Minnesota Department of Human Services

Disabilities Services Division

HIV/AIDS Programs

An Assessment of the HIV/AIDS Care Advocacy and Case Management System in Minnesota for “Access to Care” Redesign

Prepared by Summit Health Group

Saint Paul, Minnesota

December 2005

Acknowledgements

The review, analysis, survey of states, meeting facilitation and report preparation involved in the Access to Care-System Assessmentwere conducted under contract from the Minnesota Department of Human Services.

Sincere appreciation is extended to:

  • Members of the Access to Care Work Group including Julie Hanson-Peréz and Japhet Nyakundi (Minnesota Department of Health), Jonathan Hanft and Michelle McCafferty (Hennepin County),Gerry Tyrrell and Karin Sabey (Hennepin County Medical Center), (Minnesota Department of Human Services),Cathy Vilasand Robin Hayden(Indigenous Peoples Task Force),Linda Brandt and Judy Valerius(Rural AIDS Action Network),Mary St. Marie (Mayo Clinic), Gayle Caruso (Minnesota AIDS Project),Tim Himango and Jill Swenson (Regions Hospital-Health Partners),Yolanda Plunkett and Howard Ellis(Turning Point),Becky Ness and Maureen Wells (Clinic 42- Allina),Luz Sanchez (CLUES), Sarah Senseman (West Side Community Health Center- La Clinica), Shirley Graham (Community Fitness Today), Johnny Herda-Brown (Aliveness Project), Jackie Taye andTanger Pratt(Minneapolis Urban League);
  • Staff at the Minnesota Department of Human Services including MichelleSims (Lead Staff),Dave Rompa, Amy Moser and Redwan Hamza;
  • Interested community members who participated in the interviews/surveys including Steve Schletty (Minnesota Department of Health), staff from the Minnesota AIDS Project and Pilot City, physicians from Hennepin Faculty Associates and St. Mary’s- Duluth Clinic,members of the HIV Planning Council, persons living with HIV/AIDS, and the African American AIDS Task Force.

KatherineCairns, MPH, MBA

Summit Health Group

651.690.1474 (v) 651.699.7798 (f)

In partnership with

  • KathrynLamp, MA
  • NealHoltan, M.D., MPH
  • StephenDent, MA

Table of Contents

Executive Summary…………………………………………………………….. 1

Vision, Missionand Strategic Direction

Major Findings

Recommendations

Background and Issues………………………………………………………... 5

Rationale

Caseload and Financing in Other states

Statewide Availability of Funded Services, 2003-2004…………………… 22

Statewide system of HIV case management

Demographic changes

Models of HIV/AIDS Access to Care Services ……………………………. 24

Models from other states

Models of Chronic Disease Management Services…………………….… 37

HRSA

Implementation in other states

Chronic Care model

Minnesota Medicaid Disease Management

Payment mechanisms and contracting strategy

Key Informant Survey, Interviews and Presentations …………….…..… 49

DRAFT Models for Minnesota HIV/AIDS Access to Care…………………... 53

Restructured Delivery System Options for Access to Care ……….…... 63

DRAFT HIV/AIDS Access to Care Work Plan ……………….…………….. 65

Attachments …………………………………………………………………….. 77

Attachment A- Survey and Interview Summaries

Attachment B- Service Delivery Model Components Identified by Stakeholders

Attachment C- Selected Resources

Access to Care Vision, Mission and Strategic Directions

The Access to Care Work Group developed and approved the following vision, mission and strategic directions to guide for its work.

Vision: As the Access to Care partnership we are open, honest and direct in our communications, willing to change, creative in identifying new approaches, and willing to listen to and acknowledge others’ perspectives.

Mission:The mission of the Access to Care Project is to assess and analyze the effectiveness of the current system of access services and create an improved system that strives to efficiently provide access to care for all PLWH regardless of their state of HIV disease and life circumstance.

