4
Program Management and Administration

As briefly outlined in Chapter 1, Title X of the Public Health Services Act established four areas for grants and contracts by the Secretary of Health and Human Services: family planning services, training, research, and informational and educational materials. Grants for family planning services can be made to states, and grants or contracts for these services can go to public or nonprofit private entities. Grants and contracts can also go to public or nonprofit private entities and individuals for training, research, and information and education. The budget for the Title X program was $300 million in fiscal year (FY) 2008. By statute, at least 90 percent of that appropriation must be used for family planning services.

The Title X program has been implemented through regulations (42 CFR 59; see Appendix C) that detail the requirements for recipients of Title X funds. The program is administered by the Office of Family Planning (OFP) (also referred to as the Central Office) within the Office of Public Health and Science, Office of Population Affairs (OPA), at the Department of Health and Human Services (HHS) and a decentralized system of 10 Regional Offices through which funds are provided to grantees in all states, the District of Columbia, and U.S. territories.

This chapter examines the administrative and management structure of the Title X program, the services and other program activities it encompasses, and its role in relation to other public or private funding sources. The information provided was drawn from Title X documents (for example, the Program Guidelines) and the commissioned paper authored by The Lewin Group, Inc. (see Appendix J this volume). In preparing this paper, The Lewin Group conducted a limited scan of published literature, government



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4 Program Management and Administration As briefly outlined in Chapter 1, Title X of the Public Health Services Act established four areas for grants and contracts by the Secretary of Health and Human Services: family planning services, training, research, and informational and educational materials. Grants for family planning services can be made to states, and grants or contracts for these services can go to public or nonprofit private entities. Grants and contracts can also go to public or nonprofit private entities and individuals for training, research, and information and education. The budget for the Title X program was $300 million in fiscal year (FY) 2008. By statute, at least 90 percent of that appropriation must be used for family planning services. The Title X program has been implemented through regulations (42 CFR 59; see Appendix C) that detail the requirements for recipients of Title X funds. The program is administered by the Office of Family Plan- ning (OFP) (also referred to as the Central Office) within the Office of Public Health and Science, Office of Population Affairs (OPA), at the Department of Health and Human Services (HHS) and a decentralized sys- tem of 10 Regional Offices through which funds are provided to grantees in all states, the District of Columbia, and U.S. territories. This chapter examines the administrative and management structure of the Title X program, the services and other program activities it encom- passes, and its role in relation to other public or private funding sources. The information provided was drawn from Title X documents (for example, the Program Guidelines) and the commissioned paper authored by The Lewin Group, Inc. (see Appendix J this volume). In preparing this paper, The Lewin Group conducted a limited scan of published literature, government 0

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02 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM and private-sector reports, and other information. It also conducted a series of interviews with Central Office staff, regional program staff, and Title X grantees and delegates, focusing on the administration and management of the program. This chapter also draws on testimony provided to the com- mittee at its public workshops by current and former grantees, as well as regional program staff, and on information obtained during the committee’s site visits (see Appendix A for a description of the workshops and lists of participants). The first six sections review in turn the roles and relationships of the Central Office, Regional Offices, grantees, and delegates; the applica- tion process for grants and contracts; the types and distribution of grantees and delegates; and the services provided by, oversight of, and funding of grantees and delegates (including coordination with other federal sources of funding for family planning services). The chapter then presents the committee’s assessment of the program’s management and administration. The final section offers conclusions and recommendations. CENTRAL OFFICE, REGIONAL OFFICES, GRANTEES, AND DELEGATES: ROLES AND RELATIONSHIPS OFP, the Central Office, is responsible for the overall administration of the Title X program. As noted above, it is located in OPA, the primary divi- sion of HHS that advises the Secretary and Assistant Secretary for Health on reproductive health. OPA is headed by the Deputy Assistant Secretary for Population Affairs, whose responsibilities include implementation of the Title X program and the Adolescent Family Life and Research program, authorized under Title XX of the Public Health Services Act. OFP develops national priorities and initiatives, policy, performance measures, budget requests, spending plans, and funding announcements for the program. It also coordinates and collaborates with other agencies within HHS (e.g., the Office of Women’s Health, the Centers for Disease Control and Prevention [CDC], the Office of Minority Health); oversees and monitors grants and contracts that are national or cross-regional in scope (e.g., training grants regarding male family planning and reproduc- tive health with the University of North Carolina, clinical training with the University of Missouri, and the National Training Center with Cicatelli Associates; research1; and the OPA Clearinghouse); responds to requests for 1 Research grants and contracts may be used for research in biomedical, contraceptive devel- opment, behavioral, and program implementation fields related to family planning. Research projects involve data analysis and related research and evaluation on issues of interest to the family planning field, as well as research on specific topics related to service delivery improve- ment. OFP has a standing announcement for service delivery improvement research, which encompasses quality of care, including the effectiveness, efficiency, timeliness, and equity of family planning services; reproductive health care of adolescents; reproductive health care of

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0 PROGRAM MANAGEMENT AND ADMINISTRATION FIGURE 4-1 Public health service regions. SOURCE: OPA, 2008b. Figure 6-1 bitmap image information; and provides leadership and direction for the Regional Offices that oversee family planning grants. In each of the Public Health Service Regions (see Figure 4-1), a Regional Health Administrator (RHA) is authorized to oversee the Title X program at the regional level through a memorandum of understanding (MOU) with the Central Office.2 The Central Office provides additional information and guidance to the Regional Offices through monthly conference calls and ongoing e-mail and telephone communication. It has developed an array males; family planning services to couples; organizational approaches to integrated services; translation of research into practice; increasing costs and their impact; and the effectiveness of Title X informational and educational activities. In addition to research covered by the standing announcement, research is currently being conducted through cooperative agreements with three grantees to analyze data on family planning needs and services over time using well- established formulas and databases; develop tools to assess and improve the quality of care in family planning clinics based on clinic data collection by a network of service providers; and analyze an array of national survey data sets to better understand the determinants of unintended pregnancy and childbearing. 2The RHA also oversees other HHS programs with a similar decentralized structure, such as those of the Office of Women’s Health.

