Integration of HIV Prevention, Care, and Treatment in Broward County

State: FL Type: Model Practice Year: 2016

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In 2014, Broward County had 19,391 people living with HIV/AIDS. In 2013, Broward County did not meet the National HIV/AIDS Strategy targets for the metrics associated with the Continuum of Care, except for linkage. Treatment is prevention. The Broward County Ryan White Part A Program and DOH-Broward HIV Prevention Program have taken an integrated approach to prevention and care. This has been reaffirmed in 2013 by a joint letter, where CDC and the Health Resources and Services Administration (HRSA) expressed their support for integrated HIV prevention and care planning in jurisdictions throughout the United States.

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Broward County Health Department
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Integration of HIV Prevention, Care, and Treatment in Broward County
Broward County is located in the southeastern portion Florida.  Broward County’s 2014 population estimate of 1,869,235, represents 9% of the State’s population, representing more than 200 different countries and speaking more than 130 different languages.  31.5% of the residents are foreign-born.   Broward County is a minority/majority county demonstrated by its 2014 population by race (Black 28.8%, Asian 3.6%, Hispanic 27.4%, other races .5%, for a total of 60.3% and White 39.7%).  The Florida Department of Health in Broward County (DOH-Broward) is the official lead Public Health Agency in Broward County and has been operational since 1936. It is part of the Integrated Florida Department of Health (DOH) and operates in cooperation with the Broward County Commission under Florida Statute 154. DOH-Broward is part of a complex public health system that includes hospitals, clinics, planning agencies, community-based organizations and others.   The public health issue is according to the United States Centers for Disease Control and Prevention (CDC) in 2013, the Fort Lauderdale Division of the Miami Metropolitan Statistical Area (MSA) has the second highest rate of new HIV infections and the fourth highest AIDS case rates in the United States. In 2014, Broward County had 19,391 people living with HIV/AIDS. In 2013, Broward County did not meet the National HIV/AIDS Strategy targets for the metrics associated with the Continuum of Care, except for linkage. The Broward County Ryan White Part A Program and DOH-Broward HIV Prevention Program have taken an integrated approach to prevention and care. This has been reaffirmed in 2013 by a joint letter, where CDC and the Health Resources and Services Administration (HRSA) expressed their support for integrated HIV prevention and care planning in jurisdictions throughout the United States. However, minimal general guidance has been provided and there is a need to better define the process.  The goal of integration in Broward County is to streamline HIV prevention and care planning in a manner that will enhance prevention efforts for the highest risk populations and improve the metrics along the Continuum of Care for those infected with HIV. The objective is to create a coordinated response to the HIV epidemic and a seamless provision of HIV services. These metrics include the percentage of persons diagnosed and living with HIV, percentage linked to care, percentage retained in care and percentage with suppressed viral load as a consequence to the integrated planning process. Creation of an integrated planning process for HIV prevention and HIV care and treatment included two years of retreats and planning meetings that resulted in a seamless Continuum of Care and reduced duplication. HIV continuum metrics have improved across the Continuum of Care. Collective Impact Methodology (CIM) was the process chosen by the Part A Program and DOH-Broward, creating a mechanism by which the complex issues of achieving a coordinated response to the HIV epidemic could be addressed. This was achieved by using a systematic approach, including collaboration from the federal government, local and state health department, Part A Program, HIV providers and community participation. The components of the CIM include the creation of a common goal, the creation plans, alignment and improvement, reflection and adaption and determining next steps. Regarding the integrated planning process, the Broward County HIV Health Services Planning Council (HIVPC) and The Broward County HIV Prevention Planning Council (BCHPPC) bodies successfully aligned planning efforts as evidenced by the following: active participation of both the Ryan White Part A Program and DOH-Broward in the Joint Planning Committees to undertake coordinated implementation of the Jurisdictional Prevention Plan and Part A Comprehensive Plan; the formation of the Integrated Committee (IC) which includes representation of all of the Ryan White Program parts, Housing Opportunities for Persons with AIDS (HOPWA) and the BCHPPC. The IC has agreed on a common mission and vision statement and developed detailed work plans to organize integration activities. Regarding the Continuum of Care metrics, there has been improvement across the entire continuum from 2013 to 2014. This practice has improved the targeted metrics from 2013-2014. The percentage linked to care was 86% (2013 percentage was 86%), the percentage retained in care was 65% (2013 percentage was 52%), percentage on Antiretroviral Therapy was 69% (2013 percentage was 47%), and the percentage with suppressed viral load was 61% (2013 percentage was 33%). By increasing the percentage of persons with known HIV status, the percentage linked to care, the percentage retained in care result in a higher percentage with suppressed viral load, therefore decreasing HIV transmission rates. This practice has improved the metrics across the Continuum of Care which will result in a decrease in community viral load, therefore decreasing transmission of the virus and rates of new HIV infection in Broward County. The website for DOH-Broward is http://broward.floridahealth.gov/  
