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CARE Act Title II Manual - 2003 Version

VII. Coordination 

2. Title I and Title II Coordination

Introduction

  1. Legislative Background
  2. HAB/DSS Expectations
  3. Title I and II Working Together
  4. References

Chapter 2
Title I and Title II Coordination

Introduction TOP

Although they operate fairly independently, Title I and Title II planning bodies work together in pursuit of CARE Act goals to strengthen the service continuum for people living with HIV (PLWH) and ensure that funds are used to fill gaps in care. More practical benefits can include reduced administrative and planning costs and lessened duplication of effort.

Coordination efforts are driven by both grantee initiative and such CARE Act requirements as cross-title membership in planning groups, and consistency across State and local comprehensive plans, and the joint work on the Statewide Coordinated Statement of Need (SCSN). Among the more visible areas of coordination is determining use of Title II AIDS Drug Assistance Program (ADAP) dollars in Title I areas. Other areas for coordination with Title II include State programs like Medicaid and substance abuse block grants. Tools to streamline planning and enhance services might be jointly developed, thus benefiting providers who are funded under both titles.

Coordination across Title I and Title II can occur on multiple levels, from less formal information sharing to more structured efforts such as:

  • Cooperation on planning-related tasks (e.g., needs assessment, comprehensive plans)
  • Joint service-related tasks (e.g., design of data collection processes, standards of care, quality management, evaluation), and
  • Consolidation or even merger of planning bodies.

Making such collaboration work requires attention to differing legislative mandates for each title. Among these are the Title I focus of responsibility on local needs and the Title II focus on the consortium area or State. Key decision makers also vary, with Title I centered on the chief elected official in the eligible metropolitan area (EMA) and Title II on the State. In addition, the specific planning task of resource allocation has significant legislative distinctions, with Title I planning council involvement being much more restricted in this area.

Legislative Background TOP

CARE Act requirements for coordination between Title I and Title II cover planning body membership, participation in the SCSN, consistency of Title II services with the SCSN, and coordination with other Federal grantees providing HIV prevention and care services.

Planning body requirements for States are outlined in Section 2617(b)(6) require them to engage in “a public advisory planning process” to secure broad input in the development and implementation of the comprehensive plan from PLWH, providers, other CARE Act entities, and other agencies, similar to those outlined for Title I planning councils (e.g., PLWH, health and social service providers, other payers).

Title II planning body requirements are also outlined for consortia. Section 2613 requires the consortium membership to be inclusive in terms of (1) agencies with experience in HIV/AIDS service delivery and (2) populations and subpopulations of persons living with HIV disease (PLWH), who are reflective of the local incidence of HIV. Such consortia are also to be located in areas where such populations reside. Section 2613(c)(2) also provides for additional involvement by diverse perspectives by requiring consortia, in establishing their service plans, to demonstrate that they have consulted with PLWH, the public health agency or other entity(ies) providing HIV-related health care in the area, at least one community-based AIDS service provider, Title II grantee, Title IV grantees or organizations with a history of serving children, youth, women, and families with HIV, and entities such as those required to be represented on Title I planning councils (e.g., PLWH, health and social service providers, other payers).

Section 2617(B)(4)(c) requires States to “develop a comprehensive plan for the organization and delivery of health and support services” to be funded under Title II that, in part—

“(C) includes a strategy to coordinate the provision of such services with programs for HIV prevention (including outreach and early intervention) and for the prevention and treatment of substance abuse (including programs that provide comprehensive treatment services for such abuse); (E) provides a description of the manner in which services funded with assistance provided under this part will be coordinated with other available related services for individuals with HIV disease; and (F) provides a description of how the allocation and utilization of resources are consistent with the statewide coordinated statement of need (including traditionally underserved populations and subpopulations) developed in partnership with other grantees in the State that receive funding under this title….”

Section 2612(c) of the CARE Act states that Title II funds may be used to provide early intervention services to facilitate access to HIV-related health services. Entities that may deliver EIS include, for example, public health departments, emergency rooms, and substance abuse and mental health treatment programs. However, entities that propose to delivery EIS must demonstrate to the State that “Federal, State, or local funds are otherwise inadequate for the early intervention services the entity proposes to provide; and the entity will expend funds pursuant to such paragraph to supplement and not supplant other funds available to the entity for the provision of early intervention services for the fiscal year involved.”

