PanWest West Texas Comprehensive HIV Health Services Plan PART 1: NARRATIVE

Transcription

1 PanWest West Texas Comprehensive HIV Health Services Plan PART 1: NARRATIVE REVISED FEBRUARY 2016

2 PanWest West Texas Comprehensive HIV Health Services Plan TABLE OF CONTENTS LIST OF ACRONYMS... EXECUTIVE SUMMARY... Page 1 iv ES 1 PART ONE NARRATIVE SECTION 1: WHERE ARE WE NOW: WHAT IS OUR CURRENT SYSTEM OF CARE? A. Description of the PanWest and West Texas Planning Areas B. Description of the Current Care System C. Assessment of the Needs of People Living with HIV/AIDS D. Description of Barriers to Care E. Quality Management Program F Priorities and Allocations G. Evaluation of 2010 Comprehensive Plan SECTION 2: WHERE DO WE GO: WHAT SYSTEM OF CARE DO WE WANT? A. Comprehensive HIV Health Services Planning Process B. Challenges from 2010 Plan C Proposed Care Goals D. Goals Regarding Individuals Aware of their HIV Status but not in care and Goals Regarding Individuals Unaware of their HIV Status E. Proposed Solutions for Closing Gaps in Care and Addressing Overlaps in Care F. Coordination with Other Funding Sources SECTION 3: HOW WILL WE GET THERE: HOW DOES OUR SYSTEM NEED TO CHANGE TO ASSURE AVAILABILITY OF AND ACCESSIBILITY TO CORE SERVICES? A. Introduction B. Goals and Objectives of the Plan C. How the Plan Addresses Healthy People 2020 Objectives D. How this Plan Reflects the Texas State Health Plan E. How this Plan is Coordinated with and Adapts to Changes that will Occur with the Implementation of the Affordable Care Act revision 1 i StarCare (initial plan by consultant New Solutions, Inc.)

3 PanWest West Texas Comprehensive HIV Health Services Plan TABLE OF CONTENTS (Continued) Page SECTION 4 HOW WILL WE MONITOR OUR PROGRESS: HOW WILL WE EVALUATE OUR PROGRESS IN MEETING OUR SHORT AND LONG TERM GOALS? A. Monitoring Progress B. Evaluation C. Impact on Priority Setting and Allocations PART TWO GOALS AND STRATEGIES SECTION 1 MISSION STATEMENT, VISION STATEMENT AND CORE VALUES SECTION 2 GOALS AND STRATEGIES SECTION 3 ACTION PLAN PART THREE APPENDICES A Ryan White Program Background B PanWest West Texas Quality Management Plan/ Improvement Plan, C HRSA HAB Performance Measures, Group 1 (Tier 1) HIV/AIDS Bureau Performance Measures Core Performance Measures 1, November D Medical Core and Social Support Services E PanWest West Texas Allocations F Healthy People 2020 Strategies Addressed With the PanWest West Texas 2014 Comprehensive HIV Services Plan revision 1 ii StarCare (initial plan by consultant New Solutions, Inc.)

4 PanWest West Texas Comprehensive HIV Health Services Plan Tables PART ONE TABLE OF CONTENTS (Continued) LIST OF TABLES AND FIGURES Page 1.1 PanWest and West Texas HSDAS Counties, 2012 Population and Key Ryan White Providers People Living with HIV/AIDS 2012 Select Counties Services Provided by PanWest and West Texas Funded Subcontractors Available Resources PanWest and West Texas Regions HAB Performance Measures Calendar Year 2013 Average Scores National HIV/AIDS Strategy Addressed With the PanWest West Texas 2014 Comprehensive HIV Services Plan Figures PART ONE 1.1 Map of the PanWest and West Texas Regions Treatment Cascade for Amarillo HSDA Treatment Cascade for Lubbock HSDA Treatment Cascade for Permian Basin HSDA Treatment Cascade for El Paso HSDA revision 1 iii StarCare (initial plan by consultant New Solutions, Inc.)

5 PanWest West Texas Comprehensive HIV Health Services Plan ACRONYMS AA ACA AETC ARIES ART BAS DSHS FPL FQHC GLBT HASA HERR HOPWA HRSA HSDA IDU ID MCM MOA MSM OAMC PASO PDSA PLWHA QM & QMC RHP RWSD SPCAA STD TA TAC TTUHSC HIV Services Administrative Agency Affordable Care Act AIDS Education and Training Center AIDS Regional Information and Evaluation System Anti Retroviral Therapy Basin Assistance Services (Permian Basin HSDA) Texas Department of State Health Services Federal Poverty Level Federally Qualified Health Center Gay/Lesbian/Bisexual/Transgender also listed as LGBT HIV Administrative Service Area (i.e. PanWest, West Texas) Health Education/Risk Reduction Housing Opportunities for People with AIDS Health Resources and Services Administration HIV Service Delivery Area (i.e. Amarillo, Lubbock, Permian Basin, and El Paso) Injection drug use, injection drug user Infectious Disease physician or infectious disease specialist Medical case management Memoranda of Understanding Men who have sex with men Outpatient/Ambulatory Medical Care Panhandle AIDS Support Organization (Amarillo HSDA) Plan Do Study Act (quality management) People/Person(s) Living with HIV/AIDS Quality Management and Quality Management Committee (QI: quality improvement) Regional Health Partnerships Ryan White Service Delivery South Plains Community Action Association (for Project CHAMPS) Sexually Transmitted Disease Technical Assistance Tech AIDS Clinic through Texas Tech University Health Sciences Center in Lubbock Texas Tech University Health Sciences Center revision 1 iv StarCare (initial plan by consultant New Solutions, Inc.)