According to the United States Centers for Disease Control and Prevention (CDC) in 2013, the Fort Lauderdale Division of the Miami Metropolitan Statistical Area (MSA) has the second highest rate of new HIV infections at 46.9 per 100,000 and the fourth highest AIDS case rates in the United States at 25.6 per 100,000. According to the Florida Department of Health surveillance data for 2014, in Broward County males comprised 82% of new HIV cases and 69% of new AIDS cases. Among males, Men Who Have Sex with Men (MSM) is the predominate mode of transmission. Blacks comprise 25% of the population, but 42% of the new HIV cases and 61% of the new AIDS cases in 2014. Additionally, Broward County was home to 19,391 people living with HIV/AIDS in 2014. In 2013, Broward County did not meet the National HIV/AIDS Strategy targets for the metrics associated with the Continuum of Care except for linkage as per Florida Department of Health surveillance data. Specifically, the percentage linked to care was 86% (target is 85%), the percentage retained in care was 52% (target is 90%), percentage on Antiretroviral Therapy was 47% and the percentage with suppressed viral load was 33% (target is 80%). The Broward County Ryan White Part A Program and the Florida Department of Health in Broward County (DOH-Broward) HIV Prevention Program have taken an integrated approach to prevention and care. This has been reaffirmed in 2013 by a joint letter, where CDC and the Health Resources and Services Administration (HRSA) expressed their support for integrated HIV prevention and care planning in jurisdictions throughout the United States. However, only general guidance has been provided. There is a need to engage stakeholders in the integration process, identify methodologies for integration, and showcase best practices for other jurisdictions to model. What target population is affected by problem? What is target population size?Broward County’s 2014 population estimate of 1,869,235, represents 9% of the State’s population, and is the second most populous county of the 67 counties in the State of Florida and eighteenth most populous county in the United States (US Census). Its diverse population includes residents representing more than 200 different countries and speaking more than 130 different languages. Almost one-third, 31.5% of the residents are foreign-born. Broward County is a minority/majority county demonstrated by its 2014 population by race (Black 28.8%, Asian 3.6%, Hispanic 27.4%, other races 0.5%, for a total of 60.3% and White 39.7%). The target population of the integration of care and treatment is the 19,391 people living with HIV/AIDS in Broward County as well as MSM of all races and ethnicities and Black heterosexuals who are disproportionately affected by the epidemic. What percentage did you reach? According to the Florida Department of Health surveillance data in 2014, there were improvements in the metrics across the Continuum of Care as a result of this practice. Specifically, the percentage linked to care was 86% (2013 percentage was 86%), the percentage retained in care was 65% (2013 percentage was 52%), percentage on Antiretroviral Therapy was 69% (2013 percentage was 47%), and the percentage with suppressed viral load was 61% (2013 percentage was 33%). What has been done in the past to address the problem? In the past, Broward County had an active prevention planning process carried out by the BCHPPC under the leadership of DOH-Broward and an active patient care planning process carried out by Ryan White patent care planning bodies. These processes worked independently of each other with limited collaboration, communication or integration. Neither program had an in depth understanding of what each program was doing to support care and prevention services for Persons Living with HIV/AIDS (PLWHA) in Broward County. Why is current/proposed practice better?The integrated approach to prevention and care allowed both the Broward County Ryan White Part A Program and the Department of Health in Broward County to have a clear road map of what care and prevention services were provided by each and to effectively plan for the provision and coordination of services for PLWHAs in Broward County. It also allows for the most efficient use of limited resources by minimizing duplication of services. Is current practice innovative? How so/explain? New to the field of public health? The current practice is new to the field of public health. In 2013, a joint letter issued by the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) first described support for integrated HIV prevention and care planning in jurisdictions throughout the United States. Even with the support of integration, minimum general guidance has been provided as to how best to implement the process. There is a need to engage stakeholders in the integration process, identify methodologies for integration, and showcase best practices for other jurisdictions to model. By 2016, integrated planning for HIV prevention and patient care is required by CDC and HRSA at the State and/or jurisdictional level. This practice is evidence based on CDC  and HRSA guidelines for its creation.  
