance abuse assessment
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 1 addiction assessment Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 100 Number unduplicated 63 Average Used 2 Expenditure $6,210
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Total AWARE 59.8% 57.4% 61.4% 57.1% 46.9% 59.4% NEED 13.8% 26.7% 12.5% 27.7% 9.9% 16.1% ASK 13.0% 24.5% 11.6% 24.5% 11.1% 15.1% RECEIVE 13.3% 23.0% 11.7% 23.4% 8.8% 15.1%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
1.0% 0.8% 2.2% -0.3% 5.7% 2.4% 1.2% 0.9% 3.2% -1.3% 3.9% 1.3% 0.0% 0.8% 2.0% 2.2%
0.0% -0.3% 1.5% -0.3% 0.8% 0.7% 0.0% -0.1% 1.1% 2.3% -8.3% 1.2% 0.8% -4.0% 16.8% 6.2%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Hetero Total AWARE 57.2% 65.5% 56.3% 65.2% 59.4% NEED 9.9% 24.0% 23.2% 24.6% 16.1% ASK 10.2% 18.4% 20.8% 23.4% 15.1% RECEIVE 10.5% 17.6% 20.1% 23.4% 15.1%
35 out of 42
Barriers •
Not knowing about service
1 00% 80%

Notes
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 59.8% 51.9% 60.0% 63.4% 57.8% 61.3% 59.4% NEED 22.5% 22.1% 21.5% 16.8% 29.9% 30.1% 16.1% ASK 18.6% 20.8% 21.5% 16.0% 27.9% 28.0% 15.1% RECEIVE 26.9% 19.6% 20.8% 20.0% 11.1% 21.7% 15.1%
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Substance abuse one-on-one counseling
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility: 3,360 Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific; if unable to participate in federal, state, or local programs; provided funding is available for extension periods.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated Number unduplicated Average Used Expenditure
FUNDING 2002-2003
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo African Am Lat ino Total AWARE 71.8% 58.8% 73.8% 59.3% 65.2% 69.5% NEED 19.7% 27.0% 18.4% 28.1% 18.5% 21.0% ASK 18.9% 21.7% 17.7% 24.9% 18.0% 19.4% RECEIVE 17.2% 21.7% 15.7% 23.5% 15.7% 18.0%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • • • • •
1.6% 0.7% 5.3% 0.7% 2.1% 4.7% 1.2% 0.7% 3.2% 0.5% 1.9% 3.9% 0.0% 3.1% 4.1% 2.2%
1.4% 1.7% 0.0% 1.6% 3.2% 1.0% 0.0% 2.0% 1.4% 2.3% -5.7% 4.9% 0.6% -9.6% 5.0% 10.5% 30 out of 42
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM /IDU IDU Hetero Total AWARE 71.7% 78.4% 59.7% 65.2% 69.5% NEED 15.9% 31.7% 27.2% 24.4% 21.0% ASK 15.2% 29.7% 22.4% 23.3% 19.4% RECEIVE 13.6% 26.5% 21.4% 23.3% 18.0%
Not knowing about service Not provided proper referrals Length of time for an appointment Individual physical or mental health Cost of service/ inadequate insurance
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Total AWARE 66.0% 59.7% 71.9% 69.2% 63.9% 65.6% 69.5% NEED 25.2% 31.2% 26.6% 18.5% 31.3% 34.4% 21.0% ASK 23.3% 27.3% 26.6% 15.4% 27.2% 32.3% 19.4% RECEIVE 29.0% 22.3% 26.0% 25.0% 22.2% 21.7% 18.0%
Notes
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Substance Abuse Group
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility: 3,360 1 hour Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific; if unable to participate in federal, state, or local programs; provided funding is available for extension periods.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 559 Number unduplicated 41 Average Used 14 Expenditure $18,056
FUNDING 2002-2003
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask – Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Total AWARE 74.8% 69.2% 77.2% 67.6% 65.7% 73.8% NEED 20.3% 35.0% 18.6% 34.6% 20.3% 23.0% ASK 18.8% 29.7% 17.4% 30.5% 18.0% 20.8% RECEIVE 18.2% 29.7% 17.0% 29.5% 18.5% 20.3%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
2.2% 1.6% 5.3% 0.8% 5.6% 4.6% 2.3% 1.2% 4.0% 2.3% 4.9% 4.0% 0.0% 3.1% 6.9% 7.5%
0.5% 0.6% 0.0% 0.5% 2.0% 0.0% 0.0% 0.5% 1.0% -0.5% -15.5% -0.6% 4.6% -9.4% 9.3% 23.5%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 72.9% 86.0% 76.2% 66.0% 73.8% NEED 13.6% 42.0% 37.7% 26.9% 23.0% ASK 12.7% 36.4% 33.1% 24.6% 20.8% RECEIVE 12.2% 34.4% 33.1% 24.6% 20.3%
26 out of 42
Barriers •
Not knowing about service
1 00% 80%

Notes
% of PLWH/A
60% 40% 20% 0%
AWARE 69.9% 66.2% 81.3% 76.9% 75.0% 74.2% 73.8%
NEED 31.1% 30.7% 32.8% 26.2% 42.4% 45.2% 23.0%
ASK 26.2% 26.7% 32.8% 23.1% 35.4% 37.6% 20.8%
RECEIVE 35.5% 27.2% 25.3% 32.8% 22.2% 26.1% 20.3%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Total
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Substance abuse family counseling
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility: 3,360 1 hour Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific; if unable to participate in federal, state, or local programs; provided funding is available for extension periods.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 3 Number unduplicated 1 Average Used 3 Expenditure $135
FUNDING 2002-2003
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Latino Total AWARE 53.8% 50.4% 55.0% 49.9% 49.7% 53.2% NEED 7.3% 17.8% 7.2% 15.9% 3.6% 9.1 % ASK 6.6% 1 4.1% 6.0% 1 4.5% 2.3% 7.9% RECEIVE 5.6% 14.1% 5.6% 1 3.3% 0.0% 7.1%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
1.2% 0.7% 3.8% 0.2% 0.8% 5.0% 1.2% 1.2% 1.3% 1.3% 1.0% 1.3% 0.0% 5.3% 4.1% 2.2%
0.8% 1.0% 0.0% 0.6% 4.0% 1.3% -1.2% 0.4% 1.2% 2.3% 6.3% -1.3% 1.7% -3.1% 0.5% -3.4%
00% 1
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Hetero Total AWARE 55.8% 50.0% 44.5% 54.8% 53.2% NEED 5.9% 1 0.4% 1 1.4% 1 6.7% 9.1% ASK 5.7% 9.6% 6.4% 15.6% 7.9% RECEIVE 5.0% 5.6% 5.2% 1 6.7% 7.1 %
40 out of 42
Barriers •
Not knowing about service
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 51 .5% 48.1 % 61 .5% 54.2% 48.3% 48.4% 53.2% NEED 1 2.6% 11.7% 1 0.8% 11.5% 1 5.6% 11.8% 9.1% ASK 1 1.7% 1 0.4% 1 0.8% 6.1 % 1 1.6% 9.7% 7.9% RECEIVE 5.4% 11 .7% 9.1% 9.2% 11 .1% 13.0% 7.1%
Notes
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Substance Abuse peer group
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility: 3,360 Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific; if unable to participate in federal, state, or local programs; provided funding is available for extension periods.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated Number unduplicated Average Used Expenditure
FUNDING 2002-2003
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 70.4% 63.3% 71.9% 61.6% 69.0% 69.1% NEED 17.6% 30.5% 17.1% 27.9% 19.0% 19.9% ASK 17.3% 28.6% 16.5% 27.4% 18.5% 19.3% RECEIVE 16.9% 29.7% 16.5% 26.7% 19.0% 19.2%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
2.2% 1.6% 5.3% 0.8% 5.6% 4.6% 2.3% 1.2% 4.0% 2.3% 1.9% 2.6% -1.5% 0.8% 3.4% 3.2%
0.1% 0.4% -1.1% 0.5% 0.4% 0.0% -1.2% 0.0% 0.6% -0.5% -15.5% -0.6% 4.6% -9.4% 9.3% 23.5%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 70.6% 72.2% 65.5% 65.4% 69.1% NEED 12.8% 33.1% 29.1% 26.1% 19.9% ASK 13.0% 31.0% 27.0% 24.9% 19.3% RECEIVE 12.5% 30.7% 27.0% 26.1% 19.2%
31 out of 42
Barriers •
1 00% 80%
Not knowing about service
% of PLWH/A
60% 40% 20% 0%
AWARE 64.1% 58.4% 80.0% 70.8% 68.5% 72.0% 69.1% NEED 26.2% 27.3% 27.7% 20.6% 34.9% 44.1% 19.9% ASK 24.3% 24.7% 29.2% 19.8% 31.5% 40.9% 19.3% RECEIVE 39.8% 25.2% 24.7% 29.2% 22.2% 17.4% 1 9.2%
Notes
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al
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Medication Reimbursement
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 1 vendor paid medication dollar Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 17,093 Number unduplicated 59 Average Used 290 Expenditure $18,802
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED $20,400
PROJECTED 2004-2005 17,604.4 59 298 $19,366
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask – Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 80.0% 73.7% 83.1 % 70.6% 74.6% 78.9% NEED 58.3% 50.7% 61 .3% 46.3% 60.6% 57.0% ASK 53.1 % 44.2% 55.8% 39.1 % 60.5% 51.5% RECEIVE 50.8% 43.5% 52.7% 39.7% 59.7% 49.5%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
5.5% 5.3% 6.5% 5.7% 5.6% 4.1% 6.0% 5.5% 7.2% 0.1% 5.2% 9.1% 1.5% 5.3% 3.0% 7.5%
2.0% 2.3% 0.7% 3.5% -4.0% -1.3% 4.0% 3.1% -0.6% 0.8% -1.4% 3.1% 1.8% 11.1% -34.2% -11.3%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 84.5% 79.5% 64.9% 73.4% 78.9% NEED 64.4% 41 .9% 49.9% 49.8% 57.0% ASK 58.7% 36.3% 45.9% 43.7% 51 .5% RECEIVE 55.2% 40.3% 47.1% 39.7% 49.5%
10 out of 42
Barriers •
1 00% 80%
Not knowing about service
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 76.0% 72.7% 75.4% 74.8% 72.1 % 77.4% 78.9% NEED 44.7% 50.6% 46.2% 59.5% 46.6% 48.4% 57.0% ASK 39.4% 41 .6% 44.6% 54.2% 43.5% 40.9% 51 .5% RECEIVE 40.9% 38.5% 42.9% 43.1 % 77.8% 52.2% 49.5%
Notes
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Residential Hospice Care
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 24 hours (1 day) Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 1,747 Number unduplicated 18 Average Used 97 Expenditure $141,837
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED $142,222
PROJECTED 2004-2005 1861 18 103 $155,669
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo African Am Lat ino Tot al AWARE 56.2% 53.9% 61.4% 47.6% 41.5% 55.8% NEED 6.1% 12.6% 5.1% 12.9% 5.7% 7.3% ASK 3.9% 11.0% 3.8% 8.7% 3.6% 5.2% RECEIVE 3.2% 12.2% 2.5% 10.0% 3.6% 4.7%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • •
2.1% 2.2% 1.5% 1.6% 2.4% 1.7% 3.5% 1.2% 4.2% 2.1% 1.0% 2.6% 0.0% 6.1% 3.4% 2.2%
0.5% 0.8% -1.1% 1.4% 0.8% 0.0% -2.4% 1.3% -1.3% 0.0% -3.5% 5.9% 1.8% -4.1% -4.2% 1.1%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Hetero Tot al AWARE 58.0% 62.4% 45.2% 54.3% 55.8% NEED 4.7% 6.7% 13.4% 10.0% 7.3% ASK 3.1% 4.3% 11.6% 6.5% 5.2% RECEIVE 1.7% 3.5% 11.6% 8.9% 4.7%
41 out of 42
Not knowing about service Service not available
1 00% 80%

Notes
% of PLWH/A
60% 40% 20% 0%
AWARE 56.7% 46.8% 57.8% 55.0% 45.2% 47.8% 55.8% NEED 2.9% 10.4% 10.9% 13.0% 10.3% 7.6% 7.3% ASK 1.9% 7.8% 10.9% 6.9% 6.9% 5.4% 5.2% RECEIVE 5.4% 1.9% 9.1% 10.9% 11.1% 4.3% 4.7%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al
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Substance abuse services- Residential
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 1 hour Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 26,028 Number unduplicated 41 Average Used 635 Expenditure $84,272
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED $96,595
PROJECTED 2004-2005 29,815 41 727 $99,494
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Latino Tot al AWARE 60.8% 57.7% 63.8% 54.4% 50.7% 60.2% NEED 11.7% 18.8% 9.8% 19.6% 11.6% 13.0% ASK 9.7% 17.7% 8.7% 17.0% 11.6% 11.1% RECEIVE 9.2% 1 7.7% 8.3% 1 5.8% 8.8% 1 0.7%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • • •
1.8% 2.0% 1.1% 1.0% 5.1% 3.2% 1.2% 1.2% 2.6% 0.0% 2.9% 3.9% -1.5% 3.1% 4.1% 5.4%
0.4% 0.5% 0.0% -0.1% 4.0% 0.0% 0.0% 0.4% 1.2% 2.8% -6.1% 2.8% 7.3% -7.0% 15.4% 13.9%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 58.0% 74.8% 58.5% 59.4% 60.2% NEED 6.0% 26.8% 21.3% 18.6% 13.0% ASK 5.0% 21 .7% 18.1% 17.5% 11 .1% RECEIVE 5.1% 1 7.7% 1 8.1% 1 7.5% 1 0.7%
37 out of 42
Not knowing about service Not RW funded Not enough beds available for detox
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 59.2% 55.8% 63.1 % 67.2% 62.6% 66.7% 60.2% NEED 17.5% 19.5% 20.0% 16.0% 30.6% 28.0% 13.0% ASK 1 4.6% 1 5.6% 21.5% 1 3.0% 26.5% 22.6% 11.1% RECEIVE 20.7% 12.7% 14.3% 20.0% 11.1% 8.7% 10.7%
Notes
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Transportation
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 1 one-way trip Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 3,516 Number unduplicated 157 Average Used 22 Expenditure $35,340
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 62.4% 63.9% 63.6% 62.4% 59.6% 62.7% NEED 35.6% 50.7% 34.7% 47.9% 35.9% 38.2% ASK 25.0% 42.9% 23.6% 38.4% 31.3% 28.1% RECEIVE 21.7% 34.8% 22.6% 29.6% 19.9% 24.0%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
10.1% 10.6% 7.8% 12.2% 9.2% 8.4% 5.7% 11.1% 9.5% 4.7% 7.7% 7.8% 7.7% 11.5% 13.6% 7.5%
4.1% 3.2% 8.1% 1.8% 2.1% 13.8% 4.1% 1.0% 8.9% 11.3% 1.7% 19.5% -5.6% -1.8% 15.2% 8.3%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 64.9% 57.6% 59.5% 61.6% 62.7% NEED 35.3% 34.4% 50.6% 38.9% 38.2% ASK 23.1% 25.2% 42.3% 33.2% 28.1% RECEIVE 21.3% 23.2% 28.5% 29.1% 24.0%
18 out of 42
Barriers • •
Not knowing about service Unreliable transportation service – no show
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 57.7% 66.2% 70.8% 61.8% 55.8% 53.8% 62.7% NEED 38.5% 53.2% 38.5% 40.5% 51.0% 41.9% 38.2% ASK 30.8% 45.5% 30.8% 29.0% 37.4% 34.4% 28.1% RECEIVE 29.0% 26.0% 36.4% 30.8% 22.2% 26.1% 24.0%
Notes
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Taxi vouchers
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility: 3,360 1 vendor transportation dollar Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific, only to be used if health condition does not permit use of public trans and experiencing time-related unavoidable emergency and no other service is available.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 14,116 Number unduplicated 449 Average Used 31 Expenditure $15,643
FUNDING 2002-2003
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 75.7% 74.1% 77.5% 71.5% 73.5% 75.4% NEED 53.0% 60.4% 49.4% 65.3% 55.9% 54.3% ASK 42.6% 53.5% 37.9% 58.0% 49.8% 44.5% RECEIVE 37.4% 46.4% 33.5% 48.5% 44.5% 39.0%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • • • •
9.8% 10.4% 7.0% 9.6% 20.4% 6.5% 6.5% 11.4% 7.3% 6.1% 10.1% 10.4% 6.2% 10.7% 12.5% 10.1%
5.5% 5.2% 7.0% 5.2% 0.8% 7.2% 8.0% 4.4% 9.4% 5.4% -9.7% 13.5% -5.8% 3.5% 33.9% 27.2%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 75.5% 80.6% 76.1% 71.5% 75.4% NEED 50.7% 57.1% 60.2% 58.4% 54.3% ASK 41.1% 36.7% 53.7% 51.8% 44.5% RECEIVE 36.0% 36.0% 46.5% 43.8% 39.0%
12 out of 42
Not knowing about service Not enough funding for vouchers Limit supply available for consumers Not eligible
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 70.2% 75.0% 81.5% 74.8% 72.6% 79.6% 75.4% NEED 54.8% 67.5% 52.3% 57.3% 68.7% 67.7% 54.3% ASK 44.7% 57.1% 46.2% 46.6% 56.2% 57.6% 44.5% RECEIVE 54.3% 43.7% 51.9% 43.1% 22.2% 30.4% 39.0%
Notes
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Financial Assistance
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility: 3,360 1 vendor dollar Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific, only in avoiding homelessness or unhealthy living conditions; have taken conservation education program, does not include cellular phone or pager bills..
