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A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results (2009)

Chapter: Appendix J: Organization, Funding, and Management of the Title X Program

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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Page 343
Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
×
Page 353
Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
×
Page 358
Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
×
Page 359
Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
×
Page 360
Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Page 361
Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Page 363
Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
×
Page 364
Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
×
Page 365
Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
×
Page 366
Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
×
Page 367
Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
×
Page 368
Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
×
Page 369
Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
×
Page 370
Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
×
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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Suggested Citation:"Appendix J: Organization, Funding, and Management of the Title X Program." Institute of Medicine. 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. doi: 10.17226/12585.
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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 decentral­ ized structure for the program’s organization, funding, oversight, and man- agement 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 respon- sible 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 343

344 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Secretary, Department of Health and Human Services Assistant Secretary for Health, Office of Public Health and Science Deputy Assistant Secretary 10 Regional Health Administrators, for Population Affairs, one in each Public Health Region Office of Population Affairs Director, Office of Family Planning 11 Regional Program Consultants (each region has 1 RPC, except Region III, which has 2 RPCs) Region I Region II Region III Region IV Region V 10 grantees 7 grantees 9 grantees 10 grantees 12 grantees 68 delegates 98 delegates 228 delegates 185 delegates 165 delegates 224 clinics 302 clinics 638 clinics 1,145 clinics 432 clinics Region VI Region VII Region VIII Region IX Region X 6 grantees 5 grantees 6 grantees 15 grantees 8 grantees 92 delegates 107 delegates 74 delegates 114 delegates 64 delegates 587 clinics 279 clinics 184 clinics 466 clinics 223 clinics FIGURE J-1  Title X program organizational structure. SOURCE: 3,4 Figure J-1 organizations (e.g., Planned Parenthood, faith-based organizations), com- vector, editable munity health centers (CHCs), and other federally qualified health centers (FQHCs). 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.3,4 Figure J-1 depicts the organizational structure of the Title X program. Table J-1 provides a summary of responsibilities for each management level. 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 home- less programs, and public housing primary care programs), certain tribal organizations, and FQHC look-alikes.

APPENDIX J 345 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 • Oversees management of RPC and regional family planning staff Health • Final authority on allocation of Title X base service funding grants, Administrator special project grants, regional priority funds • With Central Office, signs off on regional training grant allocations Regional • Oversees and monitors regional family planning service grantees (e.g., Program through grant reviews, annual site visits, Comprehensive Program Consultant 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

346 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM The decentralized, regional structure through which the Title X pro- gram 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 pro- gram 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 com- munication. 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 effi- ciency. RPCs find the topic-specific conference calls quite helpful and expressed interest in holding more of them on a variety of topics, such   o S far, one call of this nature has been scheduled; it concerned grants management, and it replaced the regularly scheduled conference call for that month.

APPENDIX J 347 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 addi- tional 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 com- mon 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 communication 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 con- vey to the Central Office, the line of communication between grantees and the Central Office is not direct. There is a sentiment among many g ­ rantees that the messages they would like to convey to the Central Office are diluted, and the RPCs do not advocate enough on their behalf. Spe- cifically, some grantees feel that the Central Office does not elicit enough   egional Offices also are in and are required to maintain a log of official contact (e.g., R phone calls, site visits), which is forwarded to the Office of Grants Management (OGM) at the end of the fiscal year.1

348 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM 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 com- municate with those delegates. In addition, many grantees host in-person conferences at least once a year to update delegates and/or clinics on admin- istrative, 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 develop- ment 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 imple- mentation, 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. 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   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.

APPENDIX J 349 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, 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, pro- gram 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 modifica- tions 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-   xamples of HHS priorities include health information technology (e.g., making sure E secure, interoperable electronic records are available to patients and clinicians), Medicare prescription drug access, and pandemic preparedness.5

350 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM 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 addi- tion, 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 out- lined 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 exper- tise 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-

APPENDIX J 351 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. 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 evalu- ated 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 train- ing, 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 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.

352 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM TABLE J-2  Summary of Areas Evaluated for Compliance with the Program Review Tool Administration Clinical Financial Management • Needs Assessment • Client Services • Budgetary Control • Project Requirements • Service Plans and Protocols Procedures • Grant Administration • Procedural Outline • Accounting Systems and • Voluntary Participation • Emergencies Reports • Privacy and • Referrals and Follow-Up • Purchasing/Inventory Confidentiality • Client Education Control/Property • Conflict of Interest • Counseling Management • Human Subject Clearance • History, Physical • Charges, Billing, and • Structure of the Grantee Assessment, and Collection Procedures • Planning and Evaluation Laboratory Testing • Liability Coverage • Facilities and Accessibility • Fertility Regulation of Services • Infertility Services • Personnel • Pregnancy Diagnosis and • Training and Technical Counseling Assistance • Adolescent Services • Reporting Requirements • Identification of Estrogen- • Review and Approval of Exposed Offspring Information and • Gynecologic Services Educational Materials • Sexually Transmitted • Community Participation, Diseases, HIV, and AIDS Education, and Project • Special Counseling Promotion • Genetic Information and • Publications and Copyright Referral • Inventions or Discoveries • Health Promotion/Disease Prevention • Postpartum Care • Equipment and Supplies • Pharmaceuticals • Medical Records • Quality Assurance and Audit • Infertility Prevention Project believe that the reviews have improved their program. 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.   s a basis for comparison, Bureau of Primary Health Care (BPHC)–supported health cen- A ters undergo accreditation by the Joint Commission on Accreditation of Healthcare Organiza- tions (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.

APPENDIX J 353 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 Com- prehensive Program Review, grant application, and annual needs assess- ment 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 govern- ing 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 agree- ments with subcontractors providing services, and a mechanism for peri- odic 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 main- tain 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 counsel- ing about family planning, contraception, infertility, pregnancy, and sexu- ally transmitted diseases (STDs), as indicated. They are assessed to ensure that medical history taking, physical examinations, and laboratory testing

354 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM are consistent with clinical guidelines and that medical records are kept in accordance with Title X regulations. In addition, a grantee will shadow a variety of clients (with their consent) through the clinic process to observe eligibility, provision of clinical services, counseling/education, and provision of birth control methods. Family Planning Annual Report Federal regulations under 45 CFR Part 74 stipulate that all Title X service grantees must submit an annual report to OFP/OPA.9 The submis- sions are synthesized into the FPAR—the only source of annual, uniform, national-level data on Title X program users, service providers, family planning and related services, and sources of revenue.10 FPAR data are used at all levels of the program (i.e., Central Office, Regional Office, grantee, delegate) to monitor compliance with statutory and federal performance requirements, guide planning and resource allocation decisions, respond to inquiries from policy makers and Congress about the program, and assess the impact of program activities on key reproductive health outcomes (e.g., unintended pregnancies averted, incidence of STDs).10 In addition to a national report, each individual region receives an FPAR that contains more detailed data on that region. To fulfill the FPAR reporting requirements, service grantees must collect and compile specific data, most of which is collected by delegates/clinics during patient-level family planning encounters (i.e., in-person appoint- ments). Clinic providers collect the data manually or electronically using a standardized encounter form called the clinic visit record (CVR). The CVR facilitates efficient data collection and formulation of concise and comprehensive records of Title X services, patient contraceptive practices, and relevant social and demographic information.11 All data provided by service grantees are deidentified to protect the privacy of individual patients who receive Title X services. The FPAR is considered a valuable tool for management, strategic planning, and financial planning purposes. It provides good, useful data that capture the characteristics of the patient population being served, their preferences in family planning, their geographic shifts, and whether the target populations are being reached. This information is important for practical assessments of consistency between the program goals a grantee cited in its grant application and the services it is actually providing. The data also allow for more directed analyses helpful in managing resources. For example, one Regional Office uses FPAR data to evaluate cost per user across Title X clinics, delegates, and grantees. In another example, a grantee prefers to use FPAR data to assess patient case loads at state departments of health.

APPENDIX J 355 However, there are several limitations to the FPAR data. First, the FPAR does not provide data on the effect of Title X services on patient outcomes over time. For example, the FPAR currently collects information on the number of patients with an abnormal Pap test or STD but does not track those patients over the next 18 months to assess whether they return to the clinic, obtain all necessary medical treatment, and remain disease free during this period. In addition, the FPAR does not track the nonclinical services provided by the program (e.g., outreach), which some RPCs cite as a limitation on the FPAR’s usefulness. For example, data are collected on the number of persons served with limited English proficiency, but not on whether the patients’ language needs were met. Performance measures, as exemplified above, are necessary for more extensive quality-related analyses that should be funded and undertaken at the national level by OFP/OPA. With these limitations, the FPAR functions predominantly as a data tool to meet federal regulatory requirements. Even though there has been much discussion of the potential use of the FPAR for quality assessments of Title X services, the current data elements do not provide a true mechanism for measuring quality of care. Moreover, some of the data collected for the FPAR are considered unnecessary and useless, such as breast exams on girls ages 14–15. To address this issue, RPCs and grantees expressed the need to add more patient outcome–oriented data and performance measures. Some specific areas suggested for measure development were community education/outreach and results of chlamydia screening (similar to Pap tests). Also highlighted was the need to incorporate a more longitudinal analysis in the FPAR to allow year-to-year comparisons. Integrating a few key new performance measures into the FPAR would eliminate duplication of efforts and make the FPAR a more complete assessment tool. The second issue is that grantees must use multiple methods to col- lect all FPAR data. While the utility of the FPAR improved significantly in recent years following the 2005 revision to the report’s data elements, the change also increased the labor-intensiveness of data collection. Specifically, with new reporting guidelines, not all information is collected at the time of the patient’s visit (e.g., Pap test results), necessitating substantial additional manual work to match all data for a particular patient. OPA has plans to further improve the FPAR by moving toward collection of a smaller, cleaner data set based on more sentinel patient information. Widespread implementation of electronic health records (EHRs) would facilitate this type of data collection. A recommended resource for identifying additional performance measures is the Family Planning Councils of America Family Planning Performance Measurement System: Phase II Final Report. Currently, there is wide variation in the methods that grantees use for data collection. Some grantees are collecting all data by hand. A few grantees have developed their own electronic system, with the assistance of

356 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM the Central Office and the collaboration of all delegates and clinics. Several grantees prefer to contract with data services organizations, such as Ahlers and Associates, a nonprofit health care management and software com- pany with a web-based family planning reporting system. Tracking current and future FPAR data and performing high-value quality-of-care analyses would be easier with EHRs. Third, because of the high capital investment required, only a few del- egate agencies and clinics have EHRs; most commonly, EHRs are associated with an FQHC, large nonprofit agency, or state department of health. Other delegates are at varying points in exploring the possibility of implement- ing EHRs. It was suggested by many grantees that OPA undertake a more extensive analysis to study how other health-related government agencies, including community health centers and the Veterans Health Administra- tion, have addressed EHR cost and investment issues. In addition, OPA would need to study methods for meeting the substantial need for technical assistance to train delegates and grantees in use of EHRs and data analysis for quality improvement. Training Programs OPA invests a fair amount of money in training and development, allocating to each region funding for its RTC. The RTCs provide learn- ing opportunities to delegates, grantees, and Title X providers and other staff. They conduct both individual delegate/grantee training programs and those that are more regional in scope. In addition to the RTCs, OFP/OPA holds an annual training conference to update Title X RPCs and grantees on important areas of family planning. The August 2008 training confer- ence focused on financial aspects of program management and included presentations by representatives from GrantSolutions and the HRSA Grants Management Office. More recently, OPA funded development of a National Family Planning Clinical Training Center (NFPCTC) that will streamline training activities across the Title X program. Because the NFPCTC is fairly new, it is too early to judge its effectiveness. Thus, this section focuses on RTCs. Training program topics are set according to the educational priori- ties of the Central Office and/or the DASPA, as well as needs assessments conducted by grantees and delegates. Often, educational priorities are politically driven (e.g., ABCs: abstinence, be faithful, use condoms; family   he T Ahlers Family Planning Reporting System is an automated data system that collects client and visit information from family planning agencies, calculates billing, and produces reports for the agency and state. The system is designed to meet federal reporting requirements, as well as to provide management information.

