Comprehensive Services Plan
2012 – 2015
Amber Alvarez, M.A.
Brazos Valley Council of Governments
HIV Administrative Services
Phone: 979.595.2801 ext. 2224 or 866.841.7288
Without the contributions of many people and groups, this plan would not be possible. Thank you to the staff at the Brazos Valley Council of Governments HIV Administrative Services, whose insights and analysis helped to shape the goals and objectives of the plan. Thanks are also extended to the subcontracted agencies of BVCOG and their directors and staff, who provided valuable information on care system characteristics, needs, and resources in their respective areas. Lastly, BVCOG HIV Administrative Services expresses gratitude to the consumers and community members who voluntarily contributed their experiences and time in the community input process to ensure this plan reflects the needs and voices of people living with HIV/AIDS in the Central Texas HIV/AIDS Service Area.
TABLE OF CONTENTS Executive Summary 1
Section 1: Where Are We Now: What is Our Current System of Care? 5
Population Description 5
Summary of PLWHA in the CTHASA 5
Current Population Served 7
Summary of PLWHA Population Out of Care 7 Most Recent Needs Assessment 10
Participant Profile 10
Needs Assessment Summary/Findings 11
Service Category Rankings and Explanation13
Unmet Need Estimates 16
Out-of-Care Respondents 17
Gaps in Care Services19
Barriers to Care Services19
Prevention Needs21 Summary of Current Care Resources 22
Austin HSDA 22
Bryan – College Station HSDA23
Concho Plateau HSDA 25
Temple – Killeen HSDA25
Waco HSDA 26
The Current Care System29
Service Category Rankings and Explanation
Services Currently Available
Access Points and Process 29
Monitoring and Evaluation Procedures 32 Section 2: Where Do We Need To Go: What System of Care Do We Need? 33
Section 3: How Will We Get There: How Does Our System Need To Change
To Assure Availability of, and Accessibility to, Core Services? 34
Section 4: How Will We Monitor Our Progress: How Will We Evaluate Our
Progress In Meeting Our Short and Long Term Goals? 39
Appendix A: Counties in the Planning Area 40
Appendix B: Performance Measures 41
Appendix C: FY2012 Allocations for RW-B and SS 42
Appendix D: Services by HSDA and Funding Status 47
Appendix E: Ryan White Part B Contracted Providers Service
Executive Summary Content and Focus of the Plan As part of the Ryan White HIV/AIDS Treatment Extension Act of 2009, grantees must complete a comprehensive services plan. For the State of Texas under Ryan White Part B, each planning area must submit a comprehensive services plan to the Texas Department of State Health Services (DSHS). This plan is viewed not as a condition of participation, or requirement, but is written as a form of strategic plan for the Brazos Valley Council of Governments HIV Administrative Services (BVCOG). This plan details the system of care and support, problems present in the system, and strategies to address the problems for the 43 county Central Texas HIV/AIDS Administrative Service Area (CTHASA). This plan covers a three year project period, April 1, 2012 to March 31, 2015.
Section One asks the question, “Where Are We Now: What Is Our Current System Of
Care?” This section includes descriptions of the HIV/AIDS population in the CTHASA, a summary of the most recent needs assessment findings and activities, current care resources in the planning area, and entry/access points to care.
The Central Texas HIV Administrative Service Area is comprised of five health service delivery areas (HSDAs). The 10-county Austin HSDA also contains the Austin TGA, a Ryan White Part A and C grantee. Over 75% of all people living with HIV/AIDS in the CTHASA reside in the Austin TGA. The four other HSDAs are often referred to as the rural HSDAs, each with one or two hub cities, while Austin is considered a major metropolitan area. As of December 31, 2010, there were 2,531 people living with HIV cases and another 3,269 living with AIDS in the planning area. Of those that are infected, DSHS estimates 1,604 people (858 HIV and 746 AIDS) are considered out-of-care.
To evaluate the needs of people living with HIV/AIDS in central Texas, a comprehensive needs assessment was conducted in the planning area in late 2009. Overall, 230 people were surveyed, with representation from each HSDA mirroring that HSDAs proportion of clients in the CTHASA. Of those surveyed, 57% said they needed health insurance and did not have the need met, 61% said they needed emergency financial assistance and the need was not met, and 62% said they needed oral health care and the need was not met. A small number of other services were noted as needed but the need not being met; this, along with other identified gaps and barriers to care, is explored more in depth in the assessment findings portion of this plan. BVCOG is also collaborating with the Ryan White Part A administrative agent and the Austin Area Comprehensive Planning Council to conduct a targeted needs assessment of traditionally unfunded/underfunded services in the Austin TGA/HSDA. Among the service categories being examined are transportation, both in rural and urban areas, as well as childcare assistance.
