A Review of the HHS Family Planning Program Mission, Management, and Measurement of Results (2009) / Chapter Skim
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Appendix J: Organization, Funding, and Management of the Title X Program
Appendix J: Organization, Funding, and Management of the Title X Program
Pages 343-406
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From page 343... ...
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)
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From page 344... ...
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.
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From page 345... ...
• 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)
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From page 346... ...
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.
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From page 347... ...
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.
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From page 348... ...
Program Management and Oversight Several tools facilitate the program's day-to-day management, regular monitoring, and ongoing improvement. These tools include the development of Central Office and Regional Office work plans, Comprehensive Program Reviews and annual site visits, the Family Planning Annual Report (FPAR)
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From page 349... ...
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
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From page 350... ...
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.
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From page 351... ...
.7 The administrative, clinical, and community outreach aspects of the Title X program are evaluated for compliance with the OFP Program Guidelines for Project Grants for Family Planning Services.3 For any areas in which the grantee is found to be noncompliant, a corrective action plan is prescribed that outlines the steps required of the grantee to achieve compliance.1 Some issues identified may be addressed through technical assistance and training at the Regional Training Center (RTC)
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From page 352... ...
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)
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From page 353... ...
Grantees may conduct chart reviews to ensure that patients receive appropriate education and counseling about family planning, contraception, infertility, pregnancy, and sexually transmitted diseases (STDs) , as indicated.
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From page 354... ...
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 submissions 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)
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From page 355... ...
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.
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From page 356... ...
More recently, OPA funded development of a National Family Planning Clinical Training Center (NFPCTC) that will streamline training activities across the Title X program.
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From page 357... ...
Specifically, training centers need to develop a basic, comprehensive, nationwide orientation program for providers and other clinic staff about family planning (cultural competency, counseling patients effec
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From page 358... ...
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.
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From page 359... ...
. Historically, the Title X program provided the highest proportion of funding for family planning services, followed by
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From page 360... ...
This section describes the Title X funding process, highlighting some of the differences 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, funding 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.
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From page 361... ...
2008 Consolidated Appropriations 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.
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From page 362... ...
, 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.
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From page 363... ...
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.
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From page 364... ...
. 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.
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From page 365... ...
, 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)
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From page 366... ...
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 distribute funds to delegates/clinics.
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From page 367... ...
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.
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From page 368... ...
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.
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From page 369... ...
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.
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From page 370... ...
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, legislative provisions allotted 50 percent of funds for use in STD programs and 50 percent for use in family planning programs.
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From page 371... ...
Because of the significant 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.
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From page 372... ...
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)
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From page 373... ...
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 different 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.
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From page 374... ...
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.
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From page 375... ...
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 significant cost savings to both the federal and state governments.20 Moreover, this study estimated that if the waiver program were implemented nationally, federal and state savings of $1.5 billion would be realized annually by the third year.
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From page 376... ...
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.
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From page 377... ...
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)
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From page 378... ...
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
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From page 379... ...
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.
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From page 380... ...
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 insurance of any kind are disqualified from participation in the Medicaid Waiver program, even if that insurance exempts coverage of family planning services.22 For those that do qualify for the waiver program, all clinical visits must be focused on contraception or infertility services.
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From page 381... ...
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 organizations.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 primary care, such networks limit beneficiary choice and access to communitybased 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.
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From page 382... ...
If additional Title X dollars were available, grantees indicated an interest in using the funds to develop educational materials for clinics, provide continuing education in family planning and reproductive health to clinicians, 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 planning and reproductive health.
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From page 383... ...
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.
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From page 384... ...
Provider Recruitment and Retention Currently, there is a shortage of nursing personnel for family planning programs. Physicians provide medical oversight, but midlevel practitioners
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From page 385... ...
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.
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From page 386... ...
Program Administration Copays and Sliding Fee Scale The chief point of dissonance between Title X and other family planning 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 services in California.
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From page 387... ...
, 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)
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From page 388... ...
noted a 30 percent decrease in utilization of the family planning clinic with implementation of the Medicaid Waiver program (and associated documentation requirements)
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Recommendations The RPCs and grantees interviewed for this study offered two recommendations for improving coordination among family planning programs.
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contracep tive use. To facilitate higher-quality care, CHCs and the Medicaid Waiver program should adopt the Title X approach to comprehensive family planning.
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2007. Title X: The National Family Planning Program.
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1997. Medicaid managed care and the family planning free-choice exemption: Beyond the freedom to choose.
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From page 393... ...
: 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:
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From page 394... ...
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.
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From page 395... ...
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: ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________
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From page 396... ...
{DO} Comments [] Family planning (14 calendar days)
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From page 397... ...
Key: {ERR}= Employee Record Review, {PR} = Policy Review, {RR} = Record Review, {DO} = Direct Observation, {PERR} = Policy & Employee Record Review, {I} = Interview
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From page 398... ...
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: ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________
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From page 399... ...
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: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________
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From page 400... ...
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
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From page 401... ...
Pelvic Exam/pap test [] Drugs/Smoking/Alcohol []
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{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.
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{DO&CR} KEY: {DO} = Direct Observation, {CR} = Client Record
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HWP- Annually {RR} Key: {RR} = Record Review, {HWP} = Healthy Women Program Additional Comments: __________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ _________________________________________________________________________________________
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J-56 APPENDIX J 405 A Review of the HHS Family Planning Program ANNEX J-2 GRANTEE CLINICAL VISIT RECORD
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