I 
Department  of Health  and Human  Services 
OFFICE OF

INSPECTOR GENERAL

THE  RYAN  WHITE  CARE  ACT: 
EXAMPLES  OF  LOCAL  COORDINATION 
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OEI-05-93-00335 
I

.  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General  (OIG),  as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department  of Health  and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations,  and 
inspections  conducted  by three OIG operating components:  the Office of Audit Services, the 
Office of Investigations,  and the Office of Evaluation and Inspections.  The OIG also informs 
the Secretary of HHS of program and management problems and recommends courses to 
correct them. 
OFFICE OF AUDIT  SERVICES 
The OIGS  Office of Audit Services (OAS)  provides all auditing sefices  for HHS,  either by 
conducting  audits with its own audit resources or by overseeing  audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrying out their respective responsibilities  and are intended  to provide independent 
assessments of HHS  programs and operations in order to reduce waste, abuse, and 
mismanagement  and to promote economy and efficiency throughout  the Department. 
OFFICE OF INVESTIGATIONS 
The OIGS Office of Investigations  (01)  conducts criminal, civil, and administrative 
investigations  of allegations of wrongdoing in HHS  programs or to HHS beneficiaries  and of 
unjust enrichment by providers.  The investigative efforts of 01  lead to criminal convictions, 
administrative sanctions, or civil money penalties.  The 01  also oversees  State Medicaid fraud 
control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 
OFFICE OF EVALUATION  AND  INSPECTIONS 
The OIGS  Office of Evaluation  and Inspections  (OEI)  conducts short-term management  and 
program evaluations  (called inspections)  that focus on issues of concern to the Department, 
the Congress, and the public.  The findings and recommendations  contained  in these inspection 
reports generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, 
and effectiveness  of departmental programs. 
This report was prepared under the direction of William C. Moran, Regional  Inspector 
General,  and Natalie  Coen, Deputy Regional  Inspector General, Office of Evaluation  and 
Inspections,  Region  V.  Participating in this project were: 
REGION V  REGION II 
Joseph L. Penkrot  (Project Leader)
 Lucille Cop 
Ellen R. Meara

Barbara Butz
 HEADQUARTERS 
William Moran
 Alan S. Levine 
For a copy of this report, please call (312) 353-4124.
 Department  of Health  and Human  Services 
OFFICE OF 
INSPECTOR GENERAL 
THE  RYAN  WHITE  CARE  ACT: 
EXAMPLES  OF  LOCAL  COORDINATION  TABLE  OF  CONTENTS 
PAGE 
INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

EXAMPLES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...3

.seattle,  Washington.  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...6

.New  Orleans,buisiana  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...9

.NewyOrk,  NewyOrk.  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..12

.Kansas C@,MissOuri  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...17

.Loshgeles,ca lifornia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...21


Broward  County,  Florida  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..24

.DetrOit,Michigan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...27
 INTRODUCTION 
PURPOSE 
To  describe  a variety  of  experiences  of Ryan  White  grantees  in coordinating  client 
services  between  providers. 
ReauthorizationStudies 
In this current report, we supplement  previously acquired  data with obsemations  and 
discussionsat  the local  level.  These  included  ourattending  planning council  and 
committee  meetings;  visiting local project  sites and providers;  holding  discussions with 
grantee administrators, project  staff, providers,  and persons with HIV/AIDS;  and 
reviewing funding and service plans, and progress reports. 
The  study complements  our report, Local  Implementation  hues,  0EI-05-93-O0336. 
These  two studies are part of a series of studies that examine the Ryan White 
program  prior to its first reauthorization,  currently pending before  Congress.  The 
previous Ryan  White  CARE  Act  (the Act)  reports  are:  Funding  Formulas  (OEI-05-
93-00330);  FY 1992  Title 1 and  Title II Expenditures  (OEI-05-93-0033  1);  Consotia 
Activities  (OEI-05-93-00333);  FY 1992 Special Projects of National  Significance  -
Expenditures  by Service  (OEI-05-93-00332);  and, Technical  Report  of 1992 Expenditures 
(OEI-05-93-00334). 
BACKGROUND 
The Act  requires that each community receiving Ryan White  Title I funds as an 
Eligible Metropolitan  Area  (EMA)  form  a network  to discuss community needs  and 
act together  to meet  those needs.  These  new networks  consist of State and local 
governments,  health care providers,  advocacy  groups,  and persons with HIV/AIDS.l 
The networks  convene  a planning council, conduct  a communitys  needs  assessment, 
and determine  who will be funded. 
The Act  is multifaceted,  with four titles directing resources  to various entities and 
allowing grantees maximum flexibility in the use of funds, particularly at the local level. 
Title I provides  emergency  relief grants to EMAs  disproportionately  affected  by the 
HIV  epidemic.  Title II provides  grants to States and territories to improve  the quality, 
availability and organization  of health care and support  services for individuals and 
families with HIV  disease.  Title III(b)  supports early intervention  services on an out-
1 Since the @an  White Act enables grantees to deliver a wide range of services to people diagnosed with either HIV or AIDS, this 
report uses the krnt HIV/AID.Y to refm to either or both groups of Ryan White clienti. 
1
 patient basis, including counseling, testing, referrals, clinical and diagnostic services, 
and other therapeutic  services.  Title IV  aims to improve  the system of services for 
children, youth, women  and families infected  with or affected  by HIV/AIDS. 
The Health Resources  and Services Administration  (HRSA)  considers  coordination  of 
services to clients and coordination  between  Ryan White  titles and programs  to be 
important.  In their application  for Ryan White funds, EMAs  must describe  to HRSA 
how their network will coordinate  to provide  semices  to clients.  In December  1994, 
HRSA  convened  a working session for some  program  participants responsible  for daily 
front-line  coordination  between  Ryan White programs.  This session stressed best 
practices in local  coordination  efforts, approaches  to overcoming  barriers to effective 
program  coordination,  and invited advice on how HRSA  could  provide  better  support 
to grantees on coordination  efforts. 
SCOPE AND  METHODOLOGY 
This report  describes ways this coordination  of services and coordination  between 
agencies  occurs in seven EMAs  and some  of the new or enhanced  services they now 
provide.  These  EMAs  received  43 percent  of the 1994 Title I Ryan White funding. 
We  used data from  the EMAs  grant applications  submitted to HRSA  in describing 
each EMAs  characteristics. 
The  EMAs  have evolved  in different ways at different speeds.  Their approaches  are 
fashioned  to meet  their communitys needs within the political  constructs available to 
them.  In each community, the involvement  and roles of State, county and city 
government  are different. 
We  limited our study to seven metropolitan  areas where  the Ryan White programs 
have attacked  their communitys  problems  in distinct ways, and at different  speeds. 
We  used four  criteria to select sites.  First, we chose  sites based  on their length of 
time as an Eligible Metropolitan  Area  (EMA).  Three  of our sites, New York,  Los 
Angeles,  and Fort Lauderdale,  were  among the original 16.  Three  other sites we 
chose,  Seattle, Detroit,  and New Orleans, were in the 1993 group  of nine cities to 
become  EMAs.  We  chose  Kansas City from  the latest of nine cities to become 
eligible.  Second,  we considered  whether  or not the Title II consortium  also serves as 
the Title I planning council.  At the time of our field work, this was the case in Los 
Angeles,  Seattle, Detroit,  and Kansas City.  New Orleans has since combined  the 
Titles I and II planning councils.  Third, we looked  for cities that represent  a variety of 
approaches  to coordinating  programs  and services.  Fourth, we favored  communities 
that would  give us a geographically  diverse sample.  Field work was conducted  in 
summer  1994. 
Not  all barriers to providing coordinated  services have been  overcome  in these 
communities.  Coordination  is still evolving in these EMAs  and others across the 
country.  In addition, much coordination  takes place between  providers  on an informal 
2 and frequent  basis.  Because  new ways to coordinate  services are still being  developed, 
this report  does  not represent  a comprehensive  description  of all ways that promote 
service coordination.  Nor does  it address all operational  and policy related  questions 
which were raised by respondents  in discussions of this topic,  such as the the awarding 
of subcontracts,  HRSA  funding cycles, and conflicting program  goals and definitions. 
We  conducted  our review in accordance  with the Quality Standards for Inspections 
issued by the Presidents  Council  on Integrity and Efficiency. 
3
 EXAMPLES