Strategic

Directions:Sustain and enhance existing linkages in the Ryan White Care system and expand linkages to other care and prevention services.

Identify best practices in access systems of care services for PLWHA for Minnesota.

Develop prioritized recommendations for implementation.

System Assessment: Cost-Efficiency and Statewide Availability of Services

Summit Health Group conducted a review of twelve different federal, state and city HIV case management programs in Aprilthrough December2004 to review information on services such as:

  • Potential models of “Access to Care” for persons living with HIV/AIDS and with other chronic health/mental health conditions;
  • Current continuum of care for persons living with HIV/AIDS;
  • Applied research that evaluated outcomes associated with different models of case management for persons living with HIV/AIDS;
  • Caseload for funded case management services;
  • Information systems used for tracking required HIV case management data; and
  • Opportunities for enhancing federal funding for HIV case management services.

Current and potential applicants for Minnesota HIV care advocacy and case management funding were reviewed to identify current and proposed cost per client served for case management or care advocacy.

1

Major Findings

  • The reported caseload per HIV case manager funded by other state HIV programs ranged from 20 to 255 clients per case manager.
  • The average state contracted caseloads identified in two states included:
  • 35 (McCoy- among HIV drug users) or
  • 48 (Massachusetts) for HIV case management programs.
  • The average contracted cost of case management for 2003-2004 contractors was $2,150 per client served.
  • The average contracted cost of case management for 2004-2005 contractors was $2,212 per client served (a 2.8% increase).
  • The proposed average cost of care advocacy for 2004-2005 contractors was $531 per client served with the actual contracted amount of $440 per client served.
  • Current and proposed HIV Case Management contractors provide a statewide system of care that is responsive to the diversity of persons living with HIV in Minnesota.
  • Statewide HIV statistics for 2003 indicate an increasing number of African immigrants with HIV. Adequate care advocacy and case management services need to be identified to reach this population with culturally competent and linguistically appropriate services.
  • The Minnesota HIV Care Advocacy and Case Management system have some similarities to programs in other states. However, additional system changes have been implemented in other states to streamline administrative procedures, improve/document client outcomes and adjust services to better meet client needs over the continuum of the chronic conditions associated with HIV/AIDS.

Recommendations

  1. The HIV/AIDS Program personnel in Oregon, Wisconsin and Missouriwill be contacted to further clarify:
  • Their service/contract model;
  • Identify caseload per FTE funded; and
  • Identify specifics of their case management standards.
  1. DHS HIV/AIDS Program Division should request a copy of the proposed 2005 and 2006 master contract for Medicaid managed care contracts with Minnesota health plans to review it for language specific to HIV/AIDS prevention, treatment, and case management services. This is usually available about six months prior to a new contract cycle.
  1. DHS HIV/AIDS Program Division staff should inquire as to whether Minnesota has included HIV/AIDS case management in its federal Medicaid waiver.
  1. Explore increased cooperation between Minnesota Department of Human Services (DHS) and Minnesota Department of Health (MDH) HIV/AIDS programs to support a continuum of care and care outcomes in publicly financed health and supportive services through the following activities.
  • Explore whether DHS can provide data on clients enrolled in the ADAP/health insurance and case management programs, to MDH for comparison to the HIV/AIDS surveillance data for the purposes of supporting a continuum of care and care outcomes.
  • Explore whether MDH can provide summary data on characteristics of HIV positive clients not in ADAP, health insurance or case management (e.g. demographic data, counties or zip codes with higher rates of unserved persons living with HIV/AIDS).
  • Explore cooperation/communication on strategies to better target case management and outreach services to HIV positive persons and assist in assessing whether case management and outreach services are reaching needy clients.
  • Explore whether MDH can play a bigger role in outreach to HIV positive persons and connecting them to access to care and other DHS services.
  1. Targeted Case Management and/or waivered services for persons living with HIV/AIDS and participating in Medicaid should be investigated as a possible additional funding source.If determined to be feasible, then language for legislative review should be prepared.
  1. Increased training meeting(s) and ongoing communication between DHS-funded case management/care advocacy staff and the MDH disease investigators would be useful to ensure a smooth transition of disease identification, care advocacy and case management.
  1. Increased and ongoing communication between DHS HIV/AIDS case management/care advocacy staff and the DHS managed care coordination committee would be useful to increase awareness of public and private resources for persons living with HIV/AIDS.
  1. The DHS HIV/AIDS Program will define levels/tiers of “Access to Care” service based on the client’s level of need for Minnesota DHS-funded services for persons living with HIV/AIDS.
  1. The DHS HIV/AIDS Program will update the Minnesota Case Management Standards, incorporating levels/tiers of care including:
  • Greater linkages between Access to Care services and the client’s HIV medical care provider;
  • Determining levels of care provided to clients based on the acuity of the client needs;
  • Caseloads for case managers will be measured by the acuity of the clients they serve;
  • Greater connection between HIV case management and care advocacy services; and
  • Community input on the revisions to the Case Management Standards.
  1. Explore the opportunities for a pilot project of fee-for-service case management services and increased technical assistance for greater Minnesota.
  1. DHS and MDH should explore a standardized intake form/data set for Access to Care service providers.
  1. Explore better linkages and communications among staff conducting case finding, partner notification, training, case management and education.