A brief summary of resources in the planning area is in the latter half of Section One. The processes for accessing the care system, its components, and entry points are also detailed in the last part of Section One.
Section Two asks, “Where Do We Need To Go: What System of Care Do We Need?” The mission, vision and values of BVCOG HIV/Health Services, needs assessment data, and feedback from providers, clients and community members have all shaped our conceptualization of what the future state of the Ryan White care system should look like in the CTHASA. This section describes the improved system of care we envision.
The Brazos Valley Council of Governments HIV Administrative Services plans for the use of and administers funds to provide access to quality medical and social services for anyone living with HIV/AIDS in the Central Texas HIV/AIDS Administrative Service Area.
The Brazos Valley Council of Governments HIV Administrative Services will be the premier administrative agency that is forward looking and innovative, and constantly improving the system of care in our responsibility.
The values that guide our practices and decisions include data and science based decision making; use of evidence based best practices; a willingness to innovate; to not shy away from difficult changes or challenges; a desire to provide high quality services as defined by professional and clinical organizations; a belief in continuous quality improvement; planning for the future and agilely responding to change; ethics; compassion; and the voice of the client/patient.
Based upon the findings from the needs assessment, the resources available, our current care system, and the epidemiology, four broad goals were identified:
Increase access to services through expansion of services and reduction of barriers
Improve the quality of services provided
Improve the care system through better planning and administration
Equip the care system to articulate with the changing nature of healthcare at national, state and local levels
Section Three provides the goals and objectives of this plan, answering the question, “How Will We Get There: How Does Our System Need to Change to Assure Availability of and Accessibility to Core Services?” Findings from the needs assessments and other information in Section One shaped the goals and objectives; plans for meeting these goals and objectives over the next three years that will move us toward the system of care are envisioned in Section Two. These goals include reducing the number of out of care PLWHA in each HSDA; increasing client receipt and agency tracking of preventive vaccinations and screenings; supporting client self-advocacy; and preparing agencies for health care reform and the changes the Affordable Care Act will bring to the CTHASA.
Section Four describes, in brief, how we will monitor our progress toward the envisioned system of care. Traditional clinical and programmatic monitoring of contracted providers will allow us to assess our progress towards the goals outlined in the plan., while client satisfaction surveys and monthly monitoring of expenditures and utilization of services will further our understanding of how far we have come in achieving our goals. Quarterly monitoring of goal-specific data and feedback, project matrices, and yearly reports to DSHS and all interested parties will also assist us in monitoring our progress and improving the overall system of care.
In sum, this comprehensive plan provides a framework for establishing and monitoring (1.) where we are now, (2.) where we want to go, (3.) how we will get there, and (4.) how we will know we are getting there. Once the three year planning cycle is complete, the process will begin anew, starting April 1, 2015.
Development of the Plan Developing this comprehensive services plan utilized various methods of input, the first of which was town hall meetings with PLWHA and others interested in HIV/AIDS community planning. In 2011, the BVCOG Planner conducted town hall meetings in the Bryan – College Station, Concho Plateau, Temple – Killeen, and Waco health service delivery areas (HSDA). Input from the Austin HSDA was obtained through recommendations from the Austin Area Comprehensive HIV Planning Council, a Part A grantee, and public comment regularly provided at planning council meetings.
Participants at the town hall meetings were presented with major findings from the needs assessment, the methodology for setting service category priorities and allocations, and the proposed goals and objectives in the comprehensive plan. Participants were then invited to discuss the proposals and offer suggestions for alternative methods of setting priorities and allocations, suggesting different contingency plans for increased or decreased allocations, and other goals and objectives. Each town hall meeting began a 30-day comment period, during which anyone could contact the BVCOG Planner by mail, email, phone (toll-free), or fax.
In 2012, the new BVCOG Planner began scheduling community input meetings to gain client and community perspectives on allocations, service system improvement goals, and emerging needs and trends. The first of these meetings was scheduled April 25, 2012 in the Bryan-College Station HSDA. Clients that have indicated they are willing to receive mail from their service provider were mailed a flyer two weeks prior to the community input meeting, informing them of the meeting and encouraging them to attend in order to ensure the proposed comprehensive plan reflects their needs, values and perspectives. Clients who are primarily Spanish speaking were sent a Spanish copy of the allocations for the Bryan-College HSDA and a flyer inviting the clients to call a Spanish speaking BVCOG employee to provide feedback as well. As community input meetings are held throughout the 2012-2013 fiscal year, the BVCOG Planner will update this plan accordingly, both with DSHS and on the BVCOG-HIV website.