HIV in the U.S.
The goal of integration in Broward County is to streamline HIV prevention and care planning in a manner that will enhance prevention efforts for the highest risk populations and improve the metrics along the Continuum of Care for those infected with HIV to create a coordinated response to the HIV epidemic and a seamless provision of HIV services. These metrics include the percentage of persons diagnosed and living with HIV, percentage linked to care, percentage retained in care and percentage with suppressed viral load. Additionally, process objectives of the integrated approach include achieving an understanding of the local health departments, Ryan White Grantees, and local planning bodies in HIV integrated planning, creating a comprehensive work plan, maximizing collaboration during implementation, identifying the critical elements of integrated planning by using the Collective Impact Methodology and documenting lessons learned for continuous improvement as well as for use by other jurisdictions. What did you do to achieve the goals and objectives? Steps taken to implement the program?The integration process began with the implementation of “PS 12-1201 (2013) High Impact Prevention (HIP) CDC Funding Opportunity Announcement”, and the establishment of the Broward County HIV Prevention and Planning Council by the Florida Department of Health in Broward County (2012). Discussions also took place around the Early Identification of Individuals with HIV/AIDS (EIIHA) which is a shared responsibility between prevention, care and treatment. DOH-Broward Prevention staff attended the Communities Advocating Emergency AIDS Relief (CAEAR) Coalition alongside Ryan White Part A and Ryan White Part A joined the Urban Coalition for HIV/AIDS Prevention Services, a group in which prevention participates. Initial integration efforts included the presentation of the Integrated “Crosswalk” a Master Comprehensive Plan Chart of care and prevention services in Broward County and the progress made to date. Additional integration efforts included the development of an integrated quarterly newsletter knows as “POZabilities” to inform the community about integrated planning and keep them updated on the process. Additionally, integrated retreats and meetings were held and Broward County Public Schools was included as the third major organization in addition to the DOH-Broward and the Ryan White Part A Grantee Office. • Any criteria for who was selected to receive the practice (if applicable)? Not applicable• What was the timeframe for the practice 2012-2021 • Were other stakeholders involved? What was their role in the planning and implementation process?o What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s)The integration process involved the active participation of the prevention and care planning bodies; BCHPPC and the HIVPC. The BCHPPC structure includes an Executive Team, Epidemiology team, High Impact/Core Prevention Team and Policy Team. Advisory workgroups of the BCHPPC include the Broward County Schools Advisory Group, the Men who have Sex with Men (MSM) Advisory Group, the Transgender Advisory Group, the Perinatal Group, the Black Treatment Advocacy Network (BTAN), Black AIDS Advisory Group (BAAG), and the Latinos En Acción Advisory Group. The advisory groups represent the groups disproportionately affected by the HIV/AIDS epidemic in Broward County. In total, the BCHPPC has 21 voting members and over 150 advisory group members. The HIPVC Structure includes the Executive Committee, the Priority Setting Resource Allocation Committee, the Needs Assessment Committee, the Quality Management Committee, the Client Empowerment Committee, the Membership Council Development Committee, the local Pharmacy Advisory Committee and System of Care. Both the BCHPPC and the HIVPC are structured to have parity, inclusion and representation of the community. Key stakeholders in both groups include PLWHAs, service providers, County and DOH staff, and other community members. A total of five (5) formal integrated retreats and exploratory meetings were held throughout 2014 and 2015 to identify and clearly understand the meaning and purpose of the integrated plan and determine what was needed to move forward with planning. Representatives from the Ryan White Grantee Office, DOH-Broward’s Prevention Program, and Broward County Schools were the participants of these meeting and retreats. At the first integrated planning retreat, participants decided that ongoing facilitated meetings among both the care and prevention groups throughout the year were necessary, since then three (3) additional meeting led by a facilitator were held. During one of the integrated retreats an integrated Vision and Mission were created as follows: Vision A transformative and transparent and integrated planning process that embraces local funding and leverages opportunities for collaboration with strategic alliances into a singular process to achieve the goals of the National HIV/AIDS Strategy goals and objectives Mission We are committed to the stewardship of public funds through efficient, deliberate, and