I 

Department of Health and Human Services 

OFFICE OF


INSPECTOR GENERAL


THE RYAN WHITE CARE ACT: 

EXAMPLES OF LOCAL COORDINATION 

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JUNE GIBBS BROWN 

Inspector General 

JUNE 1995 

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 OIG’S 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 

Joseph L. Penkrot (Project Leader)


Ellen R. Meara


Barbara Butz


William Moran


For a copy of this report, please call (312) 353-4124.


REGION II 

Lucille Cop 

HEADQUARTERS 

Alan S. Levine 
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); Consoti”a 

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 community’s 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 out1 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 EMA’s characteristics. 

The EMAs have evolved in different ways at different speeds. Their approaches are 

fashioned to meet their community’s 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 community’s 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 President’s 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 community’s 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 provider’s 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

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SEATTLE, WASHINGTON


SeattleEM4 Background 

The Seattle EMA includes King, Snohomish, and Island Counties and represents 42 

percent of the State’s 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 

Public Health is the Title I grantee and 

is also the lead agency for the Title II 

consortia. Title I responsibilities include 

providing services for HIV/AIDS 

education, prevention, testing, 

counseling, and client care services. As 

a consortium, they are responsible for 

consortium management, which includes 

planning, coordinating, monitoring, and 

evaluating program activities. They also 

maintain a centralized contracting and 

reporting system, and identify and seek 

funds for consortium activities. 

?%e SeattleEM4 PlanningCouncil 

The HIV/AIDS Planning Council is a 32 

member body responsible for all 

planning and allocation activities for care 

services and prevention/education. It 

has two co-chairs, one from the Seattle 

King County Health Department and 

9 

sEA1-H.EEMA cHARA(n’ERIs-I’fa 

EMA population is 2 million 

75% of the AIDS cases in Washington 

State reside in the EMA 

Estimated HIV/AIDS infection is 11,750 

91$~0of the HIV/AIDS population lives in 

King County 

85’%.of the infected population is white, 

8% is African-American, 4% is Hispanic, 

and the remainder is Native American or 

Asian Ameriean 

Gay/hi-sexual males make up 78% of the 

HIV/AIDS population 

Gay/bisexual men who injected drugs 

make up 11% of the population, while 5% 

are heterosexual intravenous drug users 

Women make up 4% of the infected 

population 

one community member. Seattle’s 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 arbiter’s 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 grantee’s housing plan. 

Consequently, the HOPWA grantee and the EMA coordinate closely to fill in gaps in 

housing services. 

Seattle’s 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 EMA’s 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 Mayor’s Division of NEwORLEANS
 EMA 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 mayor’s 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


citizens lives in poverty. New Orleans are injection drug users


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€
Sem”cesto 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 EMA’s 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 cityfunded program is providing case management services targeting African-Americans 

and Hispanics. 

New Services 

Among the other new services offered to clients since the EMA’s 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 care for HIV/AIDS patients beginningwith prevention and early detection 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 State’s 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€
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NEW YORK,


New YorkEMA Background 

The New York EMA includes New York 

City’s five boroughs and the Tri-County 

Region north of the city, comprised of 

Westchester, Putnam and Rockland 

Counties. New York City has about 96 

percent of the EMA’s AIDS cases. 

New York City faces myriad problems 

that compound the fight against 

HIV/AIDS. The city has large numbers 

of infected individuals who may be 

homeless, immigrants, tubercular, 

injection drug users, poor, mentally ill, 

non-English speaking, or prisoners. 

To address the epidemic in the New 

York Em HRSA awarded over 

$100,000,000 in Ryan White funds for 

1994. In addition, both New York City 

and New York State provide substantial 

funding for HIV/AIDS services. 

The New York City Department of 

Health is the Ryan White Title I 

grantee. The Department of Health has 

intergovernmental agreements with the 

three suburban counties to administer 

Title I funds. They also contract with 

the Medical and Health Research 

Association of New York City, Inc 

(MHRA), a private, non-profit 

organization, to administer the Title I 

program in New York City, and with the 

Westchester County Department of 

Health to administer the Title I program 

in the Tri-county region. 

Through New York’s contract with 

MH~ the EMA is able to bypass 

NEW YORK


NEw YORK EMA


cHARAcmRIsTIcs 

EMA population is 8.5 million 

New York City has 56,581 cumulative 

AIDS cases, 17% of the national total 

The New York EMA has 26% of the 

cumulative AIDS cases reported for the 

nation’s 34 EMAs 

There are 17,000 people living with AIDS 

in New York City 

Estimated New York City HIV/AIDS 

infection is 165,000; 1 person in 50 living 

in New York City is HIV-infected 

Between 30% and 40% of the city’s 

200,000 injection drug users are HIVinfected 

52% of New York City’s AIDS cases are 

associated with injection drug US%43’%o 

with homosexual activity 

18% of New York City’s AfDS cases are 

femaley 86% of these are either AfricanAmerican or Latina 

AIDS is the third leading cause of death 

in New York Ci~ in New York City, 

AIDS is the leading cause of death for 

those between the ages of 25 and 44 

One of four of the nation’s pediatric 

AIDS cases is in New York City 

Nearly 11,000 New York City children 

have been orphaned by AIDS 

There are 7 Ryan White Tkle II consortia 

serving New York City 

The Tri-county area of the EMA has 11% 

of the State’s population outside of New 

York Chy, but has 21$Z0of the State’s 

reported ADS cases outside of New York 

City 

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 EMA’s 45 member planning council serves at the invitation of the 

