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A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results
Appendix J
Organization, Funding, and Management of the Title X Program
The Lewin Group
Although the first federal grants to support family planning were made in 1965, the formal structure for operation of a national family planning program did not occur until Congress enacted Title X of the Public Health Service Act of 1970 (P.L. 91-572). This legislation established the decentralized structure for the program’s organization, funding, oversight, and management that remains in place today.
PROGRAM ADMINISTRATION
The program’s operational structure consists of a Central Office and 10 Regional Offices, grantees, delegates of the grantees, and clinical service sites. The Office of Family Planning (OFP), also referred to as the Central Office, administers the Title X program at the federal level and is responsible for establishing administrative policy.1 OFP is part of the Office of Population Affairs (OPA), located within the Office of Public Health and Science at the U.S. Department of Health and Human Services (HHS). OPA is headed by the Deputy Assistant Secretary for Population Affairs (DASPA), to whom the Director of OFP reports.
A Regional Health Administrator (RHA) in each of the 10 Public Health Service Regions is authorized to oversee the Title X program at the regional level through a memorandum of understanding (MOU) with the Central Office.2 Regional Program Consultants (RPCs) carry out the day-to-day program management and allocation of funding to grantees (i.e., entities that assume legal and financial responsibility for performing Title X activities). Grantees may be state or local health departments, nonprofit
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FIGURE J-1 Title X program organizational structure.
SOURCE: 3,4
organizations (e.g., Planned Parenthood, faith-based organizations), community health centers (CHCs), and other federally qualified health centers (FQHCs).a Grantees may operate clinics or negotiate an agreement with a contract agency (delegate) that will provide services. Delegate agencies and clinics may be CHCs, student health centers, Planned Parenthood agencies, hospitals, other nonprofit health care providers, or state or local health departments.3,4Figure J-1 depicts the organizational structure of the Title X program. Table J-1 provides a summary of responsibilities for each management level.
a
FQHCs include all organizations receiving grants under Section 330 of the Public Health Service Act (e.g., community health centers, migrant health centers, health care for the homeless programs, and public housing primary care programs), certain tribal organizations, and FQHC look-alikes.
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TABLE J-1 Responsibilities for Each Administrative Level of the Title X Program
Title X Entity
Primary Responsibilities
Central Office
Administers program at national level
Sets policy and develops national priorities and initiatives
Coordinates and collaborates with other offices within HHS and Office of Public Health and Science (OPHS)
Oversees research and educational aspects of program
Oversees and monitors grants and contracts that are national or cross-regional in scope (e.g., OPA Clearinghouse, National Family Planning Training Center)
Creates budget requests and annual spending plan
Develops Family Planning Services Announcement for Federal Register
Develops performance measures
Develops funding announcements
Communicates with Regional Offices
Plans OFP national meetings
Regional Health Administrator
Oversees management of RPC and regional family planning staff
Final authority on allocation of Title X base service funding grants, special project grants, regional priority funds
With Central Office, signs off on regional training grant allocations
Regional Program Consultant
Oversees and monitors regional family planning service grantees (e.g., through grant reviews, annual site visits, Comprehensive Program Reviews, regular communication with grantees via phone and e-mail)
Oversees and monitors family planning training and technical assistance (TA) grantees (e.g., approves training plan, facilitates TA for providers in region)
Communicates with Central Office
Supports and oversees regional areas of special focus (e.g., HIV prevention, male-related projects)
Participates in OFP national meetings
Provides record of all official correspondence with grantees to Office of Grants Management for filing (e.g., site visit reports, corrective action plans)
Grantee
Selects, arranges contract with, monitors, and reimburses delegate agencies
Coordinates TA for delegates (if applicable)
Guarantees provision of data for Family Planning Annual Report (FPAR) by clinics or delegates
Participates in Comprehensive Program Reviews and annual site visits
Reviews and approves educational and informational materials used by delegates or clinics
Delegate
Provides services in accordance with Title X guidelines and applicable federal, state, and local laws
Reports FPAR data
Participates in site visits by grantee and Regional Office
Clinic
Provides services in accordance with Title X guidelines and applicable federal, state, and local laws
SOURCES: 1,2
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The decentralized, regional structure through which the Title X program is administered is seen by staff at the federal, regional, and state levels as advantageous because it places a majority of decision-making authority in the hands of the RPCs, who are most familiar with the specific needs of their region as well as the strengths, needs, and weaknesses of their grantees. The decentralized structure allows RPCs to administer the Title X program most effectively by taking into account differences in populations and cultures and selecting grantees that are best able to meet the needs of a particular state or geographic region within a state. Most grantees feel strongly that decision-making authority should remain in the hands of the RPCs rather than the Central Office.