Coordination  of Ryan White programs  is effected  by a network  of concerned  grantees, 
government  agencies, providers,  advocates  and persons  with HIV/AIDS.  Together, 
these networks  determine  where the affected  communitys  needs lie and decide  who is 
best able to meet  these needs, 
The  networks can be  effective  at coordinating  programs  designed  to provide  services 
to clients.  Those  not on planning councils still can participate  in informal  provider 
networks  or serve on committees  dealing with HIV/AIDS  issues.  The networks bring 
together  people  who  are concerned,  knowledgeable,  and influential to discuss and act 
on these issues.  These  networks provide  a good  forum  to discuss the nature and 
extent of HIV/AIDS,  how to provide  services to those infected,  and ideas on ways to 
slow the spread  of the disease. 
We  saw considerable  evidence  of the dynamics of these networks  during our EMA 
visits where we attended  planning council, executive committee,  subcommittee,  and 
other group meetings.  Each EMA  we visited presents different  approaches  in 
coordinating  Ryan White  programs  and services, and overcoming  barriers to 
coordination.  For  example: 
In Seattle,  Washington,the EMA  pools  Titles  I and 11funds.  The  different  titles  are invisible  to 
providers  and clients. 
In New Orleans, LouisianA a merger  of the Titles  I and Title  11planning  councils  will end turmoil  in 
the EMA  relating  to responsibilities  for delivering  services. 
In New Yorlq New York  the EMA  contracts  out  the Ryan  White  program  to deal with  the largest 
concentration  of HIV/AIDS  cases in the country.  The EMA  must  also deal with seven consortia 
serving  their  clients. 
The Kansas  City, Missouri EMA  operates  in two States.  This EMA  also relies  heavily on HIV/AIDS 
clients  to provide  guidance  to their  operations. 
In Los Angeles, Californ@ the EMA  is linking  10 large providers  in a case management  network.  This 
linkage  serves to reduce  duplicate  services and provide  a more  rational  delivery  of services to clients. 
The BrowardCounty,Florida EMA  is starting  a county-wide  case management  network,  linking  all 
providers  of Ryan  White  services. 
The  Detroi~  Michigan  EMA  considers  provider  coordination  important  in determining  Ryan  White 
funding.  One-fourth  of a providers  application  score  relates  to their  coordination  with other  providers 
of HIV/AIDS-related  sewices. 
4 The Ryan White program  also provides  increased  services to combat  HIV/AIDS.
Ryan White  programs  greatly help persons  with HIV/AIDS  by providing  services they
otherwise would  not receive.  Many clients have no medical  insurance coverage,
including Medicare  and Medicaid,  and rely on Ryan White  services to meet  their
needs.
While  States and local  communities  have contributed  substantial resources  to fight this
disease, Ryan White  programs  are responsible  for many more,  and new services being
available to persons with HIV/AIDS.  These  are services that would  not be  available
in that EMA  without Ryan White funds.
5
 SEATTLE,  WASHINGTON

SeattleEM4  Background 
The  Seattle EMA  includes King, Snohomish,  and Island Counties  and represents  42 
percent  of the States population.  King County, which includes the city of Seattle, is 
geographically  large.  Its 2,134 square miles make it the 17th largest county in the 
United  States.  Snohomish  County also is over 2,000 square miles, while Island County 
is 209 square miles. 
The  Seattle-King  County Department  of  sEA1-H.EEMA  cHARA(nERIs-Ifa 
Public Health is the Title I grantee and 
EMA  population is 2 million 
is also the lead  agency for the Title II  9 
consortia.  Title I responsibilities include    75% of the AIDS  cases in Washington 
providing  services for HIV/AIDS  State reside in the EMA 
education,  prevention,  testing, 
  Estimated  HIV/AIDS  infection  is 11,750 
counseling,  and client care services.  As 
a consortium,  they are responsible  for    91$~0of the HIV/AIDS  population  lives in 
consortium  management,  which includes  King County 
planning, coordinating,  monitoring,  and 
  85%.of the infected  population  is white, 
evaluating program  activities.  They also  8%  is African-American,  4% is Hispanic, 
maintain a centralized  contracting and  and the remainder  is Native American  or 
Asian Ameriean 
reporting  system, and identify and seek 
funds for consortium  activities. 
  Gay/hi-sexual  males make  up 78% of the 
HIV/AIDS  population 
?%e SeattleEM4  PlanningCouncil 
  Gay/bisexual  men who injected  drugs 
make up  11% of the population,  while 5% 
The HIV/AIDS  Planning Council is a 32 
are heterosexual  intravenous  drug users 
member  body  responsible  for all 
planning and allocation  activities for care    Women  make  up 4% of the infected 
population 
services and prevention/education.  It 
has two co-chairs,  one from  the Seattle 
King County Health Department  and 
one  community member.  Seattles model  of care is based  on a continuum  of care 
covering  a range of 28 component  services from nutrition to primary care.  The 
planning council uses special workgroups,  task forces  and committees  extensively in 
helping to decide  EMA  priorities. 
Servicesto Clientx 
The planning council  describes  two levels of HIV/AIDS  in determining the needs  and 
service priorities of  clients.  The  stages are:  1) those who  are disabled-by  HIV  2) 
those who  are HIV  positive, but not disabled.  The  Seattle EMA  commits  at least 65 
percent  of its funds for services to clients who  are disabled by HIV. 
6  The planning council identified  24 distinct client services as priorities for  1994.  In 
terms of funding commitments,  case management,  primary care, home  health care, 
housing, and early access are the five areas receiving the most EMA  funds. 
New Selvices 
The Seattle EMA  is unique in its aggressive and coordinated  approach  to the housing 
needs  of its AIDS  clients.  Based  on housing and residential care plans developed  by 
two AIDS  service organizations  (ASOS)  and the Seattle-King  County Department  of 
Health,  the EMA  developed  two AIDS-specific  care facilities offering  skilled nursing 
and assisted living. 
Other new services available to HIV/AIDS  clients include: 
	 an arbiters office  to assist persons with HIV/AIDS  reach agreement  with 
health insurance companies  on coverage  issues; 
	 dental care, added  to the semice  components  after clients indicated  a need 
for these services; and, 
	 a network  of services exclusively for women  with HIV,  including primary 
care, case management  and advocacy,  day and respite care, information  and 
referral, and emotional  support. 
AdrninktrativeCoordination 
The Seattle EMA  and Washington  State have developed  a planned  approach  to the 
HIV/AIDS  epidemic.  The  State is divided into six regional AIDS  networks for 
purposes  of distributing HIV/AIDS  related funding.  King County makes up an AIDS 
network, while the other two counties in the Seattle EMA  are part of a separate AIDS 
network.  When  Seattle became  a Ryan White Title I grantee, they arranged with the 
State to give Title I monies  to a statewide pool  of HIV/AIDS-related  funds, which also 
includes Title 11funds. 
The State distributes these HIV/AIDS  funds so that each AIDS  network  receives  an 
equal dollar amount for each reported  living AIDS  case.  Because  the Seattle EMA 
has an estimated  75 percent  of the AIDS  cases in the State, the EMA  receives  75 
percent  of the combined  Title I and 11dollars distributed by the State. 
By pooling  funds in this way, the State avoids some  conflicts that might occur between 
city and State governments,  and between  titles, over how to allocate  funds.  Because 
there is no distinction within the EMA  between  Title I and 11funds, the Seattle EMA 
planning council  acts as the planning body  for both  Titles I and II.  This arrangement 
also benefits  providers who need  to fill out only one  application  for their funding and 
meet  only one  set of reporting  requirements  for both  Titles I and II. 
7
 Another  form  of coordination  in Seattle is the Case Management  Residential  Services 
Workgroup.  This Workgroup, which etiends  beyond  theplanning  council  and 
providers,  advocacy  representatives,  Title IIIb and State representatives,  meets 
monthly to try to resolve  case management  and other service related issues.  The 
workgroup  discusses new services, new procedures,  and other issues relevant to direct 
service delivery or planning for service delivery.  In addition, each month,  some  of the 
major  service providers  in the area give updates  about  their waiting lists and service 
issues needing  resolution. 
In 1992, when the Seattle area became  eligible for Housing  Opportunities  for Persons 
With AIDS  (HOPWA)  funding, the HOPWA  grantee developed  a 5 year housing plan 
which takes into account both  the Ryan White funded  housing and the complementary 
HOPWA  funds.  Although  the planning council does  not perform  the planning 
function for HOPW~  it must approve  the HOPWA  grantees  housing plan. 
Consequently,  the HOPWA  grantee and the EMA  coordinate  closely to fill in gaps in 
housing services. 
Seattles housing plan for people  with HIV/AIDS  provides  a continuum  of different 
types of housing clients need  at different stages in their illness including:  emergency 
housing, transitional housing, longer-term  housing, assisted living, and skilled 
nursing/residential hospice  housing.  The  housing plan also addresses  an emerging 
issue in the Seattle area, housing for mentally ill and chemically addicted  clients with 
HIV/AIDS. 
Client-levelcoordination 
In Seattle, there are two agencies funded  for case management  services.  These
providers  are responsible  for  case managing most of the EMAs  disabled AIDS  clients.
In Seattle, only disabled  clients are eligible for Title I and II case management
services.  Some  services for HIV/AIDS  clients, like housing, are accessible  only
through a case manager.  This limitation on clients permits case managers to maintain
low caseloads  and to serve only those clients with the most complex  needs.
In spite of only two providers being funded  for case management,  other Ryan White
providers  employ  case managers or other workers who function like case managers.
These  case managers  are funded  through other funding streams.  For  example,  one
primary care clinic funded  by Title IIIb, hired a case manager  to follow  up on clients
and coordinate  with any other case managers for that client.
Despite  a somewhat  complex  arrangement  of case managers with vastly different
duties, our respondents  are not disturbed by the way case management  works in
Seattle.  The  caseloads  in the Seattle EMA  are still relatively small compared  with
some  other cities, and case managers are comfortable  having frequent  contact with
each other about  common  cases, problems  and other case management  related issues.
8
 NEW  ORLEANS,  LOUISIANA

