OFFICE OF 

INSPECTOR GENERA 

THE RYAN WHITE CARE ACT: 

SPECIAL PROJECTS OF NATIONAL SIGNIFICANCE 
OFFICE OF INSPE(XOR 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 Setices, 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 services 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 

caqing 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 inspection was performed 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 the project were: 

CHICAGO HEADQUARTERS 

Barbara Butz (Project Leader) Alan S. Levine 

Jean DuFresne 

For a copy of this report, please call (312) 353-4124. 
Department of Health and Human Semites 

OFFICE OF 

INSPECTOR GENERAL 

THE RYAN WHITE CARE ACT:


SPECIAL PROJECTS OF NATIONAL SIGNIFICANCE 

SSWZC* 

�N + “%

E JUNE GIBBS BROWN 

3

s Inspector General 

‘% -g 

*baa APRIL 1994 

> OEI-05-93-00332 
TABLE OF CONTENTS


PAGE 

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...1


FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4


� SPNS Grantee Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4


�SPNS Expenditures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4


APPENDIX


fkSPNS Grantees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..+. ..A-l

INTRODUCTION


PURPOSE 

To describe grantee expenditures under the Ryan White Act’s Special Projects of 

National Significance. 

BACKGROUND 

On August 18, 1990, Congress passed Public Law 101-381 entitled The Ryan White 

Comprehensive AIDS Resources Emergency (CARE) Act of 1990 (the Act). The 

purpose of the Act was to provide “emergency assistance to localities disproportionately 

affected by the Human Immunodeficiency Virus (HIV) epidemic and to make financial 

assistance available to States and other public or private nonprofit entities to provide for 

the development, organization, coordination and operation of more effective and cost 

efficient systems for the delivery of essential services to individuals and families with HIV 

disease.” Congress funded the Ryan White Act at about $221 million for Fiscal Year 

(FY) 1991,$276 million for FY 1992, and $348 million for FY 1993. The FY 1994 

appropriation is $579.4 million. 

The Act, which is administered by the Health Resources Semites Administration 

(HRSA) within the Public Health Semite (PHS), 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 cities, or 

eligible metropolitan areas, disproportionately affected by the HIV epidemic. Title 11 

provides formula grants to States and territories to improve the quality, availability, and 

organization of health care and support semices for individuals and families with HIV 

disease. Title III(a), intended to provide formula grants to States for early intervention 

services on an outpatient basis, has not been funded to date. Title III(b) supports early 

intervention services on an out-patient basis, including counseling, testing, referrals, 

clinical and diagnostic services, and other thers pe utic services. Title IV was to provide 

demonstration grants for research and services for pediatric patients, and requires studies 

on partner notification and HIV disease in rural areas. Congress appropriated $22 

million for FY 1994 for existing HRSA pediatric and adolescent AIDS demonstration 

projects to be folded into Title IV. 

Suecial Proiects of National Simificance 

Up to 10 percent of funds appropriated for Title 11may be set aside for Special Projects 

of National Significance (SPNS) grants. The SP!4S grants are competitive grants to 

public and private nonprofit entities for special projects that advance knowledge and 

skills in the delivery of health and support sewices to persons with HIV or AIDS. 

Projects are also chosen for their potential for national replication and must include 

provisions for internal evaluation and dissemination of findings. Grants are provided on 

a 3-year cycle. 

1 
In FY 1991, Title II was funded at $88 million, and out of this, about $4.4 million went to


22 SPNS grantees with actual spending occurring in FY 1992.1 In FY 1992, $5.7 million


was appropriated for 26 SPNS projects to spend in FY 1993. The next year, the projects


were funded at $6.3 million. For FY 1994, nearly $11 million was appropriated for SPNS


grantees to spend in FY 1995. See Appendix A for a description of the 22 SPNS


projects funded in FY 1991 (1992).


Projects must target one of the following goals:


�� Improve access to health and support services through the reduction of 

sociocultural, financial and/or logistical barriers as especially experienced by rural 

residen~ wome~ childreq adolescen~ incarcerated persons, recently released 

inrnat+ American Indians and Alaska Natives. 

�� Provide advocq semices to ensure adequate, appropriate and timely receipt of 

health and support semices. 

� Reduce social isolation of people with HIV to improve their quality of life. 

�� Integrate mental health setices with primary care services to develop a 

comprehensive treatment regimen. 

Grantees submit annual reports which contain a description of the project’s progress in 

reaching the goal(s) and objectives stated in their management plan. The management 

plan is required as part of the grant application, and must describe measurable project 

objectives that specifically relate to the selected service goal (such as access), the 

project’s methodology, and the population to be served by the proposed project. The 

annual progress report must also include descriptions of any problems encountered, steps 

taken to remedy the problems, and any significant findings to date. Continuation funding 

decisions are based upon these reports. 