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 83,638 Number unduplicated 719 Average Used 116 Expenditure $92,001
FUNDING 2002-2003
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED $91,940
PROJECTED 2004-2005 98,338 723 136 $108,172
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 75.6% 62.0% 76.6% 65.6% 70.9% 73.2% NEED 59.9% 55.6% 60.9% 55.3% 59.4% 59.1% ASK 50.1% 44.7% 50.1% 45.2% 53.5% 49.1% RECEIVE 40.3% 38.1% 41.8% 37.2% 39.2% 39.9%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • • • •
10.0% 9.8% 10.9% 8.3% 13.2% 16.1% 7.8% 10.8% 10.1% 5.9% 13.5% 6.5% 10.8% 11.5% 11.6% 9.7%
9.3% 9.8% 6.6% 12.0% 5.3% 9.3% 3.3% 8.3% 8.0% 14.3% 5.7% 9.9% 0.0% 10.8% 15.6% -2.7%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 79.7% 70.7% 66.3% 60.5% 73.2% NEED 62.7% 50.4% 66.5% 47.0% 59.1% ASK 54.5% 37.2% 50.4% 39.1% 49.1% RECEIVE 42.5% 31.9% 41.1% 35.8% 39.9%
9 out of 42
Not knowing about service Eligibility criteria Lack of funding for service Limited financial assistance provided – not enough
1 00% 80%
% of PLWH/A

Notes
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 69.2% 70.1% 63.1% 71.8% 64.6% 66.7% 73.2% NEED 55.8% 53.2% 52.3% 63.8% 60.5% 54.8% 59.1% ASK 42.3% 46.8% 41.5% 52.3% 49.0% 45.2% 49.1% RECEIVE 36.6% 36.9% 41.6% 41.5% 33.3% 47.8% 39.9%
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Child care services
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility: 3,360 Vendor dollar Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific; shall be used only for medical, social, or support service with documentation, in event of a hospital stay, time will not exceed 7 days and only if there are no other arrangements.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 15,394 Number unduplicated 23 Average Used 669 Expenditure $15,394
FUNDING 2002-2003
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED $19,740
PROJECTED 2004-2005 19,031.8 31 614 $20,935
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Latino Total AWARE 32.7% 48.3% 36.5% 40.1 % 18.6% 35.4% NEED 2.2% 20.3% 1.8% 1 2.5% 8.0% 5.4% ASK 1.2% 15.3% 0.9% 10.1% 3.4% 3.7% RECEIVE 0.8% 1 % 4.1 0.6% 9.3% 1 .7% 3.2%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
1.7% 1.0% 5.0% 1.0% 2.1% 0.4% 4.6% 0.9% 2.4% 4.7% 1.9% 5.1% 1.5% 1.5% 2.7% 2.2%
0.5% 0.4% 1.2% 0.4% -0.4% 2.3% 0.0% 0.3% 0.8% 1.6% 3.6% 4.8% -1.6% -6.2% 5.4% -6.5%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM /IDU IDU Het ero Tot al AWARE 30.9% 40.0% 33.7% 48.3% 35.4% NEED 1.5% 2.8% 7.2% 1 7.8% 5.4% ASK 0.4% 0.8% 6.8% 1 3.2% 3.7% RECEIVE 0.0% 1.2% 4.5% 13.2% 3.2%
42 out of 42
Barriers •
Not knowing about service
1 00% 80%

Notes
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Total AWARE 43.3% 28.6% 44.6% 36.6% 30.6% 28.0% 35.4% NEED 7.7% 15.6% 7.7% 3.1 % 8.2% 4.3% 5.4% ASK 5.8% 10.5% 6.2% 1 .5% 5.4% 2.2% 3.7% RECEIVE 2.2% 5.8% 7.8% 7.7% 0.0% 8.7% 3.2%
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Mental Health Group
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility: 3,360 Each adult Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 56 Number unduplicated 11 Average Used 5 Expenditure $1,680
FUNDING 2002-2003
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 71.8% 67.1% 73.9% 62.4% 71.3% 71.0% NEED 23.4% 39.5% 22.9% 34.1% 23.8% 26.2% ASK 18.0% 29.8% 17.2% 27.9% 18.2% 20.1% RECEIVE 13.3% 27.9% 12.0% 25.3% 10.6% 15.8%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
6.1% 5.3% 9.7% 5.4% 10.4% 5.3% 6.3% 5.8% 6.2% 5.6% 5.8% 11.8% 0.0% 9.9% 10.9% 7.5% 22 out of 42
4.3% 4.8% 1.9% 6.5% 0.8% 1.4% 1.9% 5.2% 2.6% 7.6% 2.9% 1.1% 13.4% -7.1% 10.0% 18.3%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 73.0% 73.1% 61.9% 71.6% 71.0% NEED 23.9% 29.2% 25.5% 32.2% 26.2% ASK 18.5% 18.8% 20.2% 25.9% 20.1% RECEIVE 12.0% 18.0% 18.8% 24.0% 15.8%
Barriers • •
Not knowing about service Hours of operation
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 65.4% 63.6% 70.8% 73.3% 63.9% 60.2% 71.0% NEED 26.9% 30.3% 29.2% 30.5% 32.0% 25.8% 26.2% ASK 21.2% 18.4% 29.2% 20.6% 21.1% 18.3% 20.1% RECEIVE 18.3% 17.3% 15.8% 27.7% 11.1% 0.0% 15.8%
Notes
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Peer Counseling
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated Number unduplicated Average Used Expenditure
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 69.8% 59.8% 74.2% 55.8% 63.3% 68.0% NEED 23.7% 33.5% 24.0% 29.1% 21.2% 25.4% ASK 17.8% 27.8% 18.6% 23.5% 14.0% 19.5% RECEIVE 14.2% 27.0% 16.0% 20.1% 8.5% 16.5%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • •
5.9% 5.9% 5.7% 5.9% 10.4% 5.2% 3.5% 5.4% 5.6% 7.3% 3.8% 11.7% 6.2% 7.6% 8.8% 5.4%
3.0% 3.5% 0.8% 4.4% 0.8% 1.1% 2.0% 2.6% 3.4% 5.5% -5.2% 3.8% 6.2% 0.6% 10.7% 13.9%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 68.9% 76.4% 57.4% 69.4% 68.0% NEED 22.9% 28.0% 26.7% 30.4% 25.4% ASK 17.0% 17.6% 21.6% 26.9% 19.5% RECEIVE 12.6% 16.8% 20.5% 24.9% 16.5%
24 out of 42
Not knowing about service Not enough groups for heterosexuals
1 00% 80%

Notes
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 61.5% 62.3% 66.2% 66.4% 57.8% 59.1% 68.0% NEED 20.2% 29.9% 29.2% 29.8% 30.6% 28.0% 25.4% ASK 16.3% 18.2% 23.1% 22.1% 21.8% 22.6% 19.5% RECEIVE 21.5% 14.4% 16.9% 21.5% 11.1% 8.7% 16.5%
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Adherence Support
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 Encounter Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 44 Number unduplicated 18 Average Used 2 Expenditure $8,030
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED $6,079
PROJECTED 2004-2005 126.9 18 7 $23,854
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 58.9% 68.1% 58.7% 64.2% 58.2% 60.5% NEED 22.2% 25.4% 20.3% 28.7% 25.3% 22.7% ASK 17.7% 25.0% 17.4% 23.3% 19.7% 19.0% RECEIVE 19.2% 25.4% 18.6% 24.5% 21.8% 20.3%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
3.8% 4.5% 0.4% 4.1% 7.6% 3.8% 0.1% 2.9% 5.4% 5.6% 5.8% 5.2% 4.6% 3.1% 4.8% 6.5%
-1.3% -1.4% -0.4% -1.8% -1.6% -1.6% 1.0% -1.2% -1.2% -2.1% 2.3% 3.1% 2.1% -4.8% -13.6% -12.1%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 60.8% 57.5% 56.8% 64.8% 60.5% NEED 25.0% 1 5.5% 20.0% 22.8% 22.7% ASK 20.9% 7.9% 16.2% 22.6% 19.0% RECEIVE 22.7% 9.5% 1 7.7% 21.7% 20.3%
29 out of 42
Barriers •
1 00% 80%
Not knowing about service
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 69.9% 49.4% 60.0% 64.1% 57.5% 54.3% 60.5% NEED 23.1% 24.7% 26.2% 22.9% 24.5% 20.4% 22.7% ASK 17.3% 19.5% 21 .5% 19.8% 19.7% 14.0% 19.0% RECEIVE 15.1% 16.3% 19.5% 24.6% 33.3% 26.1% 20.3%
Notes
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Nutrition Counseling
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 visit Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific, to be administered by registered dietician or other qualified person.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 5.652 Number unduplicated 117 Average Used 48 Expenditure $10,250
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Latino Total AWARE 70.6% 65.7% 75.0% 61 .9% 62.4% 69.8% NEED 42.7% 45.3% 46.4% 38.1% 39.5% 43.2% ASK 32.8% 36.5% 36.2% 30.0% 26.2% 33.4% RECEIVE 29.0% 36.0% 32.6% 28.4% 23.2% 30.2%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
9.7% 9.9% 8.8% 10.7% -0.2% 11.6% 11.5% 10.1% 8.1% 13.3% 5.8% 11.2% 3.1% 13.5% 11.4% 10.5%
3.2% 3.8% 0.5% 4.4% 2.5% -2.6% 4.9% 3.6% 1.6% 3.1% 6.2% 4.4% -3.5% 2.3% -4.6% -13.0%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM /IDU IDU Het ero Tot al AWARE 72.1 % 72.7% 57.6% 71.5% 69.8% NEED 46.1% 33.6% 37.3% 45.3% 43.2% ASK 35.4% 33.7% 25.7% 33.8% 33.4% RECEIVE 31 .0% 31 .2% 28.3% 28.9% 30.2%
17 out of 42
Barriers •
Not knowing about service
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 63.5% 59.7% 72.3% 69.5% 57.1 % 64.5% 69.8% NEED 35.6% 45.5% 30.8% 43.5% 40.1% 32.3% 43.2% ASK 29.8% 34.2% 27.7% 30.0% 28.8% 21 .7% 33.4% RECEIVE 23.7% 29.8% 31.2% 27.7% 33.3% 34.8% 30.2%
Notes
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Home Health Care
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 Encounter Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 1747 Number unduplicated 18 Average Used 97 Expenditure $141,837
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED $142,222
PROJECTED 2004-2005 1861 18 103 $155,669
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Total AWARE 64.9% 70.3% 68.8% 63.4% 51.1% 65.9% NEED 27.5% 33.5% 28.0% 30.0% 22.3% 28.5% ASK 21.4% 31.4% 22.8% 25.6% 18.8% 23.2% RECEIVE 18.4% 28.8% 19.8% 23.0% 18.8% 20.3%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
5.4% 6.1% 2.0% 7.0% 3.2% 1.8% 4.7% 5.3% 4.4% 3.5% 1.1% 3.9% 4.6% 7.6% 3.4% 5.4%
2.9% 2.9% 2.6% 3.4% 3.2% 2.9% 1.1% 2.9% 2.6% 0.0% -3.6% 15.4% -6.5% 11.3% -3.0% -4.5%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 68.3% 65.6% 55.8% 67.3% 65.9% NEED 30.3% 23.1% 26.6% 28.2% 28.5% ASK 23.3% 19.9% 24.8% 23.5% 23.2% RECEIVE 19.8% 16.7% 21.9% 22.4% 20.3%
20 out of 42
Barriers •
Not knowing about service
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 62.5% 55.3% 63.1% 71.0% 55.5% 59.1% 65.9% NEED 13.6% 28.9% 23.1% 38.9% 22.6% 22.6% 28.5% ASK 12.5% 25.0% 18.5% 31.3% 19.2% 17.2% 23.2% RECEIVE 16.1% 9.6% 25.0% 20.0% 22.2% 21.7% 20.3%
Notes
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Insurance Assistance
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated Number unduplicated Average Used Expenditure
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need -Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 39.3% 33.5% 41.0% 32.1% 29.5% 38.3% NEED 18.2% 25.2% 17.3% 25.5% 16.2% 19.5% ASK 9.8% 19.4% 8.0% 18.5% 11.9% 11.5% RECEIVE 9.7% 15.8% 8.1% 15.2% 11 .9% 10.7%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
7.9% 8.4% 5.8% 8.1% 4.9% 9.4% 8.2% 9.3% 7.0% 4.3% 11.5% 7.6% 4.6% 3.9% 7.6% 10.9%