innovative processes that maximize the use of resources to reduce new HIV infections and community viral load in Broward County Initial guidelines provided by the CDC/HRSA for integration encouraged the development of a coordinated jurisdictional response to HIV/AIDS and to avoid duplication of processes. Many points of intersection and shared knowledge, data, and processes were included in the guidelines such as epidemiological profiles, by-laws, and community involvement. The plan was to be more economical by sharing resources and increasing collaboration and communication. The plan also fostered integration of prevention into care services and community viral load as a recognized form of prevention, care coordination and partner services. Collective Impact Methodology (CIM), a framework for solving complex social problems, was applied by the Part A Program and DOH-Broward, creating a mechanism by which to achieving a coordinated response to the HIV epidemic could be addressed. CIM is based on the premise that no one organization alone can tackle or solve complex multi-faceted problems that affect society. The CIM approach of involving multiple organizations and entities from different sectors was achieved by including collaboration from the federal government, local and state health department, Part A Program, HIV providers and community participation. The processes of the CIM includes five key elements 1.) creation of a common goal, 2.) common progress measures 3.) mutually reinforcing activities, 4.) continuous communication, and 5.) backbone organization. The common goals for Integration were adopted from the first three (3) goals of the National HIV/AIDS Strategy; reducing new HIV infections, increasing access to care and improving health outcomes for people living with HIV, and reducing HIV-related disparities and health inequities. These goals provided a framework for the alignment and organization of an integrated work plan. Objectives, strategies, and activities from both prevention, care and treatment were organized into one single document names the “Crosswalk” and then progress from each activity were added into this documents providing an up-to-date status of local efforts which was able to be communicated to both the Ryan White HIV Planning Council (HIVPC) and the Broward County HIV Prevention Planning Council (BCHPPC) planning councils. The “Cross Walk” and its presentation were part of the criteria for CIM elements 3 and 4. Shared outcome measures are based on the Continuum of Care that provide population percentages for individuals who are aware of their HIV positive status, linkage to care, retention in care, on antiretrovirals and virally suppressed. The Continuum of Care is a shared set of measurements that fall under the responsibility of both Prevention, Care and Treatment. The targets for these indicators are set forth by the National HIV AIDS strategy 2020: Increase the proportion of newly diagnosed patients linked to medical care to 85 percent, Increase the proportion of Ryan White program clients who are in continuous care to 90 percent, Increase the proportion of virally suppressed to 80 percent. A baseline set of measures was able to be provided for the overall Broward County population. Ryan White Part A measures were superimposed over the last 3 indicators to compare percentages, however, this populations is limited to those HIV positive individuals in Ryan White Care. The comparison of continuum measures provided evidence for the effectiveness of the Ryan White program in improving outcomes for those living with HIV. The targets set forth will also assist in measuring success of the combinations of activities selected to be implemented in Broward County within the Integrated Plan. Moving forward with evaluation, next steps will be to create several continuums that reveal more specific outcome information such as 1.) an HIV Incidence continuum which would exclude retention in care measures 2.) an HIV Prevalence continuum which would exclude linkage to care measures 3.) an HIV Prevention continuum for ‘high risk’ negative individuals and 4.) a Ryan White only continuum. Common definitions for each continuum measure will also be developed between both Prevention, Care and Treatment and a local monitoring and evaluation report will be produced outlining Prevention, Care and treatment progress towards the goals of the NHAS. A number of mutually reinforcing activities included alignment and improvement. These were accomplished through attendance at UCHAPS meetings, the development of an integrated newsletter known as “POZabilities” and a series of integrated videos, integrated meetings and retreats, mutual membership on both the prevention and care planning bodies with standing item agenda updates, meeting presentations, master calendar, mathematical modeling and participation in joint presentations for Region IV and VI HHS (Department of Health and Human Services) meeting, United States Conference on AIDS (USCA), American Public Health Association (APHA) annual conference and The CDC Prevention Conference. Continuous Communication, another