Mayor, and is chaired by the Mayor’s 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 council’s 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 State’s 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 State’s 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 York’s 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 

Rico’s 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. Communitybased 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 State’s Department of Health is the Title II grantee and 

oversees the Title 11consortia. Meetings between the managers of Title I and Title IIfunded 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 EMA’s consortia are 

represented on the planning council’s 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 York’s overwhelming numbers, mechanisms like the Title II AIDS 

networks contribute to New York’s 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

� 

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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 

Kansas City Health Department is the 

Title I grantee and also dispenses 

HOPWA funds. The Kansas City 

Health Department also serves as the 

lead agency for Missouri Title II. 

A case management contract with the 

State of Kansas formalizes EMA 

participation by the four Kansas 

counties. 

The EMA includes urban, suburban and 

rural communities, and they vary 

markedly. For example, the median 

household income for Wyandotte County 

is $23,780, barely half that of adjacent 

Johnson County at $42,741. Five of the 

eleven EMA counties have at least 10 

percent of households below the poverty 

level. Very few, about ten percent, of 

the Missouri persons with HIV/AIDS 

have private insurance. More than 46 

percent have no insurance, while the 

balance are Medicaid eligible. 

KANSASCITYElm cHARAcxEREmcs 

EMA population is 1.6 million 

Estimated HIV/AIDS infection is 8,400 

Most live in the Kansas City metropolitan 

area 

72% of the infected population is white, 

2270 is African-American, 3% is Hispanic, 

and the remainder is Native American, 

Asian American or no data is available on 

heritage 

Gay/bLsexual males make up 69% of the 

HIV/AIDS population 

6% are intravenous drug users, with 

another 8% are combining male to male 

sexual activity with injecting drug usage 

Heterosexual transmission represents 4% 

of the HIV/AIDS cases 

Women make up 7% of the EMA’s 

infected population and face the highest 

risk of infection through heterosexual 

transmission 

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 EMA’s 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 EMA’s activities. Sixteen subcommittees 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 EMA’s 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) bam”ersto carelcnminal justice systeq (7) minon’~ issues, (8) hospice, (9) foster 

careladoptio~ (10) buddy ~stq (11) advocaqy (12) infomafi”on 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 EMA’s 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 EMA’s 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 client’s 

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 client’s 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

LOS ANGELES, 

Los AngelesEM4 Background 

Los Angeles County is one of the largest 

and most racially, ethnically and 

culturally diverse local jurisdictions in the 

United States. The 1990 census data 

shows 41 percent Caucasian, 37 percent 

Latino, 11 percent African-American, 11 

percent Asian/Pacific Islander, 1 percent 

American and Alaskan Native. One of 

six people in the EMA lives below the 

Federal poverty level. One of seven 

receives some form of public assistance; 

1 of 6 is entitled to Medicaid; 1 of 3 

under the age of 65 has no health 

insurance. 

In FY 1993, Los Angeles received over 

$19 million in Title I funds, and $1.375 

million in Title 11monies. There are 

also five grantees in Los Angeles county 

who receive $1.5 million in Title III-B 

funds. Aside from Ryan White money, 

Los Angeles received over $80 million in 

other Federal funds, the majority of 

which came from AIDS research grants. 

In addition, Los Angeles received more 

than $26 million from the State and over 

$52 million from local funds. 

Los Angeles County is governed by a 

five-member Board of Supervisors. The 

Board designated the Los Angeles 

County Department of Health Services 

as the entity responsible for 

administering Ryan White Title I 

Formula and Supplemental Grants. 

