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Appendix F
Committee Site Visits
The committee conducted 16 site visits to Title X grantees and delegates during April–July 2008 to gather information about the experiences of local administrators and service providers with the Title X program. Approximately 4,600 sites receive Title X funds. The sites visited were selected to reflect various geographic regions, clinic types (including health departments, community health centers, hospital and academic centers, and Planned Parenthood health centers), and patient demographics (including race and ethnicity). Sites were chosen based on convenience sampling and were not considered to be a representative sample of Title X sites. The following sites were visited:
Adagio Health Aliquippa, Aliquippa, Pennsylvania;
Charlottesville/Albemarle Health Department, Charlottesville, Virginia;
Fred Leroy Health and Wellness Center, Omaha, Nebraska;
Harbor UCLA Medical Center, Torrance, California;
La Clinica De La Raza, Oakland, California;
Midwife Center for Birth and Women’s Health, Pittsburgh, Pennsylvania;
Mobile County Health Department, Mobile, Alabama;
New York Presbyterian Hospital, New York, New York;
Orange County Health Department, Orange, Virginia;
People’s Community Clinic, Austin, Texas;
Planned Parenthood of Middle and East Tennessee, Nashville, Tennessee;
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Planned Parenthood of Mid-Michigan, Ann Arbor, Michigan;
Planned Parenthood of Wisconsin Inc., Madison, Wisconsin;
Trousdale County Health Department, Hartsville, Tennessee;
Unity Health Care, Washington, DC; and
University of Nebraska Medical Center Family Planning Clinic, Omaha, Nebraska.
One or two committee members conducted each half-day visit. They followed one of several loose interview guides (see Boxes F-1 through F-4), which varied based on the type of site, to assist them in gathering information. The questions in sections I and II of the interview guides were provided to the sites for completion prior to the visits. Committee members interviewed senior administrators, Title X coordinators, and service providers. The committee was interested in obtaining information about each program (including services provided, demographics of patients served and the surrounding community, and staffing), financing (for example, proportion of Title X versus other funding), and grantee and delegate perspectives on the Title X program.
Staffing varies greatly among the sites—from 2 to 40 full-time employees. The percentage of the sites’ funding provided by Title X ranges from 4 percent to 75 percent, but is less than 15 percent for most sites. Title X funds are used for a mix of staff, services, goods, administrative costs, and facility costs. A summary of the strengths and weaknesses of the Title X program cited by interviewees is presented below, followed by a summary of the interviewees’ perceptions of the Family Planning Annual Report (FPAR) and additional findings.
STRENGTHS AND WEAKNESSES OF TITLE X
In general, the interviewees emphasized that Title X is an extremely beneficial program. Most noted that Title X funds allow them to provide services they would otherwise struggle to offer, including the direct provision of contraceptive methods. They appreciate that Title X funds are more flexible than many other funding sources and can be used to cover such expenses as staffing, overhead, outreach, and patient education. Interviewees also said that Title X increases access for underserved populations, including adolescents and the uninsured. Some of the administrative features and requirements of the program were also cited as strengths. For example, one interviewee noted that “the counseling requirements make the nurse ask questions she might have otherwise overlooked.” The interviewees generally reported positive relationships between grantees and delegates.
At the same time, interviewees had many suggestions for improving the program. Several reported finding the goals and priorities of the
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BOX F-1
Title X Site Visits to Hospital-Based Centers
Site information (should be completed by the site prior to the visit)
Location (city, state)
Hours/days of operation
Geographic market (rural, urban, suburban)
Annual visits (number)
Demographics (clients served annually)
median age and range
% female
average income
race/ethnicity
How are patients referred to your center?
Highest volume (days/times)
Staffing
Number of staff
Types of staff (e.g., case manager, social worker, nurses, residents, physicians)
Staff case load
Tools (electronic or otherwise) used in the work
Recent/current process improvement efforts/projects
Are there any current reports on performance, productivity, etc.?
Does the site work in conjunction with other clinics or other organizations that provide family planning services?
Finances (should be completed by the site prior to the visit)
Income—How is your organization funded (breakdown by percentages)?
Federal %
Title X funds %
Medicaid funds %
MCH grants %
TANF %
Social services block grants %
State appropriations %
Grants %
Gifts %
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Private payer %
Out of pocket/self-pay %
Uncompensated care %
Functions of staff
Expenses—What do Title X funds pay for?