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0 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM of Internet-based communication resources. Each Regional Office is also assigned a liaison at the Central Office who serves as a point of contact for any questions or issues. Under the RHA, a Regional Program Consultant (RPC) carries out day-to-day program management and relationships with grantees, assisted by the regional family planning staff. The RPC selects grantees for family planning services and regional training,3 subject to RHA and OFP approval, oversees and monitors their performance, and is the liaison between OFP and grantees, as discussed more fully below. Grantee agencies, which are selected through a competitive process delineated in 42 CFR 59 and The Program Guidelines for Project Grants for Family Planning Services (OFP, 2001; see Appendix D), are responsible for delivering family planning services and developing networks of care. Grantees have legal and financial responsibility and accountability for the funds awarded and for the performance of the activities approved for fund- ing (OFP, 2001). Grantees may offer services directly and/or contract with delegate agencies to provide services under a negotiated, written agreement (OFP, 2001). Delegate agencies for family planning services must be appropriately licensed health care facilities that agree to provide services in accordance with Title X guidelines and applicable federal, state, and local laws; report data for the Family Planning Annual Report (FPAR); maximize third-party revenue (e.g., Medicaid); and participate in site visits by the grantee and the Regional Office. If services are provided by a delegate agency, grantees are responsible for monitoring the quality, cost, accessibility, acceptability, and perfor- mance of the services provided under the grant to ensure compliance with Title X guidelines; making sure that required data and other reports are provided; and reviewing and approving delegates’ informational and edu- cational materials. Grantees and delegate agencies can operate one or more clinics and provide services other than family planning (e.g., general medi- cal or prenatal care), although these other services are not funded by Title X (see The Lewin Group, 2009 [Appendix J], Figure J-1 and Table J-1, for the organizational structure of the Title X program and a summary of the responsibilities at each management level). In 2006 (the last year for which national data are currently available), 88 grantees4 and 4,480 clinic sites offered Title X family planning services, 3 Each region manages one General Training and Technical Assistance grant, with grantees selected through a competitive process. In some regions, grantees are public or private entities that focus exclusively on training and education or training centers developed within the orga- nizational structure of a Title X services grantee (e.g., Center for Health Training—Region IX and Family Planning Council of Southeast Pennsylvania—Region III). 4 For a listing of the grantees, see the 2007–2008 Directory (OPA, 2008a).

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05 PROGRAM MANAGEMENT AND ADMINISTRATION operating in nearly 75 percent of the counties in the United States (RTI International, 2008). Clinics that received Title X funding provided services to almost 5 million clients in that year (RTI International, 2008). APPLICATION PROCESS Grantee Requirements The Title X statutory language, regulations, and Program Guidelines establish the requirements for entities to become grantees. By statute, public or nonprofit private entities can receive grants or contracts to offer fam- ily planning services, provide training, conduct research, and develop and distribute informational and educational materials. Providers of family planning services must offer a “broad range of acceptable and effective medically approved family planning methods” and provide services without coercion and “in a manner which protects the dignity of the individual” (42 CFR § 59.5 [a]). If a clinic offers only a single method or an “unduly limited number” of methods, it cannot receive a grant but can participate as a delegate agency in a project (an activity supported by Title X funds) that offers a broad range of services (Program Guidelines, section 3.1). Projects that receive funds must provide for speci- fied medical and social services, informational and educational programs, and training for personnel, as well as coordination with and referral to other health care providers (42 CFR § 59.5 [b]). (See the discussion below regarding services provided.) Before applying for Title X funding, potential grantees must assess the need for family planning services in the service area. They must provide data regarding the population in need of the services, maternal and infant health statistics, barriers to care, existing services, and the need for addi- tional services to meet community/cultural needs, as well as identify the high-priority populations and target areas for the services to be offered (OFP, 2001). Grantee Selection As noted above, grantees are selected through a competitive bidding process, in accordance with HHS objective review procedures.5 The Pro- 5 HHS objective review is the Department’s formal review and evaluation process: “an ini- tial screening of an application is conducted to ensure it provides adequate information and complies with the requirements set forth in the agency’s funding opportunity announcement. After the initial screening is complete, the application is submitted to an ad hoc independent panel of peers or experts, a standing review committee, or a group of field readers for review in accordance with the evaluation criteria included in the funding opportunity announcement.

