Tools for Grantees: Chief Elected Official Guide

Executive Summary

• Title I: CEO Responsibilities
• Title II: CEO Responsibilities
  
• Implementing CEO Duties

CEO Duties

• Title I: Administration/Use of Funds
  
• Title I: Use of Funds
  
• Title I: Planning

• Title II: Administration/Use of Funds
  
• Title II: Use of Funds
  
• Title II: Planning

HAB/DSS Expectations of Title I and II CEOs

When the CEO Designates Responsibility for Title I

• Avoiding Problems
  
• Making Intergovernmental Agreements (IGAs) Meaningful
  
• Staff Roles
  
• Anticipating and Solving Problems

  The Planning Council is Not Representative
  Fund Disbursement is Delayed
  Planning Council Discord and Public Perceptions of CEO Disinterest
  Contracting Not Reflective of Planning Council Priorities

Executive Summary TOP
The Ryan White CARE Act provides Federal funding to local communities and States to fill gaps in care for people living with HIV disease (PLWH). Under two programs of the CARE Act-Title I (urban areas) and Title II (States)-responsibility for managing these funds falls to chief elected officials (CEOs), such as mayors, county executives and governors. In turn, CEOs often delegate implementation to staff within their own offices or to agencies like health departments.

As the recipient of CARE Act Title I and Title II funds, the CEO spearheads the development of a comprehensive HIV/AIDS service system. CARE Act awards include both formula grants based on the number of HIV/AIDS cases and competitive supplemental funds for areas with severe need. In using these resources, CEOs are required to work in partnership with communities to plan and deliver HIV/AIDS services. CEO partners include the administrative agency designated by the CEO to oversee the program (e.g., the health department), the Title I or II planning body and its diverse voices of expertise, and PLWH. Other CARE Act partners include city or county finance or grants offices that disburse and account for CARE Act funds.

The CEO ensures that CARE Act partners meet their legislative requirements and submits written assurances that requirements are being met. Assurances are submitted as part of the annual funding application to HRSA's HIV/AIDS Bureau, Division of Service Systems (HAB/DSS)-the office that administers Titles I and II.

This guide outlines CEO responsibilities as follows: (1) Assuring that grant funds are administered appropriately, and (2) Facilitating planning in partnership with Title I and II planning bodies to best meet the needs of people living with HIV disease. In some areas, these duties are the same for Titles I and II. In others, they vary. This guide can be used to orient staff of administrative agencies and planning bodies for working with the CEO to implement Title I or Title II programs.

CEO Responsibilities TOP
CEOs have responsibilities in two major areas: administration of funds and planning.

Title I: Administration/Use of Funds. The Title I CEO establishes a mechanism to administer funds for the timely delivery of essential services to PLWH throughout the eligible metropolitan area (EMA). Title I programs must be used to address gaps in HIV services not being met by other programs. CARE Act services must be provided regardless of an individual's ability to pay. Local funding of HIV service programs must be maintained at a level at least equal to the prior year's level to ensure that CARE Act funds are used to supplement, but not replace, local spending. Other administrative responsibilities of Title I CEOs are as follows:

• CEOs must ensure that Title I funding for services to women, infants, children, and youth with HIV disease is in proportion to their representation among total AIDS cases in an EMA, if not provided through other programs.
  
• Establish intergovernmental agreements with other jurisdictions within the EMA that provide HIV-related services that account for at least 10 percent of the EMA's reported AIDS cases.
  
• The CEO must assure that Quality Management programs are established to assess the extent to which HIV health services are consistent with the most recent Public Health Service (PHS) treatment guidelines and to develop strategies to ensure that these services are consistent with guidelines to improve access to and quality of HIV health services.
  
• CEOs must require Title I providers to participate in an HIV/AIDS community-based continuum of care, if such exists, and maintain appropriate relationships with "key points of entry" to assure referrals into care for PLWH.
  The CEO must assure that outreach is conducted to inform clients of the availability of services.
  
• CEOs must assure that the maintenance of effort requirements are met and that existing services and funds are not supplanted with CARE Act funds.

CEOs must ensure that all funds are expended in accordance with established PHS regulations and CARE Act legislative requirements. This includes assuring that their administrative agent is in compliance with all fiscal requirements, including formally addressing grievances regarding the distribution of funds.