6 EXECUTIVE SUMMARY February 2016 Revisions: The Comprehensive HIV Health Services Plan was implemented March 2014 and was revised August 2014 for Fiscal Year 2015 for the Administrative Agency s application renewal to the Texas Department of State Health Services. Revisions were made in several strategies in Goals 1, 2, and 3 but not the actual goals. The goal s success will be measured through the strategies. Currently, the start and completion dates remain the same as the plan was implemented in March 2014 and goes through 2017 but are subject to change based on ARIES updates and the PDSA process. The Plan was again revised May 2015 as required annually by DSHS. The May 2015 revisions are slight as the Plan was to majorly revise it in May 2016 with a new plan required September However, to make the best use of resources, the Administrative Agency is updating the plan February 2016 and looking to implement a targeted assessment in March 2016 to develop a new comprehensive plan by August The Administrative Agency s goal is to align the Comprehensive HIV Health Services Plan with the current DSHS Texas HIV Plan Update for (currently rev. December 2013) to better meet the Texas HIV Spectrum of Engagement from public awareness to viral load suppression. For the time being, the plan Goals and Objectives remain the same and sine of the objectives changed. Epidemiologic and demographic data will be updated. This PanWest West Texas Comprehensive HIV Health Services Plan was designed to fulfill federal and state mandates and provide a road map for action over the next three years. 1. WHERE WE ARE NOW: WHAT IS IN OUR CURRENT SYSTEM OF CARE? The PanWest HIV Administrative Service Area (HASA) includes three HIV Service Delivery Areas (HSDA): revision ES 1 StarCare (initial [plan by consultant New Solutions, Inc.)

7 o Amarillo HSDA o Lubbock HSDA o Permian Basin HSDA The West Texas HASA has one HSDA, El Paso, and is also included in this analysis. Together these four HSDAs comprise the 64 farthest west counties in Texas, ranging from the Panhandle to the Mexico border. The total population is approximately 2.1 million people. PanWest and West Texas HSDA counties have experienced significant growth between 2000 and Midland County grew 26%, El Paso County 22%, Randall County 20%, Ector County 19%. The poorest counties, represented by the lowest median incomes and the highest federal poverty levels include Potter (Amarillo HSDA), Hale (Lubbock HSDA) and El Paso Counties. Regional Epidemic In 2012, the Pan West region had a total of 1,361 people living with HIV/AIDS (PLWHA). The three PanWest HSDAs have between 434 PLWHA (Amarillo) and 492 PLWHA (Permian Basin). West Texas has 1,843 PLWHA, almost all of whom live in El Paso County. In the six years between 2007 and 2012, new HIV diagnoses averaged 23 in the Amarillo HSDA, 27 in the Lubbock HSDA, 30 in the Permian Basin HSDA and 103 in the El Paso HSDA. PLWHA race ethnicity varies across the region. The farther north the HSDA, the larger the percentage of White/Caucasian PLWHA. This ranges from 51% in the Amarillo HSDA to 9% in the El Paso HSDA. Black/African American PLWHAs are similar percentages throughout the PanWest region, ranging from 13% in the Amarillo HSDA to 15% in the Lubbock HSDA. The farther south the HSDA, the larger the percentage of Hispanic/Latino PLWHA. This ranges from 85% in El Paso to 29% in Amarillo. Men who have sex with men (MSM) is the most frequent transmission mode in all four HSDAs. The PanWest HSDAs have smaller percentages reporting MSM transmission mode than West Texas. PanWest HSDAs range between 51% and 55% MSM compared to 68% in West Texas. Injection Drug Use (IDU) transmission mode is higher in PanWest than West Texas. Heterosexual transmission mode ranges from 14% in Lubbock HSDA to 21% in Amarillo HSDA. Assessment of the Needs of People Living with HIV/AIDS The 2013 PanWest West Texas Comprehensive Needs Assessments informs this comprehensive plan. It included an online survey of 328 consumers, 29 in depth interviews with out of care consumers, key informant interviews, one case manager focus group, a behavioral health analysis, and a resource inventory. 1 Description of the Current Continuum of Care 1 PanWest West Texas 2013 Comprehensive Needs Assessment can be found at revision ES 2 StarCare (initial [plan by consultant New Solutions, Inc.)

8 The StarCare Speciality Health System HIV Services Administrative Agency (AA) is committed to meeting HRSA s goals of increasing access to care and decreasing health disparities, with particular emphasis on the needs of newly infected and disproportionately impacted populations. This is being effectively accomplished through one multi service subcontractor in each of the PanWest HSDAs and three funded subcontractors in the El Paso HSDA. The three Ryan White Part B funded service subcontractors in the PanWest are located in the population centers of each HSDA. These providers assess, link and refer to non Ryan White funded community resources throughout the region. In the West Texas HASA, La Fe CARE Center and SPCAA Project CHAMPS (as of Feb. 2015) provide HIV medical care and medical case management. Family Service of El Paso, Inc. provides mental health therapy and counseling. In both the PanWest and West Texas regions, Subcontractors work with local community health care and social service providers to deliver services to encourage consumers access to care, ensure the provision of appropriate HIV health care and meet client medical and supportive service needs. Each subcontractor must establish, implement, and monitor a referral process to ensure follow up with services that they don t directly provide. This approach fosters collaborative relationships and has enabled the subcontractors to explore the availability of community services, avoid duplication of services, and provide the service with minimal time lapses. It also ensures Ryan White Part B funding is used as the payer of last resort. Strengths and Challenges of the PanWest and West Texas Continuums of Care The following strengths in service provision provide a foundation for this plan and achievement of its goals: High quality medical care provided by experienced physicians in each HSDA. Availability of a full range of Ryan White core services. Bilingual staff are widely available in West Texas organizations that serve PLWHA. A variety of funding sources complements Ryan White funding. Well developed social service continuums of care in the population centers of the HSDAs. Challenges include: Increasing demand for limited Ryan White funding, including funding for needed core services. Challenges in continuity of medical care at one West Texas provider. Changes in the Texas Ryan White case management system are challenging for all providers. Quality of case management services is uneven in the El Paso HSDA. Given Ryan White requirements to fund core medical services, funding for social services is limited. Collaboration with non Ryan White funded community agencies is needed, but may be time consuming and difficult to accomplish. In West Texas and other rural areas, the ongoing HIV stigma can be acute, limiting access to services due to consumer disclosure concerns. Quality Management revision ES 3 StarCare (initial [plan by consultant New Solutions, Inc.)