Ryan White Reauthorization Reauthorization of the Ryan White Treatment Extension Act of 2009 is anticipated in 2013. The 2014 update of this comprehensive plan will incorporate any changes necessary in response to the reauthorization.
Limitations The community planning process is not an exact science, and limitations surface particularly with regard to data collection and the extent to which it may be generalized to the entire PLWHA population. The HIV/AIDS services allocation process is a lower form of actuarial work, estimating the needs of the population as well as the cost of providing services.
Limitations in data gathering for the needs assessment are discussed in Section One in the summary of the most recent needs assessment. Of the clients that participated in the needs assessment, only two reported not currently being in care. For this reason, the needs assessment findings may not be generalized to the out of care population in the administrative service area. This limitation also informed the development of the first goal in Section Three: reducing the number of out of care PLWHA in each HSDA.
Implementation Prior to implementation of this plan, a comment period was opened from April 25, 2012 to May 20, 2012 to allow a last chance for input. Suggestions offered were evaluated according to the criteria in the community input plan and adjustments made accordingly. Community input meetings in all five HSDAs of the CTHASA will be conducted to inform the communities this plan serves and to provide community input for the 2013 update of this plan.
Section 1: Where Are We Now: What is Our Current System of Care? Population Description Population Description: Summary of PLWHA in the CTHASA As of December 31, 2010, there are 2,531 living HIV cases and 3,269 living AIDS cases in the Central Texas HIV/AIDS Service Area (CTHASA). Of these 5,800 individuals, 80.66% (4678) are male while 19.34% are female. Additional data describing the demographic composition of people living with HIV/AIDS (PLWHA) in the CTHASA are best displayed in table format. The following tables were created using data extracted from the Enhanced HIV/AIDS Reporting System (eHARS) database and Texas State Data Center population estimates as presented in the Texas Department of State Health Services (DSHS) 2010 Texas Integrated Epidemiologic Profile for HIV/AIDS Prevention and Services Planning. The data reflect HIV/AIDS infection cases in the Central Texas HIV Administrative Service Area through December 31, 2010.
Age in 2010
13 to 24
25 to 34
35 to 44
45 to 54
55 & up
Though the 35-44 age group contained the highest percentage of people living with HIV in the CTHASA as recently as 2008, the 45-54 age group has grown rapidly since the last comprehensive plan, and now compromises the highest percentage of PLWHA. In part, this shift reflects the success of statewide and local initiatives to increase adherence to treatment, as more PLWHA are living longer with the disease. Along with the rest of the nation, the CTHASA is facing an aging population with HIV/AIDS, and must be flexible in order to develop a system of care that best serves clients of all ages.
Race – Ethnicity
Race / Ethnicity
The racial/ethnic composition of PLWHA within the CTHASA mirrors the epidemiologic profile seen in much of the rest of Texas, in that the highest proportion of PLWHA racially/ethnically identify as White. However, 38.8% of PLWHA in the state of Texas racially/ethnically identify as Hispanic and 11.5% as Black, whereas CTHASA percentages reflect a higher proportion of PLWHA racially/ethnically identified as Black, and a lower percentage of PLWHA racially/ethnically identified as Hispanic. This should not mask the fact that the proportion of Hispanic individuals with HIV/AIDS has steadily increased in the past several years from 19% (1,028 PLWHA) in 2005, to 23% (1,300 PLWHA) in 2008, to 24% (1,401 PLWHA) in 2010. As it is well documented that Hispanic individuals (particularly Hispanic men) are more often diagnosed at later disease stages and less likely to engage in care, greater attention should be directed toward prevention and care among this group.1
MSM / IDU
The risk category proportions for PLWHA in the CTHASA closely reflect the state of the epidemic seen in the rest of Texas. Men who have sex with men (MSM) account for the highest percentage, followed by individuals exposed through heterosexual contact, intravenous drug use (IDU), combined MSM/IDU, and perinatal modes of exposure. MSM historically account for the largest portion of PLWHA in the CTHASA, though the steady percentage of reported IDU transmission and the increase in reported heterosexual transmission should not be overlooked in the planning process, as intravenous drug users have consistently been at higher risk for being out of care, and heterosexual transmission is the primary route of exposure for women.
Population Description: Current Population Served The following data represent the current population served in the CTHASA for all Ryan White and State Services contracts reported in the AIDS Regional Information and Evaluation System (ARIES). Presenting data with the populations served under Ryan White Part A and Part C funding removed would depict accomplishments under BVCOG HIV Service’s funding streams (Ryan White Part B and State Services), but would not give a full picture of the entire population served in the planning area.