APPENDIX J 357 involvement for teenagers) without scientific evidence to support them. In contrast, RPCs and grantees agree that topics that could significantly improve use of Title X services include understanding how to help women choose birth control methods and how to make contraceptive use more effective. Along with OPA training priorities, per Title X regulations, grantees undertake a needs assessment each year to identify areas for training and improvement. This provides RPCs and grantees with some flexibility in training topics. The needs assessment survey has 80 different topics and asks grantees what type of training they need. The results are used to customize training for the grantee (e.g., patient wait time, need to conduct patient flow analysis). All RPCs and grantees interviewed stated that they are pleased with the quality of the training programs conducted by the RTCs. The consultants contracted (via competitive application) to manage the RTCs are highly regarded among RPCs and grantees. They are considered to be knowl- edgeable in the spectrum of topics important to family planning and often compile best practice documents that are very useful. RPCs and consultants work together to balance the amount of training among grantees to ensure that everyone’s needs are met. There is usually a good balance between identifying problems in the region and training according to OPA priori- ties. As with other aspects of the Title X program, however, there is never enough funding for grantee training as consultants can be expensive, and there is a cap on how much money a region may allocate to its RTC. Frequently requested areas for training pertain to financial manage- ment, general program administration, clinical care, and interpretation and implementation of regulations at the clinical level. Specific examples of training program topics include: • Pregnancy options counseling • Contraception updates • Program administration (e.g., customer service, how to approach patients about fee collections) • Hands-on clinical skills (e.g., examination of male patients for nurse practitioners) • STD update • HIV update • HIPAA However, those interviewed identified several areas of unmet need in terms of training. Specifically, training centers need to develop a basic, com- prehensive, nationwide orientation program for providers and other clinic staff about family planning (cultural competency, counseling patients effec-

358 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM tively based on their needs, clinical and administrative efficiency, decreasing wait times). Also, there is a need for greater emphasis on the training of first-level staff (e.g., people who obtain informed consent, receptionists, community outreach, and community health care workers), who need to understand how to communicate in client-centric ways. Additional pro- grams also are needed in how to manage Title X grants and screen for violence and violence prevention. Centralized training does not always work for states or geographic areas that contain many rural clinics. Thus, there is great interest in expand- ing use of web-based distance learning programs. To date, certain RTCs have developed distance learning programs for their respective regions; however, the information in these programs typically is available only to grantees within the region and has not been shared widely across the Title X program. To advance learning among providers, it is important to institute a tool that consolidates information created at the local level. RPCs and grantees interviewed stated the importance of the national training center in serving as the clearinghouse for all training tools (e.g., compiling of dif- ferent modules, resources), including distance learning information. The main factor substantially limiting the ability of grantees to partici- pate in training programs is the cost of travel. A few delegates and grantees have been very resourceful in working around the travel funding issue by implementing polycoms in all health departments for videoconferencing training sessions. Some grantees also identified the need for uniform training of RPCs and RHAs in the principles of family planning and evidence-based medicine and how to interpret clinic guidelines. For example, some grantees feel there is wide variation in advice given by RPCs in different regions, particularly in terms of what clinics can and cannot do in obtaining consent and what services are offered. Also, consultants who participate in the objective review committees responsible for reviewing grantee applications do not receive uniform train- ing or any training at all. This results in wide variation in how consultants assess clinics, particularly with regard to financial status. Implementation of standardized training would enable consultants to provide more consistent evaluations of grant applications. Effect of Political Issues on Program Administration and Management The DASPA’s status as a political appointee is one of the most significant issues affecting the Title X program. As a political appointee, the DASPA typically manages the Title X program according to the overall political agenda of the presidential administration that made the appointment. Each

APPENDIX J 359 new DASPA brings new ideas and new priorities for the program. If the DASPA is associated with an administration that does not approve of family planning, the Title X program can be subject to substantial changes that may shift funds to programmatic areas that are ineffective, freeze funding despite increases in program costs, or limit program resources in other ways. Even DASPAs associated with administrations that support family planning can develop plans to change operational or programmatic aspects of the Title X program (e.g., centralization). Often, multiple DASPAs are appointed within the time frame of an administration. For example, from 2006 to 2008, three different DASPAs were appointed by the George W. Bush Administration. Over the years, several DASPAs even have gone so far as to attempt to retract the ­funding- related decision-making authority of the RHAs. Although the original language of the Title X statute provides decision-making authority to the DASPA, the Secretary of HHS transferred this authority from the DASPA to the RHAs in the 1980s. This transfer has helped maintain the integrity of the funding processes associated with the Title X program. Other DASPAs have initiated activities that have increased the amount of cost sharing by Title X clients when clinic sliding fee scales were already in place for this purpose. One proposal would have changed the cost- s ­ haring requirements of those at 100 percent of the federal poverty level. This would have increased the financial burden on the poorest of the poor, who should not have to choose between buying milk or contraceptives. Another political factor affecting DASPAs is the well-funded private- sector and nonprofit groups involved in family planning. Their advocacy and lobbying efforts may have a strong influence on proposed legislation or administration policies. Constant change with each political administration is highly disrup- tive, burdensome, and time-consuming for all Title X participants. OPA leadership becomes a “moving target” of inconsistency, with the Director of OFP providing the only source of stability. Suggested better approaches to Title X leadership are either to restructure the DASPA’s position as a nonpolitical, civil service position or establish requirements that the DASPA be an individual who supports family planning. Program Funding Allocations Several sources of federal and state funding provide support for family planning services, including Title X, Medicaid, Social Services block grants, Maternal and Child Health (MCH) block grants, and, more recently, the State Children’s Health Insurance Program (SCHIP) and Temporary Assis- tance for Needy Families (TANF). Historically, the Title X program provided the highest proportion of funding for family planning services, followed by

360 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Medicaid. In 1993, the Medicaid Waiver program was instituted, allowing states to waive normal Medicaid eligibility requirements to cover family planning services for those low-income individuals who otherwise would not qualify. Thus, in the last two decades, Medicaid has taken the lead in financial support of family planning services. However, Title X remains the only program dedicated solely to family planning. (The various sources of funding for family planning services are detailed below.) Although the Title X program has achieved many programmatic suc- cesses, it has been challenged financially throughout its duration. This section describes the Title X funding process, highlighting some of the dif- ferences among regions and challenges in managing multiple funding cycles and sources of funding. Historical Overview of the Title X Budget and Structural Changes Funding for Title X was established under the Family Planning Services and Population Research Act of 1970 with a budget of $6 million, and it grew rapidly in the following decade as clinics proliferated throughout the country.12 By 1980, the Title X budget was $160 million.13 However, fund- ing for the Title X program decreased significantly in the 1980s as part of the broader Reagan Administration initiative to reduce federal spending on all social service programs.12 The Reagan Administration block grant initiative had a significant effect on both the administrative structure and funding of the program. The initiative aimed to streamline and consolidate administration of social ser- vices programs and reduce funding across the board by 25 percent. Title X funding dropped to $120–140 million and remained flat until 1992. OPA also undertook an initiative to consolidate the number of grantees under state departments of health. If the state chose not to serve as the Title X grantee, then the contract would be awarded to a single grantee serving the state or another geographically defined area designated by OPA. Although the Clinton Administration provided steady increases in Title X funding to $254 million by 2000, the program budget remained underfunded. One study estimated that in 2000, funding was actually 58 percent lower than the $162 million allocated in 1980 when adjusted for inflation.14 Financial pressures on the Title X program continue today, due to increasing demand for services, expanding scope of services, rising costs of services and supplies, and the changing dynamics of health care delivery   y the 1980s, some grantees had developed “consortiums” to oversee many clinic sites, as B is the case today. However, there also were a number of grantees operating a single or very few clinics, which created a significant administrative burden on OPA.

APPENDIX J 361 and financing. Currently, the fiscal year (FY) 2008 Consolidated Appropria- tions Bill provides $299.9 million for the Title X program, an increase of $16.8 million from the previous fiscal year. If keeping pace with inflation, the program budget would be funded at $759 million.15 Figure J‑2 displays Title X program funding as compared with inflation-adjusted rates. Title X Funding Resources According to the Title X statute, at least 90 percent of funds must be used for clinical services as defined in Section 1001; the remaining 10 percent may be used for administration, training, informational materials, and research. The budget is sectioned accordingly. Box J-1 summarizes and defines the different Title X funds. Over the past 30 years, the allocation of Title X funds has depended on a complex, multilevel set of processes. At the federal level, methodolo- gies used by the Central Office to determine allocations to each region are different for each type of funds. Each region may use its own methodology to allocate funds to grantees. Regions also consider the level of funding Title X Appropriations, FY 1980-2009 (actual and constant dollars, in millions) 350.0 300.0 250.0 200.0 150.0 100.0 50.0 0.0 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20 20 Actual Dollars Constant Dollars FIGURE J-2  Estimated funding for Title X when adjusted for inflation. SOURCE: Reprinted with permission from unpublished tabulations from the ­ uttmacher Institute.34 G Figure J-2 vector, editable

362 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM BOX J-1 Summary of Title X Program Funds SERVICE FUNDS Title X dollars for clinical services (90 percent of the total budget) are allocated from the Central Office to each Regional Office through four different types of funds. • Regular service funds, also called base funding • Supplemental services expansion funds, used to distribute increases in Title X funding • Regional project priority funds, used at regional discretion to address specific needs in that area • Male reproductive health project funds to support initiatives to increase male participation in reproductive health programs GENERAL TRAINING AND TECHNICAL ASSISTANCE FUNDS Remaining dollars for administration and training (10 percent of the total budget) cover the costs of overall program management (e.g., personnel, travel, rent), as well as regional training and technical assistance. Regions receive these r ­ esources via three funding sources: • Training base fund to support the operation of a regional training center and training grantee • Priority set-aside funds, used for training priorities established by OPA • Technical assistance base to cover costs for grantee training in specific areas identified through an annual needs assessment ADDITIONAL FUNDS All regions also receive other family planning–related funds from HHS for special initiatives, which they may distribute to Title X service grantees. The purpose of the supplemental grants is to integrate screening and preventive services for HIV/AIDS and STDs. Minority AIDS Initiative funds provide supplemental funding for HIV/AIDS screening and counseling in efforts to support broad implementation of the Centers for Disease Control and Prevention’s (CDC’s) Revised Recommen- dations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings. As part of the National Infertility Prevention Program, grantees also may receive CDC funds for chlamydia screening and treatment to reduce the incidence of the STD and its complications (pelvic inflammatory disease, infertility) if left untreated. 

APPENDIX J 363 requested by grantees, the populations they intend to serve, and clinical services they intend to provide as listed in their grant application. Each region’s planned distributions to grantees are described in its budget plan submitted annually to the Central Office. In turn, grantees also may employ their own methodologies for funding delegate agencies and clinics. Thus, the current funding levels and mechanisms vary by region and grantee. The specific methodologies for distribution for each type of funds are described below to the extent that information was available. Methodology for Allocating Regular Service Funds Allocations from the Central Office to Regional Offices. For the regular service funds, allotments are based on a historical formula that measures each region’s need according to three data sets—Guttmacher Women in Need, census data, and the Bureau’s Common Reporting Requirements (BCRR, the pre-FPAR equivalent). The exact formula and weighting of each data set are not available, but this process resulted in each region (and state or ­designated geographic area) receiving a percentage of the total Title X b ­ udget. At one point in the early 1980s, the Central Office considered changing the regional allocations; however, Congress passed language in the FY 1987 appropriations bill that prevented changes in the percent- ages allocated to each region. Hence, throughout the program’s operation, the regular service funds and any subsequent budget increases have been a ­ llotted to each region according to its established percentage. In 2003–2004, at the request of the Acting Assistant Secretary of Health, the Central Office undertook an internal exercise to reexamine the methodology for regional allocations. Using current data derived from the Guttmacher Women in Need report, census data, and the FPAR, it was found that the current allocations to each region continued to match up very well, and no further efforts have been initiated to evaluate or change the base funding. Actual monetary values provided to each region are avail- able in the FPAR. Allocations from Regional Offices to Grantees. Similar to the process described above, the Regional Offices use historical, preset, percentage- based calculations for allocating regional funds to specific geographic areas. Regular service funds are allocated to grantees through a competitive pro- cess managed by the Regional Offices. The Regional Office issues a Request   he T Bureau’s Common Reporting Requirements are the HHS Bureau of Primary Health Care’s guidelines for annual reporting designed for community health centers. The BCRR was also used as the guideline for reporting on Title X until 1995, when the FPAR was instituted.