Still, some regional staff and grantees attribute variation among regions in large part to the personalities of those working in the Regional Offices. For example, in some regions, the RPC works closely with the Office of Minority Health and the Office of Women’s Health, both of which also are under the direction of the RHA, while in other regions, these programs operate without any coordination. Other points of variation are attributed to differences in state regulations regarding family planning clinics. For example, the forms and process a clinic uses to obtain patient consent for a particular procedure may be dictated by specific state regulations.
The level of communication and the relationship between RHAs and RPCs is relatively consistent among regions. RPCs tend to find their RHA very responsive and attentive to the needs of the Regional Office and of the Title X program. While RHAs have final approval of all allocations to grantees, the extent to which they are involved in the programmatic work of the regional family planning office varies. For example, some RHAs attend regional Title X meetings hosted by the Regional Office and work actively to promote cooperation among related offices in the region. Although the RHAs are the official supervisor responsible for performance reviews, day-to-day communication and management of the Title X program occur between the RPC and the Central Office.
The Central Office communicates regularly with the Regional Offices through monthly conference calls and ongoing e-mail and telephone communication. The monthly conference calls are open to RPCs and usually cover process-related topics (e.g., directed supplements, preparation for a national meeting, Title X priorities). In some instances, the Central Office may use the conference call to address a specific issue, such as clinic efficiency.b RPCs find the topic-specific conference calls quite helpful and expressed interest in holding more of them on a variety of topics, such
b
So far, one call of this nature has been scheduled; it concerned grants management, and it replaced the regularly scheduled conference call for that month.
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as performance measurement, innovations in contraception, and research related to service delivery improvement.
Each Regional Office is assigned a liaison at the Central Office who serves as the first point of contact for any questions or issues. The Central Office is highly regarded as responsive, communicative, and supportive by all regional staff. However, the Central Office may not always have the time and/or money to create written guidance for the Regional Offices and instead may communicate guidance orally; this results in confusion or additional time spent seeking clarification by the Regional Offices. Additionally, the Central Office liaisons assigned to each Regional Office vary in terms of seniority and knowledge of the Title X program, which can affect the extent to which the liaison is able to assist his or her assigned Regional Office. Of further note, RPCs receive no formal training for their position.
One hour before their monthly conference call with the Central Office, the RPCs hold a regularly scheduled call among themselves to discuss common issues (e.g., setting a sliding fee scale) and/or provide new Regional Office staff with pertinent information. All Regional Office staff members (e.g., program officers, administrative assistants) are invited to be on the call. These calls are important because they provide Regional Office staff members with an opportunity to communicate outside the presence of the Central Office and to share insights and issues with each other. Yet without more overt leadership and decision-making authority that comes from the Central Office, they serve as a forum in which issues surface but are not resolved.
The relationship dynamic between RPCs and grantees varies widely among regions. Many grantees describe a very positive relationship with their RPC, citing their relationship as open, effective, transparent, and positive. In these relationships, the RPCs are in regular communicationc with grantees and even schedule regular conference calls to address current questions or issues. These grantees see their RPC as someone to whom they can go with programmatic and financial questions. However, some grantees feel that they do not experience the level of openness and communication that they need and want from their RPC.