NZw OrleansEM% Background 
Seven parishes (counties)  comprise  the New Orleans EMA  - Orleans  (which includes 
New  Orleans,)  Jefferson,  St. Bernard, Plaquemines,  St. Tammany,  St. Charles, and St. 
John the Baptist. 
The  Office  of Health policy  and ~DS  ~ 
Funding, in the Mayors  Division  of  NEwORLEANESM
A  characteristics
Human  Resources  is the Title I grantee. 
  EMA  population  is 1.2 million

In May  1994, the newly elected  mayor
moved  this function from  the    Estimated  HIV/AIDS  population  is 9,588.

Department  of Health  to the mayors  Of these

office  in order  to address the problems 
b  80% live in Orleans  parish

the EMA  faces more  quickly. 
*  14$%live in Jefferson  Parish 
New  Orleans is beset with many urban    Non-hispanic  whites make up 60% of the 
HIV/AIDS  population;  African-
problems,  all of which are compounded 
Americans  are more  than a third of the 
by widespread  poverty.  Over 30 percent  total, with Latinos  and others  less than 4$% 
of all those living in New Orleans live  of the HIV/AIDS  population 
below  the poverty level.  In New 
  90% of the infected  are men;  more  than 
Orleans,  46 percent  of all children, and 
2/3 of these are gay or hi-sexual 
55 percent  of African-American  children
live in poverty.  One  in five senior    One in ten of the HIV/AIDS  population

are injection drug users

citizens lives in poverty.  New Orleans 
also faces widespread  increases in  ~
sexually transmitted diseases.  Louisiana
has the highest gonorrhea  rates in the natiory the chlamydia rate is 25 percent  higher
than the rest of the country, and their syphilis rate leads the nation.  New  Orleans
syphilis rate is the highest in the State.  The lack of safe sexual practices  evidenced  by
these figures suggests that AIDS  will become  even more  widespread  among  New
Orleans  young and poor.
l%e Nm  OrleansEM  PlanningCouncil 
After  a year or more  of uncertainty, acrimony, considerable  overlap  of council 
membership,  and duplicative administrative activities, the Title I and Title II planning 
councils merged  in July 1994.  The newly combined  planning council administers Titles 
I and II.  The  single planning council intends to eliminate duplication  and 
fragmentation  and to perform  coordinated  strategic planning, needs  assessment, 
funding prioritization  and evaluations.  In addition, Titles IIIb and IV play an active 
role in planning council  deliberations  and decisionmaking. 
9 Semcesto Clienfi 
In 1993, the New Orleans EMA  received  $3.2 million from Title I and $359,000  from 
Title II.  To  provide  appropriate  services to clients, the EMA  uses the continuum  of 
care defined  by Louisiana with only minor revisions.2  Primary medical  care for hard 
to reach populations,  case management,  dental services, substance  abuse treatment, 
emergeney  assistance, mental health, advocacy,  drug reimbursement,  housing related 
senices,  and buddy/companion  services are the EMAs  Title I priorities for  1994. 
Primarv Medical  Care 
Almost  all primary medical  care for low income  HIV/AIDS  clients is furnished at 
Medical  Center  of Louisiana  at New Orleans  (formerly  Charity Hospital,  and still 
commonly  referred  to by that name)  and paid for by the State of Louisiana.  Many of 
the other EMA  service providers  are located  near Charity Hospital  and the medical 
complex  close by, or near the French Quarter where many of New Orleans  AIDS 
Service Organizations  originated. 
Communitv Services 
Using Ryan White funds, three neighborhood-based,  community health clinics are now 
providing  services to HIV/AIDS  clients.  The  new emphasis on primary care 
recognizes  that locating services in other neighborhoods  may serve to overcome  either 
transportation  difficulties in reaching established services and/or  the stigma of dealing 
with providers  perceived  to be  exclusively for gay, white, males.  In addition,  a city-
funded  program  is providing  case management  services targeting African-Americans 
and Hispanics. 
New Services 
Among  the other new services offered  to clients since the EMAs  inception  include: 
	 case management  and transportation  services to geographically  remote  St. 
Tammany  Parish, including delivery of food  and medications  to those too  ill 
to travel; 
  primary medical  services to HIV/AIDS  clients in St. Charles Parish; 
  in concert  with HOPW~  housing for families affected  by HIV/AIDS; 
	 subcontracts  to provide  home  health and other services in public housing 
developments  and the surrounding neighborhoods;  and, 
2 Louisiana definesfive levek of carefor HIV/AIDSpatients beginningwithprevention and earlydetection to ambulatory care for 
those in the advanced s%agesof AIDS. 
10  	 neighborhood  day care for HIV  positive children and other affected  family 
members. 
Adrninktiative-hvel Coordination 
The merging of the planning councils restores full Title II participation  in providing 
the panoply  of continuum  of care services to clients.  The planning council is now 
united in its goals and can devote  their efforts to service delivery and coordinating 
services to clients. 
Prior to New Orleans becoming  an EMA  in 1993, United  Services for AIDS 
Foundation,  the Title II Consortium  for New Orleans,  distributed monies  to a range 
of providers  involved in the continuum of care for HIV/AIDS  clients.  When  New 
Orleans became  an Em  the former  mayor asked the United  Services for AIDS 
Foundation  planning council to become  the Title I planning council, but he later 
withdrew the request. 
About  that same time, the State of Louisiana  considerably  reduced  the Title II funding 
in New  Orleans.  As  a result, United  Services for AIDS  Foundation  no longer funded 
social service activities in New Orleans and limited itself to legal advocacy  and 
emergency  assistance.  Its role in the continuum  of care was substantially diminished. 
Title I assumed responsibility for services formerly paid by United  Services for AIDS 
Foundation.  Despite  political events and a lessened  Title 11presence,  the EMA 
delivered  services to clients and made  some  new client services available. 
Client-levelCoordination 
Currently, little client-level coordination  takes place  in New Orleans.  No  common 
case reporting  or intake assessments are required  by the EMA.  Clients have multiple 
case managers,  and there is no forum  to bring case managers from  different providers 
together  to discuss cases, services available, or ways to overcome  barriers to care.  The 
State of Louisiana  provides  training, guidelines and licensing for case managers.  But 
no EMA  requirements  for case managers presently exist.  The  EMA  has consistently 
supported  the States case management  requirements  and will issue written guidelines 
this year consistent with those policies. 
In the future, changes may mitigate the current lack of client-level coordination.  The 
EMA  is beginning  to implement  a uniform reporting  system that will allow 
coordination  on a client level between  case managers and agencies. 
11 NEW  YORK,
 NEW  YORK