0.8% 0.2% 3.6% -0.7% -1.7% 3.3% 4.7% -0.1% 3.3% 0.0% 0.9% 9.7% -0.2% -4.4% 4.1% -19.6%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Total AWARE 42.4% 39.7% 26.0% 35.3% 38.3% NEED 17.3% 11 .4% 23.9% 27.4% 19.5% ASK 9.2% 6.5% 14.5% 19.2% 11.5% RECEIVE 9.9% 8.1 % 11.1 % 14.5% 10.7%
32 out of 42
Barriers • •
Not knowing about service Service has been denied
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 42.3% 27.3% 38.5% 30.2% 30.1% 25.8% 38.3% NEED 21.2% 26.0% 21.5% 16.4% 22.8% 17.4% 19.5% ASK 9.6% 18.4% 16.9% 12.5% 15.2% 6.5% 11.5% RECEIVE 8.7% 8.7% 17.1% 16.9% 11.1 % 26.1% 10.7%
Notes
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Buddy emotional support
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 1 hour Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 637 Number unduplicated 49 Average Used 13 Expenditure $13,377
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 51.4% 58.9% 58.3% 49.0% 32.7% 52.7% NEED 21.9% 27.8% 21.7% 27.5% 22.5% 23.0% ASK 12.5% 18.9% 13.5% 17.2% 6.9% 13.6% RECEIVE 9.3% 17.7% 10.7% 14.3% 3.6% 10.8%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
9.4% 9.5% 8.9% 8.9% 14.0% 7.9% 9.3% 8.3% 10.2% 15.5% 5.8% 10.2% 9.2% 17.5% 12.2% 10.8%
2.8% 3.1% 1.2% 3.0% 3.9% 4.4% 0.0% 2.7% 3.0% 3.3% 7.0% 2.3% 5.0% -2.3% -18.4% -6.6%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 55.1% 53.7% 42.2% 54.2% 52.7% NEED 22.3% 25.6% 22.0% 24.2% 23.0% ASK 13.5% 11.6% 14.1% 14.9% 13.6% RECEIVE 10.5% 7.7% 9.7% 14.9% 10.8%
27 out of 42
Barriers • •
Not knowing about service Waiting for service
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 51.9% 44.2% 58.5% 48.9% 44.2% 36.6% 52.7% NEED 19.2% 26.0% 24.6% 30.5% 27.2% 17.2% 23.0% ASK 13.5% 15.8% 15.4% 13.1% 15.0% 6.5% 13.6% RECEIVE 6.5% 13.5% 10.4% 15.4% 33.3% 13.0% 10.8%
Notes
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Buddy household tasks
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 1 hour Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 1,029 Number unduplicated 91 Average Used 11 Expenditure $20,408
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 50.4% 48.8% 56.3% 45.4% 25.9% 50.1% NEED 21.9% 27.8% 23.5% 22.5% 20.7% 23.0% ASK 12.7% 19.3% 13.3% 15.1% 13.7% 13.9% RECEIVE 9.3% 17.1% 11.1% 11.2% 8.2% 10.7%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
9.1% 9.2% 8.5% 9.3% 14.0% 6.5% 7.6% 10.2% 7.4% 7.0% 7.7% 13.0% 6.2% 9.7% 10.9% 6.5%
3.2% 3.4% 2.2% 4.1% 4.7% 1.3% 1.1% 2.2% 3.9% 5.5% 6.3% 7.3% -0.7% 3.2% -20.4% -3.3%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 53.1% 52.8% 40.7% 47.5% 50.1% NEED 23.8% 23.2% 18.1% 24.5% 23.0% ASK 14.5% 9.2% 11.6% 16.9% 13.9% RECEIVE 10.4% 4.5% 10.4% 15.8% 10.7%
28 out of 42
Barriers • •
Not knowing about service Not enough volunteers available
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
AWARE 50.0% 45.5% 50.8% 45.8% 42.2% 37.6% 50.1% NEED 18.3% 29.9% 18.5% 26.7% 23.8% 11.8% 23.0% ASK 10.6% 16.9% 12.3% 17.1% 12.9% 5.4% 13.9% RECEIVE 4.3% 9.6% 13.0% 13.8% 33.3% 8.7% 10.7%
Notes
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al
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Buddy advocate
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific.
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated Number unduplicated Average Used Expenditure
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask – Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 36.9% 47.9% 38.9% 44.1% 24.6% 38.8% NEED 14.2% 23.2% 15.6% 20.0% 8.0% 15.8% ASK 9.4% 17.7% 9.5% 16.4% 5.5% 10.9% RECEIVE 7.6% 15.3% 8.1% 14.2% 1.7% 9.0%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • • • • •
4.9% 4.8% 5.5% 4.0% 7.2% 3.0% 8.2% 6.1% 3.6% 2.6% 2.9% 3.7% 1.5% 10.8% 4.8% 4.3%
1.9% 1.7% 2.5% 2.5% 0.3% 0.2% 2.4% 1.4% 2.3% 3.7% 2.2% 8.1% -2.2% -2.3% 0.5% -7.6%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 39.3% 35.6% 32.0% 45.4% 38.8% NEED 15.1% 10.4% 13.1% 23.8% 15.8% ASK 11.1% 3.2% 10.2% 15.6% 10.9% RECEIVE 8.6% 2.8% 9.9% 13.2% 9.0%
36 out of 42
Not knowing about service Not provided proper referrals Length of time for an appointment Individual physical or mental health Cost of service/ inadequate insurance
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Tot al AWARE 46.2% 31.2% 46.2% 35.1% 34.0% 29.0% 38.8% NEED 11.5% 19.5% 12.3% 20.8% 16.4% 9.8% 15.8% ASK 8.7% 15.8% 10.8% 10.0% 11.6% 5.4% 10.9% RECEIVE 6.5% 7.7% 13.0% 12.3% 11.1% 13.0% 9.0%
Notes
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Respite Services
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated Number unduplicated Average Used Expenditure
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo African Am Latino Total AWARE 36.8% 54.8% 41.8% 44.6% 21.6% 40.0% NEED 7.1% 25.9% 7.3% 17.7% 10.6% 10.4% ASK 3.1% 22.0% 2.8% 15.6% 3.8% 6.4% RECEIVE 2.0% 20.8% 1.9% 14.4% 2.2% 5.3%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
4.0% 4.0% 3.8% 4.3% 10.0% 1.4% 1.3% 4.5% 2.0% 6.8% 1.9% 5.0% 1.5% 6.1% 2.7% 4.3%
1.1% 1.0% 1.2% 0.6% -0.4% 1.1% 3.3% 0.9% 1.3% 1.6% 5.4% 4.5% -4.0% -3.9% -1.6% -8.7%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Hetero Total AWARE 37.1% 36.8% 36.9% 53.6% 40.0% NEED 6.6% 11.3% 10.7% 21.2% 10.4% ASK 2.3% 1.2% 9.3% 19.9% 6.4% RECEIVE 1.7% 1.7% 8.2% 16.6% 5.3%
39 out of 42
Barriers •
Not knowing about service
1 00% 80%

Notes
% of PLWH/A
60% 40% 20% 0%
AWARE 46.2% 31.2% 44.6% 38.2% 34.7% 29.0% 40.0% NEED 10.6% 18.2% 9.2% 11.5% 12.2% 8.6% 10.4% ASK 8.7% 13.2% 7.7% 5.3% 9.5% 4.3% 6.4% RECEIVE 3.2% 8.7% 11.7% 9.2% 11.1% 13.0% 5.3%
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Total
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Client Advocacy
Service Unit, Eligibility, and Funding
Total PLWH/A: Unit: Eligibility:
FUNDING 2002-2003
3,360 15 minute face-to-face Diagnosis of HIV infection, EMA resident, no income to 300% of Federal Poverty Level, Agency specific
EXPENDED AND PROJECTED EXPENDED UNITS 2002-2003 Number duplicated 389 Number unduplicated 23 Average Used 17 Expenditure $16,660
SOURCES RW Care Title I & MAI RW Care Title II Other Total Allocated
1 00%
AMOUNT FUNDED
PROJECTED 2004-2005
GAPS (a “-“ indicates that more service was provided than was asked for or needed.)
Population Need – Ask Ask Received
% of PLWH/A
80% 60% 40% 20% 0%
M ale Female Anglo Af rican Am Lat ino Tot al AWARE 65.4% 68.2% 70.1% 64.2% 46.5% 65.9% NEED 35.8% 47.2% 36.9% 41.9% 30.3% 37.9% ASK 24.2% 33.0% 23.5% 31.0% 22.2% 25.8% RECEIVE 23.4% 33.4% 23.3% 31.1% 21.0% 25.2%
Total Male Female MSM MSMIDU IDU Hetero Anglo African Am Latino HIV asymp HIV symp AIDS asymp AIDS symp Homeless Recently Incarcerated Consumer Rank
Barriers • • •
12.0% 11.6% 14.2% 13.5% 5.3% 14.5% 9.7% 13.4% 10.9% 8.1% 7.7% 9.2% 6.2% 16.8% 6.8% 8.6%
0.6% 0.9% -0.4% 1.1% 1.4% 2.9% -3.3% 0.2% -0.1% 1.2% 3.6% 6.2% -1.3% -1.0% 7.0% -11.1%
1 00%
% of PLWH/A
80% 60% 40% 20% 0%
M SM M SM / IDU IDU Het ero Tot al AWARE 69.7% 58.8% 58.4% 65.3% 65.9% NEED 38.5% 28.5% 45.1% 35.4% 37.9% ASK 25.0% 23.2% 30.5% 25.7% 25.8% RECEIVE 23.9% 21.8% 27.7% 29.0% 25.2%
19 out of 42
Not knowing about service Service not available Not enough funding for service
1 00% 80%
% of PLWH/A
60% 40% 20% 0%
AWARE 60.6% 65.8% 72.3% 63.4% 61.9% 59.1% 65.9% NEED 31.7% 39.5% 33.8% 45.0% 36.1% 28.0% 37.9% ASK 24.0% 30.3% 27.7% 28.2% 29.3% 19.4% 25.8% RECEIVE 20.4% 24.0% 28.9% 29.2% 22.2% 30.4% 25.2%
Notes
HIV asymp HIV symp AIDS asymp AIDS symp Homeless Rec Inc Total
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2. WHERE ARE WE GOING? SHARED VISION, AND VALUES FOR A CONTINUUM OF CARE FOR PLWH/A Vision
The shared vision of the Council is an HIV/AIDS Continuum of Care that will assure 100% access to HIV related health care and prevention-for-positives, with 0% disparities among the populations infected and affected by HIV and AIDS. For persons infected with HIV and AIDS, treatment for their infection will be available, accessible, affordable, and culturally appropriate.
Values
Availability of services to all PLWH/A and assurances that those eligible receive Ryan White funded care. No person will be denied services because of inability to pay. Accessibility of services through reducing the individual, organizational and structural barriers to care including: • Increasing knowledge about the continuum of care, treatment, and eligibility. • Addressing issues of denial. • Providing culturally and linguistically appropriate services. • Assuring nondiscriminatory and high quality services to all PLWH/A. • Providing client-centered services including convenient and timely appointments. • Minimizing red tape and facilitating navigation of the continuum of care. • Increasing cooperation, coordination, and integration of service providers. Affordability of services through assuring all PLWH/A are aware of, and apply for all benefits they need and are eligible to receive. Empowerment through community planning where those infected and affected collaborate with the Council and providers in establishing policies, allocating resources, designing and delivering services. • Aligning the expectation of services to match the eligibility and capacity of the continuum of care. Acceptance of responsibility of those infected to use safer practices with partners. Effective and efficient use of resources through ongoing monitoring of the quality and cost of services and outcomes of the care model. Leveraging funds and resources to better use non-Ryan White funding to access housing, drug treatment, transportation, and other services and resources. Making decisions based on the most current data and scientific research regarding the needs of those affected by HIV/AIDS and the methods of providing care that produce the most positive outcomes for infected people.