During the 2011 Ryan White Part B year (April 1, 2011 – March 31, 2012), 3,815 clients were served, 65.78% of all diagnosed PLWHA in the CTHASA. About 43% of clients are in the 25-44 age group, with an additional 48.62% in the 45-64 age group. The age distribution mirrors that of the nation; as a result of more effective treatment methods and the increasing duration of the epidemic, the population living with HIV/AIDS is growing older. Males make up 77.35% of clients, females 21.65%, and individuals who identify in ARIES as transgendered make up an even 1%. Non-Hispanic Whites are 39.55% of clients, African Americans 30.22%, Hispanics 28.49%, and other (Asian, American Indian, Alaskan Native, Hawaiian native, or Pacific Islander, Multi-racial, and Other) are 1.73% of clients. Changes in the racial and ethnic make-up of the CTHASA client population are similar to that in the State of Texas as a whole.
During the same time period, clients received 80,006 units of case management (medical and non-medical), totaling nearly 16,001 hours of service. Federal and state HIV care services funding enabled subcontractors to provide over 29,633 units of outpatient ambulatory medical care, 4,995 dental visits, 4,157 mental health visits, and fill 33,959 prescriptions. These totals are just from what is attributed to HOPWA, all Parts of Ryan White, and State Services funds; additional services were made possible through agencies’ donor funds, private insurance, and patient assistance programs.
POPULATION DESCRIPTION: Summary of PLWHA Population Out of Care The Health Resources and Services Administration (HRSA) defines an individual as being out of care/having unmet need if that individual is HIV positive, knows his or her status and is not engaged in primary medical care (CD4, viral load test or filled an anti-retroviral prescription) in a 12 month period.2 The Texas Department of State Health Services (DSHS) follows more rigorous criteria: “A person living with HIV is said to have unmet need for medical care [out of care] if there is no evidence of a CD4 count, a viral load test, antiretroviral therapy or an outpatient/ambulatory medical care visit during a defined 12 month period.”3 These criteria are fairly broad, and do not necessarily reflect adherence to treatment. Rather, the out of care criteria are most useful for analyzing the extent to which PLWHA are engaged in regular contact with the care system. The table below depicts the distribution of out of care PLWHA in the CTHASA by risk and demographic categories, using DSHS data and DSHS criteria for unmet need of care. These data are current through December 31, 2010, and were obtained from eHARS.
Unmet Need in CTHASA
Total CTHASA PLWHA Population
(Unmet Need + Met Need)
The CTHASA presently has an estimated out of care percentage of 27.66. Overall, males tend to share the highest burden of unmet need, about 83%. This corresponds with the gendered distribution of HIV/AIDS in the CTHASA (about 81% of all PLWHA in the CTHASA are male). Whites also tend to have the highest out of care rates, corresponding with the racial/ethnic distribution of HIV/AIDS. Overall, African Americans appear to have a slightly lower rate of unmet need, while Hispanic individuals have a slightly higher out of care rate than the racial/ethnic distribution of the disease would suggest. However, 2009 data reveal that, among MSM (the risk category with the highest percentage of PLWHA in the CTHASA), African Americans have a higher out of care rate. The same dataset shows the highest percentage of unmet need for IDU is among Hispanic individuals. It is essential to note that out of care estimations only address PLWHA who are aware of their positive status. This means that the number and demographic composition of individuals living in the CTHASA who are not aware of their positivity and are subsequently not engaged in care is less certain. The age group with the highest percentage is the 45-54 years of age group, which may be attributable to the overall aging of the PLWHA population in central Texas.
The statewide percentage of individuals with unmet need for care is 33%. This has dropped from 38.6% in 2009 because, as the total number of PLWHA in Texas has increased, the out of care population remained stable. Additionally, DSHS began requiring reporting of undetectable viral loads and all CD4 tests in 2010, which increased the number of PLWHA in Texas recorded as having met need for care. Though unmet need in both the Concho Plateau and Temple-Killeen HSDAs is above this new percentage, the overall number and percentage of individuals who are out of care has decreased since 2009 in every HSDA in the CTHASA.
The Austin HSDA currently has the lowest out of care rate at 25%. This is attributable to a number of factors beyond state-level changes in viral load and CD4 test reporting requirements. The Austin HSDA contains the Austin Transitional Grant Area (TGA), five counties surrounding the city of Austin that receive Ryan White Part A and Minority AIDS Initiative (MAI) funding. BVCOG currently funds five agencies in the Austin HSDA, all of which also receive funding through Ryan White Part A. As shown in the section on access points and processes in the current care system, this broad provider network offers multiple avenues for clients to enter or return to care. The Austin TGA Return to Care Collaborative has been successful identifying and contacting clients who are currently out of care. Another unique feature of this HSDA that contributes to the lower out of care rate is that the TGA receives HRSA funding specifically for Outreach to individuals who are not aware of their HIV status, or are aware, but have fallen out of care.