364 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM for Proposals (RFPs) announcing the level of funding available for the competition in a designated geographic area (e.g., state of Connecticut, $2.5 million). The grant applications are evaluated by that region’s Objec- tive Review Committee (ORC) according to criteria established in the Title X statute. OFP includes information on the scoring of the criteria in the RFP. The same scoring methodology is used by all 10 regional ORCs (see Box J-2). The RPC and RHA determine the length of the grant award—2–5 years, depending on the ORC score: • Score of 95–100 points: 5 years • Score of 85–94 points: 3 years • Less than 85 points: 2 years Once grant applications have been scored by the ORC and winners have been announced, the Regional Office calculates disbursements for regular service funds according to the methodology of its choosing or past award amounts. Most of the methodologies were established some time ago. In noncompetitive years, grantees complete an application annually to receive funds for the remainder of the project period. Among Regional Offices, there are some commonalities and differences not only in the data used for these disbursements, but also in the way that regions may weight the data. Commonly used data include the ORC score, the FPAR, and Women in Need. Differences are notable in the percentage of the grant that is attributable to past awards. Some examples of the regional variations are provided below. BOX J-2 Criteria and Scoring for Award of Regular Service Funds • Project plan provides for requirements set forth in Title X regulations (maxi- mum 20 points) • Extent to which services are needed locally (maximum 20 points) • Adequate 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)

APPENDIX J 365 One region makes decisions on the allocation of regular service funds based on performance and a historical formula. Performance criteria include FPAR data (e.g., numbers of users, numbers of HIV and Pap tests) and grantee quarterly reports. The historical formula provides a means with which 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. Also taken into consideration are the resources and history of the grantee within the Title X program (most are returning applicants). Another region uses a more mathematical 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 is based on the number of women served previously who are at 100 percent of the federal poverty level and below (FPAR data) • 20 percent is based on Guttmacher Women in Need data A third region makes decisions about allocations by reviewing FPAR data on the clients/populations being served, the ORC score, the grant appli- cation plan, and the income level of the population served. The ­decision- making process is more qualitative than quantitative. A fourth region simply allocates 90–100 percent of the immediate past award to the grantee. Generally, there is no grantee turnover; 57 percent of grantees are governmental (state or territory departments of health), and 43 percent are nonprofit organizations that have been providing services for several decades. As such, there is rarely competition among grantees. Most regions have added, on average, one to two new grantees over the past 10 years. Much more turnover occurs at the delegate level, in terms of both lost and gained delegate agencies. Although each region maintains some sort of methodology for allocat- ing its base funding to grantees, these methodologies actually are employed infrequently, as most grantees remain the same from year to year. Generally, it is only when another grantee is added to a region that the methodology may be used. RPCs believe that the strength of the Title X program is founded on a structure that maximizes flexibility in regional administration and manage- ment of the program, including that pertaining to the allocation of funds to grantees. They also believe that there are many ways of achieving the same programmatic success, and what works for one region may not work for another.

366 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Allocations from Grantees to Delegates/Clinics. Most of the variability in allocations throughout a region occurs at the level of the delegate/clinic. Once grantees have been awarded Title X funds, they contract with delegate agencies or provider organizations (e.g., clinics) and negotiate which clini- cal locations will participate in the Title X program. Most often, grantee selections of delegates/clinics are undertaken through a competitive process with a scoring mechanism typically based on the budget available, the applicant capabilities, and the applicant statement of work. Additional fac- tors taken into consideration include delegate/clinic past performance (i.e., whether they do a good job providing services, results of site visits, compli- ance with OPA rules) and familiarity with the health care infrastructure of the geographic area. Although grantees have some leeway in deciding how many delegate/ clinic locations will receive funding, they must ensure that funding is dis- tributed appropriately throughout the geographic area associated with the grant award. One way that some grantees accomplish this is by using the annual needs assessment of their geographic area to identify areas with an unmet need for family planning services. There is significant variability in methodologies used by grantees to dis- tribute funds to delegates/clinics. Most grantees use a standard base amount paid to delegates/clinics to cover basic costs plus a per patient rate based on a selected data set. However, the base amount can vary considerably from one grantee to another. For example, one grantee uses a base amount of $80,000, while another uses $5,000. The funding amounts guaranteed to delegates/clinics relative to previous awards also can vary widely. One grantee may guarantee 50 percent of the previous year’s funding, while another may guarantee 75 percent. Table J-3 provides some examples of the different methodologies employed by Title X grantees. For many grantees, these methodologies are the product of a conscious effort in the last decade to simplify the process and calculations for allo- cating grants to delegates/clinics. Among grantees, delegates, and clinics, the most highly regarded change in methodology is the inclusion of a per patient calculation in the formula. Even delegates and clinics that lost some funds with the new calculations were supportive because of the transpar- ency and fairness of the allocation process and confirmation that the right patients were being served. Thus, grantees have found this method to be very effective in supporting family planning services where they are most needed and in demand. Methodology for Allocating Other Service Funds Supplemental Expansion Funds. Although traditionally the Central Office has integrated supplemental expansion funds into the larger budget for

APPENDIX J 367 TABLE J-3  Examples of Methodologies Used by Grantees to Allocate Regular Service Funds to Delegates and Clinics Grantee A Grantee B • Standard base of $5,000 paid to delegate • Women in Need (weighted 10 percent) agencies for basic costs • Previous allocation (all health districts plus have been receiving funds almost since • Per client allocation based on number of the beginning) (weighted 50 percent) insured and uninsured, non-Medicaid • 3-year case load (numbers) (weighted patients seen in previous year 40 percent) • 10 percent variability applied to accommodate shifts in case load Grantee C Grantee D • Allocate more funding to agencies serving • 75 percent of funding is maintained higher numbers of uninsured, low-income (cannot lose more than 25 percent of teenagers (less than 135 percent of federal funding, and funding cannot increase by poverty level) more than 33 percent) • Take into account all of a program’s • Base starting amount is $80,000 income from fees and public and private • Takes into account: insurance — Number of users • Set goals for how much money agencies — Number of warning letters should be generating or used in the (compliance) previous year, whichever was higher — Number of special populations served • Use per patient rate for allocations based — Number of adolescents under age 17 on the number of patients expected to be — Chlamydia screenings (e.g., aligned seen and those actually seen (e.g., if a with CDC guideline) 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, grantee owes it money) regular service funds, a different approach was employed for the 2007 increase: $15.8 million of the $16.8 million overall increase was allo- cated through a separate process based on regional size and number of clients served as reported in the 2005–2006 FPAR. Small regions received $1.3 million, medium-sized regions received $1.6 million, and large regions received $1.9 million. In contrast with previous budget increases, use of the 2007 funds was restricted. Grantees had to compete for the funds and could use them only for expansion of family planning services to individuals not currently being served.1 Funds could be awarded for any aspect of grantee Title X program operation, including the purchase of additional supplies   here T was $1 million set aside for research and development of additional data collection capabilities.

368 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM BOX J-3 Criteria for Award of Supplemental Expansion Funds • Description of targeted area and justification for additional services (25 points) • Relative need for funds (25 points) • Project plan of strategies to expand service delivery (20 points) • Description of clinical efficiency strategies used to maximize resources (20 points) • Capacity of the proposed project to make rapid and effective use of resources (10 points) (e.g., contraceptives) or payments for additional staff members, as long as such requests were tied to anticipated increases in Title X clients. Applications were reviewed by the RPC, who made recommendations to the RHA. Examples of data of interest to the Regional Offices include the projected number of new clinic users, calculations of cost per user over the course of the 3-year project period, and FPAR data. Many grantees indi- cated that they did not overcommit to increasing users during the first year of the award to allow time for program implementation. Most increases in users were planned for years 2 and 3. The criteria for awarding supplemen- tal expansion funds are provided in Box J-3. The new requirement that delegates must compete for supplemental funding is challenging for small, rural communities. There tend to be sole or few providers of family planning services in these communities, so competing for funds means competing for less money than in larger areas with multiple delegates. In addition, it is more challenging to increase the number of users given the greater distances that patients must travel for services. Regional Project Priority Funds. The Central Office allocates regional proj- ect priority funds through equal allotments of $472,000 to each region. This approach is intended to equalize the smaller and larger regions. If project priority funds were allocated only by percentages, the larger regions would receive most of the resources. These funds may be used at regional discretion to support specific regional priorities and/or needs, Title X pro- gram priorities, legislative mandates, and efforts to address key issues.1 Until 2005, regions received separate funds to support male adolescent clinic projects ($30,000) and information, education, and communication activities ($30,000). However, in 2006 those funds became part of the region’s base funding. Regions are allotted the additional project priority

APPENDIX J 369 funds, and are allowed substantial flexibility in how the funds will be used to continue activities in these or other areas. Regions can vary in the way the RPC and RHA determine allocations for regional project priority funds. Use of a competitive process is optional, but encouraged by the Central Office. Many regions simply fold regional project priority funds into the regular service funds, while others prefer to develop their own criteria for assessing grantee applications. For example, one region bases allocations on the ORC score, data on special initiatives (e.g., STDs), and previous performance. Another region uses the eight ques- tions highlighted in Box J-4 as criteria for evaluating grantees interested in receiving regional project priority funds. Still, a few regions use a more formulaic methodology for determina- tions. One region’s methodology includes: • Description of proposed use of funds (15 percent) • Extent of unmet need (30 percent) • Lack of other resources (30 percent) • Grantee performance (15 percent) • Grantee budget (10 percent) For existing grantees, funding often remains at the previous rate, unless there is evidence that the funds have not been used wisely or that the num- ber of clients has decreased. For new applicants, examples of criteria for evaluation may include percentage of federal poverty level of users, number of non-English speakers, socioeconomic status of users, number of provid- ers/geographic area, state and county statistics, and data from the National Infertility Prevention Program. Regions that have unused funds at the end BOX J-4 Example of Criteria Used for Distribution of Regional Project Priority Funds • Briefly summarize need and plan, including time frame • Briefly describe if and how budget relates to plan • Measurable goals to track • Suggestions for other project metrics • How likely (from reviewer perspective) project will experience success • Whether project identifies potential new service delivery partner • Questions that might be addressed to grantee for clarity of intention and direc- tion for this project • Other comments

370 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM of the year may issue a notification to request applications from grantees. Applications should be as descriptive as possible (e.g., funds to address increased cost of providing service, funds to meet OPA priority). General Training and Technical Assistance Funds. The Central Office pro- vides each region with funds for training and technical assistance programs. Three types of such funds are available: training base funds, priority set- aside funds, and technical assistance funds. The training base funds, total- ing $4.7 million in FY 2008, support the 10 RTCs as authorized under the Public Health Service Act. Regional allocations range from $385,000 to $555,000, depending on the size of the region. Consultants interested in managing the RTCs compete for awards and are scored according to the criteria published in the RFP. Recently, this competitive process was centralized by OFP. In addition to the training base funds, each region receives $50,000 in priority set‑aside funds and $30,000 in technical assistance funds. These funds are not competed. Instead, for the set-aside funds, OFP provides the criteria for RPC and RHA use in evaluating applications. The technical assistance funds are discretionary, with allocations determined by RPCs. Directed Supplements, External Funding of Targeted Programs, and Special Projects. Directed supplements and other external sources of funding are awarded only to existing Title X service grantees (not new grantees). Three types of such funds are available to those that qualify. Two of the programs (male reproductive health funds and HIV/AIDS screening and counseling funds) are directed supplements that depend wholly on Title X funds. The third program—for chlamydia screening—is funded entirely by CDC. The male reproductive health funds are 100 percent Title X and are part of the service funds; however, because they target a specific population, they also are considered a directed supplement. These funds must be used only to support initiatives that aim to increase male participation in repro- ductive health programs. For HIV/AIDS screening and counseling services, a portion of the Title X funds is combined with funds provided through the Minority AIDS Initiative fund. CDC funds chlamydia screening and treatment at Title X service sites through a completely separate process. When CDC instituted the National Infertility Prevention Program to support chlamydia screening, legisla- tive provisions allotted 50 percent of funds for use in STD programs and 50 percent for use in family planning programs. Funds are supplied directly to delegate agencies and clinics from CDC; OPA does not function as an intermediary and does not monitor chlamydia screening programs. Rather, the program operates as a collaboration between CDC and OPA, with grantees reporting data to both agencies.

APPENDIX J 371 RPCs and grantees are highly supportive of the directed supplements they receive and believe that the Title X program has ultimately benefited significantly from a closer association with public health. However, grantees also stated that they would prefer to receive the funds as part of the regu- lar service funds rather than as a directed supplement. Typically, directed supplement funds are awarded very late in the overall Title X project period (e.g., August 2008 for project year 2008). The grantees provide services regardless of when they receive the funding. As long as they meet the overall Title X program goals (male reproductive health, HIV/AIDS screening/counseling, chlamydia screening), they do not see the purpose of separating the directed supplements from regular service funds. (Issues related to multiple funding cycles are discussed in the next section.) In addition to directed supplements, OPA may issue funds for special research projects, such as the ABC model of counseling. Because of the sig- nificant shortfalls in funding just to provide basic family planning services, many grantees remain concerned about the restrictions and requirements associated with funds for special projects. In some regions, many clinics have been closing or decreasing hours in the past few years to stay open. As such, OPA’s first goal should be maintaining core services and funding sup- plies (e.g., OPA should be spending more money on IUDs). Many believe that a better approach would be to put all the funds into one fund and allow grantees to distribute them for clinical services under Section 1001 of the Title X statute as they see fit. Key Challenges in Title X Allocations Funding Cycles One of the most challenging aspects of Title X funding is the coordi- nation and management of the multiple funding and project cycles at the federal, regional, and state levels. When Congress passes the annual appro- priations bill, the Central Office releases all service and training funds (i.e., regular service funds and regional project priority funds) to the regions. Typically, appropriations are made in accordance with the federal fiscal year (October 1–September 30). As stated previously, once regions receive their funding, they begin the process for grantee allocations. If there is a delay in reaching an agreement on the appropriations, Con- gress may issue a continuing resolution that allows government programs   s A noted earlier, ABC refers to a model for family planning counseling services based on extramarital abstinence, being faithful in marriage or committed relationships, and consistent and correct condom use. The ABC model was designated as a Title X priority area by the DASPA appointed by the George W. Bush Administration.