Budget for staff
Budget for services (e.g., medical operations, education, outreach)
Budget for goods (e.g., labs and associated costs, pharmaceuticals and dispensing costs)
Administrative costs
Facility costs (purchase/rent, maintenance)
Site Concerns
Begin by asking each interviewee: what are the two most important things you would like to share about your experiences with Title X.
Services
Range of services
What types of services do Title X funds provide? Education
___ Counseling
___ History, physical assessment, labs
___ Fertility regulation (contraception)
___ Infertility services
___ Pregnancy diagnosis and counseling
___ Adolescent services
___ GYN services
___ STD and HIV/AIDS
___ Special counseling (future pregnancies, substance use, sexual abuse, domestic violence)
___ Health promotion/disease prevention
___ Postpartum care
___ Other (please list)
Who else provides these services in the community?
Scheduling
How are urgent vs. emergent patients scheduled (priority matrix)?
Appointment wait time (how many days or weeks?)
Quality
Do staff follow any standing clinical protocols or care pathways?
What quality metrics are evaluated at the site?
Referral and Follow-up
Are patients classified based on any risk factors? If so, what risk factors?
What is the mechanism for post-visit follow-up?
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Perspectives on Title X
What are benefits/strengths of the Title X program?
What are drawbacks or weaknesses of the program?
What do Title X funds allow you to do that other funding sources do not?
What changes or improvements (administrative, service provision, etc.) would you suggest for the program?
How do Title X requirements (e.g., child abuse reporting) affect the provision of services?
How do you implement the mandate to encourage parental involvement?
Describe hard-to-reach groups in your area and describe any efforts at outreach.
Describe the ease/burden of collecting information for FPAR. What elements seem unnecessary? What additional elements would you include?
How does the administrative structure work from your perspective? What is your relationship (communication) with the grantee and/or RPC?
How have any funding limitations affected the number of patients served or the care that is delivered? (e.g., hours of operation, decreasing type or amount of services)
Have you identified/developed any best practices for service delivery or outreach?
Are there any training or workforce issues (finding and retaining adequately trained staff in sufficient numbers to provide services)?
Do you see Title X requirements as a barrier to participation for certain family planning providers? How?
How does your program intersect with the hospital’s administration?
Does your program coordinate with other clinics or organizations that provide family planning services?
Additional comments
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BOX F-2
Title X Site Visits to Community Clinics
Site information (should be completed by the site prior to the visit)
Location (city, state)
Hours/days of operation
Geographic market (rural, urban, suburban)
Annual visits (number)
Demographics (clients served annually)
median age and range
% female
average income
race/ethnicity
How are patients referred to your clinic?
Highest volume (days/times)
Staffing
Number of staff
Types of staff (e.g., case manager, social worker, nurses, residents, physicians)
Staff case load
Functions of staff
Tools (electronic or otherwise) used in the work
Recent/current process improvement efforts/projects
Are there any current reports on performance, productivity, etc.?
Does the site work in conjunction with other clinics or organizations that provide family planning services?
Finances (should be completed by the site prior to the visit)
Income—How is your organization funded (breakdown by percentages)?
Federal %
Title X funds %
Medicaid funds %
MCH grants %
TANF %
Social services block grants %
State appropriations %
Grants %
Gifts %
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Private payer %
Out of pocket/self-pay %
Uncompensated care %
Expenses—What do Title X funds pay for?
Budget for staff
Budget for services (e.g., medical operations, education, outreach)
Budget for goods (e.g., labs and associated costs, pharmaceuticals and dispensing costs)
Administrative costs
Facility costs (purchase/rent, maintenance)
Site Concerns
Begin by asking each interviewee: what are the two most important things you would like to share about your experiences with Title X.
Services
Range of services
What types of services do Title X funds provide?
___ Education
___ Counseling
___ History, physical assessment, labs
___ Fertility regulation (contraception)
___ Infertility services
___ Pregnancy diagnosis and counseling
___ Adolescent services
___ GYN services
___ STD and HIV/AIDS
___ Special counseling (future pregnancies, substance use, sexual abuse, domestic violence)
Who else provides these services in the community?
Scheduling
How are urgent vs. emergent patients scheduled (priority matrix)?
Appointment wait time (how many days or weeks?)
Quality
Do staff follow any standing clinical protocols or care pathways?
What quality metrics are evaluated at the site?
Referral and Follow-up
Are patients classified based on any risk factors? If so, what risk factors?
What is the mechanism for post-visit follow-up?
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Perspectives on Title X
What are benefits/strengths of the Title X program?
What are drawbacks or weaknesses of the program?
What do Title X funds allow you to do that other funding sources do not?
