The Health Center Program: H1N1 Information for Health Center Program Grantees

NOVEL H1N1 FREQUENTLY ASKED QUESTIONS

The Health Resources and Services Administration (HRSA) funds health centers throughout the United States that deliver comprehensive, high-quality primary and preventive health care to patients regardless of their ability to pay.  Health centers are an essential primary care provider for America’s most vulnerable populations:  the poor, uninsured, and homeless; minorities; migrant and seasonal farm workers; public housing residents; and people with limited English proficiency (LEP).  For over 17 million people across the country today, health centers serve as a primary care “health home,” providing comprehensive primary and preventive care and coordinating a wide range of medical, dental, behavioral, and social services.  Health centers ensure the availability and accessibility of essential primary and preventive health services as well as supportive and enabling services that promote access and quality of care—such as translation, case management, outreach, nutrition, and transportation.  These services are even more critical during emergencies.

Health centers are private non-profit or public entities that operate under individually approved scopes of project and vary significantly in size and capacity from one another.  Although Health Center Program grantees are not considered assets of the Federal government, they are a vital component of the Nation’s health care safety net and, as such, are well positioned to play an important role in delivering critical services and assisting their local communities during an emergency.  Therefore, HRSA encourages Health Center Program grantees to be proactive in their emergency preparedness planning and to coordinate with existing partners at the State and local level in the development of State and local preparedness and response plans.  As health centers work within their communities to identify contributions they can make to community preparedness, they must also take into consideration the need to maintain their ongoing capacity to deliver access to quality primary health care service to their patients.

PLANNING AND COUNTERMEASURES

1. What does HRSA require of health centers in the area of emergency preparedness?
   
   HRSA’s Bureau of Primary Health Care (BPHC) has issued emergency management expectations and guidance to health centers related to planning and preparing for emergencies through two policy documents:  Policy Information Notice (PIN) 2007-15¹and PIN 2007-16.²  As health centers engage in planning within their local communities, each health center should consider its medical care capabilities and community needs and infrastructure prior to an emergency to delineate and strengthen its response to a wide range of disasters.   
   
   
2. What are HRSA’s expectations of health centers around developing plans and procedures for emergency management?
   
   Health centers must have risk management policies and procedures that proactively and continually identify and plan for potential and actual risks to the health center in terms of its facilities, staff, and patients, as well as its financial, clinical, and organizational well-being (refer to PIN 2007-15).  Plans and procedures for emergency management must be integrated into a health center’s risk management approach to assure that suitable guidelines are established and followed so that it can respond effectively and appropriately to an emergency. 
   
   
3. What specific health center expectations would be most critical during the novel H1N1 flu outbreak?
   
   Health centers are expected to plan for the provision of ongoing, continuing preventive and primary care to their patients.  By maintaining the ability to treat their patients, health centers can help alleviate some of the congestion of patients seeking treatment elsewhere, such as local hospital emergency departments.  In many instances, health centers also coordinate with hospitals and State and local health departments as part of emergency management planning, preparedness, mitigation, and response.
   
   
4. How does the Public Readiness and Emergency Preparedness Act (“PREP Act”) affect deemed health centers?
   
   Where it applies, the Public Readiness and Emergency Preparedness Act (PREP Act)  applies to the exclusion of the Federal Tort Claims Act (FTCA) FTCA in the case of deemed health centers, regarding the administration and use of certain H1N1 countermeasures, as specified in declarations issued by the Secretary.
   
   The PREP Act authorizes the Secretary of the Department of Health and Human Services to issue a declaration (PREP Act declaration) that provides immunity from tort liability (except for willful misconduct) for claims of loss caused, arising out of, relating to, or resulting from administration or use of certain countermeasures to diseases, health conditions, or threats to health caused by pandemics, epidemics, or chemical, biological, radiological, or nuclear agents.  PREP Act protections apply to “qualified persons” (including healthcare and other providers), “program planners” (individuals and entities involved in planning and administering programs for distribution of a countermeasure), manufacturers, and distributors, the United States, and their officials, agents and employees.  The PREP Act’s immunity protections only apply to “qualified persons” and to “program planners” if the countermeasure was administered or used by a person in a population described in a PREP Act declaration and in a geographic area described in a PREP Act declaration (or if the healthcare provider or other covered person could have reasonably believed that these requirements were met).  The Secretary issued PREP Act declarations for H1N1 antiviral countermeasures and for H1N1 vaccine on April 26 and June 15, 2009, respectively.³  These declarations are applicable to any population that receives the countermeasures in accordance with their terms.  Additional information about the PREP Act may be found at http://www.hhs.gov/disasters/emergency/manmadedisasters/bioterorism/medication-vaccine-qa.html. 
   