HAB/DSS Expectations TOP

HAB/DSS expectations for Title I and Title II coordination relate to legislative requirements on planning body membership, the SCSN and comprehensive plans, and service delivery coordination.

Planning Body Membership

Title II areas are expected to include in their planning body representatives from of local and State level agencies, such as representatives from other CARE Act titles and membership similar to that of Title I planning councils (e.g., HIV prevention providers, the State Medicaid program).

SCSN

Requirements for the SCSN (outlined in the SCSN chapter in this Manual) address the focus of the SCSN and required involvement, which includes Title II, both the Title I grantee and planning council, other CARE Act entities, and other programs. In particular, HAB/DSS generally expects Title II programs to describe, in their annual application, how they participated in developing the SCSN and how their implementation plan relates to and is consistent with the SCSN.

Planning Activities

HAB/DSS expects and encourages Title I and Title II coordination on a broad range of activities, even beyond those specifically mandated in law. This is especially true in those geographic areas where planning council and consortium service areas overlap. In overlapping service areas, the following types of cooperation should be pursued:

  • Inclusion of the other title as a representative on the planning body. This might include joint committees. Notably, HAB/DSS does not specifically promote consolidation of a Title II planning body and Title I planning council into a single entity. Rather than prescribe a particular model of coordination, HAB/DSS encourages planning bodies to determine the model that works best in their community.
  • Information-sharing procedures to ensure effective communication between the two planning bodies.
  • Coordinated needs assessment activities, where possible, particularly the epidemiologic profile and other specific needs assessment activities such as development of a joint resource inventory.
  • Coordinated or combined comprehensive plans.
  • Consideration of joint priority setting.
    Collaborative contracts with providers that are funded by both titles.
    Coordination of capacity development, outreach, and early intervention services (EIS), expectations for which are outlined in greater detail in both the CARE Act and HRSA/HAB policies.
    Consideration of uniform data collection and reporting systems and collaborative approaches to evaluation and quality measurement.
    Mutual understanding of both how Title II funding is used in EMAs and what, if any, contribution Title I might make to State-administered programs (e.g., ADAP, health insurance continuity).
    Collaboration on planning body member training, which might include technical training on topics such as needs assessment, comprehensive planning, resource allocation, and understanding HIV treatments. Joint training for PLWH members should also be considered.

Title I and II Working Together TOP

Differences in Planning Body Authority and Autonomy

In exploring ways to work together, Title I and Title II planning bodies must consider the following differences in their respective authority and autonomy.

  • Planning councils are public bodies established by the EMA’s chief elected official (CEO). Legislation defines their key responsibilities, such as determining service priorities, allocating resources across priorities, and assessing the administrative agent's timeliness in disbursing funds. The procurement process and monitoring of funded service providers are grantee responsibilities. Legislation forbids planning council participation in the procurement process.
  • Since Title II planning bodies are not as defined in the legislation, their setup is more diverse than planning councils. Title II bodies are shaped primarily by the Title II grantee. They may be incorporated bodies with responsibility not only for needs assessment and planning, but—unlike planning councils—also for procurement and contract management. In some areas, a separate local lead agency fulfills those roles or the State may serve as lead agency.

These variations have implications for what structures can be used and responsibilities undertaken, particularly with regard to allocations and contracting.