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06 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM gram Guidelines specify that applications must include a needs assess- ment; a narrative description of the project and how the applicant intends to conduct it; a budget and justification for requested funds; standards and qualifications for personnel and facilities; project objectives that are “specific, realistic and measurable”; and “other pertinent information as required” (OFP, 2001, p. 4). To invite applications, OPA publishes Notices of Availability of Funds delineating these basic requirements, as well as additional information regarding priorities and issues that applicants should consider and evalua- tion criteria. The notices are published online at www.grants.gov. Applications for service grants are submitted to the Office of Grants Management for Family Planning Services at the Central Office, but appli- cations are reviewed and decisions made about the awarding of grants, their duration, and their amount at the regional level. The region’s Objective Review Committee (ORC) evaluates applications according to the follow- ing criteria in the Title X statute: • Whether the project plan provides for requirements set forth in Title X regulations (maximum 20 points) • Extent to which services are needed locally (maximum 20 points) • Adequacy of facilities and staff (maximum 20 points) • Capacity to make rapid and effective use of federal assistance (maximum 10 points) • Need of applicant (maximum 5 points) • Availability of other, nonfederal resources within the community (maximum 10 points) • Number of patients and number of low-income patients (maximum 15 points) The same scoring methodology is used by all 10 regional ORCs, but there are differences in how the above criteria are applied and used in fund- ing decisions. While applications are reviewed using the ORC process, competition rarely occurs among grantees since there are few applications for any given award, and there is almost no grantee turnover (less than 2 percent per year). However, according to OFP, there is more competition currently than in the past. As discussed more fully below, 57 percent of grantees are governmental (state or territory departments of health), and 43 percent The review groups are made up of qualified subject matter experts with in-depth knowledge of program issues directly relating to the agency’s mission. Once the application review is com- plete, written recommendations are provided to program management staff and the agency’s leadership, who make the final determination regarding funding” (HHS, 2006).

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07 PROGRAM MANAGEMENT AND ADMINISTRATION are nongovernmental entities that have been providing services for several decades (RTI International, 2008). Most regions have added or replaced, on average, one to two new grantees over the past 10 years (The Lewin Group, 2009). Once the ORC review process has been completed, the RHA and RPC determine the duration of the grant and the amount of funding. Grantee Funding Each region receives a core allocation of regular service funds by the Central Office, based on a historical formula that measures each region’s need according to three data sets—the Guttmacher Institute’s Women in Need of Contraceptive Services and Supplies (hereafter referred to as Women in Need) (Guttmacher Institute, 2008b), census data, and the Bureau of Primary Care’s Common Reporting Requirements.6 The Lewin Group notes that precise information is unavailable on the formula and weighting of each data set (The Lewin Group, 2009). In the early 1980s, the Central Office considered changing the regional allocations, but Congress included in its appropriations bill language that prevented such changes (see discussion, Methodology for Allocating Regu- lar Service Funds, Appendix J). Since then, both the regular service funds and any subsequent budget increases have been allotted to each region according to its established percentage. In 2003–2004, OFP, at the request of the Acting Assistant Secretary of Health, reexamined its methodology for regional allocations (The Lewin Group, 2009). At that time, OFP determined that the allocations continued to reflect the need in each region accurately. No further efforts have been initiated to evaluate or change the basic funding formula. The RHA and RPC have discretion to determine how funds will be distributed to grantees within their region. While they set forth a meth- odology for distribution of funds in the annual regional work plan, The Lewin Group (2009) reports that most methodologies were established some time ago and are used infrequently, as most grantees remain the same from year to year. It is only when a new grantee is added to a region that the methodology may be used. In all the regions examined by The Lewin Group, awards were based on the ORC score, the FPAR, and Women in Need. However, the regions varied in the weight they gave 6 The HHS Bureau of Primary Care’s Common Reporting Requirements are the guidelines for annual reporting designed for community health centers. These requirements also were used as the guidelines for reporting on Title X until 1995, when the FPAR was instituted (The Lewin Group, 2009 [see Appendix J]).

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0 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM to these data, and some grants were based largely on past awards to the grantees.7 According to the testimony of Title X grantees before the committee, grantees are largely unaware of how funding allocations are determined and are concerned about the lack of transparency, inequities in the alloca- tions, and the data that are used. In testimony provided during one of the committee’s public workshops, for example, a participant indicated that the distribution of funds in one of the Title X regions resulted in payments of less than $50 per user to some grantees and more than $200 per user to other grantees. The participant stated that “some degree of variation is both expected and appropriate, but a large discrepancy is not warranted,” and that allocations appear to be influenced by political considerations. Another example cited is that one grantee may have two clinics and receive $400,000, while another grantee in the same region may support 140 clinics and receive $2.1 million. The Lewin Group (2009) notes grantee concerns about the lack of adjustment for population shifts and the limitations of bas- ing allocations on data from Women in Need rather than on the number of people being served. These discrepancies lead grantees to believe that good performance is not being incentivized appropriately because some groups are receiving more money for serving fewer clients. (Such discrepancies may reflect geographic distribution, as it is more expensive to operate clinics in more remote areas. They may also reflect patient populations with differ- ent needs; for example, a homeless woman who uses drugs may require more and more expensive services than a 25-year-old married woman who is seeking contraception. However, data do not exist to support these or other explanations.) Greater transparency is also needed as to the criteria for determining the length of a grant (The Lewin Group, 2009). In addition to regular service funds, grantees receive supplemental expansion funds, regional priority funds, directed supplements, other exter- nal funding for targeted programs, and special project funds. These funds 7 The Lewin Group reports that one region makes decisions on the allocation of regular service funds based on performance (using FPAR data [e.g., numbers of users, HIV tests, Pap tests] and grantee quarterly reports); a historical formula to assess the needs of the community (e.g., Women in Need, state and federal health statistics, needs assessments, National Survey of Family Growth); the number of Title X program users and the size of the grantee; and the resources and history of the grantee in the Title X program. Another region uses a more math- ematical methodology for calculating regular service fund grants (or regional project priority funds) (50 percent of funding is based on the grantee’s immediate past award, 30 percent on the number of women served previously who are at 100 percent of the federal poverty level and below [FPAR data], and 20 percent on Women in Need). A third region makes decisions about allocations by reviewing FPAR data on the clients/populations being served, the ORC score, the grant application plan, and the income level of the population served. Its decision- making process is more subjective. A fourth region simply allocates 90–100 percent of the immediate past award to the grantee (The Lewin Group, 2009 [see Appendix J]).