   The PREP Act also authorizes a fund to provide compensation to eligible individuals who suffer specified injuries from administration or use of a countermeasure pursuant to the declaration.  Any requests for compensation must be filed within one year of administration or use of the countermeasure to the HRSA Preparedness Countermeasures Injury Compensation Program by contacting CICP@HRSA.gov or 1-888-275-4772.  Health center patients who inquire about filing claims for H1N1 countermeasure-related injuries may be directed to the following website, http://www.hrsa.gov/countermeasurescomp/, for additional information. 
   
   
5. Other than the protections afforded by the PREP Act, what considerations might apply regarding potential FTCA issues?
   
   Again, the PREP Act is the exclusive Federal remedy for certain H1N1 countermeasure-related injuries.  For other benefits based upon deemed Public Health Service employee status (e.g., FTCA coverage and Department of Justice legal representation), to the limited extent that these may be applicable in an H1N1 context, these will only be available for health center services provided within the approved scope of project.  See further guidance in PIN 2007-16 and HRSA policy guidance of May 1, 2009, by which HRSA/BPHC communicated that the novel H1N1 influenza outbreak qualifies as an “emergency” for purposes of using the emergency change in scope request process outlined in PIN 2007-16.
   
   In addition, BPHC has determined that the provision of certain H1N1-related health services to individuals who are not patients of the deemed health center, and in accordance with the provisions of PIN 2007-16, benefits patients of these entities and general populations that could be served by these entities through community-wide intervention efforts within the communities, and therefore are subject to and covered by FTCA as described in the general determination for H1N1 activities available at http://bphc.hrsa.gov/h1n1.
   
   
6. Can health centers establish abbreviated policies and procedures around medical records for emergency situations?
   
   Every Health Center Program grantee is required to establish and follow policies and procedures consistent with its Quality Improvement/Quality Assurance program for ensuring the provision of high quality patient care and appropriate utilization of services.  For example, in a declared emergency, an abbreviated health record could identify the patient, record the medical evaluation (including any testing, diagnosis, or clinical impressions) and the treatment provided or prescribed.  Consideration should be given to assuring that policies and procedures address emergency and non-emergency situations.
   
   
7. Will Health Center Program grantees receive grant funds from HRSA for additional outreach, extended hours, and/or additional translation services for those at risk?
   
   HRSA has not been allocated funding for grantees specifically for H1N1 preparedness at this time.  The Federal Government, however, has provided more than $1.0 billion in funds particularly for the current H1N1 pandemic to States, territories, and certain large metropolitan areas through HHS Hospital Preparedness Program grants and Center for Disease Control and Prevention’s (CDC) Public Health Preparedness Program grants.  Limited funding traditionally flows through the States to HRSA grantees via similar funding programs.  More information on this funding can be found in the “H1N1 Guidance to HRSA Grantees” at http://www.hrsa.gov/h1n1/.  HRSA encourages its grantees to work closely with their States, territories, and cities to determine the availability of any H1N1 preparedness funding from these sources. 
   
   
8. How will health centers be reimbursed for administering vaccines to patients in their communities?
   
   Further details regarding the provision of H1N1 vaccine will be forthcoming.  Health centers are encouraged to avail themselves of all possible funding sources, both public and private, that would assist them in covering the costs associated with vaccine administration.  Medicare reimbursement policy is set forth in the following policyhttp://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0920.pdf.

COLLABORATIONS—WORKING WITH OTHERS

9. How can health centers prepare for a possible surge in patient load? 
   
   Health centers are encouraged to coordinate with local and regional health care providers to identify and define appropriate roles and responsibilities in the event of an emergency.  During a novel H1N1 influenza surge, health centers can work with hospitals and other health care providers, for example, by providing their mobile health assets for triage and treatment of influenza-like illnesses (ILI).  For health centers that have the ability to engage in surge capacity, the considerations for clinical patient surge preparedness include the following: expanded hours, temporary locations, and/or medical mobile units or vans; steps for securing additional clinical personnel; and identifying sources for supplemental medical supplies, vaccines, and pharmaceuticals.  For health centers to ensure continued FTCA coverage and Department of Justice representation, to the limited extent applicable in the H1N1 context, they must comply with established processes for maintaining such coverage (see PIN 2007-16).
   
   
10. How can health centers participate in addressing the influx of patients that may be seeking care during a wide-spread outbreak of novel H1N1 virus within their communities?
    
    Many health centers have defined their role within their local community prior to an emergency and have already engaged with community leaders, identified key organizations, and developed ongoing relationships.  Well in advance of an emergency, health centers should establish relationships with local hospitals and other large community healthcare providers regarding the possible roles that health centers might perform in connection with emergency situations.
    
    
11. How can Primary Care Associations (PCAs) and Primary Care Offices (PCOs) assist in ensuring that States integrate health centers in novel H1N1 influenza preparedness planning and in supporting health centers during a novel H1N1 pandemic?
    
    Many health centers have illustrated how, in times of crisis, they are at the frontline providing services to a population of people who otherwise would not receive them.  They have done so through collaborative partners such as Primary Care Associations (PCAs), Primary Care Offices (PCOs), National Cooperative Agreements (NCAs), organizations like public health departments and social service agencies, and through communications work involving in-language community newspaper and radio outlets.
    