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CORE STRENGTHS AND WEAKNESSES
Strengths 1. The Council committees encourage community-based participation. 2. Scope of the continuum of services. 3. The high quality of medical care. 4. Regionally AIDS Education Training Center (AETC) center is accessible. 5. Outreach and testing are done well – culturally appropriate. 6. Insurance continuation is done well in the metropolitan area. 7. Well-developed standards of care for core services. 8. Documented outcomes for significant number of core services. 9. Increased services that are culturally and linguistically appropriate. 10. Improved collaboration with DHHS. 11. Better understanding of the HRSA requirements. 12. Structure in place for initiating action on a range of issues. 13. System of reporting monitoring services that is used by most providers and permits unit costing and monitoring services. 14. The EMA has a group of experienced individuals who offer expertise. 15. Have system-wide standardized forms- referral, intake, and release of information. Weaknesses 1. Council and delivery system is not focused on bringing persons into care or maintaining clients in care. 2. Lack of common vision in terms of goals and how to work with clients. 3. Many of the services were enabling rather than incorporating self-sufficiency as a goal. 4. HIV/AIDS care services are not well linked to the health care system outside of HIV/AIDS services. 5. Inadequate collaboration between HIV/AIDS service providers throughout the continuum of HIV services (both Ryan White funded and other providers). 6. Time necessary to move from committee recommendations to council policy and practices. Approval process is cumbersome. 7. Inadequate review procedure of policy and planning documents. 8. Access to benefits is not consistent across the system. 9. Points of access could be improved. 10. Benefits counseling could be done by more than just case mangers. 11. Client advocacy model is not meeting the needs of all clients. 12. The case management model is strong but actual practice and compliance with model could be improved through improved training. 13. There is inconsistent quality control. 14. There is a poor transportation system and the supplementary system of transportation for PLWH/A fills some gaps, but consumers in focus groups say this system is “unreliable” and that often volunteers to man the system were not available.
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15. Peer counseling—there are several models in use to assure culturally appropriate services, however peer counseling training is inadequate. 16. Council activities and goals are not well-publicized, known or understood outside of Planning Council and providers.
GOALS AND OBJECTIVES
This section details the EMA’s primary objectives for the next three years. They are based on workshops conducted with a project advisory group on February 7, 20036, the implementation plan drafted for the FY 2004 Ryan White CARE Act Title I application, the Sacramento Ryan White Title I and II directives and standards of care, and input from the Committee and Council members. Relevant Directives and Standards are shown in Attachment 2. Shown below are goals and specific objectives to meet the goals. It is organized by the recommended continuum of HIV services. The objectives are designed to meet the needs of eligible PLWH/A throughout the EMA, resolve unmet needs and service gaps, and overcome barriers and disparities noted earlier in the plan. The goals and objectives are based on a case management-centered system where the main access to Ryan White-funded services is through a case manager. It is further based on the universal adoption of the client tracking system being introduced into Sacramento EMA. Last, as indicated in the next section, it is outcome-based, and there is a presumption that baseline and continuing data will be collected on outcomes.
Table 2-1 Goals and Objectives- Who & When
Who
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are subitems (e.g. 1.1, 1.2, etc.)
When
System-Wide
1. Adopt an HIV/AIDS Continuum of Services with emphasis on recent HRSA directives to bring those with unmet need into care and to coordinate prevention-for-positives with ongoing care. 1.1. 1.2. Adopt recommended Continuum of HIV Services in 2003 Comprehensive Plan. Modify HRSA tools to measure unmet need to Sacramento EMA.
Council Council, NAC Support Staff Grantee Consultant Nov 2003
Jan 2004 – Aug 2004
See Minutes from the Planning Workshop February 17, 2003. Members of the ad hoc committee included: Kane Ortega, Katana Barnes, Ola Adams-Best, Alan Lange, Lisa DaValle, Julie Gallelo, Marty Keale, Adrienne Rogers, Bill Puryear, Kay Merrill, Peter Feeley, Craig Spatola*
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Who
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are subitems (e.g. 1.1, 1.2, etc.)
When
1.3.
Develop and adopt plan for outreach to those out-of-care or with delayed care.
Council, NAC Support Staff Grantee Consultant Providers
Jan 2004 – Aug 2004
2. Adopt service standards for all services and enforce standards through outcome-based reporting and monitoring. 2.1. Continue to develop and revise standards for all services to comply with HRSA directives and needs of PLWH/A. Must meet Public Health Service (PHS) guidelines. Assure precise service definitions, units of service, outcome measures, and indicators of care. In standards specify cost reimbursement and average unit costs. Specify outcomes and quality control indicators in standards.
Council (SSC) Ongoing
2.2.
Grantee Council (SSC) Support Staff Grantee Support Staff
Ongoing
2.3.
Yearly, MarchApril
3. Increase access to the community-wide resource guide by making it more widely available and accessible in paper and on-line formats in English and Spanish. 3.1. Contract to have the guide converted to a database web-accessible guide.
DHHS HIV Education and Prevention Program Sacramento Alliance to Prevent AIDS (SAPA) Consultant Sacramento Alliance to Prevent AIDS Grantee Grantee Sacramento Alliance to Prevent AIDS Consultant DHHS HIV Education and Prevention Program Sacramento Alliance to Prevent AIDS Consultant Jan 2004 – Jan 2005
3.2. 3.3.
Update through provider information form on a semi-annual basis. Have the guide conform to the adopted continuum of HIV services. Develop bilingual version(s) of the resource guide, as determined necessary by needs assessment.
June 2005 Ongoing Sept 2004 – Jan 2005
3.4.
Feb 2006
4. Coordinate care across providers for PLWH/A. 4.1. Reduce the proportion of Sacramento residents who test HIV positive but do not return for their results or delay care. Improve local ability to appropriately screen clients for service eligibility.
Council SAPA Providers Grantee Providers Consultant(s) Ongoing
4.2.
Jan 2004 – Ongoing
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Who
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are subitems (e.g. 1.1, 1.2, etc.)
When
4.3.
Share client data across providers, with assurances that client information is adequately protected.
Grantee Providers Consultant(s)
March 2004 – Ongoing
5. Integrate STD testing and medication into outpatient standards of care and directives. 5.1. Revise outpatient standards to include standard STD testing, counseling, and medication. Assure logistics in place to do STD tests. Monitor to assure compliance with protocol for STD testing, counseling, and medication.
Grantee Council (SSC) Support Staff Providers Grantee Support Staff Clinics Grantee March 2004 – June 2004
5.2. 5.3.
July 2004 – Oct 2004 Oct 2004 ongoing
6. Integrate protocols for adherence counseling into outpatient care standards and directives. 6.1. Revise outpatient and case management standards to include adherence counseling and follow-up. Assure clinics and providers have expertise to counsel and follow-up on adherence issues. Monitor to assure compliance with adherence counseling and follow-up.
Council (SSC) Grantee Grantee Support Staff Providers Grantee Mar 2004 June 2004
6.2. 6.3.
May 2005
July 2005
7. Plan for increased caseloads as a result of intensified case-finding and procedures bringing those out-ofcare into care. 7.1. Monitor clinic caseloads and adjust allocations where client loads are increasing for new clients. Adjust protocols to track and assist those who have been out-of-care to outpatient services.
Council (PAC) Grantee Grantee (QM) Council (SSC) Providers Yearly, July-Nov Nov 2004 - Mar 2005 – Ongoing
7.2.
8. Improved ability to track clients, services, and costs system-wide. 8.1. Universal adoption and use of web-based client tracking tool developed by grantee (after appropriate beta testing – see Objective 41).
Grantee Providers. Mar 2004
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Who
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are subitems (e.g. 1.1, 1.2, etc.)
When
Core Services Primary Care
Early intervention 9. Bring those out-of-care into care. 9.1. Create links to HIV/AIDS counseling and testing to track HIV positives who delay care. Track those brought into care for first time and maintain contact with clients using web-based client tracking system. Outreach to populations known to be more likely to be out-of-care (African Americans, women). Provide intensive case management to those out-of-care who come into care for initial visit. Follow-up with home case management visit if positive person does not seek care after 6 months.
Grantee County HIV Education and Prevention Program SAPA Grantee Providers Council (ACC) Grantee Providers Providers Grantee County HIV Education and Prevention Program Providers April 2004 – Ongoing
9.2.
April 2004 ongoing
9.3.
Ongoing
9.4. 9.5.
Dec 2004Ongoing
Dec 2004
10. Improve the entry and maintenance to care to those testing positive. 10.1. Use system-wide case tracking system to monitor individual patterns of care. 10.2. Assure that there is a minimum of 2 primary care visits a year per HIV positive client. Outpatient Care 11. Coordinate primary HIV/AIDS outpatient care with substance abuse services. 11.1. Identify substance users who seek / need substance abuse treatment through intake or care. Refer person to residential or outpatient substance abuse treatment. Use client-tracking system to chart progress of individual. Use intensive case management to help persons obtain substance abuse treatment.
Grantee Providers (caregivers and CM) Providers Grantee Providers Council (SSC) Providers Ongoing Grantee Council (SSC) Grantee Providers` January 2006 January 2005 Ongoing
11.2. 11.3. 11.4.
Ongoing January 2006 Ongoing Mar 2005 – Ongoing
12. Provide universal monitoring and reporting health status of PLWH/A. 12.1. Adhere to standards of care and directives (see Goal 2).
Council (SSC) Grantee Providers Ongoing
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Who
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are subitems (e.g. 1.1, 1.2, etc.)
When
13. Target those with difficulty adhering to regimens for adherence counseling and support. 13.1. Adhere to standards of care and directives for adherence (see Goal 2). 13.2. Create individualized treatment adherence plans. 13.3. Increase client knowledge about the positive outcome of adhering to medication and possible negative outcomes of developing resistant strains by stopping regimens. 13.4. Make information about medication and adherence available in newsletters and on website. 14. Integrate health education/risk reduction counseling into medical visits. 14.1. Adhere to standards of care and directives (see Goal 2). 15. Improve services to women and families to improve their access to and maintaining care. 15.1. Expanding clinical hours and providing childcare. 15.2. Use case conferencing to discuss family need among providers seeing family members. 15.3. Adhere to standards of care for women and families (see above). 16. Develop individualized treatment adherence plans based on updated acuity scale. 16.1. Utilize standard acuity scale (see above). 16.2. Have physicians / caregiver complete acuity scale and develop treatment plan. 17. Provide case conferences between providers to discuss client needs and outcomes. 17.1. Work with primary care giver and case manager to update individual service plan.
Providers Ongoing Council (SSC) Grantee Providers Providers Nov 2003 - Dec 2004 – Ongoing May 2005 Ongoing Council (PAC) Grantee Providers Grantee Providers Council (SSC) Grantee Providers Mar 2006 – Ongoing Sept 2004- May 2005 April 2005 – Ongoing Council (SSC) Grantee Providers June 2004 – Ongoing Council (SSC) Grantee Providers Grantee. Providers Grantee Providers Consumers. Consultant Council (ACC) Grantee May 2004 – Ongoing May 2004 – Ongoing
July 2004 – Ongoing
Sept 2004Ongoing
Oral Health
18. Offer access to emergency dental care. (See Title I Ryan White HIV Dental Program Operations Manual, 1999).
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Who
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are subitems (e.g. 1.1, 1.2, etc.)
When
18.1. Through case management or client request, offer all clients emergency dental visits. 19. Develop system of dental referrals with area dentists. 19.1. For more intensive / specialty dental treatments beyond limit in standard of care, create referrals with area dentists. 20. Reduce waiting time for clients to make dental appointments and receive care. 20.1. Monitor and establish stricter protocols for appointments and waiting time. 20.2. Implement quality control procedures for dental care.
Council (PAC, SSC) Grantee Providers
Ongoing
Grantee Providers
April 2004 Ongoing
Council (SSC) Grantee Council (SSC) Grantee
Mar 2005
June 2005
Substance Abuse Services – Residential
21. To provide residential drug and alcohol treatment for PLWH/A ready to begin treatment in order to increase their opportunities for appropriately accessing HIV primary care and medication therapies and improving health outcomes. (See Substance Abuse Treatment Services.
July 1999.)
21.1. 21.2.
Identify individual from intake or care assessment. Provide residential treatment programs for clients who require intensive alcohol/drug treatment. Significant increase in clients completing residential treatment program.
Providers Council (PAC) Grantee Providers Providers
Ongoing
Ongoing
21.3.
Mar 2006
Substance Abuse Services – Outpatient
22. Provide outpatient treatment designed to reduce or eliminate alcohol and drug use/abuse by PLWH/A in order to allow initiation of or improve adherence to HIV medication regimes. (See Substance Abuse Treatment
Services. July 1999.)
22.1. Identify individual from intake or care assessment. 22.2. Include ongoing standard survey of selfreported substance use. After baseline, steady reduction of substance use/abuse by selfreport. 22.3. Based on self-assessment, significant reduction of risk behaviors by those in drug treatment.
Providers
Ongoing
Council (SSC) Grantee Providers
Sept 2004 – Ongoing
Grantee Providers
Mar 2005
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Who
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are subitems (e.g. 1.1, 1.2, etc.)
When
22.4. For those in outpatient treatment, a significant increase in those reporting improved or stable living situation.
Providers
Mar 2005
Mental Heath
23. Individual or group mental health services to address clinically diagnosed mental illnesses and overcome issues of denial. (see Mental Health Standards. July, 1999.) 23.1. Increase services to chronically and severely mentally ill by a licensed psychiatrist or social worker. 23.2. Develop specialized mental health services for transgender, monolingual Latinos, and clients with significant co-morbidities. 23.3. Clients may apply for mental health services or, based on intake and clinical assessment, be referred to mental health services. Follow-up on referral. 23.4. Provide and monitor psychotropic medications for treatable mental illnesses as dictated in standards of service, directives, and PHS standards.