CALIFORNIA


LOS ANGELEs Eh4A CHARACTERISTICS 

EMA population is 9 milIion 

EMA is over 4,000 square miles, and 

includes 88 cities 

There are over 27,000 confirmed AIDS 

cases in Los Angeles County, the 2nd 

largest Iocal caseload in the United States 

Estimated HIV/AIDS infection is 40,000 

to 51,000 

49%of the infected population is white, 

28% Latino, 20% African-American, 2% 

Asia@acific-Islander, and 1% American 

and Alaskan Native. In 1986, the rates 

were 70% white, 1570 Latino, 14$% 

African-American, 1% Asian/PacificIslander, and an unknown number of 

American and Alaskan native 

Gay/hi-sexual males comprise 72% of the 

HIV/AIDS population 

8% are injection drug users, with another 

6% combining male to male sexual activity 

with injecting drug usage 

Heterosexual transmission represents 3% 

of the HIV/AIDS cases 

Method of transmission is unknown for 

8% of the HIV/AIDS population 

As of November, 1994, there are 9,433 

living reported adult/adolescent AIDS 

cases and 373 living reported pediatric 

AIDS cases 

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-levelCoordination 

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€
� 

� 

� 

� 

� 

� 

� 

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BROWARD COUNTY, FLORIDA


BrowardCountyEM Background 

Ryan White Title I funds provide over 

$6,800,000 to the Broward County, 

Florida EMA. The Office of HIV/AIDS 

Support Services in Broward County’s 

Human Services Department administers 

Ryan White Title I as well as (HOPWA) 

grants from the Department of Housing 

and Urban Development. 

Broward County provides all the health 

and social service programs for Ryan 

White clients except those funded by the 

State. Consequently, no 

intergovernmental agreements between 

the EMA and the municipalities are 

required. 

There are 29 municipalities in the 

Broward County EMA, the largest being 

the city of Fort Lauderdale. Over 10 

percent of Broward County’s population 

falls under the Federal poverty level. 

There are several large concentrations of 

Haitian-Americans in Broward County. 

The BrowardCountyEMA Pkmning 

council 

Broward County’s Board of County 

Commissioners appoints the 30 member 

Broward County HIV Health Services 

Planning Council to serve indefinite 

BROWARD COUNTY EMA 

CHARACTERETICS 

EMA population is 1.3 million 

Estimated HIV/AIDS infection is 17,226 

44% are between the ages of 30-39, 23% 

are age 40-49, and 12% are older than 49 

African-Americans now make up 37% of 

the HIV/AIDS population, compared to 

30% in 1990, but comprise only 15% of 

Broward County’s population. White 

Angles represent 57% of the HIV/AIDS 

population, and Hispanics 6% 

Women comprise 17% of the HIV/AIDS 

population. Nearly 3/4 are AfricanAmerican 

Gay or bi-sexual males are more than half 

the HIV/AIDS population 

18% of the HIV/AIDS population are 

injection drug users, with another 6% 

combining male to male sexual activity 

with injecting drug usage 

Heterosexual transmission represents 6% 

of the HIV/AIDS cases 

Method of transmission is unknown for 

2% of the HIV/AIDS population 

There are 5,107 living reported 

adult/adokscent AIDS cases and 107 

living reported pediatric AIDS cases 

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 AfricanAmerican 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 children’s 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 EMA’s 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 Florida’s 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 Subcommittee 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 client’s name into the computer and get 

information. The food bank would have access only to the relevant part of that 

client’s 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, 

The City of Detroit Health Department 

(DHD) is the Title I grantee and is also 

the HOPWA grantee. The DHD has 

provided primary medical care services 

to a largely indigent population for more 

than 50 years. Their client population is 

90 percent minority. Over half of these 

have no health insurance; about 40 

percent are Medicaid eligible. 

Widespread poverty and chronic 

unemployment in the Detroit area 

compound the EMA’s responsibilities of 

providing primary medical care and 

psychosocial services to meet the needs 

of clients living with HIV/AIDS. In 

March of 1993, Detroit’s unemployment 

was 12.6 percent, nearly double the State 

jobless rate. 

Henry Ford Hospital and the Detroit 

Medical Center provide primary medical 

care to about 30 percent of the persons 

with HIV/AIDS. Community providers, 

private physicians and the Veterans 

Administration Hospitals treat another 

and St. Clair Counties, 

DETRoIT EMA CHAIUCXENSTICS 

� EMA population is 4.4 million 

�	 Estimated HIV/AIDS population is 

10,600. Of these 

b 63% live in Detroit 

+ 15% live in Oakland County 

b 14% live in Wayne County, 

outside of Detroit 

b 6% live in Macomb County 

b 25Z0live in Lapeer, Monroe 

or St. Clair Counties 

Q About 2/3 of HIV/AIDS population is 

African-American, about 1/3 white, about 

3% are of Latino, Arab-Caldean, Native 

American or Asian heritage 

Gay, hi-sexual males are almost half the 

HfV/AIDS population 

A third or more of the HIV/AIDS 

population are drug users 

Women comprise more than a fifth of the 

HIV/AIDS population; the majority are 

African-American 

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 

EMA’s 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 client’s neea3 and personal support systenw; 2) development of a comprehensive, individualized 

serviceplan; 3) coordination of servicesrequired to implement the plan; client monitoring to a.mx the eflcacy of the plan; and 4) 

petiodic re-evaluation and adaptation of the plan as necessary.” 

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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-levelCoordination 

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