    PCAs can: facilitate the sharing of important information to health centers through electronic alerts; conduct outreach to increase awareness and participation in various regional/State pandemic planning and response activities; and learn from the health centers what issues they are facing and what assistance is needed.  PCAs have established mechanisms to engage with health centers in collecting critical information.  Further, PCAs can work to ensure that health centers are included in novel H1N1 influenza response plans by tapping into regional/State pandemic planning and response activities.
    
    HRSA expects PCAs to coordinate with PCOs and to routinely report, in their annual funding applications, the status of their efforts regarding emergency preparedness planning and development of emergency management plans, including participation or attempts to participate with State and local emergency planners.  Many PCAs play active roles in the State as coordinators, managers and disseminators of real-time information during emergencies.  For example, six PCAs received funding from HRSA to establish emergency communication networks within their States in FY 2006 based on the catastrophic effects of 2005 hurricane activity (i.e., Alabama, Florida, Louisiana, Mississippi, North Carolina, and Texas).  

COMMUNICATION STRATEGIES

12. How can health centers contribute to community awareness and education to lessen the severity and impact of a novel H1N1 virus outbreak?
    
    As part of their ongoing health education services, health centers can and should inform and raise awareness among their patients and the community about novel H1N1 preventive measures; how to recognize symptoms of the novel H1N1 virus infection; and what to do if and when they or a member of their family gets sick.  Health centers should provide information in a culturally appropriate means to accommodate people with limited English proficiency.  School-based health centers should participate with school administration in educating students and parents about the novel H1N1 influenza virus and appropriate preventive and treatment measures.
    
    
13. How can health centers specifically address the needs of high risk groups such as pediatric patients?
    
    Health centers are required to provide childhood immunization services.  In addition, each health center is expected to measure its performance in this area, to set goals for performance improvement, and to report on its progress.  Novel H1N1 vaccine immunizations could be incorporated into the health center’s ongoing immunization activities.  Additional information, including a short message that may be helpful in communicating to patient’s families, is available at http://www.cdc.gov/h1n1flu/childrentreatment.htm. 

SPECIAL POPULATIONS

14. How can health centers address the unique issues of special populations, such as migrant and homeless populations, relative to novel H1N1 influenza?
    
    Health centers are uniquely positioned to provide the benefits of community-based and patient centered care for at risk, vulnerable populations—including migrant and seasonal agricultural workers (MSAWs), pediatric patients, and homeless, elderly, and disabled individuals.  Health centers may employ and intensify existing outreach services to ensure that the needs of these target populations are being addressed as appropriate; for example, planning how the homeless will be vaccinated and where the homeless will be sheltered if they exhibit symptoms of ILI.  Mobile vans and temporary locations could be established for education, immunization, and treatment services.  Health Center Program grantees that serve these homeless and migrant populations routinely deliver services in areas where these patients live and/or work.
    
    Through their emergency preparedness plans, most health centers should:

• Identify the location of special population groups within the communities they serve;
• Ensure accurate communication of information in languages other than English by the use of trained bi/multi-lingual and bi/multi-cultural staff, translations of educational materials and documents, sign language, and language interpretation services;
• Be knowledgeable about the formal and informal community institutions that help to meet the diverse needs of the community;
• Assess their ability to interface and address the emergency medical response needs of the special populations, including collaborating with local and State emergency management officials and the health care delivery network;
• Establish procedures and mechanisms to meet the identified medical response needs of the special population groups, including developing transportation and/or mobile medical units, providing interpreters and materials in other languages, identifying other cultural issues, training staff in cultural competency, and working collaboratively with other health and social services organizations to meet the larger needs of special populations in the event of a disaster; and
• Involve representatives from the representative populations in the planning and training activities.

15. Where can homeless individuals be treated if they contract the virus?
    
    Prescribed bed rest and isolation are concerns for homeless individuals.  Many shelters do not allow bed rest during the day, have no separate facilities or space for isolating contagious persons, and space their beds closely together to address the demand.  Many shelters also lack the staff capacity for effective medical screening.  Medical Respite Care facilities are available in some communities, but they typically operate at capacity even without a pandemic.
    
    The same difficulties exist for homeless children, with additional complications.  If likely flu cases are identified at school, parents may not be located to pick them up.  When parents do arrive, they may have nowhere to go until a shelter opens, or must continue living in a car or other location that may not provide a good environment for recovery.  Families experiencing homelessness may have nowhere to go until a shelter opens, or must continue living in a car or other location that may not provide a good environment for recovery. 
    
    Guidance is available from the CDC, along with other relevant resources, at http://www.nhchc.org/CommunicableDiseases.html. The National Health Care for the Homeless Council is also developing a practical guide for shelter providers, which is expected to be complete by mid-October.