What changes or improvements (administrative, service provision, etc.) would you suggest for the program?
How do Title X requirements (e.g., child abuse reporting) affect the provision of services?
How do you implement the mandate to encourage parental involvement?
Describe hard-to-reach groups in your area and describe any efforts at outreach.
Describe the ease/burden of collecting information for FPAR. What elements seem unnecessary? What additional elements would you include?
How does the administrative structure work from your perspective? What is your relationship (communication) with the grantee and/or RPC?
How have any funding limitations affected the number of patients served or the care that is delivered? (e.g., hours of operation, decreasing type or amount of services)
Have you identified/developed any best practices for service delivery or outreach?
Are there any training or workforce issues (finding and retaining adequately trained staff in sufficient numbers to provide services)?
Do you see Title X requirements as a barrier to participation for certain family planning providers? How?
Does your clinic operate within a larger group of community centers? If so, how do you coordinate with other clinics in your area to provide reproductive health services?
Do you work in conjunction with other organizations (other than community-based clinics) that provide family planning services?
Additional comments
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BOX F-3
Title X Site Visits to Health Departments
Site information (should be completed by the site prior to the visit)
Location (city, state)
Hours/days of operation
Geographic market (rural, urban, suburban)
Annual visits (number)
Demographics (clients served annually)
median age and range
% female
average income
race/ethnicity
How are patients referred to your department?
Highest volume (days/times)
Staffing
Number of staff
Types of staff (e.g., case manager, social worker, nurses, residents, physicians)
Staff case load
Functions of staff
Tools (electronic or otherwise) used in the work
Recent/current process improvement efforts/projects
Are there any current reports on performance, productivity, etc.?
Does the site work in conjunction with other health departments or organizations that provide family planning services?
Finances (should be completed by the site prior to the visit)
Income—How is your organization funded (breakdown by percentages)?
Federal %
Title X funds %
Medicaid funds %
MCH grants %
TANF %
Social services block grants %
State appropriations %
Grants %
Gifts %
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Private payer %
Out of pocket/self-pay %
Uncompensated care %
Expenses—What do Title X funds pay for?
Budget for staff
Budget for services (e.g., medical operations, education, outreach)
Budget for goods (e.g., labs and associated costs, pharmaceuticals and dispensing costs)
Administrative costs
Facility costs (purchase/rent, maintenance)
Site Concerns
Begin by asking each interviewee: what are the two most important things you would like to share about your experiences with Title X.
Services
Range of services
What types of services do Title X funds provide?
___ Education
___ Counseling
___ History, physical assessment, labs
___ Fertility regulation (contraception)
___ Infertility services
___ Pregnancy diagnosis and counseling
___ Adolescent services
___ GYN services
___ STD and HIV/AIDS
___ Special counseling (future pregnancies, substance use, sexual abuse, domestic violence)
___ Health promotion/disease prevention
___ Postpartum care
___ Other (please list)
Who else provides these services in the community?
Scheduling
How are urgent vs. emergent patients scheduled (priority matrix)?
Appointment wait time (how many days or weeks?)
Quality
Do staff follow any standing clinical protocols or care pathways?
What quality metrics are evaluated at the site?
Referral and Follow-up
Are patients classified based on any risk factors? If so, what risk factors?
What is the mechanism for post-visit follow-up?
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Perspectives on Title X
What are benefits/strengths of the Title X program?
What are drawbacks or weaknesses of the program?
What do Title X funds allow you to do that other funding sources do not?
What changes or improvements (administrative, service provision, etc.) would you suggest for the program?
How do Title X requirements (e.g., child abuse reporting) affect the provision of services?
How do you implement the mandate to encourage parental involvement?
Describe hard-to-reach groups in your area and describe any efforts at outreach.
Describe the ease/burden of collecting information for FPAR. What elements seem unnecessary? What additional elements would you include?
How does the administrative structure work from your perspective? What is your relationship (communication) with the grantee and/or RPC?
How have any funding limitations affected the number of patients served or the care that is delivered? (e.g., hours of operation, decreasing type or amount of services)
Have you identified/developed any best practices for service delivery or outreach?
Are there any training or workforce issues (finding and retaining adequately trained staff in sufficient numbers to provide services)?
Do you see Title X requirements as a barrier to participation for certain family planning providers? How?
How do the services you provide with Title X funds fit into the public health structure in your area? Does the site work in conjunction with other health departments or organizations that provide family planning services?