372 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM to be funded as a portion of the previous year’s appropriation (for up to 6 months) until the current year’s funding is available. However, delays in appropriations can interfere with grantee planning and use of service funds. Because the same financial resources are not available, Regional Offices and grantees conserve funds by limiting travel and training expenses. In some extreme cases, grantees may not be able to expand or maintain certain aspects of clinical services (e.g., they may have to decrease staff hours for family planning services). At the level of the grantee, the dynamics of the funding process can be very complicated. Each grantee maintains one account with the federal government, through which the different service funds and training funds are made available at different times throughout the year. A grantee’s budget period (annual funding period) and project period (total contract period, e.g., 3 years) can vary substantially from those of other grantees within a given region. Each grantee is designated a specific start date for both its budget period and project period as identified in the notice of its grant award. Yet this date may or may not coincide with the dates when the different funds are made available to the grantee. For example, a grantee’s budget and project start date may be January 1, but the date for availability of the supplemental services expansion funds may be August 1. Each grantee also may have grants being competed in differ- ent years. For example, a grantee may compete for supplemental services expansion funds in 2008 and recompete for regular service funds in 2009 and HIV funds in 2010. Grantees that are a state department of health also are subject to state funding periods that may or may not align with the federal timetable. Thus, the Title X program funding cycles tend to be out of sync with many grantees’ budget and project periods and, in some instances, federal reporting periods. This creates a perpetual situation in which grantee funds must be carried over from one budget year to another. While the amount of the carryover may be small (e.g., $62,000), it involves a time- and labor- intensive process that takes resources away from clinical services and staff training. This process was established initially to balance the workload associ- ated with reviewing grant applications throughout the year. Considering that there are 88 grantees receiving funds in the Title X program, the work- load would be high if all grant applications arrived at the Regional Offices and OPA grants office simultaneously. However, this approach also has resulted in a process that can be per- ceived as fragmented and difficult to coordinate. In addition, management of all these cycles requires significant time and resources. For example, one region has 5 grantees with a December 31 start and 10 grantees with a July 1 start. The Regional Office must hire two sets of ORC consultants,

APPENDIX J 373 doubling all costs. The process also creates a significant amount of paper- work that could be streamlined. Several solutions were suggested by those interviewed. One method of streamlining processes without changing federal funding cycles has been to coordinate the budget and project periods of all grantees within a region. One region already has instituted this approach using a June 1 start date. Given a date midway through the fiscal year, grantees are assured full funding for their budget period regardless of whether there is a delay in appropriations. Grantees in this region also have found it easier to manage all of their sources of funding. Another solution is for the federal government to create a universal start date for projects. Many interviewed indicated a willingness to make the trade-off between having more work at one point during the year and having two or more differ- ent sets of start dates. A third suggestion was to institute 5-year project p ­ eriods more broadly, especially for grantees that have been providing family planning services for an extended time. Lastly, OPA could evaluate the strategies used by CHCs and other public health programs to coordi- nate budget and project periods. Transparency Many grantees feel that OPA should gather all stakeholders to simplify regional allocation methodologies and funding processes across the board. Such revisions should be an outgrowth of an independent evaluation of funding distributions. In addition, all expressed concern about the lack of transparency at the OPA and regional levels in the methodologies used to determine allocations to grantees. Some grantees feel that Central Office allocations have not been adjusted sufficiently to shifts in the population. Another point of concern is the lack of transparency in revealing publicly to grantees what other grantees are receiving. As a result, some question the equity of allocations among grantees. For example, 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. Thus, grantees believe that good performance is not being incentivized appropriately because some groups are getting more money for serving fewer clients. Greater transparency also is needed as to the criteria for determining a specific grant length and why the designated length was awarded to a particular grantee. Some grantees believe that there are notable limitations in basing allo- cations on data from Women in Need. For example, there is no way to know whether women identified will use Title X services. Rather, some believe that funding should be based solely on how many people are being served.

374 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Competition The Title X competitive process is designed to create opportunities for new grantees, clinics, and consultants, as well as stable networks of care. In general, grantees have mixed feelings about the competitive grant applica- tion process. Some grantees think the application process is better than that for other HRSA programs, even though they feel unnecessarily restricted by the application page limits (i.e., 50 pages for competitive applications, 30 pages for noncompetitive applications). Several grantees also indicated a desire for more guidance in the application process. Some grantees would like OPA to consider different allocation processes for the different applicant types, especially since some state departments of health have been providing family planning services for almost 40 years. These grantees would like OPA to develop one process for state depart- ments of health and long-serving nonprofit and private-sector ­grantees, and another process for newer nonprofit and private-sector organizations. For example, instead of competing for funds, state departments of health and long-standing grantees could provide a revised justification for renewed funding, and in addition, OPA could review the state’s project period performance to determine whether any funds were misspent, as well as to ensure that funds were received by the right delegates/clinics. Competing Local Priorities Some grantees are further challenged by competing local priorities, such as state-based financial obligations to invest in health information technol- ogy systems using a portion of Title X funds. These obligations can have an impact on the amount of funds available for clinical services. For example, a technology company contracted by one state to build a state-wide health information technology (HIT) network requires payment of $300–400 per person per month for each professional in the health department who uses a computer. While a state-wide HIT system is considered a good and neces- sary investment, it can have an impact on the ability of state health clinics to purchase contraceptives. Coordination of Title X and Other Sources of Funding for Family Planning Programs As noted above, several past and current sources of federal and state funding have provided support for family planning services, including the Title X program, the Medicaid Waiver program, the federal 330 program, MCH block grants, Social Services block grants, and TANF. Funds from CDC can be used only for its STD prevention program. Title X, the fed-

APPENDIX J 375 eral 330 program, and the Medicaid Waiver program are the predominant sources of family planning support in today’s health system. The discussion in this section is based on a limited scan of the published literature, gov- ernment and private-sector reports, and other information. To supplement those findings and to provide context based on the experiences of those involved in the Title X program, Lewin also interviewed four RPCs and three grantees. Overview of Non–Title X Family Planning Funding Sources As stated earlier, Title X of the Public Health Service Act provides the only focused support (both historically and presently) for family planning through grants to 38 state agencies and 39 private-sector non­governmental organizations that collectively serve all 50 states, territories, and the ­District of Columbia.17 Because of the relative openness of the program to low- income individuals as compared with the other sources and providers of family planning services, RPCs, grantees, and clients consider access to family planning and annual screening to be better in Title X clinics. As noted, while Title X remains the centerpiece of family planning, funding for family planning services through the Medicaid Waiver pro- gram now marginally exceeds that of Title X. To date, 27 states have implemented some form of the waiver program.18 The federal government pays 90 percent of each state’s Medicaid expenditures for family planning services and supplies and requires only a 10 percent match with state funds. In FY 2006, Medicaid funding for family planning services was estimated at $1.4 billion for all health care provider settings.17 Of this amount, Title X clinics alone received $320 million in Medicaid payments, slightly more than the $262 million allotted in Title X grant funds.19 A 2003 federally funded evaluation of the Medicaid Waiver program in six states found sig- nificant cost savings to both the federal and state governments.20 Moreover, this study estimated that if the waiver program were implemented nation- ally, federal and state savings of $1.5 billion would be realized annually by the third year. In addition to macro-level benefits, the Medicaid Waiver program has had a positive influence programmatically by enabling Title X grantees and providers to serve greater numbers of clients. Some stakeholders believe that Title X and the Medicaid Waiver program complement one another as a more comprehensive effort to serve those in greatest need.21 The waiver program has provided a dependable source of revenue for clinics, helping to ensure overhead. Without reimbursement from the Medicaid Waiver pro- gram, many Title X clinics would not be able to continue operation given the constant increase in the costs of staff and supplies. However, unlike Title X, the waiver program has a strict set of requirements and limits cov-

376 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM erage to the core services that are needed to promote effective contraceptive use rather than more comprehensive reproductive health.22 Section 330 of the Public Health Service Act governs the operation of FQHCs (e.g., CHCs), which provide a broad scope of primary and preven- tive care health services, including reproductive health services.23 CHCs are private, nonprofit, community-based health centers located in high-need or medically underserved areas that function as major safety-net providers for low-income and/or uninsured Americans. There are more than 1,000 CHCs operating more than 6,000 delivery sites in all states, territories, and the District of Columbia. Since 2000, federal investments in CHCs, most often by the Bureau of Primary Health Care (BPHC) at HHS, have doubled to more than $2 billion today.24 BPHC funding of Title X fam- ily planning services was estimated at $5.8 million in FY 2006.19 By law, CHCs are required to offer prenatal care, screening for breast and cervical cancer, voluntary family planning, and other basic services provided by an obstetrician or gynecologist. In 2007, 95 percent of CHCs provided family planning services. Some CHCs receive Title X funding to supplement their budget for reproductive health services. However, as with the Medicaid Waiver program, CHCs operate according to an independent set of require- ments, some of which do not fit well with Title X. The MCH (Title V of the Social Security Act) and Social Services (Title XX of the Social Security Act) block grants are provided directly to and controlled by state governments. The MCH grants typically go to state departments of health, while the Social Services grants go to the state’s social services agency.17 Federal law permits states to use both grants for family planning services. However, for MCH grants, the law also requires states to contribute $3 for every federal $4. There are no such requirements for Social Services grants. In FY 2006, grants to Title X clinics for family planning services were estimated at close to $23 million for MCH and more than $28 million for Social Services.19 Although traditionally, family planning was an important part of the MCH program’s overall mission, state MCH programs have shifted away from providing direct patient care for family planning.25 Most states use MCH grants to fund prenatal care, population-based services (e.g., immu- nizations), or program infrastructure. For example, some MCH grantees use the grant to pay for county health department staff (e.g., nurse prac- titioners, public health nurses) that may also serve Title X or for outreach activities to promote AIDS prevention. Generally, grantees feel that county or local support was better prior to the Medicaid Waiver program. After implementation of the waiver program, many county commissioners cut supplemental budgets with the perception that clinics had enough funding with the new federal dollars, forgetting two important facts: (1) clinics are serving more clients because of the waiver program and (2) the waiver pro-

APPENDIX J 377 gram does not reimburse clinics for 100 percent of costs, especially when the visit goes beyond the use of contraception. In contrast, the Social Services block grants have tremendous flexibility in applicability across the spectrum of social services programs.25 Family planning is the only medical service for which the grants are applied as a supplement to other funding. Severe budget cuts in the mid-1990s left the program financially crippled, and as a result, most clinics receiving Title X funding no longer receive Title XX funds. In some states, lost funding from the Social Services cuts was replaced by TANF grants (also provided directly to states) used to administer the state’s welfare programs. Like the Social Services grants, TANF funds can be used to supplement funding of fam- ily planning programs. However, TANF requirements are quite stringent, and as a result, many grantees eliminated use of the grants for their family planning programs. In fact, none of the grantees interviewed for this study received Social Services or TANF funds. For the Title X program overall, TANF grants amounted to $10 million in FY 2006.19 Some states also provide limited funding for family planning activities through state appropriations outside the context of Medicaid or the block grants. Specifically, many states’ Medicaid agencies use state appropriations to provide medical services, including contraceptive services, to people who do not meet Medicaid eligibility criteria (e.g., certain immigrants). In 2006, one study estimated that independent state appropriations for family planning services reached $241 million.17 Five states (California, Florida, New York, North Carolina, and Oklahoma) accounted for 57 percent of all state appropriations. Generally, state appropriations account for at least 10 percent of all family planning funding in 20 states. It is important to note that for close to 30 years (since 1980), state appropriations for family planning services have remained flat. Coordination vs. Duplication of Effort Because no single program finances family planning adequately, ­grantees must combine different sources of funding and program requirements to operate a comprehensive reproductive health program. In general, the mul- tiple sources of funding are not difficult to manage, and all grantees have found ways to make funding sources work together. It would be easier if all family planning funding came from one source, but grantees do not have an issue with coordination of the different funding sources, especially if they are affiliated with the state department of health. Free-standing and private-sector clinics are perceived as having greater challenges in coordina- tion of funding. The inclusion of a financial audit in the Comprehensive Program Reviews provides adequate oversight of the coordination and use of mul-