While some RPCs solicit input and information from grantees to convey to the Central Office, the line of communication between grantees and the Central Office is not direct. There is a sentiment among many grantees that the messages they would like to convey to the Central Office are diluted, and the RPCs do not advocate enough on their behalf. Specifically, some grantees feel that the Central Office does not elicit enough
c
Regional Offices also are in and are required to maintain a log of official contact (e.g., phone calls, site visits), which is forwarded to the Office of Grants Management (OGM) at the end of the fiscal year.1
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input from grantees and delegates about the ramifications of its decisions. Opportunities to voice concerns directly are limited to the national grantee meeting hosted by the Central Office every 2 years; however, formalities of this meeting do not offer grantees substantial time to communicate with the Central Office individually. As an adjunct, Central Office staff members sometimes are able to attend the annual regional meetings (time and money permitting), which grantees consider a very effective way to communicate information directly.
Grantees communicate with delegates and/or clinics on a regular basis. Some grantees divide their delegate agencies and/or clinics into groups according to geographic region and assign specific staff members to communicate with those delegates. In addition, many grantees host in-person conferences at least once a year to update delegates and/or clinics on administrative, clinical, and policy topics related to Title X and family planning. With a few exceptions, delegate agencies and clinics do not have regular communication or interaction with the RPC or the Central Office.
PROGRAM MANAGEMENT AND OVERSIGHT
Several tools facilitate the program’s day-to-day management, regular monitoring, and ongoing improvement. These tools include the development of Central Office and Regional Office work plans, Comprehensive Program Reviews and annual site visits, the Family Planning Annual Report (FPAR), and regional training programs.
Work Plans
Day-to-day management and strategic planning for the Title X program are founded on the annual development of Central Office and Regional Office work plans and budget plans. The Central Office work plan is an internal document comprised of all grant announcements, administrative and training activities, and research projects for that year. Prior to its implementation, the plan must be approved by the Assistant Secretary of Health. If situations arise that require the Central Office to depart significantly from the work or budget plan, it is required to develop an addendum that also must be approved by the Assistant Secretary.d
Before the start of the fiscal year, each Regional Office submits its work plan to the Central Office. Areas to be covered in the regional work plan are outlined by the DASPA in the Regional Memorandum of Agreement and
d
Changes to the spending plan that involve less than a few thousand dollars do not need to be approved by the Assistant Secretary of Health.
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Work Plan Guidance sent to RHAs each year. Specifically, regional work plans must include the following:
Funding methodology, including how service grants and regional priority funds will be distributed within the region
A list of Comprehensive Program Reviews and site visits scheduled in the region for the coming fiscal year
A list of service and training meetings that the region plans to hold with grantees (e.g., annual regional meetings, meetings with grantees following the award of a grant), where possible including agendas for these meetings
Travel plans for Regional Office staff members, including priority level, project cost, and purpose of travel
Grantee training plans, including the location, date, and format of the training; the national priorities addressed by the training; the names of the people conducting the training; and the total number and type of trainees who will be present (e.g., nurse practitioners, administrators, medical doctors)
Regional objectives and efforts related to national Title X priorities, legislative mandates, HHS priorities,e and other key issues, along with specific regional outputs linked to each priority
In general, RPCs find regional work plans to be a valuable tool for strategic planning and program management. Often, previous years’ work plans serve as reference documents for future planning and monitoring activities. Sections of the work plan that address grantee performance, program outcomes, and meeting planning were identified as especially useful. However, some limitations associated with the regional work plans also were cited. Because so much of each region’s work is prescribed, there is little flexibility in the content of the work plans from one year to another. In many instances, the same work plan is used each year, with modifications based on the guidance from the Central Office and/or the needs of the region. Thus, some offices view the work plans as additional paperwork that could be moderated if multiyear plans were developed.
Comprehensive Program Reviews and Annual Site Visits
Site visits by Regional Offices to grantees and by grantees to delegates and clinics serve as the primary mechanism for oversight of the Title X pro-
e
Examples of HHS priorities include health information technology (e.g., making sure secure, interoperable electronic records are available to patients and clinicians), Medicare prescription drug access, and pandemic preparedness.5
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gram. Regional Offices use two types of site visits to monitor grantees: the Comprehensive Program Review, performed every 3 years; and the annual site visit, used as a follow-up to areas identified for improvement. Grantees perform annual site visits to a selected number of their delegate agencies and clinics. Reports on the Comprehensive Program Reviews and annual site visits are held in the individual grantee’s official grant file at the Health Resources and Services Administration’s (HRSA’s) Grants Office. In addition, a copy of the Comprehensive Program Review report is held at OFP.