Council (PAC) Grantee Providers Council (PAC) Grantee Providers Council (SSC) Grantee Providers Mar 2006
Mar 2006
Ongoing
Council (SSC) Grantee Providers
Ongoing
Hospice Services
24. To provide hospice service to all PLWH/A who need intensive non-drug related residential care. 24.1. Maintain hospice program’s residential, fullcare facility. 24.2. Based on acuity and/or demonstrated need, provide residential hospice or full-service residential housing to those needing medical care for OIs. (March 2007)
Council (PAC) Grantee Providers Council (PAC, SSC) Grantee Providers Mar 2007
Mar 2007
Primary Linking and Access Services Case Management
25. Outreach to clients in need of case management. (See
Case Management Service Standards for Persons Living with HIV/AIDS. July, 2001)
25.1. Provide uniform intake with eligibility check for Ryan White and non-Ryan White services. Update every 6 months to maximize all Ryan White and non-Ryan White benefits. 25.2. Provide case management where it is most easily accessed (e.g. field/home based). 25.3. Determine eligibility for insurance continuation or applying for insurance.
Grantee Consultants Providers Council (PAC) Grantee Providers Providers
Sept 2004
Ongoing
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Who
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are subitems (e.g. 1.1, 1.2, etc.)
When
26. Provide culturally and linguistically appropriate case management. 27. Uniform acuity assessment. 27.1. All case managers to use uniform intake and check for eligibility for Ryan White Funded and other care services. 27.2. Utilize acuity scale to develop service plan and make referrals.
Grantee Provider Sept 2004
Provider
Mar 2005
Transportation
28. Assess transportation needs of clients and develop long-term transportation plan for services. (See
Transportation Services. January, 2003.)
28.1. Provide vouchers or tokens on an equitable basis based on need. 28.2. Monitor quality and timeliness of transportation provided.
Council (PAC, SSC) Grantee Providers Grantee
Ongoing
Jan 2005
Insurance Continuation
29. If client is eligible, pay insurance premiums to continue insurance coverage. 29.1. Pay co-payment on existing insurance if PLWH/A unable to pay. 29.2. Effort to keep all PLWH/A on existing insurance, COBRA, or other insurance and pay premium if necessary.
Council (PAC) Grantee Providers Grantee Provider Ongoing
Ongoing
Support Services Emergency Financial Assistance
30. Provide emergency financial assistance to clients with pressing emergency needs. 30.1. Standardize process of distributing emergency funds in “Utility Assistance Standards”. 30.2. Provide assessment of need in acuity rating; update every 6 months. 30.3. Distribute funds based on directive for emergency care. 30.4. Provide prescription medication reimbursements (non-ADAP to fill gaps). 30.5. Partial rent subsidy and utility assistance to people with HIV to provide stability and facilitate access to or maintain HIV treatment.
Council (SSC) Grantee Providers. Provider Jan 2005 Oct 2005 – ongoing Jan 2005
Provider Providers Grantee Grantee Providers
Ongoing
Ongoing
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Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are subitems (e.g. 1.1, 1.2, etc.)
When
30.6. Clients accessing Emergency Financial Assistance to continue to access routine medical care (minimum 2 primary care visits per year).
Council (SSC) Grantee Providers
Feb 2005; annual analysis.
Housing
31. Stabilize living situation to ensure maintenance of medical care and treatment adherence through the provision of short-term housing assistance or rental assistance subsidy. 31.1. Coordinate housing referrals with HOPWA, Section 8 housing, and Shelter Plus Care. 31.2. Develop linkages with landlords and other providers of housing to develop capacity to meet demand for temporary housing. 31.3. Significant increase in number of clients receiving housing assistance who maintain routine medical care (minimum 2 primary care visits per year).
Providers Jan 2005 – July 2005
Providers
Ongoing
Council (SSC) Grantee Providers
Feb 2005 – Ongoing; annual analysis
Food
32. To ensure that that persons with HIV/AIDS who are having difficulty getting nutritious foods have access to proper nutrition to improve health outcomes. (See Objective 34) 32.1. Provide home-delivered food bundles to PLWH/A who would otherwise be unable to provide for their own nutritional needs. Provide nutritional supplements to clients receiving nutritional counseling. Monitor quality and clients satisfaction of home-delivered meals.
Providers Ongoing
32.2. 32.3.
Providers
Ongoing Mar 2005, Yearly survey
Grantee
Child Care
33. Provide financial support for childcare for children of PLWH/A (or juvenile siblings of youth PLWH/A) in order to improve clients’ ability to access and maintain primary and supportive service care. (See
Standard on Child Care Services).
33.1. Develop a pool of reliable day-care providers who parents can hire or drop children while attending appointments. Contract for number of slots. Monitor demand and use.
Providers Grantee
Mar 2005- Feb 2006
Psychosocial Support Services
34. Provide non-licensed nutritional counseling.
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Who
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are subitems (e.g. 1.1, 1.2, etc.)
When
34.1. Assure that clients understand and have access to supplements. 35. Overcome denial and develop community contacts for PLWH/A. 35.1. Provide peer and non licensed counseling to PLWH/A.
Providers
Ongoing
Council (PAC) Grantee Providers
Ongoing
Complementary Care
36. Provide massage, acupuncture, and chiropractic services to those eligible. (See Complementary/Alternative
Therapies. January 2003.)
36.1. Based on standards and directives, direct all persons requesting and eligible to complementary care. 36.2. Measure outcomes of complementary care (functionality and side effects).
Providers
Ongoing
Grantee Providers
Mar 2005
Services to Providers
37. Provide trainings to providers on non-HIV sources for services and funding. 38. Use of the most effective and efficient service delivery practices based on research findings. 38.1. Distribution of and training on best practices for prevention to positives, core, linking, and support services to line and management staff of providers with semi-annual updates.
Council Grantee Consultant Oct 2004; semi –annual updates Council Grantee Mar 2004ongoing
39. Improve client ability to navigate the continuum of HIV services. 39.1. Extensive provider education offered to help them be fully familiar with continuum of HIV services and options for clients. 39.2. Provide updated resource guide that is accessible to clients and case managers.
Council Grantee Consultant DHHS HIV Education and Prevention Program Sacramento Alliance to Prevent AIDS January 2005, once every quarter
July 2005
40. Develop new models of outreach and maintaining services for people of color. 40.1. Implement those recommendations of the Community Care Network for People of Color currently underway that the Council concurs with. 41. Understanding of unit cost and cost reimbursement programs used.
Council (ACC) Mar 2004 – Aug 2004
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Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are subitems (e.g. 1.1, 1.2, etc.)
When
41.1. Workshops on cost reimbursement, unit costs, and financial control should be offered by the grantee.
Grantee
Apr 2004, and yearly
Program Administration Assessment and Evaluation
42. Distribute and train providers on client-tracking system. 42.1. Full beta testing of system. 42.2. Provider training and protocols. 42.3. Rollout with scheduled benchmarks. 43. Continuous data collection among PLWH/A. 43.1. Develop plan for continuous data collection among clients of HIV/AIDS care and those out of care. 43.2. Annual special studies among a specific target population with special needs. 43.3. Inclusion of client satisfaction surveys at providers. 43.4. Increase return rate of client satisfaction surveys. 44. Transparency in costing and reimbursement. 44.1. A full audit of the financial reimbursement scheme should be contracted to provide a clean bill of health to the cost-reimbursement system and make suggestions where it maybe improved.
Council Grantee Consultant Council Grantee Consultant Council (NAC) Consultant Grantee Consultant Providers Grantee Providers Council Jan 2004 - Aug 2004 Mar 2004 – Ongoing Ongoing Grantee Consultants Grantee Grantee April 2004 Mar 2004 ongoing Mar 2004
Nov 2004 ongoing
June 2005
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Timeline
The timeline below displays the beginning and ending time for each objective. Table 2-2 Timeline
Goals and Objectives
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are subitems (e.g. 1.1, 1.2, etc.) System-Wide
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1. Adopt an HIV/AIDS Continuum of Services with emphasis on recent HRSA directives to bring those with unmet need into care and to coordinate prevention-for-positives with ongoing care. 1.1. Adopt recommended Continuum of HIV Services in 2003 Comprehensive Plan. 1.2. Modify HRSA tools to measure unmet need to Sacramento EMA. 1.3. Develop and adopt plan for outreach to those out-of-care or with delayed care. 2. Adopt service standards for all services and enforce standards through outcome-based reporting and monitoring. 2.1. Continue to develop and revise standards for all services to comply with HRSA directives and needs of PLWH/A. Must meet Public Health Service (PHS) guidelines. 2.2. Assure precise service definitions, units of service, outcome measures, and indicators of care. In standards specify cost reimbursement and average unit costs. 2.3. Specify outcomes and quality control indicators in standards. 3. Increase access to the community-wide resource guide by making it more widely available and accessible in paper and on-line formats. 3.1. Contract to have the guide converted to a database web-accessible guide. 3.2. Update through provider information form on a semi-annual basis. 3.3. Have the guide conform to the adopted continuum of HIV services. 3.4. Develop bilingual version(s) of the resource guide, as determined necessary by needs assessment. 4. Coordinate care across providers for PLWH/A. 4.1. Reduce the proportion of Sacramento residents who test HIV positive but do not return for their results or delay care.
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Goals and Objectives
4.2. Improve local ability to appropriately screen clients for service eligibility. 4.3. Share client data across providers, with assurances that client information is adequately protected. 5. Integrate STD testing and medication into outpatient standards of care and directives. 5.1. Revise outpatient standards to include standard STD testing, counseling, and medication. 5.2. Assure logistics in place to do STD tests. 5.3. Monitor to assure compliance with protocol for STD testing, counseling, and medication. 6. Integrate protocols for adherence counseling into outpatient care standards and directives. 6.1. Revise outpatient and case management standards to include adherence counseling and follow-up. 6.2. Assure clinics and providers have expertise to counsel and followup on adherence issues. 6.3. Monitor to assure compliance with adherence counseling and follow-up. 7. Plan for increased caseloads as a result of intensified case-finding and procedures bringing those out-of-care into care. 7.1. Monitor clinic caseloads and adjust allocations where client loads are increasing for new clients. 7.2. Adjust protocols to track and assist those who have been out-ofcare to outpatient services. 8. Improved ability to track clients, services, and costs system-wide. 8.1. Universal adoption and use of web-based client tracking tool developed by grantee (after appropriate beta testing – see Objective 41) Core Services Primary Care
Early intervention
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Fall 2006
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Goals and Objectives
9.2. Track those brought into care for first time and maintain contact with clients using web-based client tracking system. 9.3. Outreach to populations known to be more likely to be out-of-care (African Americans, women). 9.4. Provide intensive case management to those out-of-care who come into care for initial visit. 9.5. Follow-up with home case management visit if positive person does not seek care after 6 months. 10. Improve the entry and maintenance to care to those testing positive. 10.1.Use system-wide case tracking system to monitor individual patterns of care. 10.2.Assure that there is a minimum of 2 primary care visits a year per HIV positive client. Outpatient Care 11. Coordinate primary HIV/AIDS outpatient care with substance abuse services. 11.1. Identify substance users who seek / need substance abuse treatment through intake or care. 11.2. Refer person to residential or outpatient substance abuse treatment. 11.3. Use client-tracking system to chart progress of individual. 11.4. Use intensive case management to help persons obtain substance abuse treatment. 12. Provide universal monitoring and reporting health status of PLWH/A. 12.1. Adhere to standards of care and directives (see Goal 2). 13. Target those with difficulty adhering to regimens for adherence counseling and support. 13.1. Adhere to standards of care and directives for adherence (see Goal 2). 13.2. Create individualized treatment adherence plans. 13.3. Increase client knowledge about the positive outcome of adhering to medication and possible negative outcomes of developing resistant strains by stopping regimens. 13.4. Make information about medication and adherence available in newsletters and on website. 14. Integrate health education/risk reduction counseling into medical visits.
Fall Winter Spring Sum Fall Winter Spring Sum Fall Winter Spring Sum 2003 2004 2004 2004 2004 2005 2005 2005 2005 2006 2006 2006
Fall 2006
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Goals and Objectives
14.1. Adhere to standards of care and directives (see Goal 2). 15. Improve services to women and families to improve their access to and maintaining care. 15.1. Expanding clinical hours and providing childcare. 15.2. Use case conferencing to discuss family need among providers seeing family members. 15.3. Adhere to standards of care for women and families (see Objective 2). 16. Develop individualized treatment adherence plans based on updated acuity scale. 16.1. Utilize standard acuity scale (see above). 16.2. Have physicians / caregiver complete acuity scale and develop treatment plan. 17. Provide case conferences between providers to discuss client needs and outcomes. 17.1. Work with primary care giver and case manager to update individual service plan. Oral Health 18. Offer access to emergency dental care. (See Title I - Ryan White HIV Dental Program Operations Manual, 1999). 18.1. Through case management or client request, offer all clients emergency dental visits. 19. Develop system of dental referrals with area dentists. 19.1. For more intensive / specialty dental treatments beyond limit in standard of care, create referrals with area dentists. 20. Reduce waiting time for clients to make dental appointments and receive care. 20.1. Monitor and establish stricter protocols for appointments and waiting time. 20.2. Implement quality control procedures for dental care. Substance Abuse Services – Residential 21. To provide residential drug and alcohol treatment for PLWH/A ready to begin treatment in order to increase their opportunities for appropriately accessing HIV primary care and medication therapies and improving health outcomes. (See Substance Abuse Treatment Services. July 1999.)