Title I: Planning. The CEO must establish a Title I planning council and, once the planning council is established, appoint members through the planning council's nominations process. Planning council membership must meet legislative requirements for representation and be selected through an open nominations process that has been approved by HRSA. Members must be trained to enable them to fulfill their responsibilities, in accordance with guidance from HAB/DSS. Title I CEOs must enable planning councils to carry out their legislatively mandated responsibilities:

• Conduct an assessment of local community needs
• Develop a comprehensive service plan, compatible with existing State and local plans
• Allocate funds according to service priorities set by the planning council
• Participate along with other CARE Act partners in the development a Statewide Coordinated Statement of Need (SCSN) to enhance coordination among CARE Act programs in addressing key HIV/AIDS care issues
• Coordinate with Federal, State, and locally funded grantees providing HIV-related services, and
• Assess the efficient administration of funds.

Title II: Administration/Use of Funds. The Title II CEO establishes a mechanism to administer funds for the timely delivery of essential services to PLWH throughout the State. Title II programs must be used to address gaps in HIV services not being met by other programs. There are five program areas under which States can deliver Title II services, providing Title II CEOs with flexibility to meet unique needs in their areas. CARE Act services must be provided regardless of an individual's ability to pay. State funding of HIV service programs must be maintained at a level at least equal to the prior year's level to ensure that CARE Act funds are used to supplement, but not replace, local spending. Other administrative responsibilities of Title II CEOs are as follows:

• CEOs must ensure that Title II funding for services to women, infants, children, and youth with HIV disease is in proportion to their representation among total AIDS cases in the State, if not provided through other programs.
  
• The CEO must assure that Quality Management programs are established to assess the extent to which HIV health services are consistent with the most recent Public Health Service (PHS) treatment guidelines and to develop strategies to ensure that these services are consistent with guidelines to improve access to and quality of HIV health services.
  
• The CEO must require Title II providers to participate in an HIV/AIDS consortium, if such exists, and to maintain appropriate relationships with "key points of entry" to assure referrals into care for PLWH.
  
• The CEO must assure that outreach is conducted to inform clients of the availability of services.
  
• CEOs must assure that maintenance of effort requirements are met and that existing services and funds are not supplanted with CARE Act funds.

CEOs must ensure that all funds are expended in accordance with established PHS regulations and CARE Act legislative requirements. This includes assuring that their administrative agent is in compliance with all fiscal requirements. Title II CEO duties unique to Title II are as follows:

• Take administrative or legislative action to ensure that good faith efforts are made to notify a spouse of a known HIV-infected patient that such spouse may have been exposed to HIV and should seek testing.
  
• Assure that any State match requirements are met.
  
• Assure that the AIDS Drug Assistance Program is operated in a fair and efficient manner to enable the most patients to be served with available resources.

Title II: Planning. The Title II CEO or designee must help ensure that health services planning is conducted with the broad and diverse input of key stakeholders, including PLWH and historically underserved populations. Public hearings must be held concerning the intended use and distribution of Title II funds. The CEO must assure that Title II planning bodies carry out the following legislative responsibilities: OR The CEO must assure that the following legislative responsibilities are carried out (by Title II planning bodies or directly by the State):

• Participation in needs assessment activities to collect data for conducting HIV services planning.
  
• Help in establishing service priorities for the allocation of funds.
  
• Participation in the development of a comprehensive plan for the provision of HIV services throughout the State, which must be updated every three years.
  
• Periodic convening of a meeting of PLWH, representatives of CARE Act Titles operating in the State, HIV service providers, and public agency representatives for the purposes of developing and updating the SCSN.
  
• Ensuring coordination between the CARE Act and other Federal HIV programs operating in the State.
  
• Assess the efficient administration of funds.

Implementing CEO Duties TOP
The CEO and CARE Act partners must clearly communicate what each expects of the other. Tables in the appendix of this guide outline mutual expectations and discuss potential problems and communication gaps. Clarity around roles is especially important when the CEO designates administration of the CARE Act grant. When duties are delegated, the following suggestions can help the CEO oversee the grant:

• Ensure designees have appropriate knowledge and skills and understand what is expected of them.
  
• Ensure that CARE Act partners have a way to communicate regularly with each other.
  
• Be sure that staff review and monitor Intergovernmental Agreements (IGAs), so they are operational-not merely paper-agreements (Title I only).
  
• Require designees and administrative agents to build and maintain relationships with HIV-infected and affected communities.
  

CEO staff can play an important role in CARE Act program administration. When lead responsibility has been designated to another department, staff should undertake the following:

• Maintain positive relationships with affected populations in the EMA or State.
  
• Maintain relationships with other CEOs, such as coordination between Titles I and II.
  
