Transcript Michael Green, PhD Chief of Planning Division of HIV and STD Programs (DHSP) Department of Public Health, County of Los Angeles Slide 1 Craig A.

Michael Green, PhD
Chief of Planning
Division of HIV and STD Programs (DHSP)
Department of Public Health, County of Los Angeles
Slide 1
Craig A. Vincent-Jones, MHA
Executive Director
Los Angeles County Commission on HIV
LOS ANGELES COUNTY
COMMISSION ON HIV
I.
Los Angeles County EMA
II.
Impetus for Integrated Planning
III. Process for Integrated Planning
IV. The New Configuration
V.
Slide 2
Lessons Learned
LOS ANGELES COUNTY
COMMISSION ON HIV
LOS ANGELES COUNTY
 Most populous county in US.
 Greater population than 42
individual states.
 88 incorporated cities and
many unincorporated areas.
 One of the most racially/
ethnically diverse areas
in the US.
 Urban, suburban and rural areas.
 Divided by the San Gabriel and
Santa Monica mountain ranges.
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LOS ANGELES COUNTY
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(1)
(2)
Slide 4
(3)
Estimate that 18.1% of HIV+ in LA County are unaware of their infection;
modified from CDC estimate.
Of 4,853 notifications pending investigation, estimate half of 2,400 who have
detectable VL or confirmatory test to be unduplicated cases.
Of 4,200 notifications pending investigation, estimate about 2,000 who have
detectable VL or confirmatory test to be unduplicated cases.
LOS ANGELES COUNTY
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 Announced February 2011
 Organizationally realigned the former HIV
Epidemiology Program, Office of AIDS Programs
and Policy and STD Prevention and Control
 Efficiency and evidence-based driven
 Largest fully integrated local health department
 Controls all HIV and STD health department
programming
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LOS ANGELES COUNTY
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
HIV and STD Prevention and Control
 HIV Testing Services
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Targeted, Routine, Social Network, Mobile Unit-Based
 STD Screening and Treatment Support
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Public Sector/Private Sector
HIV Care and Treatment Services
Integrated Behavioral Health in Primary Care Settings
Navigation, Linkage, Retention Initiatives
Geographic-specific STD Control Effort
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LOS ANGELES COUNTY
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Syndemic Planning and Geospatial Analysis
Use of Surveillance Data/Data Matching/Data Sharing
Public Health Investigation and Use of Community
Embedded Disease Intervention Specialists
Biomedical Interventions (PEP)
Integrated TLC+, PrEP and Social Network Testing
Housing Services Coordination with HOPWA
Medical Care Coordination
Integrated Community Planning
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LOS ANGELES COUNTY
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
Evaluate HIV/STD surveillance, program, and other
data to identify areas for programmatic focus,
inform planning processes, and implementation
strategies by:
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Slide 8
Matching HIV/STD surveillance and program data to
evaluate testing, linkage, retention, and viral load
suppression across the spectrum of engagement in care,
Use of HIV/STD surveillance data to identify geographic
areas and populations most impacted by HIV/STD
syndemics,
Improve accuracy and efficiency of data collection and
facilitate useful reporting.
LOS ANGELES COUNTY
COMMISSION ON HIV
“It’s going to be messy. Whether you support it, or whether
you oppose it . . . it’s going to be messy.”

David Brooks, political pundit, on health care reform
“It’s going to be messy. It’s going to be politically contentious.
But it—in the end—it’s going to happen.”

EJ Robinson, political pundit, in response to David Brooks
Accepting that transformational change of any type is difficult—it creates
anxiety and disquiet (even among those who support it), and will be full of
unexpected events and turns—before you begin . . . is key to a process
that, eventually, finds its way to the desired result.