9 The Administrative Agency established a joint Quality Management (QM) program for use in both the PanWest and West Texas regions. This program provides a documented, ongoing process to guide and continuously improve HIV/AIDS services. The primary purpose of the QM program is to enhance the quality of medical and other services provided to PLWHA in the regions. It requires collaboration between all Ryan White funded subcontractors to ensure services are of the highest quality and provide efficiently and effectively in conformance with established standards of care and best practices. The cornerstone of the QM program is the Quality Management Plan. The QM Plan is developed and reviewed by the Quality Management Committee (QMC), which is comprised of representatives from the Administrative Agency (AA) and each funded PanWest and West Texas provider. Training is an important component of the QM program. The AA directly and indirectly offers training to contracted providers as part of the QM Plan. NOTE: In January 2015, StarCare HIV Services Administrative Agency (AA) issued a request for proposals for HIV services for PanWest and West Texas. Proposals were received for each area and the AA finalized selection in June 2015 with the following subcontractors selected to provide services by September 1, 2015: West Texas each primarily providing medical services and case management El Paso HSDA: Centro de Salud Familiar La Fe La Fe CARE South Plains Community Action Association (SPCAA) Project CHAMPS El Paso PanWest primarily providing medical services and case management Amarillo: Panhandle AIDS Support Organization (PASO) Lubbock: SPCAA Project CHAMPS Permian Basin: PBCC Basin Assistance Services (BAS) The contract for Family Services of El Paso, mental health services provider, expired August 31, The contract for SunCity, HOPWA provider, expired January 31, The new HOPWA provider is Project CHAMPS El Paso. 2. WHERE DO WE NEED TO GO: WHAT SYSTEM OF CARE DO WE WANT? Comprehensive HIV Health Services Planning Process The PanWest West Texas Comprehensive HIV Health Services Plan is the result of a collaborative planning process that included research, interactive discussion and plan development. In February 2014 the AA staff participated in a planning session that included a review of the previous mission, vision and shared values statements, making modifications. They outlined draft goals and strategies with discussion of required actions over the next three years. This information was developed into a draft plan that was presented and reviewed by the Texas Department of State Health Services (DSHS) staff. Throughout the planning process AA staff considered the Texas HIV Plan s Spectrum of HIV Engagement, the National HIV Strategy, Healthy People 2020, and Ryan White Program requirements revision ES 4 StarCare (initial [plan by consultant New Solutions, Inc.)

10 Mission, Vision and Core Values The mission, vision and core values statements were included in the 2010 PanWest Comprehensive Plan, and slightly revised for this joint Plan. This mission statement is the foundation for the PanWest West Texas Comprehensive HIV Health Services Plan. Mission Statement To support an effective, community wide response to HIV/AIDS by focusing on high quality medical and support services and leveraging community resources. The following ideal vision underpins the Plan. Vision Statement HIV care is accessible and effective. All the work of the AA and its subcontractors is for the purpose of benefiting the health and well being of PLWHA. Recognizing the importance and complexity of this task, five values are shared by those who embrace this program. Core Values We believe all services build on the core values of: Dignity, Respecting Diversity, Professionalism and Quality, Availability and Accessibility, and Collaboration. These core values will encourage people living with HIV/AIDS to access treatment and be maintained in HIV medical care and support services. Dignity: All clients will be treated with dignity. Respect Diversity: Recognize and respect cultural and individual differences. Professionalism and Quality: Provide quality services in a professional manner. Availability and Accessibility: Health care services will be available and accessible. Collaboration: Work with community organizations to enhance access to the complete continuum of services, from HIV prevention to care and treatment revision ES 5 StarCare (initial [plan by consultant New Solutions, Inc.)

11 3. HOW WILL WE GET THERE: HOW DOES OUR SYSTEM NEED TO CHANGE TO ASSURE AVAILABILITY OF AND ACCESSIBILITY TO CORE SERVICES? The Comprehensive HIV Health Services Plan establishes four goals for AA and Subcontractor achievement. All goals reflect the findings and recommendations of the 2013 PanWest West Texas Comprehensive Needs Assessment, the updated epidemiological profiles and the Ryan White HIV/AIDS Program requirements. The Plan goals, their associated strategies, and actions: Improve the case management system in the HSDAs, Expand access to behavioral health services, Ensures access to high quality HIV medical care, Emphasize collaboration to provide the complete prevention and care continuum. The AA feels confident that these goals promote a system of care that will promote the health and wellbeing of people living with HIV/AIDS in the region. The goals and accompanying objectives of the Comprehensive HIV Health Services Plan are outlined below. GOAL I Improve the Case Management System Throughout the PanWest and West Texas Regions. As the first priority of the AA, the strategies of Goal I emphasize the importance of case management in supporting PLWHA in accessing medical care and needed supportive services. Effective case managers promote engagement and retention in HIV medical care, identify and support clients who are at risk for dropping out of care, and link them to non Ryan White funded community services. The following strategies are associated with this goal: Implement the HRSA HIV/AIDS Bureau (HAB) medical case management (MCM) core performance measure medical visit frequency by July By December 2017, medical visit frequency will increase by 10%. Monitor performance improvement related to this measure using the PDSA cycle through December Once the initial measure is successfully implemented and the quality management process (PDSA) is in place, expand the process to include the second core MCM performance measure gap in medical visits, targeting implementation by July By July 2016, gap in medical visits will decrease by 5% and decrease by 10% by July Monitor performance improvement related to this measure using the PDSA cycle or local EMR through December Develop regional best practices for (1) MCM performance measure medical visit frequency, (2) maintenance in medical care and (3) medication delivery at the June 2014 annual provider training. Develop measures demonstrating conformance to best practices for medication delivery by January 2017 and use the provider self audit on an ongoing basis revision ES 6 StarCare (initial plan by consultant New Solutions, Inc.)