SCOPE AND M131’HODOLOGY 

The Ryan White Act will come up for reauthorization in FY 1996. This study is one in a 

series of studies on the implementation of the Ryan White Act which will provide 

information useful for the debate surrounding reauthorization. The other reports are: 

The Ryan White CARE Act: Funding Formulas 0E1-05-93-O0330€

l%e Ryan White CARE Act: FY 1992 Title I and Title II€

Expenditures By Sewice OEI-05-93-00331€

lThe meal year for regular Title II grantees begins in April following the beginning of the fiscal year. 

However, due to the competitive nature of the grants, SPNS grantees do not reeeive their awards until [he 

following October, creating a year delay in spending. This created some initial confusion in our requests for 

information from both HRSA and the grantees. However, appropriated IV 1991 funds were spent and 

reported on by the grantees as FY 1S92 funds, and are so regarded in this report. 

2 
i%e Ryan White CARE Act: Consorh”aActivities 0EI-05-93-O0333


l%e Ryan White CARE Act: Technical Repoti of W 1992€

Expenditures 0EI-05-03-O0334€

To obtain information regarding SPNS service category expenditures we used information 

in the “HRSA AIDS Activities” manual issued in December 1992, as well as grantee 

award and expenditure information given to us by HRSA. We also contacted some of 

the grantees for this information. 

This inspection was conducted in accordance with the Standardsfor Inspections issued by 

the President’s Council on Integrity and Efficiency. 

3€
FINDINGS


SPNS GRANTEE ACIWHTES 

The SPNS grant awards for FY 1992 ranged from about $112,000 to $275,000. The 

scope of the projects varied widely. For example, with a grant of approximately 

$142,000, one project recruited older women from the African-American communities in 

their city to volunteer as emotional support persons and network conveners for AfricanAmerican women with HIV disease. For about the same grant amount, another grantee 

conducted anti-discrimination activities by operating a hotline, developing multi-lingual 

brochures, developing a directory of resources and coordinating the activities of public 

and private agencies capable of addressing HIV discrimination. Several of the grantees 

focused on coordinating mental health services with primary care services, and one of the 

grantees tested a model for training members of minority populations as community 

health advisors in rural counties. 

Below are the SPNS service goals and target populations as served by the SPNS 

grantees:2 

Sexvice Goals 

access - 13 grantees;


advocacy seMces -6 grantees;


social isolation -5 grantees; and,


mental health -6 grantees.


Grantees include community based


departments (6), public or private


Target Pomdations


rural -3 grantees;


women - 3 grantees;


children - 3 grantees;


adolescents - 1 grantee;


prison inmates -2 grantees;


recently released inmates -3


Native Americans -1 grantee;


open population - 3 grantees.


grantees; 

and, 

service organizations (10), State and local health 

hospitals (3), institutions of higher education (2), and 

national service provider organizations (1). In terms of geographic distribution, 11 of the 

projects are located in the east, four each are located in the midwest and the south, and 

two are located in the west. One project is located in Puerto Rico. 

SPNS EXPENDITURES 

From the FY 1991 appropriation, HRSA granted $4.4 million to 22 SPNS grantees to 

spend in FY 1992. We found that the grantees actually spent $3.3 million, or 75 percent 

2The numbers of grantees add up to more than 22 because some projects address more than one service 

or population. 

4 
of the awarded money, leaving over $1 million to carry over into the next year. We 

divide expenditures into four broad categories: medical services, SUppOfi servi~$ 

pharrnaceutix and administration/pkmning and evaluation. The medical services and 

support services categories are comprised of a number of semices which are broken out 

in Table 1. Below, Figure 1 shows that 22 percent of the funds were spent on medical 

services, 65 percent went to support services, less than 1 percent went to 

pharmaceuticals, and at least 12 percent were expended on administration and planning 

and evaluation. 

It is important to keep in mind that due to the innovative natures of the SPNS grantees, 

actual services provided by the grantees may change from year to year. 

FY 1992 SPNS Expenditures 

Rgum 1 

- Servic-(6!5%) 

Medical Services (22%) 

AdmilJFlanning (12%) 

Table 1 breaks out SPNS grantee expenditures by actual service (as opposed to category 

or goal) provided. We obtained this information in two ways. First, if the SPNS project 

was specific in the service it provided, such as mental health counseling, we used 

information provided to us by HRSA. 