CIM core component and important aspect of integration, was accomplished through the “POZabilities” newsletter, mutual membership on planning bodies, standing item agenda updates, joint project officer calls between CDC (Prevention and Broward County Schools) and HRSA (Ryan White Part A), and a series of integrated retreats and steering committee meetings. The final element of the CIM is the existence of a backbone organization to steer and guide this process. A steering committee has been delegated by grantees to identify data required for the integrated plan, identify expertise that should be referenced and to determine next steps to complete the integrated plan. The steering committee serves as the backbone organization and reports back to grantees but also reports out to both planning bodies on the integration process. Through the use of the CIM methodology, the Ryan White HIV Planning Council (HIVPC) and the Broward County HIV Prevention Planning Council (BCHPPC) have successfully aligned their planning efforts while remaining independent planning bodies to ensure integrated HIV prevention, screening, care, and treatment funding and services. Eventually, an integrated committee will be formed with equal members from Prevention and Care and treatment. This committee will have two co-chairs representing each planning body and will include a diverse group of subject matter experts and community representatives. The committee will be critical in evaluating the content and execution of the integrated work plan and will serve as a quality assurance component. A few challenges were noted in the integration process which included lack of specific guidance by the CDC and HRSA, resources for planning, data access, securing buy-in and support from both planning bodies, identifying experienced and available members to participate in the integrated committee and the involvement of the community as a whole. Finally competing responsibilities for actively involved members of the process was also a challenge. Any start up or in-kind costs and funding services associated with this practice? Please provideactual data, if possible. Else, provide an estimate of start-up costs/ budget breakdown. In kind costs were provided by the Ryan White Part A Program and the Department of Health in Broward County Prevention Program for staff time and resources.  
What did you find out? To what extent were your objectives achieved? Please re-state your objectives from the methodology section.The goal of integration in Broward County is to streamline HIV prevention and care planning in a manner that will enhance prevention efforts for the highest risk populations and improve the metrics along the Continuum of Care for those infected with HIV to create a coordinated response to the HIV epidemic and a seamless provision of HIV services. These metrics include the percentage of persons diagnosed and living with HIV, percentage linked to care, percentage retained in care and percentage with suppressed viral load. According to the Florida Department of Health surveillance data in 2014, there were improvements in the metrics across the Continuum of Care. Specifically, the percentage linked to care was 86% (2013 percentage was 86%), the percentage retained in care was 65% (2013 percentage was 52%), percentage on Antiretroviral Therapy was 69% (2013 percentage was 47%), and the percentage with suppressed viral load was 61% (2013 percentage was 33%). Additionally, process objectives of the integrated approach included achieving an understanding of the local health departments, Ryan White Grantees, and local planning bodies in HIV integrated planning, creating a comprehensive work plan, maximizing collaboration during implementation, identifying the critical elements of integrated planning by using the Collective Impact Methodology and documenting lessons learned for continuous improvement as well as for use by other jurisdictions. Regarding the integrated planning process, the HIVPC and BCHPPC bodies have successfully aligned their planning efforts as evidenced by the following: active participation of both the Ryan White Part A Program and DOH-Broward in the Joint Planning Committees to undertake coordinated implementation of the Jurisdictional Prevention Plan and Part A Comprehensive Plan; the formation of the Integration of Prevention and Care in Broward County Committee (IC) which includes representation of all of the Ryan White Program parts, Housing Opportunities for Persons with AIDS (HOPWA) and the BCHPPC. Additional integration process outcomes achieved were the creation and presentation of the Integrated “Crosswalk”, a Master Comprehensive Plan Chart of care and prevention services in Broward County and the progress made to date; the development of an integrated quarterly newsletter knows as “POZabilities” to inform the community about integrated planning and keep them updated on the process and the regular occurrence of integrated retreats and meetings with the major organizations involved (Broward County Public Schools, DOH-Broward and the Ryan White Part A Grantee Office). The