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LOS ANGELES COUNTY
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Improved planning and coordination of services
and resources—
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National HIV/AIDS Strategy (NHAS)
Treatment Cascade (national “Continuum of Care”)
Early Identification of Individuals with HIV/AIDS (EIIHA)
Testing, Linkage to Care, Treatment Plus (TLC+)
Enhanced Comprehensive/HIV Prevention Planning (ECHPP)
Emergence of disparities/inequities/social determinants as a key Commission focus and priority
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LOS ANGELES COUNTY
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Implementation of the Affordable Care Act (ACA):
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Need to improve service delivery efficiency and reduce
duplication of effort
Prospects of additional savings and resources
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Need to generate more enthusiasm/momentum for HIV
prevention planning after CDC changes
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Consistent with the Commission’s strategic plan
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Possible reductions in federal and state Ryan White/federal
appropriations and other resources
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LOS ANGELES COUNTY
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1)
Commission and PPC attempted merger in 2002:
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Commission approved it; PPC opposed it—unanimously
PPC was concerned that care/treatment focus would
shift attention away from prevention,
Commission’s relationship with DHSP concerned PPC,
The planning body votes created hard feelings/
resentments for a decade.
2)
Quarterly joint Co-Chair meetings not successful.
3)
Joint Public Policy (JPP) Committee formed, 2008:
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Three separate attempts to integrate policy work,
Both bodies’ single policy unit for five years.
LOS ANGELES COUNTY
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LOS ANGELES COUNTY
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In 2009, Commission and PPC formed a joint
“Integration Task Force” to improve collaboration
and exchange between the two planning bodies—
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Slide 14
The first year was spent educating members about the full
range of LA County’s HIV services and activities—and
defining terminology acceptable to both groups;
Began integrating care/prevention services/interventions
into a TLC+ framework; ECHPP eventually became the
predominant strategic prevention approach.
LOS ANGELES COUNTY
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Transformation depends on “change leaders” capable
of ascertaining when timing and momentum are right
for change (“catalysts for change”):
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Following International AIDS Conference (IAC), where
“treatment as prevention” was predominant;
Improved relations between two planning bodies due to
joint development of Comprehensive HIV Plan;
Diminished enthusiasm for HIV prevention planning due to
limited role in CDC’s new HIV Planning Guidance;
In preparation for ACA roll-out, HIV service delivery will be
re-organized/re-structured on a broader scale.
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LOS ANGELES COUNTY
COMMISSION ON HIV
Integration Task Force becomes Comprehensive HIV
Plan (CHP) Task Force, to oversee Plan development.
Final Los Angeles County Comprehensive HIV Plan
2013 – 2017 submitted to HRSA and CDC, 3/2013:
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Links HIV prevention, care and treatment services to NHAS
goals, treatment cascade, and ACA;
Local continuum of care consistent with local/national
priorities; addresses disparities/health inequities;
Goals/objectives to be monitored/updated annually.
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LOS ANGELES COUNTY
COMMISSION ON HIV
FRAMEWORK: The term “unification” was selected
carefully—to represent a union of interests, rather
than one interest consuming or absorbing the other.
TIMELINE: Commission and PPC agreed to complete
the process in six months—by July 2013—because:
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procrastination weakens stakeholder resolve/enthusiasm;
the HIV planning body could not devote more time to unification with
ACA implementation advancing so rapidly;
unification needed a sense of urgency to generate a timely County
response (from other, necessary departments).
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LOS ANGELES COUNTY
COMMISSION ON HIV
Following successful development of the CHP, the
Commission agreed (unanimous) to “merge” in Spring
2012; PPC agrees (unanimous) in September 2012:
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Two (2) co-chairs from the Commission/and 2 from the PPC;
Merger is formally renamed a “unification”; and
CHP Task Force agrees to an expedited timeline.
LOS ANGELES COUNTY
COMMISSION ON HIV
CHP Task Force anticipated the following challenges:
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Generating/maintaining stakeholder support/enthusiasm;
A continuing, relevant role for HIV community health
planning after implementation of the ACA;
Integrating HIV care and prevention perspectives into a
single, jurisdictional HIV response;
Presenting HIV care and prevention in a balanced manner
that gives both perspectives sufficient consideration;
Synchronizing planning, priorities, allocations and standards
of HIV care and prevention;
Effectively blending two distinct organizational cultures.
