Appendix A
Data Sources and Methods

The Committee on a Comprehensive Review of the HHS Office of Family Planning Title X Program was asked to provide a critical review and assessment of the Title X program. The purpose of this study was to examine Title X administration and management, and to assess whether the Title X objectives and operational requirements meet the needs of the program’s target populations and have been adapted to ongoing changes in technology and medical practice, social changes, and other related influences that affect these populations since the program was created in 1970. To provide a comprehensive response to its charge, the committee examined data from a variety of sources. These data sources included a review of recent literature, input provided during a series of public workshops, commissioned papers, and site visits to selected recipients of Title X funds. The study was conducted over a 24-month period.

The committee comprised 16 members with expertise in family practice, obstetrics and gynecology, adolescent health, behavioral science, demography, program administration and evaluation, health services research, health economics, law, and policy. The committee held five 2-day meetings in December 2007, February 2008, May 2008, August 2008, and October 2008.

LITERATURE REVIEW

The committee used several strategies to identify literature and other documents relevant to its charge. First, it conducted a search of four bibliographic databases to obtain articles from peer-reviewed journals: PubMed,



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Appendix A Data Sources and Methods The Committee on a Comprehensive Review of the HHS Office of Family Planning Title X Program was asked to provide a critical review and assessment of the Title X program. The purpose of this study was to examine Title X administration and management, and to assess whether the Title X objectives and operational requirements meet the needs of the program’s target populations and have been adapted to ongoing changes in technology and medical practice, social changes, and other related influ- ences that affect these populations since the program was created in 1970. To provide a comprehensive response to its charge, the committee examined data from a variety of sources. These data sources included a review of recent literature, input provided during a series of public workshops, com- missioned papers, and site visits to selected recipients of Title X funds. The study was conducted over a 24-month period. The committee comprised 16 members with expertise in family prac- tice, obstetrics and gynecology, adolescent health, behavioral science, demography, program administration and evaluation, health services research, health economics, law, and policy. The committee held five 2-day meetings in December 2007, February 2008, May 2008, August 2008, and October 2008. LITERATURE REVIEW The committee used several strategies to identify literature and other documents relevant to its charge. First, it conducted a search of four biblio- graphic databases to obtain articles from peer-reviewed journals: PubMed, 183

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184 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Sociological Abstracts and Social Service Abstracts. The searches focused on Title X and U.S. family planning services, using the key- words Title X, public funding, national family planning programs, family planning, reproductive health services, maternal health services, women’s health services, student health services, adolescent health services, evalua- tion studies, Medicaid, and community health centers. From approximately 2,000 articles, staff identified those relevant to the committee’s charge and created an EndNote database. Second, Title X documentation—including legislation, regulations, previous program evaluations (see Appendix D for a review), guidance documents (Program Review Tool, Title X Pro- gram Guidelines, Office of Population Affairs [OPA] Program Instructions), Family Planning Annual Report (FPAR) guidance, products resulting from Service Delivery Improvement Requests for Applications (RFAs) (past and present final reports), and the Program Assessment Rating Tool (PART) evaluation—were added to the committee’s EndNote database. The previ- ous program evaluations were also used to identify relevant articles and documents. Finally, committee members, meeting participants, and the public submitted articles and reports. In total, the committee’s database of relevant documents included more than 200 articles and reports. PUBLIC WORKSHOPS The committee hosted three public workshops to gather additional information on specific aspects of its charge. These workshops were held in conjunction with the committee’s December 2007 and February and May 2008 meetings. The first workshop was intended to provide an overview of the structure and purpose of the Title X program and the committee’s charge, which was discussed by representatives from the study’s sponsors. Several invited stakeholders shared their perspectives on Title X, particu- larly with respect to the scope of its services and how well it is serving its target populations. The second workshop focused on a variety of topics, including the place of Title X in a state’s overall health system and the per- spectives of organizations that represent grantees and of current and former grantees and delegates. The third workshop addressed the role of Title X regional program consultants, drug pricing and its impact on the cost of operating Title X programs, and the measurement of quality in family planning services. Each workshop was open to the public. Individuals were invited to present information to the committee, answer questions from the committee and the audience, and participate in subsequent discussions. The agendas for these meetings are presented in Boxes A-1 through A-3.

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185 APPENDIX A BOX A-1 Committee on a Comprehensive Review of the HHS Office of Family Planning Title X Program The National Academies Keck Building 500 Fifth Street N.W., Room 101 Washington, DC Thursday, December 6, 2007 AGENDA WELCOME AND INTRODUCTIONS 1:00 p.m. Ellen Wright Clayton, M.D., J.D. Chair OVERVIEW OF THE OFFICE OF POPULATION AFFAIRS AND 1:15 p.m. TITLE X Susan Orr, Ph.D. Acting Deputy Assistant Secretary for Population Affairs SPECIFIC ASPECTS OF TITLE X Susan B. Moskosky, M.S., R.N.C. Director, Office of Family Planning Office of Population Affairs DELIVERY OF STUDY CHARGE Susan Orr, Ph.D. Acting Deputy Assistant Secretary for Population Affairs DISCUSSION OF STUDY CHARGE 2:15 p.m. GENERAL DISCUSSION 2:45 p.m. BREAK 3:15 p.m. STAKEHOLDER PERSPECTIVES 3:30 p.m. Mary Jane Gallagher President and CEO National Family Planning and Reproductive Health Association 3:40 p.m. Rachel Benson Gold Director of Policy Analysis and Washington Office Operations Guttmacher Institute 3:50 p.m. Dorothy Mann Executive Director Family Planning Council, Inc. DISCUSSION 4:00 p.m. RECEPTION 5:00 p.m.