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0 PROGRAM MANAGEMENT AND ADMINISTRATION are allocated separately, using both competitive and other methods, and are awarded at different times during the year from regular service funds. Based on its proposal and the amount of the final award, a grantee determines the delegate agencies and clinic locations and how much fund- ing will be made available to each to ensure the best access geographically and by population. The Lewin Group (2009) reports that some grantees use the annual needs assessment to identify areas with an unmet need for family planning services, but that there is significant variability in the methodology used by grantees in distributing funds to delegates. Although most grantees pay delegates/clinics a standard base amount for basic costs plus a per patient rate, there is wide variation in those base amounts. The Lewin Group cites the examples of one grantee whose base amount is $80,000 and another whose base amount is $5,000, although these varia- tions may reflect numbers of clients served. The percentage of the previous year’s funding that is guaranteed by grantees also varies considerably. The Lewin Group provides examples of the different methodologies employed by Title X grantees (see Box 4-1). The Lewin Group reports that in recent years, many delegates have attempted to simplify their methodologies for allocating grants to delegates/ clinics. One means used was to include a per patient calculation in the formula. The Lewin Group notes that even delegates and clinics that experienced a loss of funds under a new methodology were supportive of the change because it introduced greater transparency and fairness into the allocation process and helped confirm that the right clients were being served. GRANTEES AND DELEGATES: TYPES AND DISTRIBUTION Grantees vary by state and include governmental entities (state, local, and territorial health departments), as well as nongovernmental entities, including hospitals, university health centers, nonprofit organizations (such as Planned Parenthood affiliates and faith-based organizations), community health centers (CHCs) of various types, independent clinics, and other federally qualified health centers (FQHCs).8 Some states have only governmental grantees (e.g., Virginia, Colorado), some have only nongovernmental grantees (e.g., Pennsylvania, California), and others have a mix of the two (e.g., New York, New Jersey).9 8 FQHCs include all organizations receiving grants under Section 330 of the Public Health Service Act (e.g., CHCs, migrant health centers, health care for the homeless programs, and public housing primary care programs), certain tribal organizations, and FQHC look-alikes. 9 For a list of grantees and delegates, visit www.hhs.gov/opa/familyplanning/grantees/services/ fpdirectory07.pdf.

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0 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM BOX 4-1 Examples of Methodologies Used by Grantees to Distribute Funds to Delegates Grantee A Grantee B • • Standard base of $500,000 paid Women in Need (weighted 10%) • to delegate agencies for basic Previous allocation (all health costs districts have been receiving money almost since the plus beginning) (weighted 50%) • 3-year case load (numbers) • Per client allocation based on (weighted 40%) • number of non-Medicaid patients Also apply 10% variability to seen in the previous year accommodate shifts in case load Grantee C Grantee D • • Allocate more funding to agencies 75% of funding is maintained (no serving higher numbers of delegate will lose more than 25% uninsured, low-income teenagers of funding; none one can increase (less than 135% of the federal funding by more than 33%) • poverty level) Base starting amount is $80,000 • • Take into account all of a Take into account: program’s income from fees and — Number of users public and private insurance — Number of warning letters • Set goals for how much money (compliance) agencies should be generating — Number of special or used in the previous year, populations served whichever is higher — Number of adolescents under • Use the per patient rate for age 17 served allocations based on the number — Chlamydia screenings (e.g., of patients expected to be seen aligned with CDC guideline) and those actually seen (e.g., if a clinic is budgeted for $100,000 to see 1,000 patients, it is paid $100 for every patient seen; if it ends up seeing fewer patients, it owes money back; if it sees more patients, the grantee owes it money) SOURCE: The Lewin Group, 2009.