variety of integrated activities implemented has resulted in a greater understanding of both prevention and care and treatment processes by HIVPC, BCHPPC and the overall community. This understanding facilitates integrated planning efforts, encourages community buy-in, and eases the coordination of additional integrated activities and work products. This process of integration is complex but feasible and requires multiple organizations and key stakeholders to join efforts in improving prevention and care outcomes as reflected though out the Continuum of Care. The framework for integrated planning has been successfully established in Broward County as several key outcomes have been achieved. The integrated process has resulted in more efficient implementation of prevention and care strategies and service provision as evidenced by the achievement of better Continuum of Care outcomes. Did you evaluate your practice?List any primary data sources, who collected the data, and how (if applicable)List any secondary data sources used (if applicable)List performance measures used. Include process and outcome measures as appropriate.Describe how results were analyzedWere any modifications made to the practice as a result of the data findings? Collective Impact Methodology (CIM), a framework for solving complex social problems, was applied by the Part A Program and DOH-Broward, creating a mechanism by which to achieving a coordinated response to the HIV epidemic could be addressed. The first two processes of the CIM includes five key elements 1.) creation of a common goal and 2.) common progress measures were the most relevant in regards to evaluating the integrated process. The common goals for Integration were adopted from the first three (3) goals of the National HIV/AIDS Strategy; reducing new HIV infections, increasing access to care and improving health outcomes for people living with HIV, and reducing HIV-related disparities and health inequities. These goals provided a framework for the alignment and organization of an integrated work plan. Shared outcome measures are based on the Continuum of Care that provide population percent estimates of individuals diagnosed with HIV infection, linked to care (NHAS Goal 85%), retained in care (NHAS Goal 90%), on antiretrovirals and virally suppressed (NHAS goal 80%). Data for the Continuum of Care measures were received from the HIV/AIDS Section, Florida Department of Health, Division of Disease Control and Health Protection Bureau of Communicable Diseases and included data from the Medical Monitoring Project (MMP), the HIV/AIDS Reporting System (eHARS) database, Florida’s CAREWare database, and ADAP (AIDS Drug Assistance Program) data. Percentage comparisons were made between 2013 and 2013 calendar years to evaluate integration progress. In 2014, there were improvements in the metrics across the Continuum of Care. Specifically, the percentage linked to care was 86% (2013 percentage was 86%), the percentage retained in care was 65% (2013 percentage was 52%), percentage on Antiretroviral Therapy was 69% (2013 percentage was 47%), and the percentage with suppressed viral load was 61% (2013 percentage was 33%). Even with these improvements, only the linkage to care percentages met the NHAS goals. Ryan White Part A measures were superimposed over the last 3 indicators to compare percentages, however, this populations is limited to those HIV positive individuals in Ryan White Care. The comparison of continuum measures provided evidence for the effectiveness of the Ryan White program in improving outcomes for those living with HIV. The targets set forth will also assist in measuring success of the combinations of activities selected to be implemented in Broward County within the Integrated Plan. Moving forward with evaluation, next steps will be to create several additional continuums that reveal more specific information such as 1.) an HIV Incidence continuum which would exclude retention in care measures 2.) an HIV Prevalence continuum which would exclude linkage to care measures 3.) an HIV Prevention continuum for ‘high risk’ negative individuals and 4.) a Ryan White only continuum. Common definitions for each continuum measure will also be developed between both Prevention, Care and Treatment and a local monitoring and evaluation report will be produced outlining Prevention, Care and treatment progress towards the goals of the NHAS. This data will also include local data sources including Active Strategy (DOH-Broward’s Performance Indicator database), Provide Enterprise (Ryan White client database), Prism, ADAP and eHARS. Eventually, an integrated committee will be formed with equal members from Prevention and Care and treatment. This committee will have two co-chairs representing each planning body and will include a diverse group of subject matter experts and community representatives. The committee will serve as a quality assurance component and will be critical to evaluating the content and execution of the integrated work plan. The final integrated work plan must have a letter of concurrence signed by both BCHPPC and HIVPC.  