Fall Winter Spring Sum Fall Winter Spring Sum Fall Winter Spring Sum 2003 2004 2004 2004 2004 2005 2005 2005 2005 2006 2006 2006
Fall 2006
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Goals and Objectives
21.1. Identify individual from intake or care assessment. 21.2. Provide residential treatment programs for clients who require intensive alcohol/drug treatment. 21.3. Significant increase in clients completing residential treatment program. Substance Abuse Services – Outpatient 22. Provide outpatient treatment designed to reduce or eliminate alcohol and drug use/abuse by PLWH/A in order to allow initiation of or improve adherence to HIV medication regimes. (See Substance Abuse Treatment Services. July 1999.) 22.1Identify individual from intake or care assessment. 22.2. Include ongoing standard survey of self-reported substance use. After baseline, steady reduction of substance use/abuse by selfreport. 22.3. Based on self-assessment, significant reduction of risk behaviors by those in drug treatment. 22.4. For those in outpatient treatment, a significant increase in those reporting improved or stable living situation. Mental Heath 23. Individual or group mental health services to address clinically diagnosed mental illnesses and overcome issues of denial. (See Mental Health Standards. July, 1999.) 23.1. Increase services to chronically and severely mentally ill by a licensed psychiatrist or social worker. 23.2. Develop specialized mental health services for transgender, monolingual Latinos, and clients with significant co-morbidities. 23.3. Clients may apply for mental health services or, based on intake and clinical assessment, be referred to mental health services. Follow-up on referral. 23.4. Provide and monitor psychotropic medications for treatable mental illnesses as dictated in standards of service, directives, and PHS standards. Hospice Services 24. To provide hospice service to all PLWH/A who need intensive non-drug related residential care.
Fall Winter Spring Sum Fall Winter Spring Sum Fall Winter Spring Sum 2003 2004 2004 2004 2004 2005 2005 2005 2005 2006 2006 2006
Fall 2006
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Goals and Objectives
24.1. Maintain hospice program’s residential, full-care facility (March 2007). 24.2. Based on acuity and/or demonstrated need, provide residential hospice or full-service residential housing to those needing medical care for OIs (March 2007). Primary Linking and Access Services Case Management 25. Outreach to clients in need of case management. (See Case Management Service Standards for Persons Living with HIV/AIDS. July, 2001) 25.1. Provide uniform intake with eligibility check for Ryan White and non-Ryan White services. Update every 6 months to maximize all Ryan White and non-Ryan White benefits. 25.2. Provide case management where it is most easily accessed (e.g. field/home based). 25.3. Determine eligibility for insurance continuation or applying for insurance. 26. Provide culturally and linguistically appropriate case management. 26.1. Provide culturally appropriate individualized treatment plan that coordinates multiple needs assessed in intake. 27. Uniform acuity assessment. 27.1. All case managers to use uniform intake and check for eligibility for Ryan White Funded and other care services. 27.2. Utilize acuity scale to develop service plan and make referrals. Transportation 28. Assess transportation needs of clients and develop long-term transportation plan for services. (See Transportation Services. January, 2003.) 28.1. Provide vouchers or tokens on an equitable basis based on need. 28.2. Monitor quality and timeliness of transportation provided. Insurance Continuation 29. If client is eligible, pay insurance premiums to continue insurance coverage. 29.1. Pay co-payment on existing insurance if PLWH/A unable to pay.
Fall Winter Spring Sum Fall Winter Spring Sum Fall Winter Spring Sum 2003 2004 2004 2004 2004 2005 2005 2005 2005 2006 2006 2006
Fall 2006
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Goals and Objectives
29.2. Effort to keep all PLWH/A on existing insurance, COBRA, or other insurance and pay premium if necessary. Support Services Emergency Financial Assistance 30. Provide emergency financial assistance to clients with pressing emergency needs. 30.1. Standardize process of distributing emergency funds in “Utility Assistance Standards”. 30.2. Provide assessment of need in acuity rating; update every 6 months. 30.3. Distribute funds based on directive for emergency care. 30.4. Provide prescription medication reimbursements (non-ADAP to fill gaps). 30.5. Partial rent subsidy and utility assistance to people with HIV to provide stability and facilitate access to or maintain HIV treatment. 30.6. Clients accessing Emergency Financial Assistance to continue to access routine medical care (minimum 2 primary care visits per year). Housing 31. Stabilize living situation to ensure maintenance of medical care and treatment adherence through the provision of short-term housing assistance or rental assistance subsidy. 31.1. Coordinate housing referrals with HOPWA, Section 8 housing, and Shelter Plus Care. 31.2. Develop linkages with landlords and other providers of housing to develop capacity to meet demand for temporary housing. 31.3 Significant increase in number of clients receiving housing assistance who maintain routine medical care (minimum 2 primary care visits per year). Food 32. To ensure that that persons with HIV/AIDS who are having difficulty getting nutritious foods have access to proper nutrition to improve health outcomes. (See Objective 34) 32.1. Provide home-delivered food bundles to PLWH/A who would otherwise be unable to provide for their own nutritional needs.
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Fall 2006
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Goals and Objectives
32.2. Provide nutritional supplements to clients receiving nutritional counseling. 32.3. Monitor quality and clients satisfaction of home-delivered meals. Child Care 33. Provide financial support for childcare for children of PLWH/A (or juvenile siblings of youth PLWH/A) in order to improve clients’ ability to access and maintain primary and supportive service care. (See Standard on Child Care Services). 33.1. Develop a pool of reliable day-care providers who parents can hire or drop children while attending appointments. Contract for number of slots. Monitor demand and use. Psychosocial Support Services 34. Provide non-licensed nutritional counseling. 34.1. Assure that clients understand and have access to supplements. 35. Overcome denial and develop community contacts for PLWH/A. 35.1. Provide peer and non licensed counseling to PLWH/A. Complementary Care 36. Provide massage, acupuncture, and chiropractic services to those eligible. (See Complementary/Alternative Therapies. January 2003.) 36.1. Based on standards and directives, direct all persons requesting and eligible to complementary care. 36.2. Measure outcomes of complementary care (functionality and side effects). Services to Providers 37. Provide trainings to providers on non-HIV sources for services and funding. 38. Use of the most effective and efficient service delivery practices based on research findings. 38.1. Distribution of and training on best practices for prevention to positives, core, linking, and support services to line and management staff of providers with semi-annual updates. 39. Improve client ability to navigate the continuum of HIV services. 39.1. Extensive provider education offered to help them be fully familiar with continuum of HIV services and options for clients.
Fall Winter Spring Sum Fall Winter Spring Sum Fall Winter Spring Sum 2003 2004 2004 2004 2004 2005 2005 2005 2005 2006 2006 2006
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Goals and Objectives
39.2. Provide updated resource guide that is accessible to clients and case managers. 40. Develop new models of outreach and maintaining services for people of color. 40.1. Implement those recommendations of the Community Care Network for People of Color currently underway that the Council concurs with. 41. Understanding of unit cost and cost reimbursement programs used. 41.1. Workshops on cost reimbursement, unit costs, and financial control should be offered by the grantee. Program Administration Assessment and Evaluation 42. Distribute and train providers on client-tracking system. 42.1. Full beta testing of system. 42.2. Provider training and protocols. 42.3. Rollout with scheduled benchmarks. 43. Continuous data collection among PLWH/A. 43.1. Develop plan for continuous data collection among clients of HIV/AIDS care and those out of care. 43.2. Annual special studies among a specific target population with special needs. 43.3. Inclusion of client satisfaction surveys at providers. 43.4. Increase return rate of client satisfaction surveys. 44. Transparency in costing and reimbursement. 44.1. A full audit of the financial reimbursement scheme should be contracted to provide a clean bill of health to the costreimbursement system and make suggestions where it maybe improved.
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3. HOW WILL WE MONITOR OUR PROGRESS AND RESULTS
The various objectives noted in the previous section can be monitored using a number of different methods. For contract work, existence of RFPs, disbursement of funds in a timely manner, and products (reports, systems, guides, etc.) and events (trainings, meetings, seminars, etc.) can be tracked. For services, number of clients can be tracked as well as outcomes, satisfaction, need and gaps. Below, there is a recommended method for monitoring and an indicator for each objective noted in the previous section. In Table 3-1, the “how” reflects actions that must be taken for the objective to be implemented. It involves Council actions, provider implementation, and consumer participation. It assumes the successful implementation of a client database with shared data, the adoption and funding of continuous data collection and ongoing data analysis. The Council must pay particular attention to detailed standards and directives. The recommendations increase the monitoring of standards and directives, and measure their impact. The successful implementation of the objectives require the active participation of Council subcommittees, not only in planning but in reviewing data and making corrections in the system where indicated. The final objectives are made to increase the transparency of funding among providers and consumers and lift a veil of misunderstanding about the procedures and methods of the grantee in allocating funds.
Table 3-1 Goal and Objectives - How & Indicators How Goals and Objectives
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are sub-items (e.g. 1.1, 1.2, etc.)
Indicators
System-Wide
1. Adopt an HIV/AIDS Continuum of Services with emphasis on recent HRSA directives to bring those with unmet need into care and to coordinate prevention-for-positives with ongoing care. 1.1. Adopt recommended Continuum of HIV Services in 2003 Comprehensive Plan. Modify HRSA tools to measure unmet need to Sacramento EMA. Develop and adopt plan for outreach to those out-of-care or with delayed care.
Council vote. Minutes. Report. Estimate of unmet need. Plan (document).
1.2. 1.3.
Hire consultant. Committee discussion. Hire consultant.
2. Adopt service standards for all services and enforce standards through outcome-based reporting and monitoring.
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Goals and Objectives
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are sub-items (e.g. 1.1, 1.2, etc.)
How
Indicators
2.1.
Continue to develop and revise standards for all services to comply with HRSA directives and needs of PLWH/A. Must meet Public Health Service (PHS) guidelines. Assure precise service definitions, units of service, outcome measures, and indicators of care. In standards specify cost reimbursement and average unit costs. Specify outcomes and quality control indicators in standards.
Committee discussion and vote.
Minutes. Standards document.
2.2.
Committee discussion with Grantee input.
Service definition updates (document). Unit costs.
2.3.
Committee discussion. Research into other EMA quality controls tools.
Outcomes for each service (document).
3. Increase access to the community-wide resource guide by making it more widely available and accessible in paper and on-line formats. 3.1. 3.2. 3.3. 3.4. Contract to have the guide converted to a database web-accessible guide. Update through provider information form on a semi-annual basis. Have the guide conform to the adopted continuum of HIV services. Develop bilingual version(s) of the resource guide, as determined necessary by needs assessment.
Hire consultant. Mail and on-line provider information form updates. Consultant to design / program guide to match continuum of services. Hire translators Executed contract. Paper and on-line resource guide. Biannual updates in guide. Match between continuum of HIV services and guide. Existence of bilingual guide.
4. Coordinate care across providers for PLWH/A. 4.1. Reduce the proportion of Sacramento residents who test HIV positive but do not return for their results or delay care. Improve local ability to appropriately screen clients for service eligibility.
Coordinate with HIV counseling and testing to follow-up on positives. HARS database tracking. Track time it takes to determine eligibility and number referred to non-Ryan White funded services. Report use of client data by more than one provider.
4.2.
Develop and distribute eligibility module for client database.
4.3.
Share client data across providers, with assurances that client information is adequately protected.
Implement client database.
5. Integrate STD testing and medication into outpatient standards of care and directives. 5.1. Revise outpatient standards to include standard STD testing, counseling, and medication.
Council committee discussion and vote. Updated standard / protocol includes STD testing, counseling, and medication (document).
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Goals and Objectives
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are sub-items (e.g. 1.1, 1.2, etc.)
How
Assure funding, tests and counselors are available at providers. Adopt client tracking with reported STD testing, counseling and medication.
Indicators
5.2. 5.3.
Assure logistics in place to do STD tests. Monitor to assure compliance with protocol for STD testing, counseling, and medication.
# STD tests and counseling sessions. Report of STD testing, counseling, and medication.
6. Integrate protocols for adherence counseling into outpatient care standards and directives. 6.1. Revise outpatient and case management standards to include adherence counseling and follow-up. Assure clinics and providers have expertise to counsel and follow-up on adherence issues. Monitor to assure compliance with adherence counseling and follow-up.
Standards committee discussion and recommendation. Council vote. Develop and provide training manual on adherence. Collect information on provider information form. Client database and provider info form to collect adherence information. Revised outpatient standards that include adherence protocols (document). Report from provider information form. Monitoring report from client database and provider information form.
6.2.
6.3.
7. Plan for increased caseloads as a result of intensified case finding and procedures bringing those out-of-care into care. 7.1. Monitor clinic caseloads and adjust allocations where client loads are increasing for new clients. Adjust protocols to track and assist those who have been out-of-care to outpatient services.
Provider use of client database. Run monitoring reports on new clients. Check with HARS. Council discussion and vote. Trend reports of new clients in the system. Revised protocols on measuring and contacting out-ofcare.
7.2.
8. Improved ability to track clients, services, and costs system-wide. 8.1. Universal adoption and use of webbased client tracking tool developed by grantee (after appropriate beta testing – see Objective 41).
Finish beta testing. Train providers. Distribute. Use of client-tracking system.
Core Services Primary Care
Early intervention 9. Bring those out-of-care into care. 9.1. Create links to HIV/AIDS counseling and testing to track HIV positives who delay care. Track those brought into care for first time and maintain contact with clients using web-based client tracking system.
LOA with counseling and testing to track and refer those testing HIV positive. LOA executed and operational.
9.2.
HARS and client tracking.
Reports from HARS and client tracking on new clients.
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Goals and Objectives
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are sub-items (e.g. 1.1, 1.2, etc.)
How
Indicators
Number of outreach sessions. New clients in system. CM reports.
9.3.
Outreach to populations known to be more likely to be out-of-care (African Americans, women). Provide intensive case management to those out-of-care who come into care for initial visit. Follow-up with home case management visit if positive person does not seek care after 6 months.
Outreach to high-risk communities. Assign CM for intensive follow-up for new clients who have delayed care or miss first appointment. CM to do home visit to those delaying care or not.
9.4.
9.5.
CM reports.
10. Improve the entry and maintenance to care to those testing positive. 10.1. Use system-wide case tracking system to monitor individual patterns of care. 10.2. Assure that there is a minimum of 2 primary care visits a year per HIV positive client. Outpatient Care 11. Coordinate primary HIV/AIDS outpatient care with substance abuse services. 11.1. Identify substance users who seek / need substance abuse treatment through intake or care. Refer person to residential or outpatient substance abuse treatment. Use client-tracking system to chart progress of individual. Use intensive case management to help persons obtain substance abuse treatment.