12 GOAL II Collaborate with Non Ryan White Funded Providers to Expand Access to the HIV Prevention and Care Service Continuum. Given budget constraints and Ryan White funding requirements, collaboration is essential in order to provide the complete continuum of HIV prevention, care and treatment to PLWHA in the regions. The Administrative Agency (AA) and Subcontractors have always worked collaboratively with other organizations to meet clients needs. By adding this goal to the Comprehensive Plan, the AA is emphasizing these collaborations and expanding involvement with them. Specific strategies include: Encourage RW funded agencies to expand collaboration with local HIV prevention outreach/counseling and testing providers to effectively link newly diagnosed consumers to HIV medical care within three months of diagnosis, reducing barriers to care. Continue to actively participate in the El Paso Community Mobilization Collaborative. With the El Paso Community Mobilization Collaborative as an example, identify opportunities to support collaborative development in PanWest HSDA(s) in 2015 and beyond. GOAL III Ensure the Delivery of High Quality Medical Care Throughout the Region. Goal III is central to the Ryan White Program and our mission providing high quality HIV medical care. The strategies associated with this goal relate to core performance measures, adequate and consistent physician/clinician staffing which was identified as a challenge in the El Paso HSDA on the 2013 Comprehensive Needs Assessment, increasing cervical cancer screening among female patients, and increasing anal pap screenings among male patients. Specific strategies include: Implement the HRSA HIV/AIDS Bureau (HAB) Core Performance Measures for viral load suppression and PCP prophylaxis by January 2015 and continue to monitor the clinical measure for CD4 cell count so that by January 2016 there is an increase of 10% in viral load suppression, 10% in PCP prophylaxis, and 10% in CD4 cell counts and by January 2017 there is another increase of 10% in viral load suppression, 10% in PCP prophylaxis, and 10% increase in CD4 cell counts. Ensure physician and mid level practitioner capacity in all HSDAs to provide timely patient access to high quality HIV medical care by January 2015 with timely patient access for newly diagnosed or returning to care to be seen less than ninety (90) days and within thirty (30) days for clients meeting priority population criteria: infants, pregnant women, CD4 less than 200, and the recently released from prison with a ten (10) day supply of HIV medication. Increase the percentage of female Ryan White patients who receive cervical cancer screening to 50% in 2015, 60% in 2016 and 75% in 2017 per cervical cancer screening performance measure. Increase the percentage of male Ryan White patients who receive anal pap screenings to 50% in 2016 and 75% in 2017 per anal pap screening performance measure revision ES 7 StarCare (initial plan by consultant New Solutions, Inc.)

13 GOAL IV Expand Access to Behavioral Health Services (Mental Health and Substance Abuse Treatment) by Integration, Co Location and/or Increased Collaboration Between Ryan White Funded Providers. and Behavioral Health Organizations. Goal IV responds to the impact of mental health disorders and substance use on linkage and maintenance in HIV medical care. The strategies associated with this goal focus on improving case manager assessment and referral to behavioral health services, working with the HIV Early Intervention (HEI) case managers in each region and integrating them in the HIV treatment team, and expanding physician and clinician skills in diagnosing and treating minor to moderate anxiety and depression. The following strategies are associated with this goal: Establish medical case management (MCM) best practices to improve assessment, referral and utilization of behavioral health services by December Expand the treatment teams in each HSDA to include both mental health professionals and HEI case managers by December Develop and implement a plan for all HIV clinic physicians and mid level practitioners to develop the necessary skills to diagnose and prescribe adult psychiatric medications for minor to moderate depression and anxiety by December HOW WILL WE MONITOR OUR PROGRESS: HOW WILL WE EVALUATE OUR PROGRESS IN MEETING OUR SHORT AND LONG TERM GOALS? Monitoring Progress The PanWest West Texas Comprehensive HIV Health Services Plan includes a detailed timeline outlining start and completion dates, appropriate reporting intervals and status reports. Some objectives and actions require monthly review while other long term objectives will be reviewed less often, but no less than semi annually. The AA is responsible for overseeing the implementation of the Plan in accordance with the stated timeframes. Specifically: The AA delegates tasks to the Quality Management Committee (QMC) and funded providers to ensure a unified direction. The AA will review ARIES data quarterly to determine the number of new admissions and readmissions of PLWHA who are out of care as well as monitoring the units of service and expenditures. The quality management process supports monitoring and evaluation of strategies and activities. The AA prepares a quarterly report for DSHS that includes HSDA activities and expenditures revision ES 8 StarCare (initial plan by consultant New Solutions, Inc.)