Second, if their activities involved more than one service, we contacted the grantees 

directly. The grantees we contacted were able to provide us with specific information to 

varying degrees. Some grantees could only describe general areas of expenditure while 

others provided specific amounts and services. For example, one grantee explained that 

costs for mental health counseling, outreach, and education/risk reduction, were all 

included under the heading “case management.” Also, in one case, the amount spent 

reported by the grantee did not match ~he amount given to us by HRSA. In this case we 

used the amount reported by the grantee as it was specifically broken down by service. 

5

SERVICES 

lvrAL 

Pharmaceutical 

Medical SeMces? 

Mental Health Treatment/ 

Therapy/Counseling 

Dental Care 

Medical Care 

supportseMceS 

Case Management 

0ther4 

Outreach 

Housing Assistance 

Education/Risk Reduction 

Other Counseling/Not Mental 

Health 

Transportation 

Client Advocacy 

Food Bank/Home Delivered 

Meals 

Emergency Financial Assistance 

~$ 

Administration 

Planning & Evaluation 

~ 

FY 1992 EXPEND. 

$3326,956 

S8Xi5 

$730Z18 

$712,123 

$15,575 

$2,520 

$2JW70 

$1,028,730 

$787,293 

!$239,095 

$37,925 

$22,588 

$19,121 

$17,004 

$9,561 

S5,935 

$5,118 

M15,983 

S32 1,936 

S94,047 

TOTAL 70 GRANTEES 

100%0 22 

* 2 

2270 

21% 6 

* 2 

* 1 

65% 

3170 9 

24940 7 

770 3 

170 1 

* 1 

* 1 

* 5 

* 1 

* 3 

* 1 

13% 

10% 22 

3% 3 

Table 1 

3This category presents dollars related to direct mcd u i services. For this reason, we place case 

management in “support setvices” rather than “reed ica1umms.= 

4Thme activities include anti-discrimination activll M. [hc dekclopment of support networks, and the 

training of cultural advisors. 

5For grantees that we did not directly contact, we assu mut 5 percent of funds were spent for administrate ion 

because the grantees we did contact often allocated signlfican[ly more than 5 percent to administration. 

According to HRS~ because of the innovative nature of I heir work, SPNS grantees are not held to the same 

5 percent cap as other grantees under Title II. Therefore, we believe 5 percent is a conservative estimate. We 

did not make the same 5 percent assumption for planning and CVJIuat ion, as these expenditures must be built 

into the project design. 

6 
APPENDIX A�

lHE SPNS GRANTEES: 

Arecii Municipal Government 

Arecii, Puerto Rico 

This project identifies women and children with HIV disease in five low-income housing 

projects, and attempts to improve their access to medical and psychosocial services 

through coordination with private and public agencies. 

Association for the Care of Children’s Health 

Bethes@ Maqdand 

This project assists communities to develop local family-to-family support networks in 

order to reduce isolation and increase social and emotional support for families affected 

by HIV disease. 

Chase-Brexton Cliniq Inc. 

Baltimore, Maryland 

The Chase-Brexton Clinic provides a basic mental health assessment for its HIV-infected 

clients and offers case management services to clients following the assessment. 

The Damien Center, Inc. 

Indianapol@ Indiana 

The Indiana HIV Advocacy Program attempts to increase access to care for HIVinfected people by eliminating the barrier of discrimination. To this end, the Advoca~ 

Program educates legislators and others about civil rights protection for HIV-infected 

persons, strengthens linkages between advocacy resources and creates new resources in 

targeted areas, uses the Indiana HIV Services Coalition to advocate for protection for 

HIV-infected persons, and maintains a data base of collected discrimination cases against 

HIV-infected persons. 

Family Planning Council of Southeastern Pennsylvania 

Philadelphi~ Pennsylvania 

The Inmates and AIDS Intervention Program assists HIV-infected inmates and their 

dependents receive care in the community after their release or parole. 

A-1

The Fortune Society, Inc. 

New Yorlq New York 

Through its ETHICS II program, The Fortune Society addresses the needs of recently 

released inmates with HIV disease. The goals are to train new staff to provide sefices 

including counseling, education, career development, court advocacy, and outpatient drug 

treatment. 

Henry Street Settlement 

New York New York 

The Henry Street Settlements’s Community Consultation Center (CCC) has developed 

the first school-based AIDS Bereavement Group for young children. Among other 

mental health semices, the CCC helps children whose parent has died from AIDS resolve 

emotional feelings and adjust after the parent’s death. 

Indiana State Board of Healt@ Acquired Disease Division 

Indianapol.@ Indiana 

The Indiana Integration of Care Project integrates mental 

health care of HIV-infected clients on a State-wide basis. 

system of comprehensive health care and human services 

system. 