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 PROGRAM MANAGEMENT AND ADMINISTRATION 350.0 Actual Dollars 300.0 Cons tant Dollars 250.0 Millions of Dollars 200.0 150.0 100.0 50.0 0.0 19 0 19 1 19 2 19 3 84 19 5 19 6 19 7 19 8 19 9 19 0 91 19 2 19 3 94 19 5 19 6 97 19 8 20 9 20 0 20 1 20 2 03 20 4 20 5 06 20 7 20 8 09 8 8 8 8 8 8 8 8 8 9 9 9 9 9 9 9 0 0 0 0 0 0 0 19 19 19 19 19 20 20 FIGURE 4-2 E stimated funding for Title X when adjusted for inflation, FY 1980–2009. New S-1 and 4-2 SOURCE: Sonfield, 2009. Reprinted with permission from unpublished tabulations from the Guttmacher Institute. The number and distribution of grantees by type have changed sig- nificantly since the inception of the Title X program. In the 1980s, many HHS programs became block grants to the states. Although Title X did not become a block grant itself, funding was reduced (by approximately 23 percent in 1982; see Figure 4-2), and grant applications from state health departments received priority consideration. This shift resulted in a decrease in the number of grantees from more than 400 to less than 100, the majority of which were state grantees.10 In 2006, 57 percent of grantees were governmental (state, local, or territorial departments of health), and 43 percent were nongovernmental (RTI International, 2008). As noted earlier, some grantees provide family planning services them - selves, but most contract with delegates in whole or in part. The delegates of state health department grantees may all be governmental entities, such as local health departments (e.g., Virginia), or they may be a mix of governmental and nongovernmental organizations. Nongovernmental del- egates (of governmental and nongovernmental grantees) include hospitals, university medical centers, community action programs, CHCs, school health programs, and nursing service organizations. Some delegates pro- vide only family planning–related services, while others offer a wider range of health care services. Some focus on particular client popula- 10 For example, the state department of health became the single grantee for the state of Texas in 1982, and 38 previous grantee organizations became delegates of that state agency, which at the time was not a direct provider of family planning services.

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 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM or provide them with information on how other grantees have addressed problems they have encountered. Grantees would like more opportunities to learn from other grantees about successful program implementation approaches that might be replicated. Finding 4-8. There is a lack of transparency and communica- tion regarding how decisions affecting program requirements are made and how funding allocations and the duration of grants are determined. Staffing Staffing is a pressing concern for many grantees and delegates. It is likely to become even more so given the shortage of and competition for trained medical personnel in most areas of the country, as well as the impending retirement of many nurses and nurse practitioners who staff the clinics, the increasing cost of salaries and benefits, the need for and cost of continued professional training (Murray, 2002), and efforts to promote nursing training at the doctoral level (AACN, 2008). There has also been a trend toward increased training for entry into practice for nurse practitioners, who make up a significant proportion of medi- cal professionals. As with other professions (such as pharmacy, which now requires a “practice doctorate”), and on recommendations from the Institute of Medicine (2003), a “doctor of nursing practice” is slated to be the training requirement for new nurse practitioners by 2015. This requirement is expected to involve one additional year of training over the length of training for the current masters-prepared nurse practitioner. The enhanced skills gained through this training will benefit patients who rely on Title X services for much of their comprehensive health care by better equipping these clinicians with “interdisciplinary, information systems, quality improvement and patient safety expertise” (AACN, 2006, p. 5, 2008). At the same time, there are some unanswered questions about this additional training requirement, such as whether it will exacerbate short- ages in the available nurse practitioner workforce and how it might affect the cost of hiring nurse practitioners. The limited pool of qualified professionals has been an ongoing prob- lem for the Title X program.21 This problem will become greater with the 21 Earlier,Title X funded certificate Women’s Health Care Nurse Practitioner education programs located in geographically diverse regions (at Planned Parenthood in Philadelphia, Emory University Medical School in Atlanta, University of Texas Southwestern Medical School in Dallas, and Harbor UCLA in Los Angeles) to provide access for participants from Title X programs. These programs graduated more than 4,000 nurse practitioners. They closed in 2005 because of changes in licensing and accreditation, which mandated a masters degree in

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5 PROGRAM MANAGEMENT AND ADMINISTRATION growth in demand for Title X services, including services that can meet the needs of increasingly culturally and linguistically diverse populations (see the section on providing appropriate care below). Recruitment and retention is the most pressing concern. Most clini- cal care is provided by nurse practitioners who have advanced nursing training at the master’s level (CDC, 2004). In 2006, midlevel health care providers, who include nurse practitioners, physician assistants, and certi- fied nurse midwives, made up 51 percent of the full-time medical staff at Title X–funded clinics (RTI International, 2008). As heard in testimony before the committee, those clinics compete for medical professionals with other types of health care organizations, but generally are not in a posi- tion to offer competitive salaries and benefits. The shortage of personnel is particularly acute in rural areas. The costs of recruiting and retaining staff who can address the needs of Title X clients, including those who can provide culturally appropriate care, have increased. In a 2001 Guttmacher investigation of 12 Title X clinics, respondents indicated that the demand for language assistance for clients with limited English proficiency increased their costs of doing business (Gold, 2003). According to the 2006 FPAR, such clients repre- sented 13 percent of Title X users (RTI International, 2008). Staff that can assist these clients are needed at every level of service, from intake to clinical encounters. However, increased competition, particularly for nurse practitioners, makes attracting these individuals to family planning clinics increasingly difficult. Finding 4-9. Title X is currently facing difficulties in recruiting and retaining staff who can meet the increasingly complex needs of diverse populations. These needs will grow in the future. Informational and Educational Materials During the committee’s site visits, in testimony provided by grantees and delegates, and in the Membership Survey of the National Family Planning and Reproductive Health Association (NFPRHA), several issues regarding informational and educational materials were raised. These issues include the manner in which materials developed by the OPA Clearinghouse are reviewed, the duplicative review by a delegate’s advisory committee after review by the grantee responsible for the delegate, and delays or nursing for nurse practitioners. Subsequently, OPA/Title X funded two programs—an online clinical specialty course designed to provide clinical competency–based family planning educa- tion for nurse practitioners (offered until 2006) and the current preceptorship program, which is offered through the National Clinical Training Grantee.