14 Input gathered from surveys, letters, website, phone calls, and public meetings will also be used as a means of evaluation. Evaluation The AA, supported by the QMC, monitors progress in achieving the goals and objectives of the plan. This, in turn, promotes evaluation of the Plan. Plan evaluation will include: Ability to implement stated action steps within the projected timeframes. Achievement of each strategy. Documented system improvements that support the four goals. Each goal will be evaluated annually and upon completion of the plan using available data. Impact on Priority Setting and Allocations In developing the PanWest West Texas Comprehensive HIV Services Plan, the AA staff was aware of each strategy s potential impact on priority setting and allocations. Many of the strategies will not increase costs to the system, but will provide alternative and cost effective uses of funds. Some of the strategies will require staff or subcontractor time to implement, but will not be a direct dollar cost. Finally, some of the strategies may result in increased costs during program initiation, but ongoing provision should not increase costs to the system significantly revision ES 9 StarCare (initial plan by consultant New Solutions, Inc.)

15 1. WHERE WE ARE NOW: WHAT IS IN OUR CURRENT SYSTEM OF CARE? SECTION 1 A: DESCRIPTION OF THE PANWEST AND WEST TEXAS PLANNING AREAS Profile of the Four HIV Service Delivery Areas This Comprehensive Plan includes the three PanWest HIV Service Delivery Areas (HSDA): Amarillo HSDA, Lubbock HSDA and Permian Basin HSDA and the El Paso HSDA (West Texas HASA). Together these four HSDAs comprise the 64 farthest west counties in Texas, ranging from the Panhandle to the Mexico border. The PanWest and West Texas regions occupy 84,000 square miles with a total population of 2,144,059. El Paso County in the West Texas HASA has the greatest population density with nearly 800 people per square mile. Lubbock County, in the Lubbock HSDA, follows with 311 people per square mile. Potter, Midland and Ector counties, in the Amarillo and Permian Basin HSDAs, range between 138 and 146 people per square mile. The map in Figure 1.1 presents the geography of the PanWest and West Texas regions. Figure StarCare (initial plan by consultant New Solutions, Inc.)

16 Each PanWest HSDA has one key Ryan White provider, which are listed in the table below. In West Texas, two organizations receive Ryan White HIV medical care funds, and one receives funding for mental health therapy and counseling. Table 1.1 PanWest and West Texas HSDAs Counties, 2012 Population and Key Ryan White Providers HSDAs AND COUNTIES 2012 POPULATION Amarillo HSDA 26 Counties Armstrong, Briscoe, Carson, Castro, Childress, Collingsworth, Dallam, Deaf 435,408 Smith, Donley, Gray, Hall, Hansford, Hartley, Hemphill, Hutchinson, Lipscomb, Moore, Ochiltree, Oldham, Parmer, Potter, Randall, Roberts, Sherman, Swisher, Wheeler Lubbock HSDA 15 Counties Bailey, Cochran, Crosby, Dickens, Floyd, Garza, Hale, Hockley, King, Lamb, 418,578 Lubbock, Lynn, Motley, Terry, Yoakum Permian Basin HSDA 17 Counties Andrews, Borden, Crane, Dawson, Ector, Gaines, Glasscock, Howard, Loving, 437,899 Martin, Midland, Pecos, Reeves, Terrell, Upton, Ward, Winkler West Texas HSDA 6 Counties Brewster, El Paso, Hudspeth, Jeff Davis, Presidio 852,173 Total PanWest and West Texas Regions 64 Counties 2,144,059 KEY PROVIDERS Panhandle AIDS Support Organization (PASO) SPCAA (Project CHAMPS) Basin Assistance Services (BAS) La Fe CARE, SPCAA, & Family Service of El Paso, Inc. Population Data Source: U.S. Census Bureau State and County QuickFacts, 2012 The demographic analysis of the HSDAs finds: Both regions experienced significant growth between 2000 and Midland County grew 26%, El Paso County 22%, Randall County 20%, Ector County 19%. The counties with the lowest median incomes and the highest federal poverty levels include El Paso County with 25% of residents below federal poverty level (FPL), and Potter and Hale counties with 22% below FPL. To compare, 16% of Texas residents are below FPL. Randall County has the highest level of education of all HSDAs while Ector County and El Paso County have the highest percentages without a high school diploma, 28% and 26%, respectively. 1 2 StarCare (initial plan by consultant New Solutions, Inc.)

17 Epidemiology Overview HIV Prevalence In 2012, the PanWest Region had a total of 1,361people living with HIV/AIDS (PLWHA) and the West Texas region had 1,843. The number of PLWHA does not vary significantly in the PanWest HSDAs with 434 PLWHA in the Amarillo HSDA, 435 in Lubbock HSDA, and 492 in the Permian Basin HSDA. In West Texas, virtually all PLWHA live in El Paso County. The table below demonstrates the concentration of PLWHA in the most populous counties in each HSDA. Table 1.2 People Living with HIV/AIDS 2012 Select Counties HSDA/County Number of PLWHA Percent of HSDA Total Amarillo HSDA Total 434 Potter County % Randall County % Lubbock HSDA Total 435 Hale County % Lubbock County % Permian Basin HSDA Total 492 Ector County % Midland County % El Paso HSDA Total 1,843 El Paso County 1, % Source: Texas DSHS, TB/HIV/STD Epidemiology and Surveillance Branch Race/Ethnicity PLWHA race ethnicity varies across the region. The farther north the HSDA, the larger the percentage of White/Caucasian PLWHA. This ranges from 51% in the Amarillo HSDA to 9% in the El Paso HSDA. Similar percentages of Black/African American PLWHA are found throughout the PanWest region, ranging from 13% in the Amarillo HSDA to 15% in the Lubbock HSDA. In the El Paso HSDA, 6% of PLWHA are Black/African American. The farther south the HSDA, the larger the percentage of Hispanic/Latino PLWHA. This ranges from 85% in El Paso to 29% in Amarillo. Gender Differences are seen in PanWest and West Texas PLWHA gender. PanWest has approximately 80% male and 20% female PLWHA in all HSDAs. West Texas has 87% male and 13% female PLWHA. 1 3 StarCare (initial plan by consultant New Solutions, Inc.)

