SCHA-LA

Residential Services: Future Direction (Mario Perez)

Posted in Uncategorized by SCHA-LA on January 14, 2010

notes to accompany the powerpoint (which I will try to get and post) Mario J Perez, Director Office of AIDS Programs & Policies, and Carlos A Vega-Matos, Clinical Enhancement Services Division

LA County Residential/Housing Investment

  • OAPP $7,051,034
  • HOPWA $14,788,755
  • TOTAL: $21,839,789

These are 2 very distinct service categories. Discreet, separate portfolios.

OAPP RCS Portfolio:

  • emergency housing $271,711
  • transitional housing $210,347
  • RCFCI $4,868,185 [residential facilities for the chronically ill] spread out geographically, distribution based on where they were able to obtain and license services, not on the geographic distribution of need.
  • ARF $1,047,049 [adult residential facilities]
  • Skilled Nursing $583,542 [1 provider]
  • Hospice $70,200 [1 provider]
  • TOTAL: $7,051,034

Looks like this:

  • 4 agencies provide EMERGENCY HOUSING – 18 beds for 216 clients
  • 3 agencies provide TRANSITIONAL HOUSING – 20 beds for 135 clients
  • 4 agencies provide RCFCI – 99 beds for 231 clients
  • 2 agencies provide ARF – 1,621 days of service for 4 clients
  • 1 agency provides HOSPICE – 234 days for 2 clients

Issues/Challenges:

  • OAPP/HOPWA overlap [emergency/transitional]
  • regulations, standards, services out of sync with changes in disease progression
  • matching actual need with level of services provided
  • inadequate incentives for self-sufficiency

Proposed Changes:

  • reduce overall OAPP investment to $5,420,660 [$1.6m savings]
  • sunset OAPP investment to emergency & transitional housing
  • reconfigure ARF in to a transitional group home
  • tighten eligibility requirements (Karnofsky used now, Global Assessment of Functioning (GAF) added to assessment)
  • set time-limits: RCFCI 24 mo, TARF 12 mo [some of this is to get “in step” with federal requirements, ie: time limits]
  • reduce # of RCFCI beds from 99 to 80

we have created an environment in which folks who don’t have critical need are receiving a level of service which is unnecessary. to the extent that  we can get folks healthier, stabler, employed, moving along the self-sufficiency continuum, but the incentives aren’t’ there to make that happen.

will lean on HOPWA partners to ensure that the shift is as seamless as possible.

these changes will result in a decreased investment of $1.6million. held off on doing this sooner to ensure that this can be done in a way that doesn’t unduly impact housing of clients.

there will be exception clauses built in to all of this. “Doctor’s note” requesting an exception if client doesn’t move along continuum.

will sunset emergency/transitional in the next month. ask the Board Of Supervisors (BOS) for extension until the RFP is released with new modifications. Need to make sure that Title II is adjusted (federal guidelines will trump the state guidelines), standards of care are approved and in place etc.

Q & A:

$14.8 HOPWA  that $ also includes some rollover money and money that came from LAHD. Actually, that money includes housing, beds, permanent, supportive services incl food, legal, CHIRP, development etc. That year approx $1.8m spent on development. With the new funding year, looking at re-examining programs in order to accommodate OAPP’s needs. [HOPWA FY is 4/1 – 3/31]

Q: how was information gathered re SNF? We get many calls per month, so confused that the number of SNF/hospice clients is 4.There is a lot of discrimination at facilities not funded by us.

A: worked with current provider who delivers SNF & hospice. staff pulled charts. there was no change in SNF/hospice. We are not the only funder. Some get hospice care at home. the rfp will look at whether services can be provided in a more cost-effective way (at home) or does it have to be funded only in an agency setting. They are $300/day – 2 most expensive services. May be able to reduce costs if people have homes.

Q. incentives/motivation for changes – questions about. also, measuring acuity with K & GAF. concerned that our doctors might move us on karnofsky and take us off the next month. will the GAF catch moderation if it is being monitored quarterly?

A. GAF will also be done quarterly. we understand that there might be difficult months and the karnofsky score might be lower, and then a month later it may go up. Do understand that it fluctuates. fairly trustworthy gauge to determine numberof hours of support needed. Karnofsky good to measure daily living function. If client has mental health or other issues the GAF can catch non-HIV-specific issues. HIV may not be the debilitating factor – it may be depression – but we will be able to see that with the GAF.

Q. Might there be higher utilization of service?

A. there might be fewer people eligible, but more people served.

Q. Is this for undocumented people as well?

A. yes. Anyone in LA County who meets eligibility requirements, regardless of documentation status. Individual providers assess eligibility. OAPP doesn’t do that. It is the providers who manage the services who do all of the eligibility-related expectations. Physician determines whether person is eligible for either skilled nursing or hospice.

Q. Is this for undocumented people as well?

A. yes

“The truth of the matter is that RCFCI has become a very, very expensive permanent housing program. Whatever needs to happen in order for that to be fixed needs to happen. We need to be real about what’s going on in this housing”.

“we need to massage some of [the] expectations between now and the release of the rfp …  staffing patterns, assessment requirements”. There are professionals besides a physician who can do the Karnofsky scoring.

Q: “without talking about what’s going into the rfp… are you looking to have a system that serves about the same number of people? in terms of numbers themselves.

A: The goal is to serve a greater number of unduplicated people living with hiv who are sick and in need of assisted living.