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6 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM other problems in obtaining payment for materials ordered from outside sources. Grantees and delegates suggested that materials used in a related program might be distributed without additional review. Concerns were also expressed about the ability of the advisory committees (rather than professional health educators or public health personnel) to select cultur- ally, linguistically, and literacy level–appropriate materials. Grantees and delegates indicated that some of the OPA Clearinghouse materials fail to meet those criteria—deficits that should be rectified at the Clearinghouse level. Challenges of Serving Populations That Are the Focus of Title X With growth in the overall population and expected parallel growth in the low-income population, cutbacks and gaps in health insurance, the large number of adolescents with unmet needs for family planning services, increased prevalence of STDs, and other societal changes (discussed in Chapter 2), the demand for family planning services has increased. While funding is a core issue that affects the ability of Title X clinics to provide care for all who seek it, the situation poses particular challenges concerning the special needs of target populations such as adolescents, men, and people with limited English proficiency. Common to all of these groups is the need for specialized outreach to overcome barriers to their seeking clinic services. Grantees noted problems in meeting the costs of outreach and having staff available for the purpose given the personnel cutbacks resulting from lim- ited funds. One grantee interviewed during a site visit lamented the lack of funds for advertising or conducting studies to determine what works to bring people to the clinic. Some grantees and delegates have tried to reach target populations by developing partnerships with other social and human service providers or schools, but they would like to do more. Adolescents pose special problems because of their lack of knowledge about reproductive health and the services they might use. As discussed above, the Title X program provides education and counseling to address this deficiency and meet the needs of individual patients. If these ben- eficial services are to be made available, resources must be committed to ensure sufficient time for provider–patient sessions and appropriate staff training. Another challenge regarding the provision of services to adolescents is the required clinical examination, in particular the requirement that pro- viders perform a pelvic exam within 6 months of the patient’s first visit. As discussed above, grantees expressed concern that this requirement may deter teens from seeking services or continuing as clients. Under ACOG’s current guidelines, adolescents may make several gynecological visits before

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7 PROGRAM MANAGEMENT AND ADMINISTRATION they have an internal examination, during which time they may develop trust in the provider. The “ABC” approach to counseling for HIV prevention (Abstinence, Being faithful, and Condoms) is also viewed by some grantees as an impediment to the provision of services to adolescents. Respondents to the NFPRHA survey indicated that the ABC approach is unrealistic, noting the difficulty of providing effective counseling on abstinence to sexually active teens who are seeking contraceptives. ACOG takes a different approach, arguing that having a confidential discussion about the patient’s general health, dating relationships, and intimacy and sexual activity and encour- aging the sharing of information are important for providing appropriate health care to adolescents (ACOG, 2004). Many studies have found that, especially for teens, the most effec- tive approach to preventing unintended pregnancies is to address broader aspects of young people’s lives, such as their investments in education, civic service, and youth development. In a review of more than 150 studies, for example, researchers from Child Trends identified approaches that have had a positive impact on teenagers’ reproductive health behaviors. Among these approaches were those that combined sexuality education for older children with positive activities such as participating in voluntary community service and youth development programs (Manlove et al., 2002). Kirby (2007) found that comprehensive programs, which include education about delay- ing sexual activity and decreasing the number of sexual partners as well as information about contraception, were considerably more effective overall than those focused on abstinence-only education in encouraging positive reproductive health behaviors and showed no significant negative effects. In addition, many private foundations are investing in research aimed at identifying ways to improve the family planning and reproductive health care available to low-income women, including teens. Although men represent a small percentage of Title X clients (approxi- mately 5 percent), adolescent and young adult males are at particular risk for STDs and sexual activity that results in unintended pregnancies, and benefit from receiving formal instruction about birth control methods. Studies have shown that efforts to target this population can significantly improve knowledge of contraception, pregnancy risk, and sexual respon- sibility, which presumably leads in turn to positive reproductive health impacts for males and females (Danielson et al., 1990; Armstrong et al., 1999; Brindis et al., 2005). Efforts are under way at clinics around the country to explore means of reaching out to men in need of reproductive health services (Brindis et al., 1998). Yet Title X providers disagree about the emphasis the program should place on serving men, as opposed to focus- ing on the primary goal of meeting the contraceptive needs of women.

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 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Provision of Culturally Appropriate Care Offering culturally and linguistically appropriate care and education raises many concerns for Title X clinics, ranging from providing medical care that is in accordance with a patient’s cultural norms to communicating effectively with patients who have limited English proficiency. The demand for assistance to clients in many languages is increasing in communities nationwide (Gold, 2003). Culturally sensitive interpreters can provide translation to ensure that adequate and essential communication takes place between a patient and his or her provider. Evidence indicates that using such trained interpreters not only improves communication but also increases patient satisfaction and health outcomes, while quality of care is compromised when needed interpreter services are not provided (Flores, 2005). As discussed in Chapter 3, HHS’s Guidance Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons also requires agencies that receive federal fund- ing from HHS to ensure that clients with limited English proficiency have access to services the agencies provide. However, the cost of providing such interpreters (or the alternative of “language lines”) is high if staff members are unable to speak the patients’ languages. Recruiting and retaining staff, including clinicians who can provide culturally and linguistically appro- priate care, is a continuing challenge. Grantees are concerned, too, that some of the Title X educational requirements may not account for cultural differences or language barriers (NFPRHA survey 4). Provision of Services That Meet Client Needs The Program Guidelines establish requirements for the package of ser- vices that all patients must receive. As discussed above, however, grantees are concerned that the requirements force them to offer too many unneces- sary and time-consuming services that patients may not want, and therefore do not allow them to individualize services to meet patients’ needs in line with scientifically based best practices. In the area of education and counsel- ing in particular, clinic personnel should have the flexibility to make deci- sions regarding issues to discuss, taking into account current evidence-based guidelines and professional norms. They should be able to focus on the information pertinent to a patient’s condition or concerns in a personally and culturally sensitive way. Such a patient-appropriate approach would also allow staff to devote more time to responding to patients’ questions, rather than delivering a litany of prescribed information that may not be relevant. Although counseling is labor-intensive, some patients may require counseling about a range of life issues and circumstances that impact on