1

Rationale for Access to Care study

The Minnesota Department of Human Services HIV/AIDS Program Division proposed this study to look at the continuum of outreach, HIV information, care advocacy and case management services funded by the Minnesota Department of Human Services. Summit Health Group was contracted to conduct this seven-month project with oversight from a Project Advisory Committee, input from statewide and diverse stakeholders with DHS staff input. Representatives from the Access to Care Project Advisory Committee identified questions to be answered by the study at their April 23, 2004 meeting. Evaluation questions identified include the following.

Access to Care Project Questions:

  1. Case Manager’s caseload size varies among current HIV funded projects. How have other states addressed the issue of caseload size among their funded grantees and are their standards for different levels of care?
  2. How can the current HIV referral and case management system be improved to maximize available resources and serve increasing numbers of clients?
  3. How can HIV case managers/social workers improve their relationship with HIV health care providers serving the same client (and health care providers improve relationship with case managers)?
  4. What are the strengths and weaknesses of the current care advocacy and case management systems for persons living with HIV/AIDS?
  5. What could a cost-effective, restructured Access to Care system look like to better serve diverse Minnesotans living with HIV/AIDS statewide?
  6. What feedback do stakeholders in the Minnesota Access to Care redesigned system have to improve the system design?
  7. What are the stages in implementing the redesigned Access to Care system in Minnesota and feedback from stakeholders in the initial implementation phase?

The Project Advisory Committee suggested individuals to contact for key informant interviews and supported a survey/interview with these HIV/AIDS service leaders in the state.

Caseload and Financing from other state HIV Programs

Materials were reviewed from twelve states/cities/federal agencies that examined cost effectiveness and standards in care advocacy and case management services for persons living with HIV/AIDS. These are summarized below.

  • State of Oregon, Department of Human Services, July 2003

The Health Division’s HIV/AIDS Case Management Task Force approved a Standard of Service for HIV/AIDS Case Management in 2003. Their “care coordination system” incorporates case management (medical, nursing, psycho-social, social work) with access to care activities, outreach activities, information and referral activities, eligibility determination and benefit counseling activities, adherence/compliance activities and primary care coordination. They identified three general systems of service delivery based on the different type of needs of geographical areas of the state- urban, corridor and rural.