• Work with planning bodies and represent the CEO at meetings.
  
• Work with external administrative agencies to coordinate programs and budgets.
  
• Mediate differences between public agencies that report to the CEO.

CEO Duties TOP
The CEO is the official recipient of CARE Act funds. Under Title I, grants go directly to the CEO of a city or urban county in an EMA. Under Title II, grants go to the governor of a State. As such, the CEO has ultimate responsibility for the grant and for ensuring that all CARE Act partners meet legislative requirements, as well as the expectations of HAB/DSS. CEO responsibilities occur in two major areas: Administration of Funds and Planning.

The CEO and the Grantee. The Chief Elected Official (CEO) is the official recipient of CARE Act Title I or Title II funds and is ultimately responsible for administering all aspects of Title I or Title II CARE Act funds and ensuring that all legal requirements are met. Grantee is the term used to describe the entity that receives CARE Act funds and has responsibility for administering the award. The CEO often delegates responsibility for Title I or Title II grant administration to an agency such as the health department-and in such cases it is referred to as the grantee.

Title I CEO: Administration/Use of Funds TOP
Establishing the Administrative Mechanism. The Administrative Mechanism is how Title I funds are disseminated locally. The CEO in Title I may delegate administrative responsibility for the grant (usually to the health department) but is responsible for ensuring that the program meets legislative mandates and that all CARE Act partners work together to deliver quality care and services to PLWH. CEOs must ensure that funds are allocated fairly across the service area and target underserved populations. The planning council assesses the effectiveness of the funding allocations process, but the CEO helps make sure that funds get out to service providers in a timely manner. The CEO should respond quickly to concerns regarding allocation of CARE Act funding and make needed corrections.

Establishing Intergovernmental Agreements. The Title I CEO must establish Intergovernmental Agreements (IGAs) with the CEOs of those political jurisdictions that provide HIV health services and include not less than 10 percent of the reported AIDS cases in the EMA.

Services to Women, Infants, Children, and Youth. The CEO must ensure that funding for services to women, infants, children, and youth is proportionate to their representation among the EMA's total AIDS cases. A waiver may be granted when an EMA can demonstrate that the needs of these populations are being met through other sources, such as Medicaid, the State Children's Health Insurance Program (SCHIP), or other Federal/State programs, including CARE Act programs. The CARE Act defines these populations as follows: Women - 25 years and older; Youth - 13-24 years old; Children - 2-12 years old; Infants - less than 24 months old.

Filling Gaps in Care and Maintenance of Effort. CEOs must ensure that CARE Act funds are used only to fill gaps in care, not to pay for services covered by other available health care funding sources, such as Medicaid or Medicare. Grantees must ensure that PLWH are enrolled in other health care programs for which they are eligible. Further, CEOs must assure that grantees maintain their prior year's level of spending for HIV-related care and provide services regardless of an individual's ability to pay or his/her health condition.

Quality Management Programs. The CEO assures that the grantee develops and implements quality management programs to ensure both that PLWH eligible for treatment and health-related services have access to those services, and that the quality of those services meets certain criteria. CEOs must sign assurances that quality management programs are in place and meet their objectives.

Coordination with Early Intervention Service Providers (EIS). The Title I CEO must ensure that Title I services are coordinated with other CARE Act programs, existing prevention activities, and other federally funded HIV related programs and services.

Definitions

Early Intervention Services under Title I and Title II include counseling, testing, referral, and information services designed to bring HIV-positive individuals into the local HIV continuum of care. The CARE Act allows the use of Title I and II funding for early intervention services (EIS) that serve to refer PLWH into care systems. Prior to using CARE Act funds for EIS, grantees must show that existing EIS services are insufficient.

Points of Entry are health care access points frequently used by traditionally underserved HIV-positive individuals to help meet their medical and social service needs. They are therefore key access points for referring such individuals into the HIV care system. The CARE Act defines these points of access to include such entities as: Emergency rooms; Substance abuse treatment programs; Detoxification centers; Adult and juvenile detention facilities; Sexually transmitted disease clinics; HIV counseling and testing sites; Mental health programs; Homeless shelters; Public health departments; HIV counseling and testing sites; Federally qualified health centers; and Other specified health care points of entry.

Title I CEO: Use of Funds. CARE Act legislation specifies the following.

• No more than 5 percent of Title I funds may be used for routine grant administration and monitoring, such as developing annual funding applications, program and financial reports, meeting audit requirements, reimbursement/accounting systems, and awarding local contracts.
  