Benefits of Coordination

Experience with collaborative and merged planning bodies shows that many types of cooperative activities can be implemented. * 

  • Joint needs assessments. Variations include use of a single needs assessment to cover both Title I and Title II; EMA and State collaboration in conducting a joint needs assessment, with EMA responses separated out for use in planning; use of State-developed needs assessment methodologies; or coordinated review of past needs assessments. Planning bodies need not merge to make this happen and can remain separate but use a single committee to conduct the needs assessment.
  • Allocation of funds across titles and funding streams. A coordinated allocations system to disseminate funds can occur through a shared system or a combined planning body.
  • Uniform State and local reporting systems and unified management information systems. Uniform reporting requirements can be developed for use by all CARE Act providers, or the State can support common data collection and management systems that better support use of CAREWare and preparation of the CARE Act Data Report (CADR), whose use is required by all CARE Act grantees.
  • Reduced duplication of provider contracts. A single request for proposals (RFP) process can be used for the two titles so that a provider has just one contract for any type of service.
  • Joint service guidelines (e.g., case management guidelines) and provider training. Such efforts are especially beneficial for providers funded under both titles.
  • Equity in access to services across areas. A funding formula can adjust for award of Title II funds to counties outside the EMAs, or a parity formula can seek to equalize per capita spending from Title I and Title II streams. Some EMAs contribute Title I funds to the State ADAP, increasing the number of drugs in the formulary and the number of clients served.
  • Coordination of Services. For example, clients in an EMA might be served by State-supported providers, such as a statewide case management system.

Challenges of Coordination and Lessons Learned

HRSA/HAB has identified the following challenges faced by planning bodies seeking to enhance collaboration. Many have been successfully addressed.

  • Variations in service boundaries complicate joint planning activities. Mergers often change and sometimes increase the size of the service area. This can complicate planning tasks like needs assessment and priority setting.
  • Multi-State EMAs planning body coordination. A merged planning body comprising a Title II planning body and multi-state EMA requires Title II representatives to become familiar with issues faced by interstate EMAs. Procedures may be needed to ensure geographic membership representation, develop intergovernmental agreements, and in some cases arrange for more than one administrative agency as a way to disburse funds efficiently throughout multiple jurisdictions. Specific arrangements may be needed to address such issues as contributions to the State ADAP and differing State licensing and regulatory requirements for services such as home care and ambulatory care. Perhaps the greatest challenge is to ensure that needs assessment and planning consider differences in health care delivery and Medicaid programs. Multi-State EMAs may want to collaborate with consortia located in each State because they bring valuable expertise in State-specific issues, which can be fed back into a larger planning body effort.
  • Allowable uses of funds may vary. Members of combined planning bodies need to know what services can be funded from which streams.
  • A merged planning body might focus on the strictest requirements. This can include such areas as priority setting, resource allocation, fundable services, and quality management programs. If Title I is stricter about allowable services to be funded, those criteria need to be followed when allocations start. Conversely, if a State has implemented more stringent case management standards of care, an EMA may need to adopt those.
  • Financial resources carry influence. The planning body that brings the most money to the merger is likely to expect to exert considerable influence in decision making. Usually, planning councils allocate more funds than Title II planning groups, although some control significant State funding for HIV/AIDS services. Planning can ensure that major activities reflect the perspectives of both titles, such as needs assessments and priority-setting processes that account for both titles.
  • Mergers may affect planning body membership representativeness and reflectiveness. The membership of a consolidated body must maintain/enhance its diversity and PLWH involvement. If the bodies are fully merged, then the combined planning body’s membership must be at least 33 percent unaligned PLWH and include individuals from all the categories specified in the Title I legislation. Ensuring rural representation is also a challenge. The planning body needs to be large enough to represent the membership of both Title I and Title II programs but small enough to be manageable. In order to minimize membership issues, different committees within the planning body may need to serve as the official planning council or Title II planning body so that the membership is not fully merged.
  • Maintaining provider involvement and minimizing potential conflict of interest. A combined planning body may have a smaller proportion of providers than separate groups. In several sites, provider caucuses have been established, including sub-caucuses of specific providers like case managers. They can meet regularly, provide recommendations to the planning body, and in some locations elect representatives to serve on the consolidated planning body.
  • New protocols may need to define relationships among the planning body, State, and HAB/DSS. For example, HAB/DSS generally communicates with Title II planning bodies only through grantees and would not visit them without first informing the State. However, a merged planning body is also a planning council, and HAB/DSS regularly communicates directly with—and visits—planning council co-chairs.