New  YorkEMA Background  NEw YORK EMA

cHARAcmRIsTIcs 
The New York  EMA  includes New York 
  EMA  population  is 8.5 million 
Citys five boroughs  and the Tri-County 
Region  north of the city, comprised  of    New York  City has 56,581 cumulative 
AIDS  cases, 17% of the national  total 
Westchester,  Putnam and Rockland 
Counties.  New York  City has about 96 
  The New York EMA  has 26% of the 
percent  of the EMAs  AIDS  cases.  cumulative  AIDS  cases reported  for the 
nations 34 EMAs 
New York  City faces myriad problems 
  There  are  17,000 people  living with AIDS 
that compound  the fight against 
in New York  City 
HIV/AIDS.  The  city has large numbers 
of infected  individuals who may be    Estimated  New York  City HIV/AIDS 
infection  is 165,000;  1 person  in 50 living 
homeless,  immigrants, tubercular, 
in New York  City is HIV-infected 
injection  drug users, poor,  mentally ill, 
non-English  speaking, or prisoners.    Between  30% and 40% of the citys 
200,000 injection  drug users are HIV-
infected 
To  address the epidemic  in the New 
York  Em  HRSA  awarded  over    52% of New York  Citys AIDS  cases are 
$100,000,000  in Ryan White funds for  associated  with injection  drug US%43%o 
with homosexual  activity 
1994.  In addition, both  New York  City 
and New York  State provide  substantial 
  18% of New York  Citys AfDS  cases are 
funding for HIV/AIDS  services.  femaley  86% of these are either  African-
American  or Latina 
The New York  City Department  of 
  AIDS  is the third leading cause of death 
Health is the Ryan White Title I  in New York  Ci~  in New York  City, 
grantee.  The Department  of Health has  AIDS  is the leading cause of death  for 
those between  the ages of 25 and 44 
intergovernmental  agreements with the 
three suburban counties to administer 
  One of four of the nations pediatric 
Title I funds.  They  also contract with  AIDS  cases is in New York  City 
the Medical  and Health Research 
Association  of New York  City, Inc    Nearly  11,000 New York  City children 
have been  orphaned  by AIDS 
(MHRA),  a private, non-profit 
organization,  to administer the Title I    There  are 7 Ryan White Tkle II consortia 
program  in New York  City, and with the  serving New York City 
Westchester  County Department  of 
  The Tri-county  area  of the EMA  has 11% 
Health to administer the Title I program  of the States population  outside  of New 
in the Tri-county  region.  York  Chy, but has 21$Z0of the States 
reported  ADS  cases outside  of New York 
City 
Through  New Yorks  contract with 
MH~  the EMA  is able to bypass 
some  of the bureaucratic  obsta~les in allocating grant funds quickly, and to avoid the 
12  pressures for downsizing that government  agencies  often face.  Also,  because  MHRA 
awards the funds, the EMA  avoids some  of the conflict of interest issues raised in 
other communities.  In other EMAs,  planning councils are open  to criticism when their 
memberships  are comprised  of service providers making direct funding decisions. 
The New  York EM  Pluming Council 
The  New York  EMAs  45 member  planning council  serves at the invitation of the 
Mayor,  and is chaired by the Mayors  Coordinator  of AIDS  Policy.  Members  serve 2 
year terms.  All boroughs  and counties are represented  on the planning council. 
Representatives  from Ryan White  Titles 11and III(b)  also sit on the planning council. 
At least 25 percent  of the planning council are persons  living with HIV/AIDS.  In 
addition, the planning council established an advisory group  of persons  with 
HIV/AIDS  to give advice to the planning council on issues before  it.  This 40 person 
group is composed  of both  council members  and non-members. 
Besides  this advisory group, three committees  and five work groups  assist the planning 
council in its work.  The  committees  are the executive committee,  which seines as the 
planning councils  steering committee,  the nominations  committee,  and the planning 
and evaluation  committee.  The work groups deal with issues relating to health, 
substance abuse, mental health, housing, social services, and infrastructure, which 
includes activities not directly related to client services. 
Sew-cm  to ClientS 
New York  State is unique in encouraging  providers  to treat HIV/AIDS  patients by
paying considerably  higher Medicaid  reimbursement  for AIDS  related  services.  The
enhanced  rates cover HIV/AIDS  testing, primary care, chronic care, case management,
long-term  nursing home  care, mental health semices, home  care and rehabilitation,
and respite  care.  In addition, hospitals meeting certain criteria can become
Designated  AIDS  Centers to receive  the highest AIDS-related  reimbursement  rates in
New York.
New York  States enhanced  reimbursement  program  allows New York  to recruit more
providers  of HIV/AIDS  related services and overcome  the difficulties faced  by other
States in attracting more  providers  to treat HIV/AIDS  patients.  Each  of the EMAs
counties  contributes  to the States Medicaid  fund which provides  one-fourth  of the
funds available to the State for the enhanced  provider  payments.
In their 1994 Supplemental  Grant Application,  the New York  EMA  identified  five
areas for semice  initiatives.  These  priorities are in primary health care, substance
abuse, mental health, housing and social services.  In addition, the application
identified  a number  of infrastructure development  activities.  These  included  personnel
recruitment  and retention in HIV/AIDS  service agencies, support  for mental health
licensure, and establishing financial technical assistance to serve Title I contractors.
13 New Semites 
Despite  the volume  and complexity  of New Yorks  AIDS  epidemic,  the New York 
EMA  has taken advantage of Ryan White in an effort  to address many of the unique 
needs  of New York  City.  The EMA  has stitched Ryan White funding into the existing 
complex  patchwork  of AIDS  service that dwarfs those in other cities.  The  New York 
EMA  is involved in funding of more  than 300 programs.  Many of these programs  are 
jointly funded  with other Federal,  State, and New York  City programs. 
Among  new programs  in the New York  EMA  made  possible  by Ryan  White funds 
are: 
	 orphan  support  services for children of people  who have died of, or are 
dying of AIDS; 
	 primary medical  care and case management  for those  of Haitian descent 
who  suffer from HIV/AIDS; 
	 the Air Bridge between  Puerto Rico  and New York  City.  This program 
coordinates  medical  services and case management  for H-IV/AIDS  patients 
who  travel to New York  City primarily to receive  medical  treatment.  Puerto 
Ricos  Medicaid  program has a limitation on spending  and very limited 
funding for HIV/AIDS  care and drug treatments. 
ProErams for Special Populations 
Title I funds have allowed  many programs  treating special needs  to be funded  as well. 
As one  city official described,  Ryan White funds afforded  the opportunity  to develop 
programs  targeting the many special needs  of AIDS  clients in New York  that would 
have no  other funding source.  In particular, many community-based  organizations 
treating injection  drug users at varying stages of their recovery  benefit  greatly from 
Ryan White  Title I monies. 
New York  City is in various stages of planning and implementing  special programs  to 
target populations  with special needs.  Many of these programs  involve collaboration 
between  various Ryan White Titles.  These  programs  include: 
	 providing  case management  services and primary medical  care to immigrants 
with HIV/AIDS; 
	 a housing program  providing housing, directly obsemed  therapy, and 
individual supportive  services for hospital patients identified with both 
tuberculosis  and HIV/AIDS; 
  serving clients triply diagnosed  with mental illness, chemical  addiction,  and 
HIV/AIDS;
14   transitional residences  providing temporary  housing and comprehensive 
programs  for homeless  substance abusers with HIV/AIDS  to help them 
make the transition from  structured living situations to more  independent 
living; 
  providing recove~  readiness to HIV/AIDS  clients who  do not see drug 
recovery  as their first priority.  These  clients often have much more 
immediate  health needs,  or other priorities like food  and shelter.  Recovery 
readiness programs  recognize  this, meet  some  of the other basic client needs, 
and work on behavior  change strategies and other intervention with clients; 
  harm reduction  programs  targeting HIV/AIDS  clients who  are injection  drug 
users who  cannot or will not use conventional  drug treatment.  Community-
based  organizations  are funded  for outreach,  education,  counseling,  and 
referral for other drug treatment and medical  sefices; 
  relapse  prevention  programs  furnishing ongoing  help to HIV  positive  clients 
who  are former  drug users.  These  programs  can involve case management, 
outreach,  support  groups, recreational  activities, and other means to keep 
clients involved in a consistent routine, and to keep  contact with them so 
that they do not relapse into drug use. 
AdministrativeCoordination 
The vast array of programs  available to HIV/AIDS  clients, the sizable contributions  of 
other funding agencies,  and the types and scale of problems  facing the New York 
EN@  makes their coordination  with other agencies imperative.  To  this end, the New 
York  EMA  has direct and frequent  interaction with New York  City programs  and also 
through its contractor,  MHRA.  The MHRA  also contracts with New York  City as the 
representative  agency for its Healthy Start/NYC  project,  as well as other maternal 
and child health, infectious  disease control  service, research  and demonstration 
projects. 
Coordination  and collaboration  with Ryan White  Title II occurs in several ways.  The 
AIDS  Institute in New York  States Department  of Health is the Title II grantee and 
oversees  the Title 11consortia.  Meetings between  the managers of Title I and Title II-
funded  programs  take place weekly at both  the city and State levels.  An AIDS 
Institute representative  is a voting member  of the planning council  and also serves on 
the executive committee.  Coordinators  from many of the EMAs  consortia  are 
represented  on the planning councils work groups. 
The Title I and Title II grantees jointly sponsor  several programs  that provide  services 
to uninsured and underinsured  clients with HIV  who  are not yet eligible for Medicaid. 
These  programs  include: 
15 c	 the AIDS  Drug Assistance  Program  (ADAP),  providing free  drugs for the 
treatment of HIV  and infections  that may occur; 
	 ADAP  Plus, providing free primary medical  care at enrolled  clinics, hospitals 
and drug treatment centers;  and, 
	 the Home  Care program  delivering services to HIV  clients in need  of home 
care. 
In addition  to joint sponsorship  of programs,  Title I funds have also been  awarded  to 
the AIDS  Institute to administer eight contracts for delivery of primary care in 
substance  abuse treatment settings. 
Titles I and 11 coordinate  strategic planning of service delivery through their support 
of the Health  Systems Agency  of New York  City (HSA).  The HSA  provides  analyses 
to the EMA  and State which facilitate their strategic planning for HIV-related 
services. 
Client-level coordination 
Despite  New Yorks  overwhelming numbers, mechanisms  like the Title II AIDS 
networks  contribute  to New Yorks  ability to administer some HIV/AIDS  services on a 
scale similar to those in smaller cities.  There  are 7 AIDS  networks,  or Title 11 
consortia,  covering  the different boroughs  and many of their neighborhoods.  The 
networks fill the role  of organizing the smaller communities  in a borough.  Each 
network  meets  at least quarterly, and its committees  often  meet monthly. 
Each network  is required  to have a case management  committee  which allows 
providers  and case managers to discuss new semices,  service needs,  and other case 
management  issues.  This also allows case managers to network with each other,  and 
to facilitate coordination  between  case managers who  share clients. 
16
 KANSAS  CITY, MISSOURI