Richard Kearns: “I live in assisted living. Those institutions are rife with mismanagement and abuse. All they’re interested in is billing. They resist letting us in there. I had to call a lot of places to find an assisted care. Because they do stuff for me, I am able to be an advocate. … Activism is healthcare. … HIV is not a steady state.  … They don’t want clients who are “too alert” to let them not provide the services they are supposed to provide.”

Sharon White: “As chair of SPN in SPA 6, I want to talk about the incarceration issue. Please form some small commission where we can do due diligence before the inmates come out. … in SPA 6 we know there are a lot of african-americans and latinos who are incarcerated. we have 1 case manager and over 100 people on our case management roster. we need to be in front of this not behind it.”

Kathy Watt: “many times, they have managed to not do drugs & alcohol while they are incarcerated. they come out with 2/4/6 years of being clean. so when they try to access CD treatment they are denied. they don’t have a support network. we must work with ADPA on this, to help providers know that having X amount of clean time should not preclude them from treatment.”

HIV Commission will look at forming a group and will get Sharon to sit on it.

HIV $ Allocations in LA County

Posted in Uncategorized by SCHA-LA on January 14, 2010

notes from the Priorities and Planning subcommittee of the LA County HIV Commission.

Vote to accept the recommendations: unanimous approval

P&P Committee

Proposing provisions to year 20 (FY2010) allocations.

4 sets of allocations in past 12 months

Year 19 allocations: part A, part B very straightforward, simple. Then we started having budget crises. Nothing was decided, but we started to plan Y20 allocations – before we did the Y19 allocations. Then we had to revise Y19 b/c the state budget, last summer hit “and life changed as we knew it”

Now, faced with Y20 revisions. To conform changes in pieces which shifted.

Going to be dealing in percentages rather than dollars. The amount of $ in the pot has shifted dramatically. percentages shift. Committee attempts to stabilize things. Didn’t want to make new allocations, but rather make current allocations conform to existing situation. (categories lost – didn’t want to start allocating to again, so some changes).

Historically, part B come from state. Now state uses Single Allocation Model (SAM). Took a bunch of money. Actually more than part B alone to LA County. Looked like an increase. We could locally decide where this $ would best be suited. Good for LA County. With this model, they also eliminated direct $ agencies. LAC had to back-fill these programs.

Used to only deal with percentage allocations (as opposed to actual dollars). Now looking at actual dollar mounts. Allocated a “threshold” dollar amount.

Now back to percentages to aid OAPP in allocation.

In committee we translated % to $ and then added $ to the state. Considered additional funding/service obligations (formerly direct-funded by state which we had to back-fill/assume responsibility for). Then initially allocated by $ amounts, but then converted allocations back to percentages.

Recommendations:

Early Intervention Services: increase allocation from 0% to 3.2%. brings more HIV+ into medical care. Focus on unmet need (HRSA push), assumes commitments previously funded by the state.

Medical Outpatient: reduced from 59.5% to 58.5%. while % allocation decreased, $  allocation rose from $21m to $23m. allocation recognizes that there are additional tx, adherence, counseling, nutrition screening and TMP. Removes ‘threshold’ requirement

Medical Transportation: reduced from 2.7% to 1.7%. OAPP revising service guidelines and distributing bus passes only through medical providers.

Nutrition Therapy: reduced from 1% to 0%. Conforming to existing allocation level

Case Management Home Based: reduce from 1% to 0.8%. service previously directly state funded. OAPP using Net County Costs (NCC) to partially back-fill reductions. Allocation seeks to ID single stream of funding for the service.

Slides with all allocations available.

Many changes had to do with the “pie” changing, not the Commission wanting to make changes. Had we kept the same percentages, some programs would have been crippled beyond being about to perform.

This process used to be a once-a-year process. This is the 4th time it’s happened this year.

“We’re not moving forward as if anything has roots”.

There will be another revision in March once we have the award and know what we are actually dealing with.

In August when the plan was approved, it was not approved in percentages. We had to do the work in dollars to make it understandable, then convert it back to percentages to be in line with what was approved. Continuity.

Committee has no authority over NCC, but recommend to OAPP, and receive feedback that this is okay. (eg: home-based case management services).

The money we allocate is Part A & Part B.

Q: Residential & transitional housing should be a higher priority. Why is it 0%?

A: That’s how the priorities and percentages fell out in committee. Also, we know all of the other funding stream for programs. If there is another funding stream, we use our money where there is not other funding. Also, some priorities are unfundable through Ryan White (ie: permanent housing)

re: Home-based case managment: OAPP has been looking “very critically” at this service category. Medi-Cal waiver program, former state direct investment, OAPP investment. When state transitioned to SAM it left providers hanging and there was some re-commitment of $ by the state to allow providers to get through transition period. overall, the ctegory took a $2m cut on paper before the $1m 4-month back-fill by the state. Last year there was $1m less for this category, and this year we expect a $2m reduction to home-based. we do not expect to adjust our investment to home-based. All that is remaining is medi-cal waiver revenue and OAPP. there is an “impressive case load”. There is no guarantee that this will be the funding level starting July 1. Looking at making “refinements” (eligibility etc) as cost-saving to ensure that the category is of most benefit to most people.

Budget Analysis Slides

Posted in CA Budget by SCHA-LA on January 14, 2010

Pres-State 2010 Budget Cuts Overview-011410 Julie Cross gave an excellent overview of what is going on with the budget, and the complex context in which we have to strategize.

Tagged with: ,