• Up to 5 percent or $3 million, whichever is less, may be used for quality management programs to ensure that HIV health services are consistent with Public Health Service guidelines and to monitor the improved health status of HIV-positive clients.
  
• No more than 10 percent may be spent collectively by providers and subcontractors on administrative costs such as "usual and recognized" overhead, management and oversight of programs, and program support activities such as quality assurance.
  
• Funds may not be used for construction, land purchase, or cash payments to intended recipients of services.
  
• Funds must be used for capacity development in communities of color and other underserved areas where the HIV epidemic is having a disproportionate impact. Title I funds may also be used for strategies to sustain new providers and organizations.

Eligible Services

• Outpatient and ambulatory health care, including HIV specialty care, substance abuse and mental health treatment, oral health, and home health or hospice care.
• Comprehensive treatment services, including treatment education and prophylaxis/treatment for opportunistic infections.
• Case management services that prevent unnecessary hospitalization or that expedite discharge as medically appropriate.
• Support and health services that enhance access to and retention in primary medical care and promote health and quality of life.
• Outreach activities and early intervention services intended to identify and link into care individuals with HIV disease who know their HIV status and are not receiving HIV-related health services. EIS services must fill documented gaps in services and increase resources in the area; Title I funds cannot replace existing funds for EIS.

Eligible Providers

Funding may be awarded to public or nonprofit entities, such as community-based organizations, hospices, ambulatory care facilities, community health centers, migrant health centers, homeless health centers, substance abuse treatment programs, mental health programs, hospitals, and hospices. Private for-profit entities are eligible to receive funding if they are the only available provider of high quality HIV care in the area.

Title I CEO: Planning
CEOs must assure that the designated planning body undertakes planning for the use of CARE Act funds. Under Title I, CEOs appoint planning council members who conduct needs assessments, set service priorities for the allocation of funds, and develop a comprehensive plan to guide them in managing the HIV service delivery system. The grantee contracts for services based on the planning council's allocation of funds to their established priorities.

Title I Planning Councils. The Title I planning council membership must reflect the demographics of the population of individuals with HIV disease in the EMA. Special consideration must be given to historically underserved populations and those experiencing significant disparities in access to services. No less than 33 percent of planning council members must be PLWH who receive Title I services (in the case of minors, this would include their caregivers) and who are unaligned with provider agencies that receive Title I funding. Alignment is defined to include board membership and employment/consulting arrangements with agencies receiving Title I funding.

In addition to the 33 percent PLWH, planning council members must include: Health care providers, including Federally qualified health centers; AIDS service organizations (ASOs) and community-based organizations (CBOs) serving affected populations; Social service providers, including housing and homeless services providers; Substance abuse treatment providers; Mental health providers; Local public health agencies; Hospital planning agencies or health care planning agencies; Affected communities, including people with HIV disease and historically underserved groups and subpopulations; Non-elected community leaders; State Medicaid agency; State agency administering the Title II program; CARE Act or other programs serving women, children, youth and families; CARE Act Title III grantees; Grantees under other Federal HIV programs, including HIV prevention providers; and Formerly incarcerated PLWH or their representatives.

Planning Council Operations. CEOs must assure that planning councils have in place a variety of policies and procedures, including the following:

• Nominations for members based on an open process, with criteria clearly stated and publicized, including a conflict of interest standard
  
• Training for planning council members so they are able to fully participate (Grantee applications need to include plans for training new members, including training timelines, goals, and budgets. The CEO and planning council chairs will need to submit signed assurances, along with the funding application, that such training will take place upon receipt of materials from HAB/DSS.)
  
• Leadership procedures ensuring that the planning council is not chaired solely by an employee of the grantee
  
• Planning council meetings that are open to the public and minutes that are publicly available and that protect the medical privacy of individuals
  
• Bylaws that establish how the planning council will conduct business, and
  
• Grievance procedures with respect to funding, including procedures for submitting grievances that cannot be resolved informally or by mediation to binding arbitration.

Assessing Needs. Needs assessment is a collaborative activity of the planning council, grantee, and community, and is used as the basis for other CARE Act planning activities including priority setting and resource allocation and planning. Needs assessments determine needs in specific areas such as:

• PLWH who know their HIV status but are not in care
  
• Disparities in access to care for certain populations and underserved groups
  
• Coordination between care programs and providers of HIV prevention and substance abuse treatment services
  
• Outreach and early intervention services, and
  
• Capacity development.