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LOS ANGELES COUNTY
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Los Angeles County
Commission on HIV
Slide 20
Prevention Planning
Committee (PPC)
LOS ANGELES COUNTY
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LOS ANGELES COUNTY
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LA County Board of Supervisors
[Chief Elected Official (CEO), per Ryan White (RW)]
LA County Chief Executive Officer (CEO)
Executive Office of BOS
Department of Public Health
(RW Grantee)
Commission on HIV
Division of HIV/STD Programs
(RW Planning Council and HIV Planning Group)
(RW Administrative Agency)
Consumers
Slide 22
Providers
Other Stakeholders
LOS ANGELES COUNTY
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chartered County
commission with
multiple roles.
:
LA County Charter Code
Title 3—Chapter 29,
governing Commission,
also known as the
.
Slide 23
• Ryan White Part A Planning Council;
• Primary community advisory mechanism on
HIV-related matters to the Los Angeles County
Board of Supervisors (BOS);
• HUD HOPWA SPNS grantee;
• Additional roles due to unification (e.g., HPG).
• Code 3.29, legalauthorityempowersCommission;
• Summarizes Commission role(s), membership,
responsibilities, etc.;
• Changes to Commission must be approved by
BOS and chaptered in Code;
• Unification began with the Ordinance.
LOS ANGELES COUNTY
COMMISSION ON HIV
1) During Fall 2012, the CHP Task Force recommended hiring a consul-
tant to 1) facilitate unification planning, and 2) who had sufficient
RWPA/CDC expertise to ensure that federal guidance/expectations
would be reliably represented and properly addressed in unification.
2) The Task Force felt that using an outside facilitator was beneficial in a
number of ways: it would enhance more orderly decision-making,
and could mitigate the impact of unexpected surprises or results.
3) As a non-conflicted, third-party facilitator, the consultant would also
be better equipped to identify and confront subjective bias or unresolved conflict if it emerged, and to maintain greater objectivity.
4) In 12/2012, HRSA approved LA County’s request for Technical Assis-
tance (TA) and assigned Emily Gantz McKay to serve as the consultant for the unification. Ms. Gantz McKay began her work 1/2013.
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LOS ANGELES COUNTY
COMMISSION ON HIV
1.
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11.
CHP Task Force and TA revise Commission Ordinance/By-Laws
Revised By-Laws submitted to Commission/project officers
Commission/PPC approve plan for transitional Open Nominations process to recruit/select new members
Membership application, evaluation/scoring materials revised
Membership applications due
Membership interviews
Commission/PPC nominates members to BOS
Commission/PPC approve revised By-Laws
BOS appoints new members at two separate meetings
New membership seated at new Commission’s inaugural meeting/
Ordinance approved by BOS
Ordinance authorizing new Commission enacted/membership
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LOS ANGELES COUNTY
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MEMBERSHIP: The formation of a unified planning
body requires a new membership, and is enacted
when the new members are installed:
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a limited number of membership seats would be added (Board of
Supervisors concern);
equal attention to RWPA and CDC guidance—even though RWPA
“requires” and CDC only “recommends” specifics;
anyone wishing to serve on the new planning body must (re-)apply—
regardless of a candidate’s current planning body member status or
participation on the Task Force.
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LOS ANGELES COUNTY
COMMISSION ON HIV
Task Force
assigned
membership
nomination
responsibilities
to work group.
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LOS ANGELES COUNTY
COMMISSION ON HIV
Transitional Open Nominations
Process Results: 46 members
and 15 alternates appointed by
the BOS—leaving only five (5)
seats vacant.
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Complies with “reflectiveness”/
“representation” requirements
from RWPA, and CDC’s Parity,
Inclusion and Representation
(PIR) recommendations;
Three types of members on the
new Commission: returning
Commission members, returning
PPC members, and new members
—representing educational/
orientation challenges.