Compared to the other four HSDAs, the Temple-Killeen HSDA has consistently had the highest percentage of unmet need for care. This HSDA faces many unique challenges that make reducing the out of care rate a particularly complex challenge. BVCOG funds only one provider in the HSDA that is diligent in following up with clients to ensure retention in care. The Temple-Killeen receives no direct medical funding from Ryan White as a local multi-specialty medical center generally fulfills client primary medical and HIV care needs. The presence of Fort Hood, one of the largest U.S. military bases, and Darnall Army Community Hospital may artificially inflate the number of Temple-Killeen HSDA residents who are presently out of care. It is uncertain whether Darnall Army Community Hospital conducts viral load and CD4 testing on site or through an external laboratory, which may affect the way these tests are reported. Given the current care resources in the area, it is expected that the out of care population in the Temple/Killeen HSDA would be similar to that of the Waco HSDA if unmet need calculations do not currently account for individuals receiving care and lab services through the military healthcare system. The BVCOG Planner is currently investigating the CD4/viral load testing and reporting procedures in this HSDA’s military healthcare system and will report findings on this matter in the 2013 update of this document.
Most Recent Needs Assessments In the fall of 2009, the Brazos Valley Council of Governments contracted with the Center for Community Health Development (CCHD) at the Texas A&M Health Science Center School of Rural Public Health to conduct a client level comprehensive needs assessment in the Central Texas HIV Administrative Service Area (CTHASA). A total of 642 survey recruitment packets were sent out, with 275 respondents; 71 from the Austin HSDA, 45 from the Bryan/College Station HSDA, 14 from the Concho Plateau HSDA, 48 from the Temple/Killeen HSDA, and 52 from the Waco HSDA. The overall response rate for the needs assessment was 43%. Though not presented in this Comprehensive Plan, the Austin Area Comprehensive HIV Planning Council (Part A) also conducted a separate needs assessment of the Austin Transitional Grant Area in winter 2009.
Participants were recruited from a query of clients who had received at least one BVCOG-funded service in the preceding 12 months, and who were willing to receive mail as identified in ARIES. The initial mailing contained a letter from the client’s case management agency, a letter from the CCHD, and a consent form. To participate, clients mailed the consent form in a self addressed stamped envelope to the CCHD, and were either contacted by phone or called the CCHD themselves. Those who participated received a $20 gift card to Wal-Mart.
The survey tool used in this needs assessment was a revision of a version used in 2006, based on the Statewide Coordinated Statement of Need Document.
The most recent directed needs assessment activity in the CTHASA is series of surveys and focus groups that the BVCOG Planner facilitated in collaboration with the Austin Area Comprehensive Planning Council in March 2012. The aim of this on-going study is to quantify and describe the need for historically unfunded and underfunded service categories in the Part A Austin TGA and the Part B Austin HSDA. The first two categories to be examined are transportation and childcare services, with other service categories such as linguistic and legal services also being investigated.
The need for transportation assistance is well documented in this HSDA, but the extent to which current funding is adequately applied to meet the unique needs of both urban and rural clients less certain. Part A currently offers bus passes and taxi vouchers through its sub-grantees. BVCOG funds one rural provider and recently one urban Federally Qualified Health Center (FHQC) to provide transportation assistance. For urban clients, considerable changes in the public transit system necessitate a renewed coordinated response from all Ryan White grantees, while many rural clients continue to require transportation assistance to meet nearly all HIV-related medical needs. As there is no Ryan White Part D grantee in central Texas, evaluation of clients’ current ability to negotiate childcare and the potential of caring for children as a barrier to accessing medical and support services is vital. Findings from this directed needs assessment will be reported in the next comprehensive plan update (2013) and will inform reallocations and other planning activities in the Austin HSDA beginning in the 2012-2013 Ryan White B contract year.
Needs Assessment: Participant Profile The sampling method for the 2009 comprehensive needs assessment has presented challenges for establishing findings that are generalizable to the larger PLWHA population. Participants were self-selected and, as with any research with a compensational component, selection bias based on the use of an incentive is possible. All data is self-reported. However, the data and findings yielded have been instrumental in ranking service category priorities and establishing the present needs, barriers and gaps in services for PLWHA in the CTHASA. The following tables present comparisons of survey participant demographic information to the overall population of PLWHA in the CTHASA near the time of survey.4