18 Age In all four HSDAs, prevalence increases with increasing age, beginning with 5% of PLWHA in the year age range and increasing to approximately 33% in the 45 to 54 year old group. The percentage decreases, however, in the 55+ group to less than 20%. Transmission Mode Men who have sex with men (MSM) is the most frequent transmission mode in all four HSDAs. The PanWest HSDAs have smaller percentages for MSM transmission than West Texas, between 51% and 55% compared to 68% in in West Texas. Injection drug use (IDU) transmission mode is higher in PanWest than West Texas. Heterosexual transmission mode ranges from 13.6% in Lubbock HSDA to 21% in Amarillo HSDA. Unmet Need/Out of Care Between 2007 and 2011, Texas Department of State Health Services (DSHS) calculated unmet need (percentage of PLWHA not receiving HIV medical care). Results found: Larger percentages of people with AIDS are in care than out of care. In all HSDAs, except Permian Basin, women tend to be out of care to a greater extent than men. Younger PLWHA are more likely to be out of care than those in older age ranges. Heterosexual and IDU tend to be out of care to a greater extent than MSM. HIV Incidence Between 2007 and 2012, new HIV diagnoses averaged between 23 and 30 in the PanWest HSDAs and 103 in the El Paso HSDA. The 2012 incidence rates ranged from 4.6/100,000 in Amarillo HSDA to 14.2/100,000 in El Paso HSDA and include 7.6/100,000 in Lubbock HSDA and 8.7/100,000 in Permian Basin HSDA. Sexually Transmitted Diseases Sexually transmitted diseases (STD) identify individuals at risk for acquiring HIV due to unprotected sexual activity. Chlamydia is the most prevalent sexually transmitted disease in both PanWest and West Texas, with increasing incidence between 2007 and Potter County has the highest 2011 chlamydia rate and the highest gonorrhea rate of all counties. Lubbock County had a significant increase in chlamydia cases and rates between 2007 and 2011, with cases increasing by 75% during this time. Lubbock also had an increase in gonorrhea cases and rates during this time. El Paso County had the highest total number of chlamydia and gonorrhea cases each year, but the 2011 incidence rates are below other counties. In 2011, Hale County has the highest syphilis rate of all key counties in the four HSDAs. This was followed by Lubbock County which had a historically high syphilis rate between 2008 and StarCare (initial plan by consultant New Solutions, Inc.)

19 Treatment Cascades Texas DSHS developed a 2012 treatment cascade for each HSDA. The Cascades estimate both known and unknown PLWHA. The Texas HIV Plan Update for reports: Approximately 18% of those living with HIV have not been diagnosed. Models of the spread of HIV have estimated that undiagnosed persons may drive almost half of new HIV infections. In 2011, approximately one in three HIV diagnoses were made late in the course of the disease which affects prognosis and lifespan. Approximately two in five Texans were not receiving HIV medical care. About half who were in medical care had not achieved viral load suppression. 2 The cascades below present the status of these attributes for the PanWest and El Paso HSDAs. They can help guide each HSDA s efforts to diagnose HIV, link the newly diagnosed to medical care and maintain PLWHA in care and treatment. NOTE: DSHS has 2014 Treatment Cascades available that will soon be added to this revision. Amarillo HSDA Treatment Cascade It is estimated that 451 people in the Amarillo HSDA are HIV positive. For 2013, DSHS finds 353 Amarillo HSDA PLWHA have a met need 3 for HIV medical care, with 248 (55%) achieving viral load suppression at the end of The met need translates to 78.3% of those who know their status accessing HIV medical in the previous 12 months, and an unmet need of 21.7%. DSHS also identified that of the 18 consumers with new HIV diagnoses in the first nine months of 2013, 15 (83%) linked to care within three months, one (6%) linked to care in four to 12 months, and two (11%) did not link at all. Finally, DSHS provides data on consumers who were retained in care in % had a met need/were maintained in care. 10% were in and out of care. 22% have no evidence of receiving HIV medical care during this time. 2 Texas HIV Plan, Update for , page 4. 3 A met need for HIV medical care uses the HRSA definition of having a CD4 or viral load test, antiretroviral medications or HIV medical care in the last 12 months. 1 5 StarCare (initial plan by consultant New Solutions, Inc.)

20 Figure 1.2 Treatment Cascade for Amarillo HSDA 2013 Lubbock HSDA Treatment Cascade It is estimated that 484 people in the Lubbock HSDA are HIV positive. For 2013, DSHS finds 319 Lubbock HSDA PLWHA have a met need for HIV medical care, with 261 (54%) achieving viral load suppression at the end of The met need translates to 76% of those who know their status accessing HIV medical in the previous 12 months, and an unmet need of 24%. DSHS also identified that of the 35 consumers with new HIV diagnoses in the first nine months of 2013, 26 (74%) linked to care within three months, seven (20%) linked to care in four to 12 months, and two (6%) did not link at all. Finally, DSHS provides data on consumers who were retained in care in % had a met need/were maintained in care. 15% were in and out of care. 24% have no evidence of receiving HIV medical care during this time. 1 6 StarCare (initial plan by consultant New Solutions, Inc.)

21 Figure 1.3 Treatment Cascade for Lubbock HSDA 2013 Permian Basin HSDA Treatment Cascade It is estimated that 556 people in the Permian Basin HSDA are HIV positive. For 2013, DSHS finds 367 Permian Basin HSDA PLWHA have a met need for HIV medical care, with 268 (48%) achieving viral load suppression at the end of The met need translates to 66% of those who know their status accessing HIV medical in the previous 12 months, and an unmet need of 34%. DSHS also identified that of the 36 consumers with new HIV diagnoses in the first nine months of 2013, 32 (89%) linked to care within three months, one (3%) linked to care within four to twelve months, and three (8%) did not link at all. DSHS provides data on consumers who were retained in care in % were maintained in care throughout this time period. 12% were in and out of care. 34% have no evidence of receiving HIV medical care during this time. 1 7 StarCare (initial plan by consultant New Solutions, Inc.)