Massachusetts AIDS DkriminationInitiatiw,Inc. 

hkwtoq Massachusetts 

health services with primary 

Referrals to a State-wide 

are enhanced by a voucher 

The Massachusetts AIDS Discrimination Initiative provides information through an 

AIDS discrimination hotline, multi-lingual brochures, and a directory of public and 

private resources to persons who experience HIV discrimination. The Initiative also 

documents the nature and scope of HIV discrimination, and coordinates activities of 

public and private agencies available to address HIV discrimination. 

Michigan Protection and Advocacy SeMces 

Lansii&Michigan 

The HIV/AIDS Advocacy Project provides legal education and advocacy services for 

persons with HIV disease to allow them to gain access to support services and medical 

care. 

Missouri Department of Heal@ Bureau of AIDS Prevention 

Jefferson City, Missouri 

This moiect

. . creates Rural Resource Centers (RRCS) to work with the established 

network of local community action agencies to provide a wide range of services for rural 

HIV/AIDS clients. The RRCS will provide information about support services available, 

A-2 
including emergency financial assistance and programs to finance dental and medical


care.


Montefiore Medical Center, Department of Family Medicine


Bromq New York


In three Montefiore Ambulatory Care Network sites, and through a Drug Abuse


Treatment Program, this project integrates an AIDS-related mental health service into its


primary care network. The mental health service provides culturally sensitive


psychosocial care to improve patients’ participation in medical and psychosocial regimens.


National Native American AIDS Prevention Center


Oaklan~ California


The National Native American AIDS Prevention Center operates community-based


programs in Tucson, Arizona and Oklahoma City, Oklahoma. The programs provide


case management and client advocacy services to increase access to care for Native


Americans with HIV disease.


New York University College of Dentistry	

New Yorlq New York	

The New York University Dental Center provides clinical outreach programs to adult 

women, adolescents, and children from social groups at high risk for HIV-infection. 

Dental screening and detection of various oral pathologies related to HIV-infection are 

provided as are routine and emergency dental care, and referral to other medical and 

social care. In addition to making care accessible to an often neglected segment of the 

HIV-infected population, the project educates dental students and increases their 

knowledge of and confidence about working with HIV-infected patients. 

North Carolina Department of Environrnen~ Heah@ and Natural Resources	

Raleig& North Carolina	

Project REACH (Rural Education, Advocacy and Care for HIV) trains members of 

minority populations as community health advisors in five rural counties. The advisors 

help community residents access local or regional services and overcome the barriers of 

transportation, confidentiality, geographic or social isolation, and stigmatization of people 

living with HIV. 

outreach Inc.	

Atlan@ Georgia	

Mothers Offering Mothers Support (MOMS) recruits older women to serve as support 

network conveners and emotional support persons for African American women with 

HIV disease. The program also gathers information from females with HIV disease, 

regarding access to care and support services. 

A-3 
Protection and Advocacy System	

Albuquerque, New Mexico	

The project is a State-wide effort to address discrimination issues in a largely rural State 

with significant minority populations. The project provides advocacy services to people 

with HIV/AIDS, and training to health care providers on advocacy and legal issues. 

Rhode Island State Department of Health, AIDSBI’D Division	

Providence, Rhode Island	

This project, in collaboration with the Rhode Island Department of Corrections, helps 

HIV-infected inmates access semices in the community upon their release. The program 

provides pre-release counseling, discharge planning, and follow-up monitoring, to ensure 

the continuity of medical semices and psychosocial care. 

St. Joseph’s Hospital and Medical Center	

Patersmq New Jersey	

The program provides mental health services to HIV patients receiving care the 

hospital’s primary care clinics. Each HIV patient receives a thorough mental health 

assessment and is assigned to the most appropriate treatment, including support services 

for the patient’s family and linkages to drug rehabilitation programs if necessary. 

Trustees of Health and Hospitals	

lbsto~ Massachusetts	

No One Alone with HIV (NOAH) is a hospital-based program designed to increase the 

sensitivity of primary care providers to the potential or actual mental health problems of 

HIV/AIDS patients. The program aims to increase the use of available mental health 

services and psychosocial support for HIV-infected patients and their families. 

University of Miami School of Medicine, Department of Obstetrics/Gynecology	

M* Florida	

Through home visits, the Transitional Advocacy for HIV-infected Women and their 

Children project provides information, support, and guidance to women newly informed 

that they have HIV-disease. Other assistance includes meal vouchers, transportation, 

pre-enrollment in the social service network, and other advocacy. 

Ware County Board of Health	

Waycr~ Georgia	

This project tests a model of establishing HIV wellness centers in five counties to provide 

early medical and social services for rural people with HIV/AIDS. Case management is 

used to overcome barriers to care such as isolation, poverty, transportation, and limited 

health resources. 

A-4