Comprehensive Program Reviews
Regional Offices are required to conduct an on-site Comprehensive Program Review of each grantee every 3 years to evaluate the grantee’s financial, administrative, educational, and clinical structure and activities.1 Specific goals of the Comprehensive Program Review are to:
Ensure compliance with Title X program laws, regulations, and guidelines.
Assess grantees’ progress with regard to carrying out the plan outlined in their approved Title X grant application.
Validate activities reported on by the grantee (e.g., expenditure of funds, scope of services).
Identify technical assistance and training needs.
Identify grantee strengths that might be useful to other grantees.
Ensure proper use of Title X funds by grantees.
Provide grantees with an opportunity to identify issues in delivering services and in carrying out program requirements that might be common to all grantees.
Provide grantees with an update on the program and emphasize program priorities.
The Comprehensive Program Review team consists of the RPC; other Title X–related program officers; and independent consultants with expertise in the clinical, administrative, financial, and community outreach and information components of the Title X program. Consultants are professionals with direct experience with Title X and may have served previously as nurses in Title X clinics or have worked for grantee or delegate agencies. In addition to visiting the grantee’s offices, the review team visits one to three delegate agencies and/or clinics overseen by the grantee (although grantees have primary responsibility for monitoring delegates and clinics).
The review is conducted using the Program Review Tool, which was last revised in January 2003.6 The tool initially was created as a standard-
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ized document, and a few regions have made slight modifications to it. The document is divided into four sections (i.e., administration, finance, clinical, and community outreach and information) and directs consultants to mark grantees as “compliant” or “noncompliant” in several different areas.f The financial review assesses compliance with federal regulations published under 2 Code of Federal Regulations (CFR) Part 230, Cost Principles for Non-Profit Organizations (OMB Circular A-122).7 The administrative, clinical, and community outreach aspects of the Title X program are evaluated for compliance with the OFP Program Guidelines for Project Grants for Family Planning Services.3 For any areas in which the grantee is found to be noncompliant, a corrective action plan is prescribed that outlines the steps required of the grantee to achieve compliance.1 Some issues identified may be addressed through technical assistance and training at the Regional Training Center (RTC). Table J-2 provides a summary of the key areas covered in the Program Review Tool.
Many RPCs feel that the Comprehensive Program Reviews are the most helpful and collaborative mechanism through which they are able to monitor and oversee grantees. They provide Regional Offices with an opportunity to interact with grantees on an individual basis and to see first-hand where grantees excel and where additional guidance is needed. However, financial and time constraints and the large number of delegate and clinic sites significantly limit the number of service sites that the review team can visit. Some RPCs believe that the ability to visit a greater number of delegates and clinics would enhance their oversight capabilities.
Also, because independent consultants do not receive uniform training, they may vary in their interpretation of certain Title X guidelines and grading of grantees (e.g., how clinics should ask for client donations, the increments used on the sliding fee scale). This creates inconsistencies in the evaluation of a grantee, not only for the current Comprehensive Program Review, but also for evaluations of the grantee’s performance longitudinally and against other grantees in the region and nationally.
Some grantees do not share positive sentiments about Comprehensive Program Reviews, indicating that they find the process strenuous and overly focused on small details rather than the larger picture. As such, they do not
f
Subcategories address more specific aspects of the program, each of which is marked as “must,” “should,” or “optional.” For example, in the administration section, the first section asks the consultant to mark whether or not the grantee complies with the regulation for client voluntary participation. In the sections underneath, the consultant is asked to comment on items such as whether services are provided solely on a volunteer basis and whether project personnel are informed of the potential for prosecution under federal law if they coerce anyone to undergo abortion or sterilization procedures.