Kimsas City EiM4 Background 
The Kansas City EMA  is comprised  of Jackson County, which includes the city of 
Kansas City, Missouri, and Clay, Platte, Cass, Clinton, Lafayette  Counties  in Missouri, 
and the Kansas counties  of Johnson, Wyandotte,  Miami  and Leavenworth. 
Kansas City became  eligible for Title I 
funding as an EMA  in 1993.  The  KANSACISTYElm  cHARAcxEREmcs 
Kansas City Health Department  is the 
  EMA  population  is 1.6 million 
Title I grantee  and also dispenses 
HOPWA  funds.  The Kansas City    Estimated  HIV/AIDS  infection  is 8,400 
Health Department  also serves as the 
lead agency for Missouri Title II.    Most live in the Kansas  City metropolitan 
area 
A  case management  contract with the    72%  of the infected  population  is white, 
State of Kansas formalizes  EMA  2270 is African-American,  3% is Hispanic, 
and the remainder  is Native American, 
participation  by the four Kansas 
Asian American  or no data  is available on 
counties.  heritage 
The EMA  includes urban, suburban and    Gay/bLsexual  males make  up 69% of the 
HIV/AIDS  population 
rural communities,  and they vary 
markedly.  For  example,  the median    6% are intravenous  drug users, with 
household  income  for Wyandotte  County  another  8% are combining  male to male 
sexual activity with injecting drug usage 
is $23,780, barely half that of adjacent 
Johnson  County at $42,741.  Five of the 
  Heterosexual  transmission  represents  4% 
eleven EMA  counties have at least 10  of the HIV/AIDS  cases 
percent  of households  below  the poverty 
level.  Very few, about  ten percent,  of    Women  make up 7% of the EMAs 
infected  population  and face the highest 
the Missouri  persons with HIV/AIDS  risk of infection  through  heterosexual 
have private insurance.  More  than 46  transmission 
percent  have no insurance, while the 
balance  are Medicaid  eligible. 
The  changing nature of the HIV/AIDS  pandemic  is reflected  in the Rrowing number  of 
African-Americans  being infected  with HIV.  African-Americans  are-18 percent  of the 
population  in the EMA,  but are more  than a third of those with HIV.  In addition, 
African-American  women  are 29 percent  of the EMAs  female  population,  but are 56 
percent  of the HIV  positive women  in the EMA. 
17 Theffinsas CityEMA PlanningCouncil 
The  steering committee  for the Missouri Title II Ryan White  Care Consortium,  is also 
the Title I planning council.  The planning council is comprised  of 20 voting members, 
9 of whom  are persons with HIV/AIDS.  Planning council by-laws require  all planning 
council  decisions be  taken to the full Consortium  for  consensus.  Only if consensus 
cannot be  reached  from  the fuIl Consortium,  and after consideration  at two 
Consortium  meetings,  a steefing  committee  vote will be  taken to resolve  the issue. 
This has occurred  only one  time. 
The full Consortium  has over 80 members  including persons with HIV/AIDS, 
providers,  Title IIIb and both  State agencies.  Besides  its Ryan White responsibilities, 
the Consortium  also sets priorities for HOPWA  spending. 
Sub-committees  have a significant role in the EMAs  activities.  Sixteen sub-
committees  have been  formed  to identi~  barriers to service, review utilization of 
existing services, and to recommend  changes to the steering committee .3  Membership 
on the sub-committees  is open  to all. 
Ikrvkes to ClienLs 
In 1993, the Kansas City EMA  received  $2.6 million from Title I, and $330,000 from 
HOPWA.  Primary care, case management,  and medications  are the EMAs  Title I 
priorities for  1994.  The priorities are determined  by the annual needs  assessment. 
The needs  assessment priority setting is based  on a 60/40 split between  the 
consortium/steering  committee  and full Consortium  recommendations.  Sixty percent 
of the priorities are decided  by the consortium/steering  committee,  and the balance  by 
the full Consortium.  Based  on the needs  assessment, Title I subcontractors  provide 
home  health services, emergency  assistance, food,  transportation,  mental health, 
substance abuse counseling,  advocacy,  early intervention pre-case  referrals, information 
and referrals, buddy/companion/child  care/adoption/foster  care, and hearing impaired 
semices. 
New Services 
New services funded  by the EMA  include  case managers in Kansas, the addition of 
rural primary care sites, dental services, and respite summer camps for children of 
HIV/AIDS  affected  parents. 
3 l%e sub-committees are: (1) pnmay  medical care, (2) case managenten~ (3) housing (4) transportatio~ foot+ and emergency 
assistance, (5) substance abuse/mental healfi  (6) bamersto carelcnminal justice systeq  (7) minon~ issues, (8) hospice, (9) foster 
careladoptio~  (10) buddy ~stq  (11) advocaqy (12) infomafion and refma~ (13) dental care, (14) early inkrventionlpre care 
refma~ (15) home healfi  and (16) volunteer. 
18  States Contributions 
The  States of Missouri and Kansas allocate  Title II funds for services to clients in the 
Kansas City EMA.  Missouri provided  $210,000 in client services in the EMA  for fiscal 
year 1993.  These  funds were primarily used for case management  and home  health 
services.  In addition, Missouri also paid $480,000 Statewide for medications  for 
HIV/AIDS  affected  patients. 
The  Kansas state-wide consortium  uses its funds for medications,  home  health services 
and insurance continuation.  Cooperation  between  the States has allowed  Kansas 
clients in the EMA  to be  case managed  and tracked by the same system used by 
Missouri  clients. 
Admihktiative-LevelCoordination 
Coordination  between  the Ryan White Titles and providers  is intrinsic to the 
administration of the program.  Kansas City had several advantages in becoming  an 
EMA.  Preceding  the EMA  were the State general fund dollars, their Title II 
experience,  and widespread  community  acceptance.  Several ASOS had arisen to fill 
service voids  - a volunteer  program,  food  bank and the free health clinic to serve as an 
anonymous  testing site.  With Title I imminent, grass-roots community  organizations 
made  a concerted  effort  to identi~  the numbers  of clients required  for funding. 
The EMA  made  the level of coordination  attained in reaching Title I status an integral 
part of the way they operate.  Since the planning council must reach decisions  by 
consensus,  cooperation  and coordination  are important  to fund activities or determine 
priorities. 
The Role  of Case Management 
In addition,  the case management  process  mandates  cooperation  between  all agencies 
involved.  Consequently,  contact is frequent between  the case managers, service 
providers,  the grantee, and the State.  Coordination  with the State of Missouri is 
facilitated by the case management  computer  system.  Titles II and IIIb case managers 
also use the same case management  system as Title I providers. 
The Role  of Persons with HIV/AIDS 
The persons  with HIV/AIDS  are vital to the EMAs  decisionmaking  process.  As  one 
person  with HIV/AIDS  said, they (the EMA)  use us to make policy,  ... (we are) not 
mere window  dressing.  One  immediate  result of including persons with HIV/AIDS  in 
the sub-committee  process  was the EMAs  funding of dental services.  Prior to this 
input, the consortium/steering  committee  process  had not considered  dental semices  to 
be  a priority.  By relying on persons with HIV/AIDS  for substantial input and activity 
in the administrative process,  the HIV/AIDS  community has a reason  to buy into the 
program.  As a result, some  potential  turf issues are defused. 
19
 The EMA  also recognized  the need  for and developed  a mentor  program  for persons 
with HIV/AIDS.  Cross-educating  across the program,  developing  a base  line of 
knowledge,  and breaking  down barriers are goals of this activity.  In the future, this 
program will develop  surveys, hold focus  groups, and participate  in quality assurance 
procedures. 
Client-levelCoordination 
Case management  is integral to ensuring a continuum  of care and delivering services 
to clients in Kansas City.  A client has just one  case manager,  and is free  to change 
case managers  at any time.  Service decisions  are made based  on both  the clients 
economic  needs  and their HIV  status.  Case managers use an acuity scale to 
determine  the appropriate  extent and type of intemention  needed.  No  services are 
provided  unless they are in line with the clients needs  assessment. 
The EMA  considers  case managers to be the gatekeepers  to all Ryan White  and 
HOPWA  services in the EMA.  The  case managers, who  are located  at primary care 
sites, are responsible  for verifjing  HIV  status, determining income  eligibility, and 
authorizing services.  Regardless  of provider,  case managers use identical intake, 
assessment, and service authorization forms.  Data from the forms is then entered  into 
the Missouri Department  of Health  case management  computer  system.  The  system 
also includes EMA  clients residing in Kansas,  The  system helps prevent  duplicating 
counts of clients or duplicate  services, and allows for oversight of case manager 
activities. 
All case managers  attend meetings every Thursday, so all Ryan White  case managers 
are present  at the same time.  Case managers are encouraged  to develop  informal 
networks to discuss cases, treatment plans, and alternatives to high cost services.  Case 
managers  also can work with the State AIDS  representative  to get Title II homemaker 
and home  health services for clients.  These  sessions train case managers so they can 
authorize  primary care, counseling,  and other services.  The weekly meetings  are also 
used to instruct case managers on the State forms  and procedures. 
20
 ANGELES,  CALIFORNIA