Intake questions and referrals from caregivers based on clinical observations. Provider (CM or caregiver referral) and include code in client database. Create module in client database that charts outcomes of clients (morbidity, QOL / functionality). Modify standard to allow intensive CM to assist substance user to enroll in substance abuse program. Create code in database. Report on number of referrals to substance abuse counseling. Client database report. Client database report. Develop a report on care patterns. Develop report on primary care visits. Report.
Report.
11.2. 11.3. 11.4.
Client database report.
12. Provide universal monitoring and reporting health status of PLWH/A. 12.1. Adhere to standards of care and directives (see Goal 2). 13. Target those with difficulty adhering to regimens for adherence counseling and support. 13.1. Adhere to standards of care and directives for adherence (see Goal 2). 13.2. Create individualized treatment adherence plans.
Contract monitoring. Include questions in provider information form. Provider follows protocol and enters into chart. Chart reviews. Monitoring report. Analysis of provider information form. Results of chart review. Implement client tracking system. Include in consumer survey (continuous data collection). Monitoring reports. Analysis of consumer survey.
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Goals and Objectives
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are sub-items (e.g. 1.1, 1.2, etc.)
How
Develop brochure to distribute at provider. Include in provider protocol during checks. Measure by consumer survey (continuing data collection). Add info to county website. Develop Council website. Regular mailing of newsletters.
Indicators
13.3. Increase client knowledge about the positive outcomes of adhering to medication and possible negative outcomes of developing resistant strains by stopping regimens. 13.4. Make information about medication and adherence available in newsletters and on website. 14. Integrate health education/risk reduction counseling into medical visits. 14.1. Adhere to standards of care and directives (see Goal 2). 15. Improve services to women and families to improve their access to and maintaining care. 15.1. Expanding clinical hours and providing childcare. 15.2. Use case conferencing to discuss family need among providers seeing family members.
Consumer survey data report.
Newsletters and website.
Monitoring.
Monitoring reports.
Providers have special clinic hours for women and families. Grantee identifies women/families with multiple providers. Provider collaboration among providers for case conferencing consumer needs. Complete logs. Council to modify standards for women. Providers adhere to standards. Capture adherence in charts and client survey.
Monitoring report.
Client conference logs.
15.3. Adhere to standards of care for women and families (see Objective 2).
Monitoring reports. Consumer survey analysis & report.
16. Develop individualized treatment adherence plans based on updated acuity scale. 16.1. Utilize standard acuity scale (see Objective 2). 16.2. Have physicians / caregiver complete acuity scale and develop treatment plan. 17. Provide case conferences between providers to discuss client needs and outcomes. 17.1. Work with primary care giver and case manager to update individual service plan.
Main provider updates plan based on case conference. Chart review. Circulate and train on accepted acuity scale. Provider use acuity scale. Make scale and form easily available. Have form on-line; PDA. Monitoring. Provider information form report. Chart review report.
Oral Health
18. Offer access to emergency dental care. (See
Title I - Ryan White HIV Dental Program Operations Manual, 1999).
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Goals and Objectives
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are sub-items (e.g. 1.1, 1.2, etc.)
How
Indicators
18.1. Through case management or client request, offer all clients emergency dental visits. 19. Develop system of dental referrals with area dentists. 19.1. For more intensive / specialty dental treatments beyond limit in standard of care, create referrals with dental schools and area dentists. 20. Reduce waiting time for clients to make dental appointments and receive care. 20.1. Monitor and establish stricter protocols for appointments and waiting time. 20.2. Implement quality control procedures for dental care.
Provider (CM, caregiver to offer referral to dental care).
Chart review analysis. Consumer survey analysis.
Create LOAs with area dentists.
LOAs. Monitoring reports.
SSC committee discussion and recommendation. Council vote. Provider adopts and maintains records on quality control.
Monitoring report. Consumer survey. Monitoring quality assessment report.
Substance Abuse Services – Residential
21. To provide residential drug and alcohol treatment for PLWH/A ready to begin treatment in order to increase their opportunities for appropriately accessing HIV primary care and medication therapies and improving health outcomes. (See Substance
Abuse Treatment Services. July 1999.)
21.1. 21.2.
Identify individual from intake or care assessment. Provide residential treatment programs for clients who require intensive alcohol/drug treatment. Significant increase in clients completing residential treatment program.
If intake or clinical assessment includes substance abuse further assess for treatment program. CM assures residential substance abuse referrals or court ordered substance treatment participation. Audit programs for quality and follow-up with participant to determine barriers.
Chart reviews. Referral logs. Consumer survey (special pop). Client database. Consumer survey (special pop). Client database.
21.3.
Substance Abuse Services – Outpatient
22. Provide outpatient treatment designed to reduce or eliminate alcohol and drug use/abuse by PLWH/A in order to allow initiation of or improve adherence to HIV medication regimes. (See Substance Abuse
Treatment Services. July 1999.)
22.1. Identify individual from intake or care assessment.. 22.2. Include ongoing standard survey of self-reported substance use. After baseline, steady reduction of substance use/abuse by self-report.
If intake or clinical assessment includes substance abuse further assess for treatment program. Consumer survey (continuing data collection).
Chart reviews. Referral logs.
Consumer survey analysis and report.
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Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are sub-items (e.g. 1.1, 1.2, etc.)
How
Indicators
22.3. Based on self-assessment, significant reduction of risk behaviors by those in drug treatment. 22.4. For those in outpatient treatment, a significant increase in those reporting improved or stable living situation.
Consumer survey (continuing data collection).
Consumer survey analysis and report.
Consumer survey (special survey)
Survey report.
Mental Heath
23. Individual or group mental health services to address clinically diagnosed mental illnesses and overcome issues of denial. (See Mental
Health Standards. July, 1999.)
23.1. Increase services to chronically and severely mentally ill by a licensed psychiatrist or social worker. 23.2. Develop specialized mental health services for transgender, monolingual Latinos, and clients with significant co-morbidities. 23.3. Clients may apply for mental health services or, based on intake and clinical assessment, be referred mental health services. Follow-up on referral. 23.4. Provide and monitor psychotropic medications for treatable mental illnesses as dictated in standards of service, directives, and PHS standards.
Improve definition and directive for psychological treatment. Direct providers to conduct assessments. Refer where appropriate. Hire consultant to develop directive and standard. Council discussion & vote. Implement and track programs.
Client tracking system report.
Revised standards and directives. Client tracking system report.
Referral where appropriate. Standard assessment for selfreferrals.
Client database report.
Chart review.
Chart review report.
Hospice Services
24. To provide hospice service to all PLWH/A who need intensive non-drug related residential care. 24.1. Maintain hospice program ’s residential, full-care facility.
Revise standards and directives. Council and Priorities and Allocations Committee discussion and vote. Include threshold of residential full service in acuity scale. Refer where indicated by scale and clinician. Revised standard and directives. Minutes indicating vote.
24.2. Based on acuity and/or demonstrated need, provide residential hospice or full-service residential housing to those needing medical care for OIs.
Client database report.
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Goals and Objectives
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are sub-items (e.g. 1.1, 1.2, etc.)
How
Indicators
Primary Linking and Access Services Case Management
25. Outreach to clients in need of case management. (See Case Management Service
Standards for Persons Living with HIV/AIDS. July, 2001)
25.1. Provide uniform intake with eligibility check for Ryan White and non-Ryan White services. Update every 6 months to maximize all Ryan White and non-Ryan White benefits. 25.2. Provide case management where it is most easily accessed (e.g. field/home based). 25.3. Determine eligibility for insurance continuation or applying for insurance.
Mandate uniform intake for RW providers, provide to non-RW providers. Update eligibility every 6 months. Provider assessment of home visits for clients who miss or delay appointments. Assure intake has screening questions for insurance status. Determine eligibility for insurance continuation. Provide general information to consumers about eligibility.
Intake analysis report. Eligibility updates every 6 months.
Client database report.
Client database report. Consumer survey analysis.
26. Provide culturally and linguistically appropriate case management. 26.1. 26.2. Provide culturally appropriate individualized treatment plan that coordinates multiple needs assessed in intake. 27. Uniform acuity assessment. 27.1. All case managers to use uniform intake and check for eligibility for Ryan White Funded and other care services. 27.2. Utilize acuity scale to develop service plan and make referrals.
Monitor CM use of acuity. Audit report. Assure intake includes assessment of cultural appropriateness. Audit individual assessment plans. Reports.
Training for CM. Chart review.
Chart review report.
Transportation
28. Assess transportation needs of clients and develop long-term transportation plan for services. (See Transportation Services. January,
2003.)
28.1. Provide vouchers or tokens on an equitable basis based on need.
28.2. Monitor quality and timeliness of transportation provided.
Enforce standards and directive for transportation. Monitor transportation vouchers. Consumer survey (continuous data collection). Contract monitoring. Consumer survey (continuous data collection).
Monitoring reports. Consumer survey analysis.
Monitoring report. Consumer survey analysis.
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Goals and Objectives
Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are sub-items (e.g. 1.1, 1.2, etc.)
How
Indicators
28.3.
Insurance Continuation
29. If client is eligible, pay insurance premiums to continue insurance coverage. 29.1. Pay co-payment on existing insurance if PLWH/A unable to pay. 29.2. Effort to keep all PLWH/A on existing insurance, COBRA, or other insurance and pay premium if necessary.
Create insurance payment group at Grantee. Grantee to pay insurers (vendor dollars). At intake assess insurance status. Refer to Grantee insurance department. Consumer survey (special pop). Client database report.
Client database report.
Support Services Emergency Financial Assistance
30. Provide emergency financial assistance to clients with pressing emergency needs. 30.1. Standardize process of distributing emergency funds in “Utility Assistance Standards”. 30.2. Provide assessment of need in acuity rating; update every 6 months. 30.3. Distribute funds based on directive for emergency care. 30.4. Provide prescription medication reimbursements (non-ADAP to fill gaps). 30.5. Partial rent subsidy and utility assistance to people with HIV to provide stability and facilitate access to or maintain HIV treatment. 30.6. Clients accessing Emergency Financial Assistance to continue to access routine medical care (minimum 2 primary care visits per year).
Revise standards / directive. Council vote. Providers implement. Assess consumer need for emergency financial assistance every 6 months. Among eligible for DEFA, follow distribution rules. Based on clinical assessment submit reimbursement to grantee. Revised standards or directive. Consumer survey analysis. Client database report. Client database report. Monitoring report. Client database report.
Based on assessment and directive provide assistance.
Client database report. Monitoring.
Consumer survey analysis of DEFA and medical care.
Consumer survey report.
Housing
31. Stabilize living situation to ensure maintenance of medical care and treatment adherence through the provision of short-term housing assistance or rental assistance subsidy. 31.1. Coordinate housing referrals with HOPWA, Section 8 housing, and Shelter Plus Care.
Joint meeting between HOPWA and Council Committee. Minutes. Coordination plan.
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Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are sub-items (e.g. 1.1, 1.2, etc.)
How
Indicators
31.2. Develop linkages with landlords and other providers of housing to develop capacity to meet demand for temporary housing. 31.3. Significant increase in number of clients receiving housing assistance who maintain routine medical care (minimum 2 primary care visits per year).
Provider of housing funds to create LOAs with landlords.
Executed LOAs. Monitor housing units available.
Consumer survey (continuing data collection).
Consumer survey analysis.
Food
32. To ensure that that persons with HIV/AIDS who are having difficulty getting nutritious foods have access to proper nutrition to improve health outcomes. (See Objective 34). 32.1. Provide home-delivered food bundles to PLWH/A who would otherwise be unable to provide for their own nutritional needs. Provide nutritional supplements to clients receiving nutritional counseling. Monitor quality and clients satisfaction of home-delivered meals.
Based on intake assessment arrange for home-delivered meals. Client database report. Client’s report increased use of supplements. Survey analysis report.
32.2. 32.3.
Providers
Client survey (special pop).
Child Care
33. Provide financial support for childcare for children of PLWH/A (or juvenile siblings of youth PLWH/A) in order to improve clients’ ability to access and maintain primary and supportive service care. (See Standard on Child
Care Services).
33.1. Develop a pool of reliable day-care providers who parents can hire or drop children while attending appointments. Contract for number of slots. Monitor demand and use.
Register and audit day care and individuals qualifying for reimbursement for childcare.
Updates list of eligible providers for day care.
Psychosocial Support Services
34. Provide non-licensed nutritional counseling. 34.1. Assure that clients understand and have access to supplements. 35. Overcome denial and develop community contacts for PLWH/A. 35.1. Provide peer and non licensed counseling to PLWH/A.
Follow directive and standard for peer and non-licensed care. Refer client based on assessment. Client database report. Consumer survey analysis. Provide nutritional info as part of care. Client database report. Consumer survey analysis.
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Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are sub-items (e.g. 1.1, 1.2, etc.)
How
Indicators
Complementary Care
36. Provide massage, acupuncture, and chiropractic services to those eligible. (See
Complementary/Alternative Therapies. January 2003.)
36.1. Based on standards and directives, direct all persons requesting and eligible to complementary care. 36.2. Measure outcomes of complementary care (functionality and side effects).
Based on standards and directives, fulfill client request for complementary care. Chart review.
Client database report. Consumer survey analysis. Chart review analysis.
Services to Providers
37. Provide trainings to providers on non-HIV sources for services and funding. 38. Use of the most effective and efficient service delivery practices based on research findings. 38.1. Distribution of and training on best practices for prevention to positives, core, linking, and support services to line and management staff of providers.
Hire consultant to write and distribute and train on preventionfor-positive programs. Report. Scheduled trainings. Trainings. Provider feedback forms. Council Trainings scheduled and provider feedback.
39. Improve client ability to navigate the continuum of HIV services. 39.1. Extensive provider education offered to help them be fully familiar with continuum of HIV services and options for clients. 39.2. Provide updated resource guide that is accessible to clients and case managers. 40. Develop new models of outreach and maintaining services for people of color. 40.1. Implement those recommendations of the Community Care Network for People of Color currently underway that the Council concurs with. 41. Understanding of unit cost and cost reimbursement programs used. 41.1. Workshops on cost reimbursement, unit costs, and financial control should be offered by the grantee.