Additional comments
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BOX F-4
Title X Site Visits to Planned Parenthood
Site information (should be completed by the site prior to the visit)
Location (city, state)
Hours/days of operation
Geographic market (rural, urban, suburban)
Annual visits (number)
Demographics (clients served annually)
median age and range
% female
average income
race/ethnicity
How are patients referred to your clinic?
Highest volume (days/times)
Staffing
Number of staff
Types of staff (e.g., case manager, social worker, nurses, residents, physicians)
Staff case load
Functions of staff
Tools (electronic or otherwise) used in the work
Recent/current process improvement efforts/projects
Are there any current reports on performance, productivity, etc.?
Does the site work in conjunction with other planned parenthood clinics or other organizations that provide family planning services?
Finances (should be completed by the site prior to the visit)
Income—How is your organization funded (breakdown by percentages)?
Federal %
Title X funds %
Medicaid funds %
MCH grants %
TANF %
Social services block grants %
State appropriations %
Grants %
Gifts %
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Private payer %
Out of pocket/self-pay %
Uncompensated care %
Expenses—What do Title X funds pay for?
Budget for staff
Budget for services (e.g., medical operations, education, outreach)
Budget for goods (e.g., labs and associated costs, pharmaceuticals and dispensing costs)
Administrative costs
Facility costs (purchase/rent, maintenance)
Site Concerns
Begin by asking each interviewee: what are the two most important things you would like to share about your experiences with Title X.
Services
Range of services
What types of services do Title X funds provide?
— Education
— Counseling
— History, physical assessment, labs
— Fertility regulation (contraception)
— Infertility services
— Pregnancy diagnosis and counseling
— Adolescent services
— GYN services
— STD and HIV/AIDS
— Special counseling (future pregnancies, substance use, sexual abuse, domestic violence)
— Health promotion/disease prevention
— Postpartum care
— Other (please list)
Who else provides these services in the community?
Scheduling
How are urgent vs. emergent patients scheduled (priority matrix)?
Appointment wait time (how many days or weeks?)
Quality
Do staff follow any standing clinical protocols or care pathways?
What quality metrics are evaluated at the site?
Referral and Follow-up
Are patients classified based on any risk factors? If so, what risk factors?
What is the mechanism for post-visit follow-up?
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Perspectives on Title X
What are benefits/strengths of the Title X program?
What are drawbacks or weaknesses of the program?
What do Title X funds allow you to do that other funding sources do not?
What changes or improvements (administrative, service provision, etc.) would you suggest for the program?
How do Title X requirements (e.g., child abuse reporting) affect the provision of services?
How do you implement the mandate to encourage parental involvement?
Describe hard-to-reach groups in your area and describe any efforts at outreach.
Describe the ease/burden of collecting information for FPAR. What elements seem unnecessary? What additional elements would you include?
How does the administrative structure work from your perspective? What is your relationship (communication) with the grantee and/or RPC?
How have any funding limitations affected the number of patients served or the care that is delivered? (e.g., hours of operation, decreasing type or amount of services)
Have you identified/developed any best practices for service delivery or outreach?
Are there any training or workforce issues (finding and retaining adequately trained staff in sufficient numbers to provide services)?
Do you see Title X requirements as a barrier to participation for certain family planning providers? How?
How does your clinic coordinate with other Planned Parenthood clinics in your area to provide services? Do you work in conjunction with other organizations that provide family planning services?
Have you had any challenges with the media (related to receiving Title X or other federal funds)?
Additional comments
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program to be unclear, as well as overly influenced by political factors rather than evidence-based research. By far the most commonly cited issue was that Title X has insufficient funding in general. Interviewees reported needing increased funds for contraceptives, staffing for screening for sexually transmitted diseases/HIV, community education, outreach, advertising, interpretation services, and sterilization services. The increasing cost of contraceptives was cited as a particular problem for clinics in light of their already overburdened finances. Several interviewees also reported that the lack of funding necessitates low salaries, making it difficult for them to recruit and retain staff. One respondent suggested that the payment scale needs to be readjusted to impose less financial burden for clients with incomes just above the federal poverty level.
Interviewees also expressed the view that the significant administrative burden associated with Title X participation is incommensurate with the often small percentage of their funding provided by Title X. One interviewee said the problem was underscored this year when additional funds were made available only if a clinic had an increased volume of patients. Moreover, interviewees reported having difficulty meeting Title X’s “unfunded mandates,” which they described as multiplying each year in the form of annual program priorities that require additional service components with no additional funding. Interviewees also expressed frustration with requirements to follow Title X program guidelines that are outdated and do not reflect current best practices as outlined by professional organizations, such as the American College of Obstetricians and Gynecologists. One interviewee stated further that the guidelines do not allow for differences among individual clinics, and that the number of requirements for each visit are unrealistic based on staff-to-client ratios. Moreover, this interviewee noted that the clinic’s client volume has been increasing yearly, while its staff has been decreasing because of limited funds and despite the need to provide more services to more people.