Priority Setting and Resource Allocation. Based on the findings of the needs assessment, the planning council establishes priorities for the provision of HIV services in the local community. Service priorities are based on:

• The size and demographics of the population of individuals with HIV disease and their needs, including those who know their HIV status but are not in care
  
• Cost effectiveness and outcome effectiveness of proposed services and strategies
  
• Priorities of PLWH for whom services are intended
  
• Coordination of services with programs for HIV prevention and treatment of substance abuse
  
• Availability of other governmental and non-governmental resources in the service area, and
  
• Capacity development needs, resulting from disparities in the availability of services for underserved populations.

Once service priorities are established, the planning council makes resource allocations. This process involves the planning council in determining how much funding will be dedicated to each service category. The planning council does not, however, select the providers to deliver services, or participate in the management of service provider contracts.

Comprehensive Plan. The CEO must assure that the planning council develops a comprehensive plan for services, which is compatible with other State, and local plans for the delivery of HIV services. This plan should be updated every three years. Planning is done by a broad group of people representing the epidemic in the EMA, including PLWH. Planning is based on needs assessment results. HAB/DSS expects EMAs to develop multi-year comprehensive plans that will:

• Address disparities in HIV care, access, and services among affected subpopulations and historically underserved communities
  
• Establish and support an HIV care continuum
  
• Coordinate resources among other Federal and local programs, and
  
• Address the needs of those that know their HIV status and are not in care, as well as the needs of those who are currently in the care system.

As well, comprehensive plans must now include strategies that:

• Identify individuals who know their HIV status but are not in care and inform these individuals of services and enable their use of HIV-related services
  
• Eliminate barriers to care and disparities in services for historically underserved populations
  
• Provide goals, objectives, and timelines (as determined by the needs assessment)
  
• Coordinate services with HIV prevention programs including outreach and early intervention services
  
• Coordinate services with substance abuse prevention and treatment programs, and
  
• Ensure compatibility with existing State and local service plans including and in particular the Statewide Coordinated Statement of Need, convened by Title II.
  
  

Coordination. The CEO must ensure that Title I programs coordinate their services with other CARE Act titles and other Federal HIV programs operating in the EMA, including providers of EIS. This is necessary to ensure referral into care for those who are newly diagnosed with HIV and those who know their HIV status but are not participating in a system of care. Another goal of coordination is to ensure that CARE Act funds are used to fill gaps in service, and that PLWH are enrolled in non-CARE Act programs for which they are eligible. The CEO must assure the development and updating of the SCSN, for which Title II has lead responsibility. Representatives of the Title I grantee and the planning council are required to participate in the SCSN process.

Responsibilities of the Title II CEO TOP
The Title II CEO has duties that are similar to the Title I CEO with respect to program administration and HIV services planning. In Title II, the governor may designate responsibility for the grant to someone like the State health commissioner. When this is done, that person in effect becomes the CEO; however, the CEO (governor) maintains the ultimate responsibility of all aspects of managing and accountability for the Title II program.

Title II CEO: Administration/Use of Funds

Services to Women, Infants, Children, and Youth. The CEO must ensure that Title II allocations for services to women, infants, children, and youth is proportionate to their representation in the State's AIDS cases. A waiver may be granted when a State can demonstrate that the needs of these populations are being met through other sources such as Medicaid, the State Child Health Insurance Program (SCHIP), or other Federal/State programs, including CARE Act programs. The CARE Act defines these populations as follows: Women - 25 years and older; Youth - 13-24 years old; Children - 2-12 years old; Infants - less than 24 months old.

Filling Gaps in Care and Maintenance of Effort. Title II CEOs must ensure that CARE Act funds are used to fill gaps in care and do not pay for services provided by other health care programs. Grantees must ensure that PLWH are enrolled in other health care programs for which they are eligible. Further, States must maintain their prior year's level of spending for HIV-related care and services.

Quality Management Programs. The Title II CEO must assure that quality management programs are established to ensure both that PLWH eligible for treatment and health-related services have access to those services and that the quality of those services meets certain criteria. CEOs must sign assurances that quality management programs are in place and meet their objectives.

Coordination. The CEO must assure that Title II services are coordinated with other services operating in States and local areas. In particular, CARE Act legislation directs that States coordinate care services with providers of HIV prevention and EIS, for the purposes of referring PLWH into care. Special emphasis is given to PLWH who know their HIV status but are not receiving services from a system of care. Title II funding can be used to pay for EIS if grantees can show that available services are insufficient to meet the demand.