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186 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM BOX A-2 Committee on a Comprehensive Review of the HHS Office of Family Planning Title X Program The National Academy of Sciences Building 2100 C St. N.W. Washington, DC Room 150 Monday, February 11, 2008 PERSPECTIVES ON TITLE X AGENDA WELCOME AND INTRODUCTIONS 1:00 p.m. Ellen Wright Clayton, M.D., J.D. Chair, Committee on a Comprehensive Review of the HHS Office of Family Planning Title X Program PERSPECTIVES ON TITLE X FROM A STATE OFFICIAL: HOW DOES TITLE X FIT INTO A STATE’S OVERALL HEALTH SYSTEM? 1:15 p.m. Joan Henneberry, M.S. Executive Director Colorado Department of Health Care Policy and Financing Former Director, Colorado Family Planning Program Q&A 1:30 p.m. PERSPECTIVES ON TITLE X FROM ORGANIZATIONS REPRESENTING GRANTEES: STATE FAMILY PLANNING ADMINISTRATORS AND FAMILY PLANNING COUNCILS OF AMERICA 1:45 p.m. Rian Frachele Vice President, State Family Planning Administrators Section Manager, Women’s and Reproductive Health Office of Family Health, Public Health, Oregon Department of Human Services 2:00 p.m. Cindy Stewart, CAE President, Family Planning Councils of America President and CEO, Family Health Council of Central Pennsylvania, Inc. Q&A 2:15 p.m. BREAK 2:45 p.m.

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187 APPENDIX A PERSPECTIVES ON TITLE X FROM CURRENT GRANTEES AND DELEGATES 3:00 p.m. Juliana Gonzales Title X Family Planning Program Coordinator El Buen Samaritano Episcopal Mission Austin, TX 3:15 p.m. Mark Hathaway, M.D., M.P.H. Outreach Director for OB/GYN Services Washington Hospital Center Clinical Director for Title X and Associate Medical Director for OB/GYN Services Unity Health Care, Inc. Washington, D.C. 3:30 p.m. David Greenberg, Ph.D. President and CEO Planned Parenthood of the Columbia Willamette, Inc. Portland, OR Q&A 3:45 p.m. PERSPECTIVES ON TITLE X FROM A FORMER GRANTEE 4:15 p.m. Michael Bloom, M.P.A. CEO, North Colorado Health Alliance Former CEO, Sunrise Community Health Q&A 4:30 p.m. GENERAL DICUSSION 4:45 p.m. ADJOURN 5:15 p.m. RECEPTION FOR COMMITTEE, PRESENTERS, AND GUESTS

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188 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM BOX A-3 Committee on a Comprehensive Review of the HHS Office of Family Planning Title X Program The National Academies Keck Building 500 Fifth Street, N.W. Washington, DC Room 101 Monday, May 19, 2008 PUBLIC MEETING AGENDA WELCOME AND INTRODUCTIONS 8:30 a.m. Ellen Wright Clayton, M.D., J.D. Chair, Committee on a Comprehensive Review of the HHS Office of Family Planning Title X Program PERSPECTIVES ON TITLE X FROM REGIONAL PROGRAM CONSULTANTS 8:45 a.m. Evelyn Glass, M.S.P.H. Regional Program Consultant Region VI 9:00 a.m. Jill Leslie Regional Program Consultant Region VIII Q&A 9:15 a.m. DRUG PRICING AND THE IMPACT ON TITLE X PROGRAMS 9:35 a.m. Jimmy R. Mitchell, R.Ph., M.P.H., M.S. Director, Office of Pharmacy Affairs Health Resources and Services Administration COMMISSIONED PAPERS The committee commissioned papers to provide in-depth information on two selected topics. The first paper (presented in Appendix J) reviews the organizational structure and management of the Title X program, with a focus on the relationships among the program’s Central Office, Regional Offices, and grantees/delegates. It examines the effectiveness of the rela- tionships between the Central Office and Regional Offices, mechanisms

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189 APPENDIX A 9:55 a.m. Adam Sonfield, M.P.P. Senior Public Policy Associate The Guttmacher Institute 10:10 a.m. Q & A 10:30 a.m. BREAK THE MEASUREMENT OF QUALITY IN FAMILY PLANNING SERVICES 10:45 a.m. Dorothy Mann Executive Director Family Planning Council, Inc. 11:15 a.m. Q & A 11:30 a.m. GENERAL DISCUSSION 12:00 p.m. ADJOURN for accountability and transparency, and the effectiveness of the FPAR for management purposes. The second paper (presented in Appendix K) assesses the quality of reproductive health services provided under the Title X program. It addresses how well the FPAR measures quality, quality initiatives under- taken by family planning programs, how the quality of services should be assessed in various settings, and the costs and benefits associated with introducing quality measures into family planning clinics.

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190 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM SITE VISITS The committee visited 16 Title X clinics to obtain perspectives on the program from administrators and service providers. The methods used and results from these site visits are summarized in Appendix F.