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TABLE J-2 Summary of Areas Evaluated for Compliance with the Program Review Tool
Administration
Clinical
Financial Management
Needs Assessment
Project Requirements
Grant Administration
Voluntary Participation
Privacy and Confidentiality
Conflict of Interest
Human Subject Clearance
Structure of the Grantee
Planning and Evaluation
Facilities and Accessibility of Services
Personnel
Training and Technical Assistance
Reporting Requirements
Review and Approval of Information and Educational Materials
Community Participation, Education, and Project Promotion
Publications and Copyright
Inventions or Discoveries
Client Services
Service Plans and Protocols
Procedural Outline
Emergencies
Referrals and Follow-Up
Client Education
Counseling
History, Physical Assessment, and Laboratory Testing
Fertility Regulation
Infertility Services
Pregnancy Diagnosis and Counseling
Adolescent Services
Identification of Estrogen-Exposed Offspring
Gynecologic Services
Sexually Transmitted Diseases, HIV, and AIDS
Special Counseling
Genetic Information and Referral
Health Promotion/Disease Prevention
Postpartum Care
Equipment and Supplies
Pharmaceuticals
Medical Records
Quality Assurance and Audit
Infertility Prevention Project
Budgetary Control Procedures
Accounting Systems and Reports
Purchasing/Inventory Control/Property Management
Charges, Billing, and Collection Procedures
Liability Coverage
believe that the reviews have improved their program.g They would like the Regional Offices and reviewers to adopt a less punitive, more educational and supportive approach that positions the review as an opportunity for learning.
g
As a basis for comparison, Bureau of Primary Health Care (BPHC)–supported health centers undergo accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).8 The process, which includes both a survey and a review, accounts for both the BPHC statutory requirements and applicable JCAHO standards. The survey generally takes 2–3 days and is conducted by a clinician and administrator from JCAHO.
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Annual Site Visits
In years in which a grantee is not subject to a Comprehensive Program Review, the Regional Office conducts an annual site visit to each grantee. These site visits provide another mechanism for Regional Offices to follow up on any item identified for improvement or corrective action in the Comprehensive Program Review, grant application, and annual needs assessment for training programs, or identified by the grantees themselves. The site visit also may entail an abbreviated review of grantee compliance with 2 CFR Part 230 and the OFP Program Guidelines. Generally, the annual site visit is conducted by the RPC and potentially another staff member; in some cases, one or more consultants may be hired to participate if an outstanding issue relates to a consultant’s area of expertise (e.g., grants management, finance).
Grantees also conduct annual site visits to their delegate agencies and clinics to ensure compliance with federal regulations and the Program Guidelines. While grantees are afforded the freedom to design the tools (forms, documents) for their site visits, they must address all areas of Title X operation and management that are part of the Comprehensive Program Review (Table J-2). Thus, there is some variability among grantees in the tools they use when conducting site visits. Some grantees use the same tables and checklists used in the Comprehensive Program Review, while others develop an abbreviated, modified version.
Areas covered during site visits include, but are not limited to, the following. Delegates and clinics must be in compliance with rules governing privacy and confidentiality under the Health Insurance Portability and Accountability Act (HIPAA), rules for client voluntary participation in Title X programs, and rules regarding the use of Title X clients in research. They must perform the required annual needs assessment to determine areas for additional training. A conflict of interest policy, written agreements with subcontractors providing services, and a mechanism for periodic self-evaluation and ongoing improvement must be maintained. Service facilities must provide safe, clean environments for patient care. They must comply with state and federal requirements for personnel, financial and programmatic reporting, and review and approval of educational and informational materials.
From the clinical perspective, delegates and grantees also must maintain written protocols for emergencies (e.g., vaso-vagal reactions, shock), as well as patient referrals to other providers. Grantees may conduct chart reviews to ensure that patients receive appropriate education and counseling about family planning, contraception, infertility, pregnancy, and sexually transmitted diseases (STDs), as indicated. They are assessed to ensure that medical history taking, physical examinations, and laboratory testing
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ANNEX J-2
GRANTEE CLINICAL VISIT RECORD
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