Title II CEO: Use of Funds. CARE Act legislation authorizes the following administrative costs for Title II:

• Up to 10 percent of funds may be used for routine grant administration and monitoring activities. A maximum of 15 percent may be used to fund administration, planning, and evaluation activities.
  
• Up to 5 percent or $3 million, whichever is less, may be used for quality management programs to ensure that HIV health services are consistent with Public Health Service guidelines and to monitor the improved health status of HIV-positive clients.
  
• No more than 10 percent may be spent collectively by providers and subcontractors on administrative costs, such as "usual and recognized" overhead, management and oversight of programs, and program support activities such as quality assurance.
  
• Funds may not be used for construction, land purchase, or cash payments to intended recipients of services.
  
• Title II funds may be used for capacity development in communities of color and other underserved areas where the HIV epidemic is having a disproportionate impact. Title II funds may also be used to support efforts to sustain new providers and organizations.

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Title II CEO: Planning
Title II CEOs must assure that planning bodies together with the administrative agency engage in planning to determine how to use CARE Act funds. The grantee or his/her designee is required to engage in a participatory planning process, which includes public hearings to gain community input on the development of the comprehensive HIV plan. Participants in planning should be the same as those for Title I (i.e., a broad and diverse input of key stakeholders, including PLWH and historically underserved populations). Title II CEOs must assure that that a Statewide Coordinated Statement of Need is developed and updated. Participants in development of the SCSN should include representatives of other CARE Act titles operating in the State, PLWH, staff of other public agencies, and HIV health service providers. The SCSN must be updated every three years.

Title II Consortia. Title II funding can be used to establish HIV care consortia, which are associations of public and private health care and support service providers. Consortia conduct needs assessment and comprehensive planning activities with the broad input of key stakeholders, including PLWH and historically underserved communities. Consortia may also be the providers of HIV services and care. Title II grantees must consult with providers of HIV services and consumers in making decisions about funding the five Title II program areas (see Ryan White CARE Act description).

Assessing Needs. CEOs must assure that needs assessments are conducted with broad community input to identify gaps in HIV services and the needs of specific communities. Needs assessments focus on the following:

• PLWH who know their HIV status but are not in care
  
• Disparities in access to care for certain populations and underserved groups
  
• Coordination between care programs and providers of HIV prevention and substance abuse treatment services
  
• Outreach and early intervention services, and
  
• Capacity development.

Priority Setting and Resource Allocation. CEOs must assure that based on the findings of the needs assessment, Title II consortia or other planning bodies establish service priorities based on:

• The size and demographics of the PLWH population in the service area and their needs, including people who know their HIV status but are not in care
  
• Cost effectiveness and outcome effectiveness of proposed services and strategies
  
• Priorities of PLWH for whom services are intended
  
• Coordination of services with programs for HIV prevention and treatment of substance abuse
  
• Availability of other governmental and non-governmental resources in the service area, and
  
• Capacity development needs to address disparities in access to services for underserved populations.

Once priorities are established, the Title II planning body determines resource allocations for each service category.

Comprehensive Plan. CEOs must ensure the development of a comprehensive plan for services that is compatible with the SCSN and any other State and local HIV service plans. The grantee must engage in a public advisory process, which includes public hearings, to develop the comprehensive plan. The comprehensive plan must be updated every three years. HAB/DSS expects States to develop multi-year comprehensive plans that will:

• Address disparities in HIV care, access, and services among affected subpopulations and historically underserved communities
  
• Establish and support an HIV care continuum
  
• Coordinate resources among other Federal and local programs, and
  
• Address the needs of those that know their HIV status and are not in care, as well as the needs of those who are currently in the care system.

As well, comprehensive plans must now include strategies that:

• Identify individuals who know their HIV status but are not in care, inform these individuals of services, and enable their use of HIV-related services
  
• Eliminate barriers to care and disparities in services for historically underserved populations
  
• Provide goals, objectives, and timelines (as determined by the needs assessment)
  
• Coordinate services with HIV prevention programs including outreach and early intervention services
  
• Coordinate services with substance abuse prevention and treatment programs, and
  
• Ensure compatibility with existing State and local service plans including and in particular the SCSN.

Coordination. CEOs must assure that CARE Act-funded providers participate in an HIV care continuum and that CARE Act providers coordinate their services with other HIV programs operating in the service area. Several types of coordination are required by CARE Act legislation.