FAMILY PLANNING ANNUAL REPORT
While a number of interviewees cited no difficulties with the FPAR, several said it imposes an administrative burden that could potentially be alleviated. Many interviewees suggested that some aspects of the FPAR are “outdated” and do not reflect current best practices, or are framed so narrowly that clinics’ responses are meaningless. For example, one question asks what family planning methods patients used but does not allow multiple answers; questions about race are similarly problematic because patients often do not fit neatly into one racial category. While most believe the data collected for the FPAR to be useful, some think the collection process could be streamlined so that grantees, delegates, and the Office of Family Plan-
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ning would have easier access for reporting and management purposes. For example, one delegate suggested that it is unnecessary for data to be collected separately by the site and by the county, and that using the “unduplicated patients” designation does not make sense because on average Title X patients make more family planning visits than paying clients. Some respondents also noted that completing the FPAR is very labor-intensive. One delegate said it takes 2 of 14 full-time staff members a full week to complete the FPAR. Several interviewees said they did not understand why many elements of the FPAR are required, and expressed a desire to gain such an understanding and to know how OPA uses that information. The interviewees did say that electronic reporting was a significant positive change.
ADDITIONAL FINDINGS
Difficult-to-Reach Groups
While the client population varies depending on the location of the Title X site, several interviewees reported that difficult-to-reach groups include women aged 20–40 who have no health problems, as well as older women who may think they are less fertile than they used to be and thus no longer need to worry about contraception. Another interviewee noted that the “undocumented, homeless, poor, and children in foster care are the most hard-to-reach in the neighborhood.” The gay, lesbian, bisexual, and transgender population was also cited as being difficult to reach. In addition, many interviewees reported having a difficult time getting males to come to their clinics, and some said they would like guidance on how to address this problem.
Follow-up Care
Most interviewees reported having detailed procedures for following up with clients to report laboratory results. However, they did not appear to have procedures in place for following up with patients to determine the effectiveness of the family planning services provided (e.g., the number of unplanned pregnancies, continuation of use of birth control methods, whether patients are seeing other providers if they are not being seen at the clinic). Interviewees agreed that this information would be desirable but that gathering it would take more staff time than is available.
Cultural Sensitivity
Several interviewees reported that, although cultural sensitivity is extremely important, it can be difficult to respect clients’ personal beliefs
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while trying to satisfy Title X requirements. This issue was cited in relation to requirements for Pap tests for women who do not wish to undergo a complete physical exam, which may include women who are virgins, as well as Muslim and Hispanic women. Language issues were also frequently discussed during the interviews. Many clinics cited difficulty with recruiting and retaining multilingual staff; this is a particular problem for small clinics that may have only a few staff members. Many respondents had one or two bi- or multilingual staff members and a phone service that provided access to an interpreter for a wider range of languages.
Best Practices
Best practices identified during the site visits included holding a Friday Clinic during which there are no scheduled appointments, and women without health insurance are welcomed; providing a warm and inviting clinic environment; offering a “Quick Start” program through which the clinic is able to provide birth control pills immediately and then arrange appointments within 3 months; engaging the local community to build trust and maintaining those relationships; cross-training personnel, which allows for growth through acquisition of advanced skills; and holding events such as a fish fry and health fair in the parking lot to reach out to the community. Most committee members found that the staff at the sites they visited were really concerned about providing high-quality care to their patients, and that in general, they were meeting that goal to the extent possible in light of the barriers to care summarized above.
On-site Medication
Several interviewees reported that they appreciate the fact that Title X enables clinics to keep medications on site because they can start clients on contraceptives or other medications immediately. However, at least one respondent objected to the Title X requirement for dispensing since some clients would be more comfortable picking up prescriptions from a pharmacy.
Scheduling
Most interviewees reported that they could generally arrange appointments within the 2-week period required by Title X. However, many reported that waits are significantly longer in their communities (presumably because of a lack of provider capacity). One respondent noted that there is usually a 6- to 8-week wait for new patient appointments and annual exams, although patients who have problems or need contraceptive
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refills can get an appointment for an “expedited visit” more quickly. Few interviewees provided information regarding client wait times at the clinic; however, those who did so said that patients were generally seen within about a half-hour of arriving at the clinic.