22 Figure 1.4 Treatment Cascade for Permian Basin HSDA, 2013 El Paso HSDA Treatment Cascade It is estimated that 2,050 people in the El Paso HSDA are HIV positive. For 2014, DSHS finds 1,439 El Paso HSDA PLWHA have a met need for HIV medical care, with 1,157 (80%) achieving viral load suppression at the end of The met need translates to 70% of those who know their status accessing HIV medical in the previous 12 months, and an unmet need of 30%. DSHS also identified that of the 106 consumers with new HIV diagnoses in the first nine months of 2014, 84 (79%) linked to care within three months, ten linked to care within four to twelve months and 12 (11%) did not link at all. DSHS provides data on consumers who were retained in care in % (1,346PLWHA) had a met need/were maintained in care. 4% (93 PLWHA) were in and out of care. 30% (611PLWHA) have no evidence of receiving HIV medical care during this time. 1 8 StarCare (initial plan by consultant New Solutions, Inc.)

23 Figure 1.5 Treatment Cascade for El Paso HSDA, 2014 SECTION 1 B: DESCRIPTION OF THE CURRENT CARE SYSTEM In 2009 significant changes occurred in the West Texas HASA a large provider who was also the administrative agency abruptly closed its doors. Many patients were left without case management, medical or other essential services. The new administrative agency, Lubbock Regional MHMR Center (now StarCare Specialty Health System), was left to establish services for these consumers, contact them and make appropriate referrals to La Fe CARE. Since that time, StarCare has made significant progress in the West Texas region while maintaining services in the PanWest region. Among other things, they: Established a second, highly regarded medical clinic at Texas Tech University Health Sciences Center (TTUHSC) in El Paso. NOTE: As of December 31, 2014, TTUHSC is no longer a Ryan White Part B provider. The new provider is SPCAA Project CHAMPS El Paso. Integrated La Fe CARE into the PanWest West Texas administrative system. Funded mental health services through Family Service of El Paso, Inc. Note: The contract for Family Service of El Paso expired Expanded West Texas HOPWA services; conducted an El Paso housing study and participated in the El Paso Housing Coalition. Continued support of existing PanWest providers with strong core services. Established a sound quality management system in both regions. 1 9 StarCare (initial plan by consultant New Solutions, Inc.)

24 Are actively participating in and/or supporting regional collaboration. Ensure availability of bilingual staff at all Ryan White funded organizations. Expanded services with increasing numbers of clients at all HIV medical clinics. Challenges include: Limited medical care options with two Ryan White funded organizations in the El Paso HSDA, and one Ryan White funded provider in each of the three PanWest HSDAs. Since losing the full time medical director in 2011, La Fe CARE has struggled with physician/clinician staffing. Case management services are uneven in the West Texas HSDA with both case management staffing and quality issues. Given Ryan White requirements to fund core medical services, funding for social services is limited. Collaboration with non Ryan White funded community agencies is essential. In West Texas and other rural areas, the ongoing HIV stigma can be acute, limiting access to services due to consumer disclosure concerns. Increase in client numbers, but no increase in funds. Uncertainty about the impact of the Affordable Care Act especially regarding the Health Insurance Premium and Cost Sharing Assistance and AIDS Pharmaceuticals since Texas is not expanding Medicaid coverage. Ryan White Funded Providers Each of the three PanWest HSDAs has a Part B funded HIV/AIDS service subcontractor (provider). Each is located in the population center of the HSDA. Using a competitive request for proposal process, the subcontractors in the Amarillo and Permian Basin HSDAs have been stable for many years. The Lubbock HSDA subcontractor, however, changed in February 2008 and continues as the provider. In 2015, the Providers served clients as follows: The Amarillo HSDA subcontractor served 282 unduplicated clients in a 26 county area. The Lubbock HSDA subcontractor served 360 unduplicated clients in a 15 county area. The Permian Basin HSDA subcontractor served 269 unduplicated clients in a 17 county area. The El Paso HSDA subcontractors served 1,100 unduplicated clients including 884 at La Fe CARE and 216 at Project CHAMPS. All Subcontractors are required to provide culturally competent services without discrimination in any form. 4 4 The AA and all Subcontractors will comply with all federal and state non discrimination statutes, regulations, and guidelines. Services shall be provided without discrimination on the basis of race, color, national origin, age, disability, ethnicity, gender, religion, or sexual orientation. Subcontractors are required to have policies and procedures in place to ensure services are accessible to the target population. Subcontractors must furnish evidence of having a plan to ensure the availability of bilingual staff and/or the services of an interpreter are available; general information and educational materials are available in the languages appropriate to the population served; and clients are educated and counseled according to individual needs and circumstances. Contracts established with Subcontractors require compliance with the Civil Rights Act of 1964, the Americans with Disabilities Act of 1991 and the Age Discrimination in Employment Act of StarCare (initial plan by consultant New Solutions, Inc.)