LOS 
Los AngelesEM4  Background 
Los Angeles  County is one  of the largest 
and most racially, ethnically and  LOS ANGELEs  Eh4A CHARACTERISTICS 
culturally diverse local jurisdictions in the 
EMA  population  is 9 milIion 
United  States.  The  1990 census data 
shows 41 percent  Caucasian, 37 percent  EMA  is over 4,000 square  miles, and 
Latino,  11 percent  African-American,  11  includes 88 cities 
percent  Asian/Pacific  Islander, 1 percent 
There  are over 27,000 confirmed  AIDS 
American  and Alaskan Native.  One  of 
cases in Los Angeles  County,  the 2nd 
six people  in the EMA  lives below  the  largest Iocal caseload  in the United  States 
Federal  poverty level.  One  of seven 
Estimated  HIV/AIDS  infection  is 40,000 
receives  some  form  of public  assistance; 
to 51,000 
1 of 6 is entitled to Medicaid;  1 of 3 
under the age of 65 has no health  49%of the infected  population  is white, 
insurance.  28% Latino,  20% African-American,  2% 
Asia@acific-Islander,  and  1% American 
and Alaskan Native.  In  1986, the rates 
In FY  1993, Los Angeles  received  over  were 70% white,  1570 Latino,  14$% 
$19 million in Title I funds, and $1.375  African-American,  1% Asian/Pacific-
Islander,  and an unknown  number  of 
million in Title 11monies.  There  are 
American  and Alaskan  native 
also five grantees in Los Angeles  county 
who receive  $1.5 million in Title III-B  Gay/hi-sexual  males comprise  72% of the 
funds.  Aside  from  Ryan White money,  HIV/AIDS  population 
Los Angeles  received  over $80 million in 
8% are injection  drug users, with another 
other Federal  funds, the majority of 
6% combining  male to male sexual activity 
which came from AIDS  research grants.  with injecting drug usage 
In addition, Los Angeles  received  more 
Heterosexual  transmission  represents  3% 
than $26 million from  the State and over 
of the HIV/AIDS  cases 
$52 million from local funds. 
Method  of transmission  is unknown  for 
8% of the HIV/AIDS  population 
Los Angeles  County is governed  by a 
five-member  Board  of Supervisors.  The 
As of November,  1994, there  are 9,433 
Board  designated  the Los Angeles  living reported  adult/adolescent  AIDS 
County Department  of Health Services  cases and 373 living reported  pediatric 
AIDS  cases 
as the entity responsible  for 
administering Ryan White Title I 
Formula  and Supplemental  Grants. 
The AIDS  Program  Office  in the Department  of Health Services provides  staff 
support  to the Los Angeles  County HIV  Health Services Planning Council.  The AIDS 
Program  Office  also serves as the applicant and grant recipient  for Title I funds and 
most other governmental,  non-research  HIV/AIDS  funding. 
21  l%e Los AngelesEM  PlanningCouncil 
The Los  Angeles  County HIV  Health Services Planning Council is a 42 member  body 
established by ordinance  of the Board  of Supervisors.  This ordinance  grants the 
planning council  the authority to review all HIV/AIDS  programs  operated  by the 
County and to make recommendations  to the Board  regarding the distribution of 
funds and unmet HIV/AIDS  community needs. 
Services to Clzknts 
Ryan White program  funds have greatly enhanced  the variety, quantity, and 
accessibility of services to HIV/AIDS  clients.  New services provided  by Ryan White 
funding include: 
Additional  community-based  outpatient  sites are providing  services to clients. 
Transportation  for Ryan White  clients is one  of the most important  new 
services provided,  given the geographic  spread  of Los Angeles  County and 
the lack of  a public transportation network. 
Translators  assist a variety of monolingual  clients with providers.  These 
translators travel to program  sites as needed  to assist non-English  speaking 
clients. 
Vision  rehabilitation is now provided  to the partially sighted. 
Self-help  programs  have been  instituted using HIV-infected  persons  to 
provide  peer  support. 
Family support  programs  allow families with one  or more  HIV  parent to 
remain intact, or promote  reunification of the families. 
Household  support  services are available for clients. 
Administrative-leveCloordination 
The  sheer size of Los Angeles  County presents issues about  the coordination  of 
services between  agencies.  The Los Angeles  County Department  of Health Services 
identifies six distinct regions, each differing in needs,  service availability, and 
demographics.  The  lack of public transportation  also is a constant factor  to be 
considered  in attempting to coordinate  agencies  or services to clients. 
Despite  these drawbacks, Los  Angeles  EMA  grantees and providers  frequently come 
together  formally and informally to resolve  common  problems.  Coordination  between 
the Ryan White Titles I and 11is simplified since the planning council  serves as the 
Title 11 consortium  for Los Angeles  County.  The Title 11 staff person  attends all 
22 council meetings  as an advisor and reports  on any new developments.  His office  is 
located  at the Title I coordination  site.  In addition, with only one  exception,  the 
organizations  receiving Title II funds also receive  Title I funds.  Titles I and 11have 
recently developed  common  data elements for reporting purposes. 
Agency  members  know what services are available from  other providers  and often  do 
cooperate  in joint  endeavors.  One  such endeavor  is the case management  computer 
system that is on-line  at 10 of the largest agencies in the County.  Other  examples  of 
administrative coordination  include negotiating agreements with local Social Security 
offices,  area food  pantries working cooperatively  with other providers,  health facilities 
being willing to work with bilingual translators, and case managers from  different 
agencies  convening monthly. 
There  are a variety of task forces  operating in the HIV/AIDS  community.  In addition 
to planning council  task forces,  individual agencies have task forces  as does  the AIDS 
Regional  Board.  The networking that results from these task forces  has beneficial 
aspects.  For  example,  people  not on the planning council who had been  involved in 
task forces  contribute  to the work  of the planning council.  Also,  the case management 
task force  is seen as a benefit  by several of the case managers with whom we spoke. 
While  coordination  between  Titles I and 11is stressed, there is not the same priority to 
coordinate  Titles IIIb and IV.  Title IIIb is funded  directly by HRSA  to local 
organizations  and is not discussed at the planning council, although IIIb agencies  are 
represented  on the planning council,  One  of the planning council co-chairs  is the 
director  of the network  of agencies serving the HIV-infected  pediatric  population  and 
their families.  Most  respondents  see Title IV as a separate  service delivery system and 
consequently,  there is not as much coordination  with the pediatric population. 
Client-levelCoordination 
There  are many examples  of client level coordination  taking place  in Los Angeles. 
Most  of these seemed  to be initiated either by an individual agency or by one  of the 
task forces  that operate  on different levels in the County.  The various task forces  that 
are ongoing  on different topics provide  a ready network  for communicating  on any 
recent  developments. 
One  example  is the work initiated by the case management  task force.  In order  to 
eliminate the duplication  of case managers for clients and the potential  for duplication 
of efforts,  a computer  system was created  to insure that only one  case manager is 
working with a client.  The task force  has defined  case management  as ~oining with 
the client to access services.  The task force  meets monthly to talk about better ways 
to serve their clients through referrals to other agencies or just to learn about  different 
ways they can be  of more  help.  The  task force  is also working to establish standards 
for case managers.  Titles I and II have recently developed  common  data elements for 
reporting  purposes. 
23 BROWARD  COUNTY,  FLORIDA