378 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM tiple funding sources. Financial consultants that serve on the review team evaluate accounting records and management of funding. The consultants are regarded highly for their ability to identify issues (e.g., a grantee not funneling fee-for-service reimbursements back into the Title X program) and provide constructive and educational guidance to grantees. From the standpoint of funding, RPCs and grantees do not feel that there is any obvi- ous area of duplication or lack of coordination. Most coordination-related issues pertain to the differences in each program’s operational requirements, which can affect access to care. Specifi- cally, the differences in requirements associated with program administra- tion and clinical services are especially pronounced among Title X, CHCs (under federal 330 rules), and the Medicaid Waiver program. RPCs and grantees do not see the need to have different rules for these three programs. Moreover, because Medicaid is a state-driven program, each state may implement different rules for use of the funds. For example, in Arizona, the Medicaid Waiver program is used to cover postpartum services (including sterilization services) for individuals living at or below 100 percent of the federal poverty level. In California, the Medicaid Waiver program has been instituted with much broader application for those at 200 percent of the federal poverty level.22 Because of these differences, Title X may serve dif- ferent purposes in different states, which adds to the complexity RPCs may experience in reviewing grant applications for their region. In general, the solution has been for RPCs to work closely with grant- ees to improve program management. However, there is great need to better define strategies that can enhance program coordination to ensure that all funds are used more efficiently. Impact of the Financial Crisis The downturn in the economy is causing state budget deficits, prompt- ing states to cut their 2009 and 2010 budgets across the board, including those associated with health care services. In addition, foundations and wealthy individuals have lost money and have less to donate. This situa- tion has had a direct effect on Title X grantees that are state departments of health. Typically, budget cuts result in clinic staff cuts, which in turn decrease the availability of services. With fewer staff, some clinics may close altogether, while others will decrease their hours of operation from 5 to 3 days a week. This affects clinics’ ability to serve family planning clients. Furthermore, family planning clinics within state departments of health become more dependent on federal funding. Another important outcome of the financial crisis is the fact that a greater number of individuals are in need of federally subsidized family planning services. Currently, more than 50 percent of Title X clients are

APPENDIX J 379 nonpaying. However, growth in unemployment, home foreclosures, and high gas prices are increasing the rates of those who are uninsured and at or near the federal poverty level. Without adequate access to family planning services or increases in federal funding, pending state and private-­sector budget cuts may result in increased rates of unintended pregnancy and STDs, as well as higher health system costs over the long term. These challenges are exacerbated by the fact that, as discussed above, federal funding for Title X has remained predominantly flat for the past few decades, while the costs of clinic staff, contraceptives, and laboratory tests have continued to increase. RPCs and grantees are hopeful that the new administration will expand Title X funding and take a greater leadership role in the purchase of contraceptives. Clinical Services Equity Requirements Title X requires that services for family planning clients be equal regardless of payment type or nonpayment. This has been a significant issue among grantees and clients. Since not every program pays for every service, there is difficulty regarding what can be done for one patient com- pared with another. For example, clinics currently have to review all carrier formularies and rules, their client mix, and desired contraception to develop a baseline so that all clients receive equal services as required by the Title X statute. Because of the equity rule, those with private insurance or ­Medicaid may not be able to receive certain contraceptives (e.g., Implanon and newer IUDs) even if their insurance/Medicaid pays for them unless those same contraceptives are equally available to Title X clients. Some clinics offer the innovative contraceptives on a sliding fee scale. Other clinics may institute an open service period each month. For instance, one clinic holds an open period for clients seeking Implanon during the first week of every month or until a designated number of Title X appointments are filled. Then, the Implanon service is closed for the rest of the month. During the open period, all clients with third-party payers that cover Implanon also may receive the service until it is closed. Although Title X funding remains inadequate, there is consensus among grantees that clinics should not have to equalize to a common denominator. Moreover, each grantee and clinic appears to be deciding independently which contraception to offer. With this disjointed approach, certain clients who could really benefit from new technology (e.g., those with cogni- tive impairment or those who are mentally challenged) may not have the opportunity to obtain it under the current rules. Establishing flexibility could help to increase revenues for struggling clinics, especially given the

380 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM current financial crisis (see below), as well as improve access and quality of care for clients. Another issue relates to the CHC and Medicaid requirements for using a pharmacy to fill prescriptions for contraceptives, whereas Title X stipulates that contraceptives be dispensed during the office visit. There is concern that, unless clients receive contraception directly from their clinician, they may not wait for the prescription to be filled. As a result, they may delay or avoid get- ting their prescription filled, increasing the risk of unintended pregnancy. Lastly, Title X is the only program that formally emphasizes client education and counseling about family planning. Both CHCs and Medicaid should enhance family planning services by adopting the Title X education/ counseling requirements. Restricted Services Under the Medicaid Waiver Program According to federal rules, individuals with third-party health insur- ance of any kind are disqualified from participation in the Medicaid Waiver program, even if that insurance exempts coverage of family planning ser- vices.22 For those that do qualify for the waiver program, all clinical visits must be focused on contraception or infertility services. The Waiver pro- gram supports many other services considered standard care under Title X, such as a comprehensive physical exam; education and counseling; routine blood work; and testing for pregnancy, cervical cancer, and STDs.22 How- ever, there are limitations on the extent of coverage. The Medicaid Waiver allows only one pelvic exam per year and any return visit associated with contraception, but in many states will not cover the cost of diagnosis and treatment for an STD found during one of these return visits.27 Currently, clinics use Title X and CDC funds to pay for some of the costs associated with STD-related services and dispense antibiotics purchased at a discount by the health department, but not all of the costs for the STD service maybe covered by these funds. In addition, there is wide variability in access to emergency contracep- tion (EC) under the waiver program. Some states do not cover EC, while others limit access through managed care programs, utilization controls, or prior authorization requirements, or based on the context of the clinic visit. In these instances, EC is provided to the client through Title X funds.28 In contrast, clients seen in CHCs may present for a certain condition but be treated for the wide spectrum of reproductive health services, includ- ing but not limited to receipt of contraceptives. Title X clients may present for any reproductive health issue (e.g., STD, pregnancy) and receive treat- ment as covered under Title X or be referred to an appropriate clinician for further care. There are no limits on the number of times that a client may request EC in either Title X clinics or CHCs.

APPENDIX J 381 RPCs and grantees stated that a more holistic view of care is needed with the Medicaid Waiver program—one that is reproductive health ori- ented versus just contraception oriented. Impact of Medicaid Managed Care In 1981, under Section 1915(b) of the Social Security Act, Congress authorized the Secretary of HHS to waive Medicaid provisions regarding free choice of provider so that state Medicaid programs could negotiate contracts with and require beneficiary enrollment in managed care organi- zations.29 Over the course of the 1990s, almost all states shifted some or all of their Medicaid beneficiaries from traditional fee-for-service plans to Medicaid managed care plans.30 Although family planning services are generally considered to be pri- mary care, such networks limit beneficiary choice and access to community- based providers of reproductive health services. For example, several states, most notably New York, entered into managed care contracts with religious plans that refused to include family planning services in their agreements. This left the states liable for coverage of family planning services through community-based providers as a direct medical assistance benefit.29 Congress amended the statute in 1986, effectively creating a “carve- out” that prohibits restrictions on managed care patients’ choice of family planning providers.31 However, the amendment has not achieved its goals of continued access to full family planning benefits because the Medicaid and other statutes did not define family planning services and supplies adequately such that it is possible to discern which managed care contract services would be subject to the free-choice rule and which would be subject to managed care network restrictions.29 In addition, the statutes did not clarify the interpretation of important issues, for example, whether primary care gatekeepers would continue to have the authority to preauthorize ser- vices from a separate provider. As a result, the definition of family planning services and supplies was left to the states’ discretion. This has resulted in variations in coverage and benefits from state to state. As the Centers for Medicare and Medicaid Services (CMS) moves toward the medical home model of care coordination among providers, it is unclear how family planning services will be affected. Some states, such as Iowa, are developing collaborative networks of safety-net providers, including CHCs, free clinics, rural health clinics, family planning agen- cies, MCH clinics, and local boards of health, to ensure broad access to and coordination of care.32 While family planning services are an included benefit under Medicaid rules, other states may promote use of primary care providers for such services. For example, South Carolina lists covered family planning services in its guide Medical Homes Network: Policies and

382 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Procedures, which states: “Eligible beneficiaries should be encouraged to receive family planning services through their primary care provider or by the appropriate referral to promote integration/coordination of these ser- vices with their total medical care. However, eligible beneficiaries have the freedom to receive family planning services from any appropriate Medicaid providers without any restrictions.”33 Given the differences in approaches to Medicaid medical homes among the states, further research is needed to better assess the potential impact on beneficiary access to and confidential- ity of family planning services. Effect of Program Management and Funding on Clinical Services Even with the limitations discussed above, the quality of care has not been affected by the current level of Title X funding. Yet there are mixed feelings about the scope of Title X services. Most RPCs and grantees believe that the scope of services is adequate and should not be increased or decreased. The current set of services is necessary to ensure quality of care and prevent downstream effects on patient health, as when a woman who comes to a Title X clinic for contraception has an STD. Furthermore, many women do not want their primary care/family practice physician to be their family planning provider. However, a few grantees felt that clinics are being asked to do too much, and this has been an issue for the past 20 years. Too many services have been added without enough funding. For example, a grantee may receive $5 million per year yet serve 150,000 patients a year, which amounts to $33 per patient. If additional Title X dollars were available, grantees indicated an inter- est in using the funds to develop educational materials for clinics, provide continuing education in family planning and reproductive health to clini- cians, and/or add colposcopy services. In conclusion, those involved in the management and provision of Title X services believe that the program has served as an important safety net for millions of women, providing valuable assistance in family plan- ning and reproductive health. The focus on quality of services, such as non­biased, nondirectional counseling and preventive health screenings, has had a substantial impact on the lives of many people. In fact, for many women, Title X clinics are a first point of entry into the health care system. Thus, Title X is considered a critical public health program for reaching underserved populations. However, all costs associated with Title X clinic operation continue to rise each year, while funding has remained relatively flat for several decades. Inadequate funding has significantly limited the ability of clinics to pro- vide Title X services. Both RPCs and grantees estimate that, with current funding levels, they can meet only 45–50 percent of patient demand. Even

APPENDIX J 383 those grantees participating in the Medicaid Waiver program are struggling to provide Title X services. One grantee estimated that, with the waiver program, only 56 percent of patient need is met. Many RPCs and grantees expressed concern about the ability to continue to provide quality services if prices continue to rise and funding remains stagnant. In addition, when funding increases are available, grantee efforts must be directed at increasing the number of users rather than ensuring the sustainability of existing programs. For example, with the current supple- mental expansion funds, some grantees can receive, at most, an additional $500,000 but must see an additional 2 million patients—an excessive requirement since they already cannot keep up with the rising costs to provide services. Moreover, the modest increases in funding seriously limit the ability of grantees to open new clinics to address unmet patient need in areas that currently do not provide Title X services. Grantees/delegates stated that there is significant pressure on them to decrease program costs and, if necessary, eliminate aspects of their programs. For example, one grantee has not purchased patient educational materials in the past 6–7 years and recently went further by eliminating interpreter services ($40,000/year). Inadequate funding even has affected the willing- ness of some delegates/grantees to provide services. Some ­delegates/grantees, including some CHCs, have withdrawn from the Title X program as a result of limited funding and complexities involved in obtaining grants. Priority Issues The main issues affecting clinic services are the cost of contraceptives and other supplies and provider recruitment and retention. Cost of Contraceptives and Other Supplies Currently, clinics can purchase contraceptives through HRSA’s 340B program. Section 340B of P.L. 102-585 limits the cost of covered out­ patient drugs to certain federal grantees (including Title X grantees), FQHC look-alikes, and qualified disproportionate-share hospitals.16 Entities par- ticipating in the program may gain substantial savings on the cost of phar- maceuticals. However, one major drawback of the program has been the ability of pharmaceutical companies to change drug prices every quarter at their own discretion. More often than not, companies have increased prices.   he 340B price for each drug can be recalculated by manufacturers on a quarterly basis. T Manufacturers may lower a drug’s price (below the ceiling) in the middle of a quarter, but may not raise a drug’s price until the beginning of the next quarter.