Slide 28
Membership: 79 applications
submitted by first deadline.
Interest in joining the new Commission far
exceeded the projected response, in part
due to (as expressed by applicants):
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Unification generated community enthusiasm;
HIV stakeholders got involved due to changes;
Applicants felt it was a new organization;
It was an opportunity to bring new issues;
Applicants excited about the new direction.
Still Unresolved: defining “HIV
prevention” consumer organizationally.
LOS ANGELES COUNTY
COMMISSION ON HIV

Structure (e.g., roles/authority)
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Policy (e.g., rev. conflict-of-interest)
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Organization (e.g., committees)
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Procedural (e.g., allocations)
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Membership
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Training
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Responsibilities
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Scope/Span (e.g., STDs)
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Staffing/Support
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Budgeting
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LOS ANGELES COUNTY
COMMISSION ON HIV
Committee/caucus
structure remained
mostlyunchanged.
Functional organization around the
type of work, rather
than topic or content. Each committee deals with care and prevention
issues equally, not in “service siloes.”
Operations
Committee
Slide 30
Planning, Priorities
and Allocations
(PP&A) Committee
Los Angeles County
Commission on HIV
Community
Engagement
Task Force
Public Policy
Committee
Executive Committee
Standards and Best
Practices (SBP)
Committee
LOS ANGELES COUNTY
COMMISSION ON HIV
Still much work left to do before Commission
can claim full HIV planning integration . . .
Slide 31
and, . . .some work goes on— indifferent to the
time-consuming nature of integration!
LOS ANGELES COUNTY
COMMISSION ON HIV
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Much of the work occurs afterwards
Stakeholder investment/buy-in
Support of the grantee/CEO
Right/opportune timing
“Consumer” definitions
Jurisdictional similarities
Aggressive timeline
Creating enthusiasm and momentum
Slide 32
LOS ANGELES COUNTY
COMMISSION ON HIV
Issue #1: How do we define “HIV-negative or prevention consumer” [vs.
“unaffiliated (HIV-positive) consumer” from HRSA]?
Issue #2: How do we integrate very different “cultures” of the former
Commission and former PPC?
Issue #3: What is the meaning of “integration” in an organizational
setting (vs. used as a programmatic reference)? For example,
what are the indicators that an organization has successfully
integrated, vs. successfully collaborated or partnered?
Issue #4: How do we allocate funds for prevention activities that have
already been determined?
Issue #5: What are the decisions that must be made before two planning
groups can integrate (vs. what decisions can be left to the
planning body to make after it has integrated)?
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LOS ANGELES COUNTY
COMMISSION ON HIV
EIGHT WAYS TO PREPARE
8 WAYS FOR A SUCCESSFUL TRANSFORMATION
How LA Did It
#1
Establish a Great Enough Sense of Urgency
Expedited Timeline,
membership process
#2
Create a Powerful Enough Guiding Coalition
CHP Task Force was
established/successful
#3
Have a Vision
The vision was key
foundation of CHPlan
#4
Communicate the Vision by a Factor of Ten
Each agenda included
topic and work
#5
Remove Obstacles to the New Vision
Took on harder tasks
first to build momentum
#6
Plan for and Create Short-Term Wins
Another benchmark
approved at each mtg.
#7
Don’t Declare Victory Too Soon
We haven’t! Expect it
may take 2 yrs to assess
#8 Anchor the Changes in the Organizational Culture
Slide 34
This will
time asCOUNTY
LOStake
ANGELES
new COMMISSION
culture emerges
ON HIV
Michael Green, PhD
Craig Vincent-Jones, MHA
Chief of Planning
Executive Director
Division of HIV/STD Programs Los Angeles County Commission on HIV
600 Commonwealth, 10th Floor
3530 Wilshire Blvd., Ste. 1140
Los Angeles, CA 90005
Los Angeles, CA 90010
213.351.8002
213.738.2816
[email protected]
[email protected]
Slide 35
LOS ANGELES COUNTY
COMMISSION ON HIV