• Prevention-Care Coordination. CEOs must assure that care-prevention coordination ensures that PLWH enter care systems and receive ongoing treatment. Particular emphasis should be placed on identifying those who know their HIV status but are not receiving treatment. The anticipated long-term impact is to normalize screening for HIV in diverse social service and health care settings and help reduce barriers to care for the traditionally underserved by expanding the network of referrals. CEOs must assure that CARE Act providers maintain appropriate relationships with "key points of entry" into the health care system (e.g., HIV counseling and testing centers, emergency rooms, substance abuse treatment programs, STD clinics, homeless shelters). Since EIS can only be funded if other sources of funding are insufficient to meet current needs, needs assessment must document that EIS gaps exist prior to using CARE Act funds.
• SCSN. Title II convenes the SCSN process to ensure Statewide collaboration between CARE Act programs and providers. Though this is not required, HAB/DSS encourages the use of the SCSN to support HIV planning Statewide. Participants in SCSN development must include: representatives of all Ryan White CARE Act titles and Part F managers, including any AIDS Education and Training Center, Dental Reimbursement Program, and Special Projects of National Significance (SPNS) demonstration grants operating in the State; PLWH; providers; and public agency representatives (e.g., maternal and child health Title V programs, mental health agencies, Medicaid, and local and regional health departments). States must ensure the participation of required groups in the SCSN process. They can use Title II funding to support the participation of PLWH and historically underserved communities in the SCSN process.

HAB/DSS Expectations of Title I and II CEOs TOP
HAB/DSS expects CEOs to ensure that CARE Act programs meet all legislative requirements. Policies and guidances have been developed to assist CEOs and CARE Act planning bodies in implementing legislative provisions of the CARE Act. The legislation also authorizes technical assistance to help grantees comply with CARE Act requirements, including peer-delivered technical assistance and guidance to planning bodies. Technical assistance is provided through the Division of Training and Technical Assistance (DTTA) within HAB. Requests for assistance must be made to HAB project officers through the Title I or Title II grantee.

When the CEO Designates Responsibility for Title I TOP
The following EMA experiences provide insight on how the CEO can ensure effective planning and implementation when Title I responsibilities are delegated. The CEO is ultimately responsible for ensuring that all Title I programs in a service area meet legislative requirements and HAB/DSS expectations.

Avoiding Problems. When responsibility of administering the Title I program is delegated to the health department or some other government agency or office, the CEO can help prevent or resolve problems by taking the following steps:

• Choose someone with related knowledge and skills. Someone with a strong public health background, knowledge/experience with the CARE Act, and direct access to you and your office is best.
  
• Make sure administrative staff are competent, knowledgeable, and diverse. Ensure staff has strong HIV/AIDS experience and pertinent technical skills.
  
• Ensure clear lines of communication among all partners. Consider establishing a team of people to conduct ongoing, regular activities to keep you informed.
  
• Require linkages among CARE Act programs, and between the CARE Act and other HIV/AIDS programs and activities. Consider a working group or task force comprised of Title I partners, Title II, HIV prevention providers, Medicaid, SCHIP offices, providers of homeless services, representatives of the incarcerated, State and/or local AIDS entities, AIDS policy groups, etc.
  
• Be sure that Intergovernmental Agreements (IGAs) are monitored and followed.
  
• Require the administrative agency to build and maintain relationships with infected and affected communities. Use methods such as community forums and hotlines to obtain consumer and community input.

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Making IGAs Meaningful. The CARE Act requires that the CEO establish IGAs with political subdivisions within the EMA. These agreements have the potential to enhance Title I services. IGAs must provide an administrative mechanism to allocate funds and services based on the: Number of AIDS cases in the subdivisions; Severity of need for services in the subdivisions; and Health and support service needs of the subdivisions. IGAs should be used to promote access to the CEO by EMA residents who live outside the CEO's election boundaries and to involve their elected officials in the Title I process. IGAs should also:

• Indicate a minimum number of seats on the planning council that will be set aside for residents of the jurisdiction.
  
• Specify how residents of the jurisdiction can be nominated for planning council membership.
  
• Require specific efforts to determine the unmet need for HIV-related health services in these jurisdictions.
  
• Establish periodic meetings between the Title I CEO and other CEOs of the other jurisdictions or their representatives.
  
• Specify a periodic evaluation of how the IGA is working, in terms of services and administration.
  

Staff Roles. The experiences of EMAs suggest that staff involvement is important whenever administrative responsibility for Title I has been designated to another department. CEO staff can help with the following:

• Attend meetings, make community contacts, and make themselves available to key stakeholders, including PLWH communities.
  