384 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Some pharmaceutical companies indicated a willingness to decrease the cost of contraceptives to pennies for low-income patients if the Title X clinic agreed to give all Medicaid patients prescriptions for contraceptives to be filled at Medicaid-approved pharmacies where they could obtain relative market prices for their products. However, several clinics did not accept this agreement because in effect, it would establish two tiers of treatment. The continual increases in the cost of contraceptives have been the primary issue negatively affecting Title X patients who want to use birth control. The lack of funding limits the variety of contraceptive methods clinics can provide. For example, many clinics can afford to provide only oral contraceptives, even though a growing number of patients would like newer methods, such as the contraceptive patch, Depo-Provera contracep- tive injection, or Implanon. Grantees work diligently to prevent this situation and often will refer out a particular service (e.g., certain STD services, screening, and treatment) in order to supply different types of contraception. However, similar to the dilemma with contraceptives, clinics continuing to provide laboratory test- ing can afford to perform only certain types of tests (e.g., several clinics still are using traditional Pap smears even though newer, more accurate testing methods are available). In some instances, clinics have run out of money to pay for contraceptives (and other supplies, including laboratory tests) midyear because of unexpected increases in the following quarter. Also, the 2008 rise in gas prices resulted in fuel surcharges of $3.97 on every order of contraceptives, regardless of how many were ordered. Those interviewed felt overwhelmingly that OPA should negotiate multi­ year, national contracts for contraceptives. In addition, other critical public health–related medications should be available through Title X clinics, such as human papillomavirus (HPV) vaccines. All clinics participating in the Title X program should have the ability to purchase contraceptives at the negotiated rate. To date, OPA has not taken this route because, as most believe, certain reproductive health services, including provision of contraceptives, are politically charged. However, other federal government agencies, such as the Veterans Health Administration (VHA) and CDC, do negotiate national contracts for pharmaceuticals. The VHA negotiates prices for drugs listed on its formulary, including contraceptives. CDC has a national contract for azythromycin, used to treat chlamydia as part of its Infertility Prevention Program. Both the VHA and CDC contracts were suggested as possible models for Title X contracts. Provider Recruitment and Retention Currently, there is a shortage of nursing personnel for family planning programs. Physicians provide medical oversight, but midlevel practitioners

APPENDIX J 385 (e.g., nurse practitioners, physician assistants) provide most Title X services. The recruitment and retention of nurse practitioners has been particularly difficult. Many private physician offices are hiring nurse practitioners and offer substantially higher salaries than public health programs. As a result, public-sector clinics cannot compete with private-sector salaries, espe- cially in rural areas. Thus, as demand for private-sector nurse practitioners increases, the pool for Title X services has decreased. Even public health departments are losing nursing staff. Historically, public health clinics were considered a desirable place to work because staff could work regular hours; however, the shift in salaries has created a lack of incentives to work in public health settings. Several states already have cut maternity care from health departments in order to conserve resources. This has affected the Title X program, as many of those patients would have come back to the health department for postpartum care and family planning services. Many health departments are left with individuals who do not quality for Medicaid. Several other factors have the potential to significantly affect the Title X program. First, the pending new requirement that nurse practitioners obtain a doctorate of nursing practice likely will add to the financial burden on nursing personnel, who must pay for additional advanced education. It also may result in a loss of diversity in the types of providers involved in family planning. Second, pending retirements of family planning providers who have been in the field for 20–30 years will leave a large gap in the provider knowledge base. Third, when clinics loose nurse practitioners or other providers, it takes time to replace them, which can negatively affect the ability to provide services. Some clinics have had to close, and some have been taken over by FQHCs. Because of the sizable increase in the number of FQHCs in recent years, there are fewer providers who have a family planning orientation. In particular, family planning services may receive inadequate attention from primary care providers who are not trained in the delivery of those services in a client-specific manner (i.e., using judgment to determine what is best and most appropriate for a specific person). While FQHCs used to employ nurses trained in reproductive health care, a growing proportion of these nurses are focused on other health issues (e.g., diabetes management) and may or may not be well versed in reproductive health services. This leaves grantees with concerns about whether women receiving Title X services will obtain the counseling and education they need. In addition, Title X grantees are concerned about their own ability to address public health issues (e.g., infectious disease) if they cannot attract family planning–specific staff. Those interviewed would like to see OPA employ some of the federal government’s strategies for recruiting and retaining health care ­ workers, such as debt repayment, scholarship programs, payment supplements,

386 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM grants, and continuing education funding. They also believe that it is worthwhile to consider how family planning fits within the context of the medical home model and whether there is a role for a targeted family plan- ning program. Program Administration Copays and Sliding Fee Scale The chief point of dissonance between Title X and other family plan- ning programs, as well as across the spectrum of clinics operating within the Title X program, pertains to differing sliding fee schedules. Table J-4 illustrates the many different fee schedules related to family planning ser- vices in California. Both Title X clinics and CHCs prohibit charging clients at or below 100 percent of the federal poverty level. However, Title X charges clients the full fee at 250 percent of that level, whereas CHCs charge the full fee at 200 percent of that level. Within their respective schedule ranges, both Title X clinics and CHCs can develop their own schedule of discount rates as long as there are sufficient increments. As a result, there are a multitude of different fee schedules for each program. For the Title X schedule of discounts (ranging from 100 to 250 percent of the federal poverty level), some clinics have implemented 10 percent increments, while others have implemented 20 percent or 25 percent increments; a similar approach is used by CHCs for their discount range (100–200 percent of the federal poverty level). Unlike Title X, CHCs are required to charge a copay at each visit. All third-party payers (Medicaid and private insurance) are billed the full amount by either Title X clinics or CHCs. Challenges in coordination are most evident when a CHC receives sup- plemental funding for Title X services. These CHCs must operate with two different fee schedules as they are prohibited from implementing the Title X fee schedule according to federal rules. If 50 percent or more of the clinic visit is dedicated to family planning, then the visit must be billed under Title X funds. It is quite time-consuming to go through this process. Documentation Requirements Another key area of contention among the different funding sources of family planning programs is the wide variation in documentation require- ments related to income, residential address, and citizenship. More specifi- cally, Title X asks individuals to self-certify their income status at the point of service. Recently, OPA issued allowances for use of documentation from participation in other federal social services programs for which citizenship

APPENDIX J 387 TABLE J-4  Example of Different Requirements Governing Copays and the Sliding Fee Scales for Funding Sources of Family Planning Programs in California Required Optional Prohibit Charge Medi-Cal managed care Out-of-pocket paying F-PACT (CA 1115 based on income* clients >100 percent of Medicaid Waiver) federal poverty level Medi-Cal fee for service Local county programs (with share of cost Expanded Access to (public–private partnership, requirements)* Primary Care (EAPC), Los Angeles only) depending on agency Medicare (seniors do not Title X at ≤100 percent of need family planning, but federal poverty level may qualify for STD services) Medi-Cal fee for service Other private insurance (except for those who must meet share of cost Federal 330 clients requirements first)* >100 percent of federal poverty level *Medi-Cal is Medicaid in California. is a condition for receipt of benefits (e.g., Women, Infants, and Children [WIC]). The federal 330 program requires proof of income (e.g., pay stub [last 30 days], income receipt, tax form), proof of current address (e.g., driver’s license, last utility bill, rent receipt), and dependent information if applicable.23 Title X and federal 330 statutes do not require proof of U.S. citizenship. The most extensive documentation requirements are associated with the Medicaid Waiver program. Historically, Medicaid did not require proof of U.S. citizenship. However, the 2005 Deficit Reduction Act codified new regulations requiring proof of U.S. citizenship as a condition for Medicaid eligibility for both adults and teens.26 Acceptable documentation for veri- fication of U.S. citizenship may include a valid birth certificate and photo ID, social security number (SSN), passport, or certificate of naturalization. CMS has written into the rules a 90-day presumptive eligibility clause that permits clinics to serve clients waiting for verification if not readily avail- able. The one exception to this requirement applies to low-income women during pregnancy, including those undocumented.   cceptable A photo identification includes driver’s license, state or federal identification card, military or merchant marine identification card, or Native American tribal documents.

388 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Some grantees report substantial expansion of resources and service hours with implementation of the Medicaid Waiver program. Yet without the citizenship requirement, they believe that they could serve even more clients, creating greater overall cost savings (as it is less expensive to provide contraception than to pay for unplanned pregnancies, whether a woman is a U.S. citizen or not). Increases in utilization have not been reported for all grantees. The key issues are the ability to navigate the system and access to documentation to meet program requirements. For example, one grantee (state department of health) noted a 30 percent decrease in utilization of the family planning clinic with implementation of the Medicaid Waiver program (and associ- ated documentation requirements). Some of the decrease is attributed to first-time and re-enrolling individuals that often wait up to 6 weeks to receive their Medicaid card. To address the coverage gap during the wait- ing period or the possibility that documentation will not materialize, this grantee implemented an innovative program whereby state general funds are set aside to cover family planning services. In addition, the family plan- ning clinics have access to the state’s Bureau of Health Statistics online and can verify citizenship status for those born in the state. If the individual was born out of state, the Bureau acts as liaison and pays for the cost to obtain a birth certificate from the other state. While waiting for their birth certificate, clients may make a one-time-only clinic visit and receive a 30-day supply of contraception. About 30 percent of individuals receiving contraception return for a follow-up visit, while 70 percent return when they receive their birth certificate. According to grantees, the Medicaid Waiver documentation require- ments also have had a significant effect on teenagers who use clinic services. Teenagers often do not have documentation (e.g., their SSN) and do not know how to get it without asking their parents. Those who previously used the clinic without documentation may have told their friends that they could no longer receive services unless they had their birth certificate or SSN, contributing to the decline in utilization. To address this problem, clinics guide students in obtaining their documentation by having them go to the school office and request their records with their SSN since they have a legal right to view their records at any time. Coverage Verification Verification of third-party insurance coverage can be challenging for Title X clinics. Patients may be on/off an insurance plan from month to month depending on whether they pay the premium. Moreover, different carriers have different rules for switching providers (some are same day, while others require 30 days), and most clients do not know the details of

APPENDIX J 389 their coverage. Thus, clinic staff must check clients’ status each time they visit the clinic (as is the case with most providers). However, for small, underfunded, understaffed clinics, this can be a cumbersome and time- c ­ onsuming process, requiring training of front desk staff and constant updates of the clinic computer system. Most grantees do not generate enough ­private-sector payments to warrant having staff dedicated to this task. Thus, many clinics just bill the insurer and hope to be reimbursed instead of calling to verify every patient. Greater attention is needed to organizing and determining payer mix and how it relates to client mix. Parental Consent Some states require parental consent for use of services under the fed- eral 330 program; however, such consent is prohibited under Title X. A few CHCs have created a “work-around” by keeping the family planning clinic separate from the rest of CHC services. These CHCs have instituted policies and procedures to support this separation of services. For example, there is no blending of visits—billing must be completely closed out for one set of services and reopened for the other set of services. Reporting Requirements Reporting requirements are different for each federal program. Elec- tronic reporting allows for mixing and matching of data elements for simplification of reporting to all. Specifically, computerized information sys- tems have made it possible to consolidate Title X clinic data for the FPAR. Electronic practice management systems ensure that information is accurate and can be used to generate various reports for different agencies as needed. Some smaller clinics still collect data by hand and report manually. Title X is the only program that requires reporting on family planning; STD data are reported to CDC. Duplication in reporting on family planning services may occur only when data for CHCs and Title X are contained in the same report. In comparison, each state may have different requirements for reporting on its Medicaid Waiver program. Typically, RPCs remain focused on Title X reporting but assist grantees in managing all reporting requirements if requested. Recommendations The RPCs and grantees interviewed for this study offered two recom- mendations for improving coordination among family planning programs.

390 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM 1. Promote the broader view of reproductive health vs. contracep- tive use. To facilitate higher-quality care, CHCs and the Medicaid Waiver pro- gram should adopt the Title X approach to comprehensive family planning. For the most part, CHCs do provide comprehensive clinical services, yet they could improve in their emphasis on client education and counseling. Similarly, the Medicaid Waiver program needs to expand coverage beyond a single pelvic exam and visits for contraceptives to the broader view of comprehensive reproductive health. Adoption of such an approach would support not only higher-quality care but also public health. 2. Convene a meeting of all family planning funding sources to improve coordination and identify ways of streamlining certain regulations and requirements. At such a meeting, each funding source could provide an overview of its program, services covered, regulatory requirements, and key issues. A strategic planning session could identify areas of potential harmonization. The outcome of the meeting could be presented at the OPA-sponsored annual regional meeting for Title X. In particular, participants in the proposed meeting could identify and agree on adoption of certain approaches throughout their respective pro- grams. Some examples include methods of classification by age group and common budget forms. Simple adjustments such as these would make it easier for grantees to apply for grants, enhance the quality of applications, and increase applicants’ familiarity with forms and processes. The meeting also would serve as a forum to discuss possibilities for streamlining more significant policies and regulations. For example, in California, anyone aged 12 or older has access to family planning without parental consent. Ideally, this policy should be standard for all programs to enhance client education and access to care. Another topic for discussion would be the ability to verify citizenship for Medicaid eligibility at the point of care. Currently, only one state has developed a program for point-of-care verification for those born in the state. Adoption of this approach broadly in all Title X clinics and CHCs could facilitate access to care. A third topic could be expanded, joint funding and implementation of health promotion and educational campaigns such as those targeted toward prevention of unintended pregnancies and STDs. Fourth, participants could discuss the advantages and disadvantages of shifting to the same fee schedule (e.g.,   ne O grantee disagreed with this recommendation, citing past experiences when the federal government “got too involved in family planning.”