One Approach to Coordination: Merger and Consolidation

While HAB/DSS expects Title I and II planning bodies with common service areas to collaborate, there is no preferred or best model. Planning bodies with overlapping geographic areas are encouraged to explore the feasibility of consolidation among other options for effective enhancing coordination. Merged planning bodies have been an effective means of integrating HIV activities in some communities but have been less successful in others.

Austin: A Merged Consortium and Planning Council

When Austin became an EMA in 1994, the community had an HIV consortium and an HIV commission. These two bodies met with representatives from the Mayor’s office (the CEO) to discuss establishment of the new planning council and decided that the efficient path would be to combine responsibilities with their existing bodies. The Austin Area Comprehensive HIV Planning Council was created as a single body that fulfills three roles: the Title I planning council, the Title II consortium, and the city/county HIV commission.

Benefits of this combined group relate to overlapping duties in needs assessment, priority setting, and organization and delivery of services. Having one set of priorities and one comprehensive plan that applies to all funding streams—CARE Act Title I and Title II, HOPWA, State, city and county—results in better coordination of funds and reduced duplication of effort.

In addition to joint planning bodies, Austin has one administrative agency. The Austin-Travis County Health and Human Services Department administers Title I, Title II, and seven other Federal and State HIV-related grants. With a single administrative agency, the procurement process is simplified. The planning council identifies needs and allocates funds from the various funding streams by service category. The administrative agency issues a single RFP for Title I and Title II, as well as the State health and social services grant. A single RFP minimizes the workload of the administrative agency and of community providers, who have more time to provide services because they need not respond to multiple RFPs. One external grant review panel evaluates proposals from numerous agencies for all the service categories. Once that process is completed, the administrative agency decides which funding sources are best used for each award. Where possible, providers are supported by a single funding stream, so they prepare only one quarterly report. A single database for all services enhances data reporting and provider and contract monitoring, while reducing the administrative workload.

 

An Alternative Approach: Collaborative but Separate Bodies

Merger or consolidation of Title I and Title II planning bodies may not always work, but other approaches exist for coordinating activities. They include: one planning body functions as a subgroup of the other; separate groups collaborate on specific activities; and separate bodies exist and share information and communicate.

San Diego: Cooperation between a Consortium and a Planning Council

San Diego’s collaboration developed through a gradual process of building trust and developing opportunities for collaboration, beginning in 1991. Consumer involvement was the catalyst. The Title I planning council, created under the auspices of the county, was perceived as exclusive and not reflective of the HIV community. The Title II consortium was formed as a community- and consumer-based group. Events forced both groups to share responsibility for funding several programs, which was solidified in a memorandum of understanding that laid the foundation for a successful partnership.

The agreement spelled out a philosophy for working together and encouraging community and consumer input to provide the best possible continuum of HIV services, prevent duplication, and maximize resources. During the next year, the two groups began combining needs assessment, planning activities, and decision making for prioritization of services and resource allocations. Title I and Title II funds were also pooled for joint decision making. San Diego now has a joint planning and allocations process. Decisions to fund a service category are made and then a process occurs to decide which services will be funded from which title.

The planning council and consortium share two important committees. The planning committee, which has co-chairs from each group and is responsible for joint needs assessment and planning. The consumer committee coordinates consumer representation and involvement. In addition to joint activities through these two committees, multiple opportunities are provided for consumer and community involvement at combined meetings of Title I and Title II groups every year.

References TOP

Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB). “Effective Integration of Consortium and Planning Council Activities.” CARE Act National Technical Assistance Call Report. Rockville, MD: U.S. Department of Health and Human Services, 1996.

HRSA, HAB. Addressing Major Title I/II Coordination Issues in Newly Developing Eligible Metropolitan Areas. Rockville, MD: U.S. Department of Health and Human Services, 1996.

* The findings presented are from a HRSA/HAB Office of Science and Epidemiology (OSE) study on the challenges of coordination and ways to overcome them. The study included three sites with a merged, single planing body (Austin, TX; Kansas City, MO and KS; and Sonoma County, California) and three sites with separate but coordinated planning bodies (New Haven, CT; San Diego, CA; and San Atonio, TX). Portland, OR was examined as a site with emerging coordination.