25 Linkage with Community Services In both the PanWest and West Texas regions, subcontractors work with local community health care and social service providers to deliver services to encourage consumers access to care, ensure the provision of appropriate HIV health care and meet client medical and supportive service needs. These include: HIV prevention and counseling and testing providers, Local health departments, including sexually transmitted disease clinics, Hospital systems and emergency rooms, Private and public clinics including family planning centers, community health centers, federally qualified health centers (FQHC), Substance abuse treatment providers, including HEI case managers, Mental health counseling programs, Food banks, churches, homeless shelters and other support organizations. Subcontractors are required to provide the appropriate linkages 5 available for their clients. to ensure needed services are Each subcontractor must establish, implement, and monitor a referral process to ensure follow up with services that they don t directly provide. This approach fosters collaborative relationships and has enabled the subcontractors to explore the availability of community services, avoid duplication of services, and provide the service with minimal time lapses. It also ensures Part B funding is used as the payer of last resort. It includes: Initial contact with the community agency to determine if the service is available. Provide the client with a written referral for the community service. When the service has been provided, the client will return with signed documentation for the case manager as proof of the service provision. If the client fails to bring the information to the case manager, the case manager will contact the referred agency to determine if the client attended the appointment/was provided with the requested service. The status of each referral is listed and tracked through an agency referral log to ensure followup and closure of all referrals. The AA monitors this system during site reviews. The process also helps the AA identify potential barriers and gaps in service provision within the HSDA. 5 Linkage may be through collaborative agreements, memoranda of understanding (MOU), other contractual relationships StarCare (initial plan by consultant New Solutions, Inc.)

26 Outpatient/Ambulatory Medical Care As a cornerstone of the Ryan White Program, all activities foster engagement and maintenance in outpatient/ambulatory medical care (OAMC). The following is a brief summary of the process by which clients access OAMC in each HSDA, and how each subcontractor assures that clients have access to a physician with HIV medical experience: The Amarillo HSDA Subcontractor does not have a contract with any physician to provide medical care but does have an agreement with two local physicians: an infectious disease (ID) specialist and a local primary care physician with several years of experience treating HIV/AIDS who also does HIV/AIDS trainings for the AIDS Education and Training Center (AETC). The primary care physician sees the majority of HIV positive clients needing OAMC and works closely with the J.O. Wyatt indigent clinic to provide HIV/AIDS care as well as primary medical care. The ID physician currently does not accept new uninsured or insured HIV patients unless they are referred by the HSDA service Subcontractor. Once a client has been determined eligible for services, the case manager screens the client to determine all needs. If the client is in need of OAMC and does not have an alternate payer source, the client is referred to the J.O. Wyatt clinic to determine eligibility. Insured clients have the option of seeing a doctor of their choice based on their insurance network. Uninsured clients who are not eligible for J.O Wyatt services are referred to the ID physician and the Subcontractor will provide payment for the cost of the service if the client is eligible. The client may choose to see another physician but that physician must be willing to bill the Amarillo HSDA Subcontractor for services provided at an acceptable rate. The service Subcontractor for the Amarillo HSDA is: Panhandle AIDS Support Organization (PASO) 1501 SW 10 th St. Amarillo, TX Local or toll free The Lubbock HSDA Subcontractor contracts with the Texas Tech University Health Sciences Center (TTUHSC) to provide two weekly clinics at the TTUHSC facility to HIV positive clients. The clinic is called the Tech AIDS Clinic (TAC) and is under the direction of an Infectious Disease Specialist. One clinic is for clients who have Medicaid, Medicare or private insurance. The other clinic is for clients without insurance. The Lubbock HSDA Subcontractor s process to ensure that clients have access to ambulatory medical care is as follows: Once a client has been determined eligible for services the Medical Case Manager schedules an appointment for the client at the TAC. The Medical Case Manager also schedules the client an appointment for any necessary lab work to be completed before the initial doctor appointment. Any services necessary to support the client with accessing medical care are offered as well, such as transportation and assistance with obtaining medications StarCare (initial plan by consultant New Solutions, Inc.)

27 Clients who have other payer sources, and choose not to use the TAC, can be seen by their primary care physician who may refer them to the Consultants in Infectious Disease practice. If clients are veterans, they are offered the choices listed above as well as an option for referral to the local Veterans Administration for services. The Lubbock Subcontractor is part of a large health care organization, South Plains Community Action Association (SPCAA), which has WIC, Headstart, Family Planning Clinics, and Primary Health Clinics in the urban and rural areas of the Lubbock HSDA. The service Subcontractor for the Lubbock HSDA is: Project CHAMPS South Plains Community Action Association, Inc Avenue X (34 th & X ) Lubbock, TX Local or toll free The Permian Basin HSDA Subcontractor contracts with Texas Tech University Health Sciences Center Permian Basin (TTUHSC PB) for one weekly clinic in the city of Odessa. The clinic is run by a specialist ID doctor. The clinics are attended by resident physicians working with the ID doctor. Permian Basin has established the following process to ensure that clients have access to ambulatory medical care: Once a client has been determined eligible for services, the client is scheduled for laboratory testing so that the results will be received by the first scheduled physician visit. The clinic does not accept walk ins. Appointments are required. If the client has been receiving care elsewhere, a Release of Information form is signed so that prior history will be obtained by the time of the physician visit. Clients without other payer sources and no physician are informed of the availability of medical services provided by the ID doctor at the weekly clinic. Clients who have alternate funding sources are informed of their right to choose a doctor who will accept their alternate payer source. Any supportive services necessary to help the client access medical care are offered as well, such as transportation and assistance with obtaining medications. The Permian Basin HSDA Subcontractor, Basin Assistance Services (BAS), is located at: Basin Assistance Services (BAS) Permian Basin Community Centers 1330 E. 8 th St., Ste. 410 Odessa, TX Local or toll free The El Paso HSDA has two HIV medical care subcontractors, La Fe CARE and SPCAA Project CHAMPS El Paso (Texas Tech University Health Sciences Center (TTUHSC) terminated its Ryan White Part B contract in December 2014). La Fe CARE is an established HIV clinic that operates five days per week with a schedule of infectious disease and primary care physicians experienced in the care of HIV disease StarCare (initial plan by consultant New Solutions, Inc.)