APPENDIX J 391 same copay or no copay) and the legislative and policy changes needed to implement such a schedule. Fifth, it would be useful to discuss strategies certain CHCs have used for effective implementation of Title X to assist those CHCs that have been most challenged. references   1. HHS (U.S. Department of Health and Human Services). 2008. Fiscal year 2008 regional memorandum of agreement and work plan guidance. From the Deputy Assistant Secre- tary for Population Affairs to Regional Health Administrators. Rockville, MD: HHS.   2. Moskosky, S. 2007. Title X: The National Family Planning Program. The basics (Title X 101). Rockville, MD: HHS.   3. OFP (Office of Family Planning). 2001. Program guidelines for project grants for ­ amily planning services. http://www.hhs.gov/opa/familyplanning/toolsdocs/2001_ofp_ f g ­ uidelines_complete.pdf (accessed January 29, 2008).   4. HHS. 2008. 2007–2008 directory. Family planning grantees, delegates, and clinics. Washington, DC: HHS. http://www.opaclearinghouse.org/pdf/fpdirectory07.pdf.   5. HHS. 2007. Secretary Mike Leavitt: HHS priorities. Washington, DC: HHS. http://www. hhs.gov/secretary/priorities/#pre (accessed July 9, 2008).   6. HHS. 2003. Title X family planning: Program review tool (revised January 2003). R ­ ockville, MD: HHS.   7. Cost Principles for Non-Profit Organizations (OMB Circular A-122).   8. BPHC (Bureau of Primary Health Care). 2008. Bureau of Primary Health Care (BPHC). Oakbrook Terrace, IL: The Joint Commission. http://www.jointcommission.org/­ AccreditationPrograms/AmbulatoryCare/BPHC/bphc.htm (accessed July 10, 2008).   9. Title 45-Public welfare and human services. Part 74-Uniform administrative require- ments for awards and subawards to institutions of higher education, hospitals, other nonprofit organizations. Subpart C-post-award requirements. Section 74.51 Monitoring and reporting program performance. 10. HHS. 2005. Title X Family Planning Annual Report: Forms and instructions. http://opa. osophs.dhhs.gov/titlex/fpar-package-01-01-2005.pdf. 11. HHS. 2007. Guide for collecting family planning encounter data in Title X-funded ­ linics: Sample family planning encounter form and agency examples. http://www.access. c gpo.gov/nara/cfr/waisidx_99/45cfr74_99.html (accessed August 20, 2008). 12. Dailard, C. 1999. Title X family planning clinics confront escalating costs, increasing needs. Washington, DC: Guttmacher Institute. 13. GAO (U.S. General Accounting Office). 1981. Results of GAO reviews of family plan- ning activities under Title X of the Public Health Service Act. Washington, DC: GAO. 14. Dailard, C. 2001. Challenges facing family planning clinics and Title X. Washington, DC: Guttmacher Institute. 15. Sonfield, A. 2009 (unpublished). Memo: Title X funding chart. New York: AGI. 16. HRSA (Health Research and Services Administration). 2008. Introduction to the 340 B drug pricing program. http://www.hrsa.gov/opa/introduction.htm (accessed August 20, 2008). 17. Sonfield, A., C. Alrich, and R. B. Gold. 2008. Public funding for family planning, steril- ization and abortion services, FY 1980–2006. Washington, DC: Guttmacher Institute. 18. Guttmacher Institute. 2008. State policies in brief: State Medicaid family planning eligibil- ity expansions. New York: Guttmacher Institute. http://www.guttmacher.org/­statecenter/ spibs/spib_SMFPE.pdf (accessed December 2, 2008).

392 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM 19. RTI International (Research Triangle Institute International). 2008. Family planning an- nual report: 2006 national summary. Research Triangle Park, NC: RTI International. 20. Gold, R. B. 2006. Rekindling efforts to prevent unplanned pregnancy: A matter of ­ equity and common sense.” New York: Guttmacher Institute. http://www.­guttmacher. “ org/pubs/gpr/09/3/gpr090302.html (accessed October 23, 2008). 21. Gold, R. B. 2007. Stronger together: Medicaid, Title X brings different strengths to family planning effort. Guttmacher Policy Review 10(2):13–18. 22. Sonfield, A., C. Alrich, and R. B. Gold. 2008. State government innovation in the ­design and implementation of Medicaid family planning expansions. New York: ­ Guttmacher Institute. http://www.guttmacher.org/pubs/2008/03/28/StateMFPEpractices.pdf (accessed October 23, 2008). 23. BPHC. 2008. Section 330 of the Public Health Service Act (42 USCS § 254b). http:// bphc.hrsa.gov/about/legislation/section330.htm (accessed October 23, 2008). 24. BPHC. 2008. Health centers: America’s primary care safety net. Reflections on success, 2002–2007. Section 330 of the Public Health Service Act. ftp://ftp.hrsa.gov/bphc/HRSA_ HealthCenterProgramReport.pdf (accessed May 29, 2009). 25. Gold, R. B., and A. Sonfield. 1999. Block grants are key sources of support for ­family ­ lanning. Washington, DC: Guttmacher Institute. http://www.guttmacher.org/pubs/ p tgr/02/4/gr020406.html (accessed October 23, 2008). 26. Deficit Reduction Act of 2005 (P.L. 109-171). 2005. http://frwebgate.access.gpo.gov/ cgi-bin/getdoc.cgi?dbname=109_cong_public_laws&docid=f:publ171.109. 27. New Mexico State Department of Human Services. 2008. Family planning waiver. https://nmmedicaid.acs-inc.com/nm/pages/static/PowerPoints/TrainingPresentations/­ FamilyPlanningWaiver.ppt#266,1,familyplanningwaiver (accessed December 2, 2008). 28. Institute for Reproductive Health Access, National Health Law Program, National ­Latina Institute for Reproductive Health, and Ibis Reproductive Health. 2005. Emergency con- traception and Medicaid: A state-by-state analysis and advocate’s toolkit. http://www. prochoiceny.org/assets/files/ecmedicaidpdf.pdf (accessed May 29, 2009). 29. Rosenbaum, S., P. W. Shin, A. Mauskopf, and A. Zuvekas. 1997. Medicaid managed care and the family planning free-choice exemption: Beyond the freedom to choose. Journal of Health Politics, Policy and Law 22(5):1191–1214. 30. Landon, B., E. C. Schneider, C. Tobias, and A. M. Epstein. 2004. The evolution of quality management in Medicaid managed care. Health Affairs 23(4):245–254. 31. Omnibus Budget Reconciliation Act of 1986, P.L. 99-509. Section 9508. 32. Iowa Department of Public Health. 2008. Highlight of best practices: medical home. http://www.idph.state.ia.us/hcr_committees/common/pdf/medical_home/best_practices_ m ­ edical_home_presentation.pdf (accessed May 29, 2009). 33. South Carolina Medicaid Managed Care Program. 2007. Medical homes network: ­ olicies and procedures guide. http://www.dhhs.state.sc.us/dhhsnew/insidedhhs/Bureaus/­ p BureauofHealthServicesandDeliverySystems/documents/MHNPP2007.pdf (accessed May 29, 2009). 34. Sonfield, A. 2009 (unpublished). Memo: Title X funding chart. New York: AGI.

APPENDIX J 393 J-44 A Review of the HHS Family Planning Program J-44 A Review of the HHS Family Planning Program ANNEX J-1 ANNEX J-1 GRANTEE SITE VISIT TOOL GRANTEE SITE VISIT TOOL AGENCY SITE REVIEW RESULTS & ACTION PLAN AGENCY SITE REVIEW RESULTS & ACTION PLAN Agency ______ Clinic Site ______ Agency ______ Clinic Site ______ Site Contact ________________________ Date of Visit __________________ Site Contact ________________________ Date of Visit __________________ Reviewer(s) _______________________________________________________ Reviewer(s) _______________________________________________________ Summary Report of (Check One): Delegate Agency Site Review ___ Satellite Site Review ___ Self- Review___ Summary Report Reviewed (Check allDelegate Agency Planning ___ Circle of Care ___ HWP ___ HRC ___ Programs of (Check One): that apply): Family Site Review ___ Satellite Site Review ___ Self- Review___ Programs Reviewed (Check all that apply): Family Planning ___ Circle of Care ___ HWP ___ HRC ___ Observation Areas of Commendation: Observation Areas of Commendation: Areas of Non- Observation Action Plan Reevaluation Timeline Compliance: Areas of Non- Observation Action Plan Reevaluation Timeline Compliance: Observation Response Auditor Recommendations: Observation Response Auditor Recommendations:

394 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Organization, Funding, and Management of the Title X Program J-45 Client Survey Patient Name (Optional): _______________________ Clinic Name: _______________________ Date: _________ Client feedback is one way for clinics to make changes to improve the quality of care for the services they provide. Please fill out this survey and make comments if needed. Your responses are anonymous and will be treated in confidence. For the following questions please √ your response Strongly Disagree Neutral Agree Strongly in the box that best fits your opinion. Disagree Agree The staff is friendly. The staff treats you with respect. The staff has a professional appearance. The staff wears nametags. The staff knows what they are talking about. The staff does not judge you. You are able to get the services you want. You got all the information needed. The staff explains things in a way you can understand. You know what to expect during a visit or exam. The staff takes time to listen to you. The staff pays attention to what is important to you. The staff explains what happens during a physical exam or test. The clinic is clean. There are good magazines and reading material. The clinic has convenient hours. The clinic lets you walk in for emergencies. It’s easy to make an appointment at the clinic. It’s easy to communicate with staff people on the phone. You don’t have to wait too long in the waiting room. You don’t have to wait too long in the exam room. The staff respects your privacy. The paperwork is explained to you. You would return to this clinic. You would recommend this clinic to your family/friends. You know when you are supposed to return to the clinic for another visit. The fees at this clinic are affordable. Comments: _____________________________________________________________________________________

APPENDIX J 395 J-46 A Review of the HHS Family Planning Program Clinical Environment & Systems Auditor Name: _________________________ Clinic Name: ______________________ Client #_________ STAFFIN G Y N N/A Comments Does Medical Director hold valid PA license to practice medicine? {ERR} Are there collaborative practice agreements in place between medical director and CRNPs? {ERR} Is there a documented system in place to ensure clinicians are credentialed for Colposcopy? {PR} Are clinicians being evaluated clinically on an annual basis? {PERR} Employee records kept confidential? {DO} Are the Rubella and Hepatitis B Vaccinations provided for all clinical staff? {ERR} Do personal records contain at a minimum: {ERR} Comments [] Job description [] Valid license and / or certification (if applicable)? [] Current annual performance evaluation signed by employee [] Resume or application [] Documentation that personnel policies/procedures were received? [] Training/continuing education information? [] Wage and salary information, including all changes? [] Evidence of personnel actions (e.g., promotion, disciplinary action, termination)? [] Routinely trained regarding HIPPA compliance? [] Staff trained in CPR Is there documentation in employee records ensuring staff are aware of meet Title X regulations Comments regarding client participation. {ERR} [] Voluntary basis [] Not subjected to coercion to use any specific method [] Acceptance of service not a prerequisite to get non Title X funded services [] Personnel subject to prosecution if they coerce client to have abortion or be sterilized Key: {ERR}= Employee Record Review, {PR} = Policy Review, {RR} = Record Review, {DO} = Direct Observation, {PERR} = Policy & Employee Record Review Additional Comments: ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________