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 PROGRAM MANAGEMENT AND ADMINISTRATION their reproductive health to enable them to be more effective contraceptive users. For example, when working with teenagers, providers should assess and counsel across a range of life issues that directly affect sexual behaviors and contraceptive use. This assessment should include a careful review of the circumstances surrounding sexual behavior and choice of partners, the ability to negotiate with partners, substance use and its impact on contra- ceptive practice, and whether an abuse history or sexual assault leaves a teenager more vulnerable. Among adult women, too, many of these fac- tors, particularly abuse and intimate partner violence, require assessment and may result in the need for counseling and referral. While providers are asking for greater flexibility and individualization in their approach to patient-centered care, it is important for the Program Guidelines to ensure that patients receive appropriate services based on a proper assessment of their history and current circumstances. Serving low-income working women presents additional challenges in many localities, given that, according to testimony heard by the commit- tee, limited funding and staffing have resulted in restricted hours for some clinics. For these women, many of whom cannot take time away from their employment, the lack of evening or weekend hours creates a barrier to care. The committee notes that some clinics do use Title X funds to cover the added costs of operating outside of normal business hours. Some grantees and delegates would also like to do more, either on-site or through off-site clinics, to meet the needs of other high-risk populations, such as the homeless, substance users, those with disabilities, and those who are incarcerated. However, such expanded services would require additional resources. The program structure and funding also limit the ability of Title X clinics to provide important services relevant to healthy pregnan- cies and birth outcomes. These services include pre- and interconception care (to improve, respectively, the health of women who are considering pregnancy and attention to issues between pregnancies that may affect birth outcomes).22 CONCLUSIONS AND RECOMMENDATIONS The committee drew the following conclusions about the management and administration of the Title X program: 22 These services include prevention and management, emphasizing health issues that require action before conception or very early in pregnancy for maximal impact, such as obesity/ weight management, adult immunizations, supplements (folic acid), mental health care, and treatment of infectious and chronic diseases (e.g., hypertension, diabetes) that could impact pregnancy and fetal health (CDC, 2006; Lu et al., 2006).

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0 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM The management structure and administration of the program generally work well, but could be improved. Specific areas for improvement include overall funding levels, pharmaceutical and laboratory testing costs, birth control method availability, administrative burden, the evidence base for and flexi- bility of the Program Guidelines, transparency and communication, staffing, shortages, and informational and educational materials. The committee offers the following recommendations for achieving these improvements: Recommendation 4-1: Increase program funding so statutory responsibilities can be met. Title X should receive the funds needed to fulfill its mission of providing family planning services to all who cannot obtain them through other sources and to finance such criti- cal supplemental services as infrastructure, education, outreach, and counseling that many other financing systems do not cover. Consistent with legislative intent, financing for the program must also support research and evaluation, training, the development and maintenance of needed infrastructure, and the adoption of important new technologies. Recommendation 4-2: Examine and, if appropriate, improve methods of allocating funds. OFP should carefully examine and, if appropriate, improve the system used to allocate funds from OFP to regions, regions to grantees, and grantees to delegates. The transparency of these funding processes should be improved so that program participants and the public are aware of the processes for making decisions about funding allocations at each level and for commenting on those decisions. Recommendation 4-3: Improve the ability to purchase drugs and diagnostics at reduced prices by consolidating purchasing sources. OFP should work with the various public and private purchasing sources for drugs and diagnostics for Title X clinics to develop a coordinated or consolidated purchasing program. Recommendation 4-4: Improve the continuity of products provided to clients of Title X clinics. The 0B drug pricing program should revise its list of available drugs less frequently and make an effort to obtain drugs with longer expiration periods. Product continu- ity would also be enhanced by the consolidation proposed under Recommendation -.