Lessons learned in relation to practiceThe primary lesson learned from the integration of prevention, care and treatment in Broward County is that integration guidance cannot be prescriptive. What works well in one jurisdiction may not work for another. For example, the merging of Prevention and Care and treatment planning bodies is not recommended for Broward County and is not necessary to complete an integrated plan. The culture, directives, organizations and priorities for BCHPPC and HIVPC are not easily merged, which would be a large challenge within itself. Both bodies function efficiently as separate bodies to complete the tasks required for the integrated process. However, members do actively participate on both planning bodies and each planning body has integration as a standing agenda item. Knowledge of the local epidemic and landscape including available resources and key stakeholders is essential and fundamental to the integration process in order to include the appropriate individuals, organizations and activities into the integration process and plan. Integration is not an easy process and there are very few models and best practices to follow as guidance. CDC and HRSA have provided support for integrated activities; however, they have provided very general guidance as to how this process should be executed at the local level. Therefore, it is imperative to document the integrated process as is occurs, including the outcomes of integrated meetings and best practices. From our integrated meetings, one of the best practices is including outside facilitators to structure and moderate some of the meetings and or retreats between all individuals and organizations represented at integrated meetings. Having outside facilitators allows for meetings to stay on task, for effective conflict resolution, and for focusing time on the meeting objectives. Lessons learned in relation to partner collaboration:Having the right stakeholders and subject matter experts from the appropriate organizations is necessary to establish community ownership for a plan that impacts such a large amount of people. The integration of Prevention care and treatment is not an easy process and requires collective input and efforts from all those involved. Continuous communication between key stakeholders and organizations in the form of regular integrated retreats and meetings, joint project officer calls, integrated published articles, co-presentation on the integration process, and regular updates at both planning meetings in a core component of the Collective Impact methodology. Having the Collective Impact Methodology to help drive the process, engage stakeholders and guide integration from early in the process has resulted in a better organized approach to Broward’s Integration. Having stakeholder buy in and representation from the appropriate organizations not only assists in communication of Integrated updates but facilitates in the engagement and buy in of the overall community by building trust, addressing community perceptions, and incorporating community representation. Did you do a cost/benefit analysis? One of the integrated activities planned is to involve Dr. David Holtgrave, a national expert in program effectiveness evaluation, to complete a cost effectiveness analysis for HIV prevention care and treatment in Broward County. The cost effectiveness analysis will determine what resources are needed to make a positive impact in the HIV epidemic in Broward County. The results of this cost effectiveness evaluation will be included into the final integrated plan and considered in the selection of appropriate combination of prevention and care strategies and program activities that will be included in the final integrated plan. Is there sufficient stakeholder commitment to sustain the practice?Describe sustainability plansThe success of the integrated planning process relies on the support of both Prevention and Care and Treatment planning bodies. Each of which highly involve stakeholders though out their own planning and program development as they rely highly on parity, inclusion and representation; meaning that both planning bodies represent the communities that are served. Both planning bodies are kept abreast of integrated planning updates and are allotted regular platforms for community feedback. Both planning bodies are also responsible for selecting the individuals responsible for reviewing the plan and will provide letter of concurrence one the plan is finalized. Resources provided by the CDC and HRSA for prevention, care and treatment will be utilized for the same activities, however, have one coordinated and integrated plan will allow for better maximization of local dollars and resources.  
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