396 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Organization, Funding, and Management of the Title X Program J-47 POLICIES & PROCEDURES Y N N/A Comments Is there a Family Planning Council Polices & Procedure (P&P) Manual on site? {DO} Is there evidence that the Medical Director has Signed off on P&P Manual updates? {RR} Is there a mechanism in place to ensure P&P updates are regularly reviewed with staff? {I} Is there a written policy regarding referrals? {RR} Physician on site or protocol in place if IM antibiotics given? {RR} SERVICE ACCESS Y N N/A Comments Is there Signage posted regarding the clinic’s days/hours of operation? {DO} Is a “Patient’s Bill of Rights” posted? {DO} Does the agency have a system in place for collecting client feedback? {I} Is there Signage posted stating a client’s inability to pay does not effect their receipt of service ? {DO} Does the agency have access to staff/services for various client language needs? {I} Are the next available appointments for the following services in compliance with FPC guidelines? {DO} Comments [] Family planning (14 calendar days) [] Emergency contraception (3 calendar days) [] Pregnancy testing (7 calendar days) How are client walk-ins handled? {I} What mechanism is in place to contact clients that missed appointment? {I} Is the clinic accessible to handicapped clients? {DO} Key: {ERR}= Employee Record Review, {PR} = Policy Review, {RR} = Record Review, {DO} = Direct Observation, {PERR} = Policy & Employee Record Review, {I} = Interview Additional Comments: ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________

APPENDIX J 397 J-48 A Review of the HHS Family Planning Program LABORATORY FOLLOW-UP Y N N/A Comments Other than the client chart, where are laboratory test results noted (log, computer, other)? {I} What is the process if no laboratory test results are received by the clinic from the laboratory? {I} Is a system in place to track clients with abnormal lab test results? {DO} [] How does this compare to the FPC Policy? [] Are client charts flagged for abnormal results in any way? Are clients with abnormal test results receiving at least 3 attempts at making lab follow-up contact (as per FPC Policy)? {DO} Is agency identifying and properly managing clients who request “NO CONTACT” or “CONFIDENTIAL CONTACT”? {I} CONSULTATION FOLLOW-UP Y N N/A Comments Does agency have the ability to both identify the Need for and refer clients for: Comments [] Prenatal care [] Abortion [] Adoption [] Mental health [] Anonymous HIV testing [] High blood pressure [] Domestic violence [] Substance abuse [] Smoking cessation [] Genetic counseling [] Sex coercion What is the process if consultation reports are not received? {I} Is a release of medical records routinely obtained? {I} GERNERAL FOLLOW-UP Comments Is there a system to track clients who need: {I} [] Deferred exams F/U for no-shows [] Depo Shot [] IUD removal after 12 years (Mirena = 5 years) Key: {ERR}= Employee Record Review, {PR} = Policy Review, {RR} = Record Review, {DO} = Direct Observation, {PERR} = Policy & Employee Record Review, {I} = Interview

398 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Organization, Funding, and Management of the Title X Program J-49 Additional Comments: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ TELEPHONE TRIAGE Y N N/A Comments Are telephone contacts documented in the chart?{I} How are incoming phone calls triaged? {I} After clinic hours? {I} CLIENT FORMS Comments Education Materials/Handouts {DO} [] All method information [] Anatomy and Physiology [] STD/HIV [] BSE/TSE FPC Educational Formulary available onsite or by computer access {DO} Educational materials are reviewed/updated annually {I} Required consents {DO} [] PVA/General Consent Comments [] HIPAA [] Method Specific [] HIV Testing Literature is in the client’s primary language {DO} EQUIPMENT / SUPPLIES Comments Exam Room {DO} [] Drapes and gowns [] Light source [] Exam table [] Waste receptacle contaminated [] Waste receptacle non-contaminated [] Gloves/Lubricant [] Specula [] IUD equipment [] Diaphragm fitting rings Key: {ERR}= Employee Record Review, {PR} = Policy Review, {RR} = Record Review, {DO} = Direct Observation, {PERR} = Policy & Employee Record Review, {I} Interview Additional Comments: ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________

APPENDIX J 399 J-50 A Review of the HHS Family Planning Program EQUIPMENT / SUPPLIES Y N N/A Comments Contraceptive Supplies {DO} [] Birth control pills Comments [] IUDs [] Emergency post coital pills [] Diaphragms [] Foams, VC Film, creams, jellies, sponges, etc. [] Condoms (male and female) [] NFP Materials [] Patch []Ring Do repackaged Pharmaceuticals have a standard label which includes: {DO} Comments [] Name of drug [] quantity of drug [] strength of drug, [] expiration date, [] name and address of agency [] manufacturer’s drug lot number Drug is repackaged with: {DO} [] Date of RX, Comments [] name of patient [] directions for use [] name of prescriber Drug Logs {DO} Controlled substances monitored {DO} Supply/Drug area secured {DO} Prescription blanks are stored in locked area. {DO} An up-to-date PDR is easily accessible. {DO} Pharmaceutical Recall Protocol. {I} Miscellaneous Supplies {DO} Comments (Accounted for and calibrated) [] Scale [] Centrifuge [] Refrigerator [] Autoclave [] Incubator [] Microscope [] BP Cuffs Key: {ERR}= Employee Record Review, {PR} = Policy Review, {RR} = Record Review, {DO} = Direct Observation, {PERR} = Policy & Employee Record Review, {I} = Interview Additional Comments: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________

400 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Organization, Funding, and Management of the Title X Program J-51 LABORTORY Y N N/A Comments Dept of Health & Clinical Laboratory Improvement Amendants (CLIA)? {DO} CLIA certificate should be displayed at every Site (even though only the primary location is listed on certificate) Original Commonwealth of PA Clinical Lab Permit onsite (Each site should have their own) {DO} Needles/sharps disposal {DO} Lab cleaning and decontamination supplies {DO} Incubator temperature log {DO} Pregnancy testing equipment control and long (Weekly controls unless part of the rest) {DO} Urinalysis control and log (Weekly controls) {DO} Hemoglobin control and log (Daily controls) {DO} Refrigerator temperature log {DO} Spill clean-up policy {RR} Staff routinely trained regarding OSHA compliance? {DO} Does agency have: {RR} Comments [] Written policy for occupational exposure? [] Is it reviewed w/staff annually? [] Accessible to employees? Food and drink in separate areas from blood and infectious materials? {DO} Staff protection {DO} Comments [] Lab coats or protective clothing [] Masks [] Sink/bactericidal soap for hand washing EMERGENCY EQUIPMENT Y N N/A Comments Written Emergency plans {RR} Infection control policy including guidelines for Needle stick injuries {RR} Ambulance/hospital back-up system {I} Emergency equipment/drug (present, up to date, adequate, available {DO} [] Ammonia inhalants Comments [] IV Fluid/Pole [] Oral airway [] Tourniquet [] Syringes & Needled [] Epinephrine/Benadryl [] Mouthpiece or ambu bag [] BP Cuff [] Stethoscope [] Fire Extinguishers Periodic emergency drills documented {RR} Key: {ERR}= Employee Record Review, {PR} = Policy Review, {RR} = Record Review, {DO} = Direct Observation, {PERR} = Policy & Employee Record Review, {I} = Interview

APPENDIX J 401 J-52 A Review of the HHS Family Planning Program Counseling & Physical Exam Audit Auditor Name: _______________________Clinic Name: ____________________ Client # __________ COUN SELI NG For each question √ all boxes that apply. Yes No N/A Comments Give comments if needed. Did staff introduce themselves to client and call the client by name? {DO} Did staff attempt to assess client’s level of understanding regarding information presented? {DO} Comments: Was client centered information provided to the client either verbally or in writing? {DO} [] BSE or TSE [] Reproductive anatomy and physiology [] Preconception health/pregnancy planning [] Cervical screening info as per national guidelines [] Pelvic Exam/pap test [] Drugs/Smoking/Alcohol [] Abstinence [] BCMs [] ECPs [] Safer sex [] HIV/STDs [] Intimate partner violence Comments: If client has substance abuse problem, and substance is injected, was safer injection/needle exchange discussed? {COC/HIVQUAL} {DO} Comments: Were teen issues covered as appropriate? {DO} [] Explained PE procedures [] Sex development [] Parental /family involvement [] Sexual coercion [] Info on Pap screening according to national guidelines For method of choice, were the following things Comments: reviewed? {DO} [] Method specific consent [] Usage & back up plans [] Side effects & contingency planning [] Danger signs [] Follow up schedule[] Use of method and STD/HIV prevention [] Emergency contraception

402 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Organization, Funding, and Management of the Title X Program J-53 Were services offered and provided in the client’s preferred language? {DO} Did client complete an informed consent form? {DO} Was an attempt made to assess the client’s understanding of information presented? {DO} Was the client’s next routine appointment given? {DO} Did a licensed practitioner do a mental health assessment during the 12 – month period? {COC/HIVQUAL} {DO} Was medication adherence discussed with client? {COC/HIVQUAL} {DO} Was client based STD/HIV risk assessment & counseling done within past 12 – months? {COC/HIVQUAL} {DO} KEY: {DO} = Direct Observation, {COC/HIVQUAL} = Circle of Care Additional Comments: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ LABORATORY For each question √ all boxes that apply. Yes No NA Comments Give comments if needed. Was a lab coat worn? {DO} Was client weight assessed? {DO} Was client’s height assessed? {DO} (1st visit and method visit) Was client’s BMI assessed? {DO} Was client’s blood pressure assessed? {DO} Did staff wear gloves when working with client body fluids (blood, urine)? {DO} PHYSICAL EXAMINATION For each question √ all boxes that apply. Yes No NA Comments Give comments if needed. Did the clinician review the chart prior to seeing the client? {DO} Was the client’s {DO} Comments: [] Thyroid assessed? [] Heart/Lungs assessed? [] Extremities assessed?

APPENDIX J 403 J-54 A Review of the HHS Family Planning Program Did the client receive a breast examination? {DO} (if appropriate) Was the client’s abdomen palpated? {DO} (if appropriate) Did the client receive (if appropriate) {DO} Comments: [] A pelvic exam [] A cervical cytology [] A bimanual exam [] Cultures and/or wet mount [] Viral load count [] Mammogram [] LEEP/ Colposcopy [] Breast U/s FOLLOW-UP / DOCUMENTATION For each question √ all boxes that apply. Yes No NA Comments Give comments if needed. Following the exam were: {DO} Comments: [] Findings shared and explained? [] Instructions for treatment and/or follow-up given? [] Instructions for action to be taken in the event of a method or treatment problem? [] Processes of notification for normal and abnormal labs reviewed? Did patient have the opportunity to have his/her questions addressed? {DO} Does the medical record correlate with the observation? {DO&CR} KEY: {DO} = Direct Observation, {CR} = Client Record

404 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Organization, Funding, and Management of the Title X Program J-55 Medical Chart Review Auditor Name: _____________________Clinic Name: _____________________ Client # ___________ CHART FORMAT Y N N/A Comments Is the medical record legible? {RR} Is the medical record orderly and is information easily accessible? {RR} Are all visits/contacts noted dates and staff signatures? {RR} CONSENT FORMS Y N N/A Comments Is a signed consent for exam and laboratory procedures present? {RR} Is a signed consent for the HWP present? {RR} Is a signed method specific consent for birth control present? {RR} Is a signed consent for HIV testing present? {RR} Is a signed HIPPA consent present? {RR} Is the medical/family history updated annually? {RR} CONTACT INFOR MATI ON Y N N/A Comments Is the client’s contact information obtained & reviewed annually? {RR} Is there a documented method for confidential contact? {RR} Is the emergency contact information documented and updated annually? {RR} FEE A SSE SSME NT Y N N/A Comments Is the client’s financial information kept in a separate portion of the medical record? {RR} Is the client’s income information documented and updated at each visit? HWP- Annually {RR} Key: {RR} = Record Review, {HWP} = Healthy Women Program Additional Comments: __________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ _________________________________________________________________________________________

J-56 APPENDIX J 405 A Review of the HHS Family Planning Program ANNEX J-2 GRANTEE CLINICAL VISIT RECORD

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A Review of the HHS Family Planning Program provides a broad evaluation of the Title X family planning program since its establishment in 1970. The program successfully provides family planning services to its target audience of low-income individuals, but there is room for improvement. While the program's core goals are apparent, a secondary set of changing priorities has emerged without a clear, evidence-based strategic process. Also, funding for the program has increased in actual dollars, but has not kept pace with inflation or increased costs. Several aspects of the program's structure could be improved to increase the ability of Title X to meet the needs of its target population. At the same time, the extent to which the program meets those needs cannot be assessed without a greater capacity for long-term data collection.

A Review of the HHS Family Planning Program recommends several specific steps to enhance the management and improve the quality of the program, as well as to demonstrate its direct contribution to important end results, such as reducing rates of unintended pregnancy, cervical cancer, and infertility. The book will guide the Office of Family Planning toward improving the effectiveness of the program. Other parties who will find the research and recommendations valuable include programs receiving Title X funding from the Office of Family Planning, policy makers, researchers, and professional organizations.

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