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 PROGRAM MANAGEMENT AND ADMINISTRATION Having a consolidated pharmaceutical program for Title X grantees would provide potential cost savings through bulk purchasing, as well as improved continuity of products. Having a more consistent and cost- effective program would benefit both clinics and patients. Recommendation 4-5: Reduce the administrative burden on Title X clinics. OPA should work with other HHS agencies sup- porting family planning to coordinate patient fee schedules and record-keeping and reporting requirements. OPA should also adopt a single funding cycle, where possible, for the awarding of grants. Title X clinics bear a significant burden in budgeting for and managing their multiple sources of funding, a burden exacerbated by the multiple funding cycles for the awarding of grants. Coordination of patient fees and record-keeping and reporting requirements for the numerous federal programs involved and establishment of a single funding cycle could reduce this administrative burden, as well as associated costs. Improvement in coordination for various federal programs may require changes to legisla- tion directed at involved agencies. Recommendation 4-6: Adopt a single method for determining cri- teria for eligible services. The federal government should adopt a single method of determining criteria for eligible services (for example, which services are available at which percent of the fed- eral poverty level), what copays if any are required, and how clinics should report clients seen. The current inconsistencies create an atmosphere that discourages coordination of Health Resources and Services Administration, Centers for Disease Control and Preven- tion (CDC), and other programs with Title X. Recommendation 4-7: Review and update the Program Guidelines to ensure that they are evidence based. OFP should review the Program Guidelines annually and update them as needed to reflect new scientific evidence regarding clinical practice. In so doing, OFP should establish a mechanism for obtaining expert scientific and clinical advice in a systematic, transparent way. Expertise should be drawn from the clinical, behavioral, epidemiological, and educa- tional sciences. In addition, it is important to enhance the flexibility of Title X clinics so they can meet the needs of individual patients while adhering to evidence-based guidelines and practices. Because the required services extend beyond those included in evidence- based professional guidelines, resources are not being used most efficiently,

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2 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM and the program is missing opportunities for patient-centered care. In addi- tion, outdated Program Guidelines can result in clinical practices that fail to meet current standards for medical care and for education and counseling. The latter include recommendations for screening and provision of infor- mation about disease prevention (such as those of the U.S. Preventive Ser- vices Task Force, ACOG, the American College of Physicians, the American Cancer Society, and the American Academy of Pediatrics), for education (such as those of the Sexuality and Information and Education Council of the United States), and specifically for the delivery and safe use of contracep- tives (of the World Health Organization in its Medical Eligibility Criteria). OFP has issued service orders (for example, regarding cervical cytology) that direct grantees and delegates to use guidelines of professional societies. These service orders are not always disseminated promptly, however, and in any event leave delegates with conflicting requirements. Incorporating such evidence-based recommendations in a timely way and promptly communicat- ing them to grantees and delegates (through, for example, regular conference calls as well as the Internet in order to disseminate up-to-date information to all levels of program staff) could improve the effective and efficient delivery of services under Title X, as could allowing greater flexibility in service pro- vision. Finally, timely updated guidelines could be used for all federal health care programs. In this way, clinical and quality advances achieved in Title X could be used to inform other HHS family planning efforts. Recommendation 4-8: Increase transparency and improve commu- nication. OFP should increase the transparency and communication of information at all levels of the program. Such information should encompass methods for allocating program funds, the process for establishing annual program priorities, suggestions for program improvements, lessons learned through research supported by Title X and other programs, and how data are used. This informa- tion should be disseminated both vertically and horizontally. In light of the limited funding and opportunities for regional or national meetings, the Internet could be used to facilitate communication among grantees and RPCs across regions. Greater use of online systems could help a great deal in disseminating information, such as updates on clinical prac- tices, from the Central Office to RPCs, grantees, and delegates, as well as exchanges among grantees and from grantees to both RPCs and the Central Office. For example, this type of communication is used by the program’s national and regional training grantees, which have Internet-based service, resource, and training tools.23 A website could be developed to provide 23 See http://www.hhs.gov/opa/familyplanning/grantees/training/index.html.

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 PROGRAM MANAGEMENT AND ADMINISTRATION information about policies, service requirements, changes in the Program Guidelines, and program improvements, as well as training for staff. Infor- mation useful for quality improvement could be included (see Chapter 5). Interactive components could facilitate communication at all levels. Recommendation 4-9: Assess workforce needs. With the help of an independent group, OFP and other agencies within HHS should conduct an analysis of family planning workforce projections for the United States in general and for the Title X program specifi- cally. The study should assess current and future workforce train- ing needs and the educational system capacity necessary to meet those needs. The study should also identify ways in which these needs can be met and financed. Given the current and predicted personnel needs throughout the pro- gram, national efforts to address the problem are appropriate. NFPRHA has suggested a workforce study to develop strategies for addressing recruitment and retention issues, including alternative staffing options. Outreach and collaboration with nurse practitioner training programs should be explored. As efforts are made to revise state licensure laws to require practitioners to have more advanced training (National Council of State Boards of Nursing, 2008), they must be fully evaluated for their impact on available staffing, and plans must be made to deal with shortages. To address the immediate problem, efforts should be made to ensure that current staff members receive the training needed to maintain their professional credentials under state laws and professional certification programs. The Title X training priorities have focused on program-specific issues to help grantees comply with changes in program priorities (see Chapter 3). Greater effort should be made to develop training modules that not only inform participants about program issues, but also meet continuing education requirements for nurse practitioners, certi- fied nurse midwives, and others who staff Title X clinics. This goal could be advanced through the priorities for training in the MOU between OFP and the Regional Offices. New means of providing training should also be explored. Internet-based programs could make training available to a broader audience at lower cost. Specific attention also should be given to clients’ language issues when considering workforce needs. Recommendation 4-10: Assess the local review of informational and educational materials. OFP should assess whether the benefits of local review of all educational materials outweigh the burdens, including costs. OFP should develop processes that eliminate dupli- cative reviews while also ensuring that consumers have an oppor- tunity for input at either the local or national level.

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