The urban system, in the Portland metropolitan area, is the most complex and comprehensive with an even distribution of primary care throughout the area, HIV-specific case management consortium (The Partnership Project), and extensive provider and support services network that is community-based. The Urban case management system has a comprehensive, centralized case management system with case managers employed by consortium member agencies. A collaborative team model with an RN and social worker case managers co-managing clients is used in this part of the state along with a networked computerized data management system. Services are based on assessed acuity stages: Stage 1=information/referral need; Stage 2=Monitoring; Stage 3=Basic; and Stage 4= Intensive need. Care plans are developed for stages 3 and 4. A standardized intake and assessment is done by any case manager. There are target population-based teams (Latino/a, women and children, multiple diagnosis).

The corridor system serves the areas around six communities (Salem, bend, Eugene, Corvalis, Roseburg and Medford). Between one and three HIV specialists are available for each of the six hub cities for primary care or consultative co-management. Other “social support wrap-around” services are available through local health departments and/or community-based organizations. These “wrap-around” services provide case management through a call or walk-in to determine some type of triage to determine urgent/emergent need with a full assessment done at a later date. The acuity stages are different and include Stage 1= information/referral need; Stage 2=Basic need; Stage 3=Moderate need; and Stage 4=Intensive need. Care plans are developed for stages 2, 3 and 4. The case manager directs thedistribution of support services. Case managers do home visits on Stage 3 and 4.

The rural system is based on rural networks related to rural health care delivery. There are smaller numbers of people with HIV and fewer resources. Medical care is provided by primary care doctors who are not commonly HIV specialists. Part time HIV case management is located in county health departments with a high level of concern for confidentiality and discrimination in the rural communities. The client may call-in or walk-in to a case management service site. Stages of service are the same as the corridor system and include Stage 1= information/referral need; Stage 2=Basic need; Stage 3=Moderate need; and Stage 4=Intensive need. Care plans are developed for stages 2, 3 and 4.

Of particular note were the results of the Quality Assurance audit that looked at compliance with documentation and services provided at each of the four stages of case management. One observation is that there appears to be a higher level of documentation/compliance at case management Stage 3 and Stage 4 compared to Stage 1 and Stage 2.

Visit the Oregon Department of Human Services Website for casemanagement provider tools, standards, report forms, Quality assurance audit results, resources and agencies at

  • Missouri Department of Health and Senior Services

The Division of Environmental Health and Communicable Disease Prevention describes three levels of combined medical and psych-social case management at with a heavy focus on enforcement efforts taken by governmental agencies depending on client compliance.

California – Los AngelesCounty

California administers HIV/AIDS related services out of the California Department of Health Services, Office of AIDS [ are delivered through the county public health system. The state has two data collection systems: ELI, evaluating local interventions, is a data collection focused on basic process evaluation of all local interventions funded by the Office of AIDS or by CDC, and HIV6, is a desktop system to record, process and report data about counseling and testing clients statewide.

California funds 34 sites for Early Intervention Programs, a multidisciplinary model to integrate HIV transmission prevention goals and services with care and treatment for clients from the time of a HIV-positive test result. The goal is to prolong health and productivity and interrupt the transmission of HIV to others. The EIP are targeted and designed for specific populations: 12 program sites are in major urban areas, Women’s Early InterventionCentersare in four sites, there are three regional sites, encompassing 22 rural counties, five sites are expansion sites and include funds earmarked for services to people of color. Information about this program and other transmission prevention and care programs is available at in the State of the State 2001 report.

The County of Los Angeles funds case management throughout the County and clients must use the AIDS service organization designated by the County of Los Angeles to serve their area. Los AngelesCounty is divided into eight Service Planning Areas (SPAs) and AIDS Project LA (APLA) services SPA4, central or downtown Los Angeles. The online resource directory, contains more than 1300 listing for HIV/AIDS services and providers in 38 categories, including case management. Only APLA provides case management for residents of SPA4 but they have other programs, like Food Bank and Dental Clinic, that may be used by other LA County residents with referral from their case managers. LA County runs Client Line (213-201-1500), an online telephone case management service for clients who are in need of assistance but do not have multiple or complex service needs, and to people who are not eligible for individualized case management services. Trained volunteers and interns staff client Line.