BrowardCountyEM  Background 
Ryan White  Title I funds provide  over  BROWARD  COUNTY EMA 
CHARACTERETICS 
$6,800,000  to the Broward  County, 
Florida  EMA.  The  Office  of HIV/AIDS 
  EMA  population  is 1.3 million 
Support  Services in Broward  Countys 
Human  Services Department  administers    Estimated  HIV/AIDS  infection  is 17,226 
Ryan White Title I as well as (HOPWA) 
  44% are between  the ages of 30-39, 23% 
grants from  the Department  of Housing 
are age 40-49, and  12% are older than 49 
and Urban  Development. 
  African-Americans  now make  up 37% of 
the HIV/AIDS  population,  compared  to 
Broward  County provides  all the health 
30% in 1990, but comprise  only 15% of 
and social service programs for Ryan  Broward  Countys population.  White 
White  clients except  those funded by the  Angles represent  57% of the HIV/AIDS 
population,  and Hispanics  6% 
State.  Consequently,  no 
intergovernmental  agreements  between 
  Women  comprise  17% of the HIV/AIDS 
the EMA  and the municipalities are  population.  Nearly 3/4 are African-
required.  American 
  Gay or bi-sexual males are more  than  half 
There  are 29 municipalities in the 
the HIV/AIDS  population 
Broward  County EMA,  the largest being 
the city of Fort Lauderdale.  Over  10    18% of the HIV/AIDS  population  are 
injection drug users, with another  6% 
percent  of Broward  Countys population 
combining  male to male sexual activity 
falls under the Federal  poverty level.  with injecting drug usage 
There  are several large concentrations  of 
Haitian-Americans  in Broward  County.    Heterosexual  transmission  represents  6% 
of the HIV/AIDS  cases 
The BrowardCountyEMA Pkmning    Method  of transmission  is unknown  for 
council  2% of the HIV/AIDS  population 
  There  are 5,107 living reported 
Broward  Countys Board  of County 
adult/adokscent  AIDS  cases and  107 
Commissioners  appoints  the 30 member  living reported  pediatric  AIDS  cases 
Broward  County HIV  Health Services 
Planning Council  to serve indefinite 
terms.  ~though  only these members  vote  on planning council issues, numerous 
community representatives  attend planning council meetings and participate  fully in 
sub-committee  decisions.  The  planning council  also solicits community  participation 
through efforts  like conducting focus  groups on specific HIV/AIDS  issues, and 
sponsoring  an Ecumenical  Conference  on HIV/AIDS  aimed  at bringing African-
American  religious leaders  and clergy into the planning process. 
24 Five sub-committees  assist the planning council.  A priorities sub-committee  works on 
the community needs  assessment and recommends  funding priorities and allocations  to 
the planning council.  A nomination  sub-committee  finds and recommends  new 
planning council members  to the county commissioners  when replacements  are 
needed.  A multi-cultural sub-committee  develops  strategies and implements  ways to 
increase minority participation  in Ryan White  activities.  A  case management  study 
committee  developed  an improved  system that will provide  a centralized  case 
management  agency for all Ryan White funded  case managers.  A by-laws 
sub-committee  ensures that planning council procedures  are adhered  to in making 
decisions. 
Services to Chntr 
In their 1994 application  for supplemental  Ryan White funds, Broward  County 
identified  12 priority services for their community.  In order  of intended  outlays, their 
priorities are:  medical/dental  treatment and diagnosis, pharmaceuticals,  case 
management,  housing, respite child care, home  health care, transportation,  nutritionist 
services, mental health therapy/counseling,  health insurance continuation,  food  bank, 
and holistic therapies. 
New Services 
Ryan White funds have allowed  the EMA  to fund medical  professionals  at several 
sites and also to provide  many new services to clients.  These  new services include: 
	 an urgent care outpatient  clinic, currently providing primary medical  care to 
approximately  360 patients monthly, and diverting 20 to 30 patients monthly 
from  using costly emergency  room  services; 
  a childrens  day care center; 
  homemaker/companion  services; and, 
	 van transportation  services to 250 unduplicated  clients, and bus passes to 30 
clients. 
AdhdnistrativeCoordination 
Considerable  coordination  occurs between  Titles I and II.  There  is some  overlap  in 
Title I planning council membership  and in the Title II consortium,  the South Florida 
AIDS  Network  of Broward  County; which is made up of 88 member  agencies.  The 
local State director  and the EMAs  grant administrator meet periodically  to share 
program  planning information.  The titles share data from  needs  assessment studies, 
provider  and consumer  surveys, focus  group meetings and other program  data.  Where 
both  titles fund the same service, like transportation,  they collaborate  on standardizing 
program  and data reporting  requirements.  As a result, providers  applying for funding 
are not faced  with different  criteria for each Ryan White title. 
25 Coordination  with other Ryan White  titles also takes place in Broward  County.  Title I 
funds have been  used to supplement  the Title III(b)  and Title IV providers  in 
Broward  County, helping to ensure a continuum of care for clients served at those 
sites.  In addition, the Title IV director is a planning council member,  active on two 
sub-committees. 
Another  form  of administrative coordination  between  titles takes place  at a statewide 
level through Floridas  annual inter-title meetings.  The first inter-title meeting was 
held in 1993 and included  representatives from  every Florida Title I EMA  grantee and 
the Title II representatives  from those EMAs.  The  1994 meeting  included 
representatives  from  all four Ryan White titles, 
Client-1evelcoordination 
Client-level  coordination  has been  a major EMA  concern.  A major barrier to this 
coordination  occurs when clients have multiple case managers.  No  exchange  of client 
information  takes place between  agencies, making coordination  of services difficult and 
inefficient. 
The  planning council convened  a special Case Management  System Study Sub-
committee  who  studied the issue for 7 months.  The  sub-committee  recommended  that 
a centralized  case management  agency with a case management  client database  be 
established.  Broward  County EMA  is in the process  of choosing  an agency to 
administer a centralized  case management  services program. 
This new case management  agency will employ  all the Ryan White Title I and 
HOPWA  funded  case managers and implement  and maintain a centralized  client data 
base  system.  The  case management  system will work in the following  way: 
An  existing Broward  County agency will employ  and train all case managers who  are 
funded  by Ryan White  Title I and HOPWA  grants.  Although  employed  and trained 
by the centralized  case management  agency, case managers maybe  physically located 
outside that site.  Each  client will do an intake interview with a case manager  only 
once.  The  case manager will enter all intake information  onto  a centralized  case 
management  database  that will be  accessible  to agencies in the area.  For  example, if 
a client enters the system at a community-based  medical  provider,  a case manager will 
collect  intake information  and enter that information  onto  the client database.  If that 
client later goes  to a food  bank, the client can show the food  bank proof  of his or her 
HIV  status and the food  bank can enter the clients name into the computer  and get 
information.  The food  bank would  have access only to the relevant part of that 
clients file, not all medical  information.  The  centralized  case management  database 
will allow a case manager  to see where the client has been  and prevent  duplication  of 
services. 
26 DETROIT,  MICHIGAN