• Build relationships with other CEOs in an EMA, including those with whom the CEO has IGAs in place. These relationships can help encourage cooperation in ensuring delivery of HIV services, protect the CEO when signing assurances on behalf of the EMA, ensure maintenance of effort in a positive way, and minimize the potential for grievances.
  
• Attend planning body meetings to keep the CEO informed of the process and any related issues, and to provide CEO input to planning.
  
• Serve as liaisons to an external administrative agency or fiscal agent to ensure that CEO expectations are communicated and that the CEO is apprised of any problems with the disbursement of funds.
  
• Communicate information from the CEO to other AIDS policy or program offices within city, county, and State governments.
  
• Promote collaboration among CARE Act partners and between Titles I and II and other HIV/AIDS-related entities in needs assessment and planning activities, prevent duplication of efforts, and prevent adversarial relationships among agencies.
  
• Serve as direct mediators between CARE Act partners or between CARE Act programs and other public agencies that report to the CEO. They can help resolve problems quickly so that care and services to PLWH are not compromised or interrupted.

Anticipating and Solving Problems. The CEO can help resolve some common problems with CARE Act programs. Following are some examples.

The Problem: The planning council is not representative. The planning council is not reflective of the epidemic in the EMA. PLWH are not adequately represented and the membership from a particular community is far short of what it should be. These issues can result in the CEO becoming the target of angry consumers, who feel their voice is not being heard in Title I decision making. Further, the level of Title I funding may be jeopardized, and HAB/DSS may require changes in membership as a Condition of Grant Award. What the CEO Can Do: (1) Arrange for an assessment of the problem. Establish a task force of representatives from the CEO office, the administrative agency, and the affected community to discover what is causing recruitment problems; (2) Have the planning council or CEO (or designee) seek technical assistance from HAB/DSS.

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The Problem: Fund disbursement is delayed. Disbursements to service providers are taking twice as long as they should. In some organizations, this is causing services to clients to be interrupted. The CEO is getting calls from angry providers who are saying they will have to lay staff off and stop certain services, and from consumers who now have to go further from home to receive services from unfamiliar organizations and providers. The planning council is preparing to file a formal grievance with the CEO. What the CEO Can Do: (1) Arrange for an assessment of the problem by the appropriate unit within your local government, a representative of your office, or an independent consultant. Be sure to have the planning body representatives and the affected community provide their input. Take corrective action based on the results of the assessment.
(2) Assign one of your staff to be a liaison with the administrative agency to monitor its activities, including its interaction with the planning body. (3) Seek technical assistance from HAB/DSS.

The Problem: Planning council discord and public perceptions of CEO disinterest. There is a perception in the community that HIV is not a priority for the CEO and that he/she is uninterested in the needs of PLWH. A growing conflict between two provider groups erupted at a recent planning council meeting. The local paper reported that HIV providers are putting the needs of PLWH second to their own individual agendas. What the CEO Can Do: (1) Keep abreast of the Title I process and be knowledgeable about the personalities and issues that influence the process. (2) Ensure that problems are resolved or addressed before they become highly visible and/or explosive. (3) Ensure that your staff and liaisons maintain active lines of communication among all key stakeholders and represent you as a leader who is accessible and knowledgeable.

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The Problem: Contracting not reflective of planning council priorities. The administrative agency is making contracts to provider agencies that are not in line with the service priorities that have been established by the planning council. Due to a number of vacancies on the planning council and a number of new members who are still learning their roles, the planning council has been unable to effectively monitor and oversee the allocations process. PLWH groups are calling your office to complain and demand that the situation be corrected. What the CEO Can Do: (1) Ensure that planning council vacancies are filled in a timely manner to avoid a lack of balance between the planning council and the administrative agent. (2) Ensure that you and your staff are monitoring the activities of the administrative mechanism. Make sure it is responding to the direction of the planning council. (3) Ensure that planning council members are diverse, talented, and appropriately trained to fulfill their responsibilities, and that they have the capacity to evaluate the administrative agent.

Effective CEO Problem Solving. When the planning council in one city confronted the CEO about the poor performance of the administrative agency, the CEO-rather than simply defending his administrative agency-formally mediated and facilitated discussions between the planning council and administrative agency staff. An HIV Coordinating Team was established with representatives from both groups and the CEO's office liaison as a way to identify and resolve problems as they arise and maintain cross communication. A new HIV Program Coordinator position was established within the administrative agency to assure that all components within the administrative agency were working together to meet their responsibilities.