Develop workbook, schedule, and give two workshops on cost reimbursements. Workshops held and report. Review recommendations of with communities of color. Council to discuss and incorporate recommendations that they can effect. Council recommendations. Hire consultant to create training on continuum of HIV services. Report. Scheduled trainings. Trainings. Provider feedback forms. Updated guide every 6 months.
Provider information form updates sent (online or by paper)
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Note: Goals are numbered items (e.g. 1,2,3 etc.) and objectives are sub-items (e.g. 1.1, 1.2, etc.)
How
Indicators
Program Administration Assessment and Evaluation
42. Distribute and train providers on clienttracking system. 42.1. Full beta testing of system. 42.2. Provider training and protocols. 42.3. Rollout with scheduled benchmarks. 43. Continuous data collection among PLWH/A. 43.1. Develop plan for continuous data collection among clients of HIV/AIDS care and those out of care.
Council contracts consultant to develop continuous data plan and protocols, including IRB. Council to allocate funds and contract continuous data collection. Identify and schedule special studies. Develop protocols to supplement core questions. Develop standard satisfaction questions and analysis. Monitor implementation at provider level. Council to establish uniform satisfaction protocol. Providers to sample yearly for client satisfaction. Implement consumer data collection and analysis. Database that links consumer database and client tracking database. Schedule special studies. Data from special studies. Standard client satisfaction data. Monitoring of client satisfaction returns as part of contract monitoring. Complete beta testing. Create training manuals and protocols for entry. Tie use to funding. Schedule client database for release. Monitor adoption. Operational webbased database. Adoption of client database. Use of database.
43.2. Annual special studies among a specific target population with special needs. 43.3. Inclusion of client satisfaction at providers. 43.4. Increase return rate of client satisfaction surveys. 44. Transparency in costing and reimbursement. 44.1. A full audit of the financial reimbursement scheme should be contracted to provide a clean bill of health to the cost-reimbursement system and make suggestions where it maybe improved.
Council to authorize funds for audit. Hire consultant. Grantee to participate in audit.
Audit report. Distribution of findings to community.
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4. ATTACHMENTS
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Attachment 1 Project Advisory Group
Sacramento EMA Needs Assessment / Comprehensive Plan PROJECT ADVISORY GROUP NAME Adrienne Rogers Alix Gillam Bill Puryear Craig Spatola David Pilcher Jeff Cowen Julie Gallelo Kane Ortega Katana Barnes Lisa Boch Lisa DaValle Marty Keale Michael Ungeheuer Ola Adams Best Otashe Golden Peter Feeley EMAIL rogersad@saccounty.net AFFILIATION Ryan White Fiscal Administrative Agent gillama@saccounty.net Epidemiologist Planning Council Alternate Member: Affected Community cspatola@yahoo.com Planning Council Chair pilched@sutterhealth.org Physician sfafjeff@jps.net Planning Council Member: Nonelected Community Leader; Provider galleloj@saccounty.net HIV/AIDS Education and Prevention Program Coordinator Planning Council Member: Affected Community katanabarnes@aol.com Planning Council Vice-Chair cdcw@cwo.com Planning Council Member: Substance Abuse Provider; Needs Assessment Committee Chair lisa.davalle@ucdmc.ucdavis.edu AIDS Education and Training Center mkeale@caresclinic.org Planning Council Member: Title III; Provider munger@co.el-dorado.ca.us Planning Council Member: El Dorado County Dept. of Public Health oadams@dhs.ca.gov HIV/AIDS Service Provider ogolden47@aol.com Planning Council Member: Physician pfeeley856@aol.com Planning Council Member: AIDS Service Organization; Priorities and Allocations Committee Chair
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Attachment 2 Directives and Standards of Care
HIV Health Services Planning Council DIRECTIVES Sacramento EMA General – All direct Services Funded by the Ryan White CARE Act Directive 1 In order to receive services funded by the Ryan White CARE Act, the person seeking said services must: a) Have a confirmed diagnosis of HIV or AIDS. b) Be in medical care for his or her HIV/AIDS condition, or at minimum, actively seeking medical care for HIV/AIDS. c) Meet all financial guidelines as established by the HIV Health Services Planning council (when implemented later this fiscal year). d) Clearly establish that any service requested (excepting primary medical care) is necessary to access or remain in medical care or maintain the health of the client. In addition: a) Providers will assist clients, as needed, in obtaining proof that requested services are necessary to access or remain in medical care, or to maintain health, via collateral contact (or other communication) with the client’s primary care physician, other care provider, or case manager. b) Ryan White contract service providers must document proof that these conditions have been met before any services can be rendered. Directive 2 Direct services must be delivered in a culturally appropriate manner, sensitive to the special needs of under represented populations served. HIV service providers funded by the Ryan White CARE Act must make a good faith effort to employ direct services staff reflective of the culture and ethnicity of the populations they serve or intend to serve. Directive 3 The service system must include access to services for all targeted populations: gay and bisexual men; African-American and Hispanic men and women; IDUs; infants and children; and other high-risk women. Directive 4 Contractors must identify which targeted populations they are serving and to what degree and any specific methods they use to address both physical and psychological barriers to treatment and services. Directive 5 The service system must show culturally appropriate methods of outreach, intake and service delivery which are responsive to applicable differences in geography, language, income, education, gender, age, sexual orientation, drug abuse, personal denial, responsibility for dependent children, and other variables. Directive 6
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Contractors must identify the methods by which they can provide accessibility for treatment and service to any person with a physical or mental disability including people with impaired speech, hearing or sight when needed. Directive 7 The service standards approved by the HIV Health Services Planning Council will be followed by the contract agency and will supersede any agency policy. Directive 8 Eligibility for services will be based on need as outlined in the service Plan of Care. Services may not be based upon the amount, or cost, of services being received currently, or in the past by the consumer. Directive 9 Lack of money will not be considered a denial of service. If all agency money has been expended for a specific category, the consumer needing the service will be notified in writing and placed on a “waiting list”. The Fiscal Agent and the Planning Council must be advised of “waiting lists” immediately and updated monthly. Directive 10 The service provider must have a process in place that documents that Ryan White is the payer of last resort, that no other resources are available, and that all appropriate referrals were made. Directive 11 Vendor dollars issued will only be reimbursed on a dollar basis, with no contractor markup allowed (i.e. Vendor paid dollar = $1.00 reimbursed dollar)
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(Note: All items in Bold are new directives for FY 2003-2004) General – All direct Services Funded by the Ryan White CARE Act Directive 1 The service provider must have a process in place that documents that Ryan White is the payer of last resort, that no other resources are available, and that all appropriate referrals were made. Directive 2 All Ryan White care service categories will be provided in a manner that provides for 100% access and 0% disparity to all populations. FY 2003 –2004 Priorities Ambulatory Care Directive 1: Alternative Therapies Regardless of the type of service (i.e. acupuncture, chiropractic, massage) a maximum of two (2) visits/sessions/treatments may be paid for, per calendar month, per client by Ryan White CARE Act funds. Any additional visits/sessions/treatments accessed during any calendar month will be the sole financial responsibility of the individual client. This does not apply to the Acupuncture Services (Substance Abuse) sub-category. Case Management Directive 1 Case management is a fundamental approach to efficient and effective intervention whether provided as an office based or as a home or field deployed strategy. To ensure and facilitate continued home or field case management services, a minimum of 35% of Sacramento-based case management services must be provided through the home or field orientation. Placer and El Dorado Counties are to determine case management ratios based on individual community need consistent with the local services allocation process for each jurisdiction.
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Service Directives Policy Number: SSC 07 Date Approved: 9/27/00 Date Revised: Subject: General Policy Directives for Ryan White Title I/II-Funded Services Reference: Ryan White CARE Act (Amended 1996) SEC. IV-62 Action Taken by the Affected Communities Committee (8/28/00), as amended by the Executive Committee (9/13/00) Policy: Over the past few years, the HIV Health Services Planning Council has taken great care to develop a coordinated system of care accessible to all PLWH within the Sacramento EMA. In order to continue this tradition, the Affected Communities Committee (ACC) has developed the following general policy directives for Ryan White-funded services: Determination of Eligibility Effective March 1, 2001, a determination of whether or not a client is eligible to Ryan White Title I/IIfunded services will be made by no later than the end of the next business day. 2. Timely Provision of Services Effective March 1, 2001, Ryan White Title I/II-funded services will be provided in a timely manner to all eligible clients when services are requested by the client or prescribed by the client’s care provider, in accordance with the client’s plan of care. 3. Share of Cost Effective March 1, 2001, all providers contracted by the Ryan White CARE Act will implement the attached Financial Eligibility/Share of Cost for Ryan White Services Guidelines (SSC-05), as adopted by the HIV Health Services Planning Council. 4. Removal of Cap on Services Effective March 1, 2001, the Planning Council will amend current and future Service Standard guidelines to remove maximum entitlements (or caps) for all Ryan White Title I/II-funded services for which there is no existing HRSA guideline, in accordance with the client’s plan of care. In so doing, the Grantee will commit to periodic and sustained monitoring of provider agencies to ensure against provider and/or client abuse. Reports of said monitoring activities will be provided to the Council on a quarterly basis.
SERVICE STANDARDS: Eligibility and Fees Service Standard Policy No. SSC 05 Date Approved: 9/27/00 Dates Revised: 1/22/03 Subject: Eligibility and Fees for Ryan White Title I/II Services 1. Ryan White Title I & II funding (“RW Funding”) is to be used for HIV/AIDS medical services and for psychosocial and support services which significantly improve access and adherence to such medical services. As such, client access to RW Funding support shall be determined in the context of each client’s need for HIV/AIDS related healthcare services or other critical needs. 2. RW Funding is to be expended in accordance with the Ryan White CARE Act, and in a cost effective, equitable manner which is based upon verified client need and encourages self-empowerment of clients. RW Funding is to be the payer of last resort. Client eligibility for services which are paid for with RW Funding shall be evaluated through Case Management services provided in accordance with the allocation priorities and directives which are adopted by the Sacramento EMA HIV Health Services Planning Council (“HIV Planning Council”), or through an alternative assessment process administered by an agency receiving Ryan White Title I & II funding (“RW Agency”). 3. In accordance with the above: A. All persons who test positive for HIV, and who reside in any of the counties which make up the Sacramento Eligible Metropolitan Area (“Sacramento EMA”), or are homeless and claiming residency within the Sacramento EMA, shall be eligible for RW Funded services (“Eligible Persons”). Family members or caretakers who can document their relationship to persons living with HIV/AIDS MAY be defined as Eligible Persons for limited RW Funded services. The financial eligibility criteria defined within this Standard apply equally to all Eligible Persons. • The counties which make up the Sacramento EMA include El Dorado, Placer and Sacramento. (Alpine County, Title II only.) • Proof of residence or of homelessness shall be based on any combination of documentation and/or personal statements which are considered reasonable by each RW Agency. B. In accordance with the Ryan White CARE Act and the limitations set out below, all Eligible Persons shall be subject to Service Fees which shall be assessed by each RW Agency at the time of service. C. The level of fees charged to each Eligible Person shall be based on the relationship of that person’s household gross annual income to the Federal Poverty Guidelines published by the US Department of Health & Human Services (“Poverty Guidelines”). Client statements on household gross annual income
should be verified with IRS data, if available.
1. 2.
Persons earning an amount equal to or less than 200% of the Poverty Guidelines shall not be charged any Service Fees for RW Funded services. Persons earning an amount greater than 200% but no more than 300% of the Poverty Guidelines shall be charged a share of the full Service Fees charged by each Agency, which share shall be proportionate to the client’s earnings as a percentage of the Poverty Guidelines less 200%. For example, a person earning 210% of the Poverty Guidelines will be charged 10% of the full Service Fees, while a person earning 290% of the Poverty Guidelines will be charged 90% of the full Service Fees. Service Fees shall be no more than the charges paid for each such service by to RW Agency by the Ryan White Title I & II Fiscal Agent (“RW Fiscal Agent”).
Approved 01/22/03
3. 4.
Persons earning an amount greater than 300% of the Poverty Guidelines shall be charged 100% of the Service Fees charged by each RW Agency. In the event that any person provides documentary proof that their total out-of-pocket expenditures for health services in the current calendar year (1 January through 31 December) have exceeded 10% of their anticipated gross income for the year, such person shall not be charged any fees by any RW Agency from that date forward to the end of such year.
D. Each RW Agency is responsible for defining and implementing such fee collection procedures as it may deem reasonable and necessary. Such Service Fees as are actually collected by each RW Agency may be retained by that agency, but must be deducted from amounts normally billable to the RW Fiscal Agent. RW Fiscal Agent will pay each RW Agency 100% of amounts normally due to such agency, less only a deduction for fees actually collected. E. RW services which are primarily designed to enhance access by Eligible Persons to RW Services or to grievance procedures established by the various service Agencies or the RW Fiscal Agent shall not be subject to any of the fee requirements of this Services Standard. This exclusion specifically applies to Case Management, Outreach, Client Advocate or Ombudsman, and Peer Support Group services. 5. Case Managers at RW Agencies may at any time submit to the RW Fiscal Agent requests for interpretation of these or any other Services Standards adopted by the HIV Health Services Planning Council, based on the unique healthcare needs of a client or on unique barriers to accessing healthcare services which may be experienced by a client. 6. Clients shall have the right to request a review of any service denials under this or any other Services Standards adopted by the HIV Health Services Planning Council. The most recent review / grievance policies and procedures for the RW Agency shall be made available to each client upon intake. Such policies and procedures shall include an explanation of the criteria and process for accessing any available advocacy or ombudsman services.
Approved 01/22/03
Reference Other Service Standards and Directives
HIV Dental Program, Operations Manual. February, 1999. Case Management Service Standards for Persons Living with HIV/AIDS. July, 2001. Complementary/Alternative Therapies. January 2003 Child Care Services. July 2000. Mental Health Standards. July, 1999. Substance Abuse Treatment Services. July 1999. Food & Nutritional Services. January, 2003 Transportation Services. January, 2003.
Approved 01/22/03

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