DetroitE&&4Background 
The Detroit  EMA  is comprised  of Wayne  County, which includes the city of Detroit, 
and Oakland,  Macomb,  Lapeer,  Monroe,  and St. Clair Counties, 
The  City of Detroit  Health Department 
(DHD)  is the Title I grantee and is also  DETRoIT EMA  CHAIUCXENSTICS 
the HOPWA  grantee.  The DHD  has 
  EMA  population  is 4.4 million 
provided  primary medical  care services 
to a largely indigent population  for more  	 Estimated  HIV/AIDS  population  is 
than 50 years.  Their  client population  is  10,600. Of these 
90 percent  minority.  Over half of these 
b  63% live in Detroit 
have no health insurance; about  40 
+  15% live in Oakland  County 
percent  are Medicaid  eligible.  b  14% live in Wayne County, 
outside  of Detroit 
b  6% live in Macomb  County 
Widespread  poverty  and chronic 
b  25Z0live in Lapeer,  Monroe 
unemployment  in the Detroit  area  or St. Clair Counties 
compound  the EMAs  responsibilities  of 
About  2/3 of HIV/AIDS  population  is 
providing primary medical  care and  Q 
African-American,  about  1/3 white, about 
psychosocial  services to meet  the needs 
3% are of Latino,  Arab-Caldean,  Native 
of clients living with HIV/AIDS.  In  American  or Asian heritage 
March  of  1993, Detroits  unemployment 
was 12.6 percent,  nearly double  the State    Gay, hi-sexual males are almost half the 
HfV/AIDS  population 
jobless  rate. 
  A third or more  of the HIV/AIDS 
Henry Ford  Hospital  and the Detroit  population  are drug users 
Medical  Center provide  primary medical 
  Women  comprise  more  than a fifth of the 
care to about  30 percent  of the persons 
HIV/AIDS  population;  the majority are 
with HIV/AIDS.  Community  providers,  African-American 
private physicians and the Veterans 
Administration  Hospitals  treat another 
15 percent.  An  estimated 6,000 people,  55 percent,  do not receive  any HIV  primary 
care. 
l%e DetroilEM  PlanningCouncil 
The Southeastern  Michigan HIV/AIDS  Council  (SEMHAC)  is the Ryan  White 
planning council for both  Titles I and II, as well as HOPWA.  The SEMHAC  has 
been  the Title 11planning council since 1989.  In 1992, when Detroit  became  eligible 
for Title I funding, SEMHAC  accepted  that same responsibility for Title I.  The 
planning council has 45 members  representing the persons with HIV/AIDS,  the EMA 
27 counties,  and 26 agencies.  Titles IIIb and IV are also represented  on the planning 
council. 
The  planning council has undergone  a metamorphosis.  The  new mayor in Detroit 
brings a change of focus  to the planning council.  This new administration is conducive 
to coordinating  with the State, counties and other entities.  As a result, the planning 
council is looking  ahead  at proposals  for advocacy,  mental health, primary care and 
emergency  assistance.  The  planning council is also trying to solicit more  input from 
the people  with HIV/AIDS  in the community. 
Servicesto Clients 
In 1993, the Detroit  EMA  received  $2.8 million from Title I, $1.5 million in Title 11 
funds, $700,000  from HOPW~  and supplemental  monies  from Michigan  Health 
Initiative funds.  Case management,  primary care/complementary  therapies, 
substance  abuse treatment, emergency  assistance, mental health, advocacy,  drug 
reimbursement,  housing related  services, and buddy/companion  services are the 
EMAs  Title I priorities for  1994.  The priorities are determined  by the annual needs 
assessment, an important  component  in the continuum  of care. 
New Services 
The  Title I and HOPWA  subcontractors  offer  a diversity of services.  The  planning 
council  opted  to reach out to the community providers  to make  sure ethnic, 
geographic  and service needs were met.  New services include housing to women  with 
children, addressing a need  identified  as a priority by Title II, and advocacy  services, 
responding  to needs  expressed by persons with HIV/AIDS.  Other new programs 
funded  by Title I include  an approach  that focuses  on African-American  persons who 
are gay and HIV  positive, and another where both  persons  with HIV/AIDS  and 
caregivers participate  in support  groups together. 
New Primary Care Network 
Two  respondents  cited the formation  of a primary care network by three hospitals to 
apply jointly for funding as a major  contribution  to providing medical  care to clients. 
This coalition  should mitigate the competition  between  these providers,  result in more 
coordination  between  the hospitals, and improve  clients accessibility to services. 
4 The EM-4 defines case management as: Client-centeredservice that links clienti with health care and psychosocial servicesto 
iksure holy,  coordinated access to medical~ appropriate levels of health care and wpport services and continui~ of care. KqY 
activities include: 1) assessment of the clients neea3 and personal support systenw; 2) development of a comprehensive, individualized 
serviceplan;  3) coordination ofservicesrequiredtoimplementtheplan; clientmonitoringtoa.mx  theeflcacy oftheplan;  and4) 
petiodic re-evaluation and adaptation of the plan as necessary. 
28  Case Mana~ement 
The  State of Michigan  sees case management  as the key that ensures that a 
comprehensive  continuum of care is available to persons with HIV/AIDS.  The  Detroit 
EMA  committed  $1 million in Title II funds for case management.  (The  other 
$150,000 in Title 11funds went for home  and community  services.)  Since  1989, about 
5,000 persons  in the Detroit  EMA  have received  case management  services. 
The two major  case management  agencies in Detroit  receive  Titles I and 11funding 
for case management.  These  agencies recently began  subcontracting  some  case 
management  activities to several other providers.  All case managers are required  to 
coordinate  all Ryan White services delivered  and to record  all services clients receive 
on the Uniform  Reporting  System (URS).  All subcontractors  must report  continuity 
of care sewices  via the URS. 
Admimkh-ahe-i%velCoordination 
Coordination  among  Ryan White grantees and providers  occurs in several ways.  First,
the planning council maintains several standing committees.  Each  committee  is
responsible  in some  way with the coordination  necessary to ensure that the continuum
of care is delivered.  Also,  coordination  is also facilitated by the subcontractors
required  quarterly reporting  and their mandated  use of the URS.  The  planning
council  can evaluate the extent of client level and administrative coordination  by
reviewing these submissions.  In addition, the planning council is awaiting the results of
a 240 client survey utilized by 15 persons with HIV/AIDS  as interviewers.  Final results
will be  available in May  1995 and should provide  insight into whether  coordination
needs  to be  enhanced.
Provider  Coordination 
Beginning in 1994, the grantee advised providers  applying for Title I funding that 
coordination  was a very important responsibility for Ryan White  provider.  Applicants 
were told to describe  how they would  coordinate,  and that coordination  now would 
account  for one-fourth  of the scoring of their application.  Providers  are required  to 
demonstrate  this in part, by securing signed agreements  of coordination  with other 
service providers.  These  agreements  can lead to a referral network between  providers 
and their staffs. 
In addition  to this formal  coordination,  providers  interact informally as well.  Providers 
call each other frequently  or meet monthly through a community network  committee 
made  up of 60 providers. 
29 State Coordination  Efforts 
The  State of Michigan  also coordinates  Ryan White activities in several ways.  They 
interact with the planning council on many activities.  They fund case management, 
participate  in the needs  assessment, and are active in resource  development.  The 
State requires  quarterly reporting from  their subcontractors  - the Detroit  case 
management  agencies,  and performs  site visits, in part to ensure that appropriate 
coordination  is taking place.  In May  1994, Michigan hosted  their first Statewide 
continuum  of care conference,  attended by the spectrum  of Ryan White  providers  and 
administrators.  In October  1994, Michigan held a 2 day consortia  training, attended 
by all consortia  regions. 
Cli&nt-leveCloordination 
In the Detroit  Eh@  coordination  begins with case management.  Every 2 weeks,  case 
managers meet  to discuss cases, exchange information  on providers  and services 
offered,  and ensure that services are being coordinated.  This network increases 
resources  and access for clients.  At the same time it lessens opportunities  for clients 
to abuse the system. 
Both  of the large case management  agencies, AIDS  Care Connection  and AIDS 
Consortium  of Southeast Michigan  (ACSEM),  hold weekly in-house  case conferences. 
At these sessions, questions are answered and expertise is shared among  staff.  At 
least monthly, ACSEM  includes a service provider  participate  in their meetings. 
30