I. INTRODUCTION

The mission of the Health Resources and Services Administration (HRSA) is to assure equal access to comprehensive, culturally competent, quality health care throughout the Nation. In particular, HRSA's Bureau of Primary Health Care (BPHC) works to assure the availability of quality health care to low-income, uninsured, isolated, vulnerable and special needs populations and to meet these populations' unique health care needs.

State and Regional Primary Care Associations (PCAs) are an important partner in enabling HRSA BPHC to achieve this mission. Because they represent safety net providers throughout the State, PCAs are uniquely positioned to work with providers, policy makers, program administrators, and communities to advance the goals of increasing access and reducing disparities.

A key element of this partnership is HRSA BPHC's provision of grant funds to the PCA in each State. These funds are intended to enable PCAs to engage in core activities and achieve outcomes in their State that advance the overall HRSA BPHC mission.

This document describes the core activities and outcomes that HRSA BPHC expects PCAs to achieve with the core grant funding. These activities and outcomes fall into the following categories:

• Organizational Effectiveness: Each PCA is expected to be an effective and efficient organization representing the interests of BPHC-supported programs and other safety net providers in the State and/or region. This includes fostering collaboration among its members, other safety net providers, and other private and public organizations with similar missions. It also entails ensuring the effective training and technical assistance is provided to BPHC-supported programs, ensuring excellence in clinical practice among its members, and having effective systems for using data and for organizational planning.
• Assessment: Each PCA is expected to assess the health policy environment and the market forces affecting the state's underserved and safety net providers on a regular basis. In addition, each PCA is expected to assist their State's Primary Care Office (PCO) in assessing unmet need and disparities across the State.
• Statewide Strategic Planning: Each State-based PCA is expected to develop a 3 to 5 year Health Center Growth and Resource plan representing all BPHC programs.
• Implementation: Each PCA is expected to educate policy makers about the underserved and the safety net, and to stimulate the development of both horizontal and vertical integrated networks in their State. In addition, each PCA is expected to assist their PCO with recruiting and retaining health care providers, and with gaining and maintaining shortage designations.

The PCAs will be expected to report on their results relative to these Expectations twice a year, through the Semi-Annual Report (SAR). The focus of the SAR will be to demonstrate the outcomes achieved through HRSA BPHC funding, and to link these outcomes to improvements in access, reductions in disparities, excellence in clinical practice, and the recruitment and retention of an appropriate health workforce.

 

II. AUTHORIZATION FOR SUPPORT TO STATES

Funding for State and Regional PCAs is authorized under the Public Health Service Act, which provides for:

• Assistance to Statewide organizations in the development and delivery of comprehensive primary health care service in areas that lack adequate numbers of health professionals or have populations lacking access to primary care services; and
• Technical and non-financial assistance to community-based providers of comprehensive primary and preventive care for underserved and vulnerable populations. Community-based providers include: Health Centers (i.e., Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Health Services for Residents of Public Housing, Healthy Schools, Healthy Communities School-Based Health Centers); National Health Service Corps (NHSC) practices (i.e., Private Practice Option and Private Practice Assignment sites); Federally-Qualified Health Center Look-Alikes; and other community-based organizations with a similar mission (i.e., provide services regardless of ability to pay on a sliding fee scale).

III. EFFECTIVE DATE

These revisions to the Program Expectations will take effect at the start of PCAs' fiscal year 2002 funding year, which is April 1, 2002. Therefore, applications for continued support as of that date must be prepared consistent with these Expectations.

 

IV. REQUIRED ACTIVITIES

A. Organizational Effectiveness

OUTCOME: The PCA is an effective and efficient organization representing the interests of BPHC-supported programs and other safety net providers in the State and/or region.

A1. Fostering Collaboration

Fosters collaboration among its diverse membership as well as other State and regional safety net providers in order to strengthen and expand the safety net. This ability is evidenced by performance measures such as:

• Participation by a majority of BPHC-supported programs, including stand alone grantees, such as Healthy Schools, Healthy Communities, Public Housing and Healthcare for the Homeless (those whose parent organization is not a traditional Community Health Center) and networks of health centers, in initiatives that aim to strengthen the safety net, such as Market Place Analysis, statewide strategic planning, and health disparities collaboratives. Regarding the collaboratives, PCAs have different levels of capacity and will need to coordinate activities and corresponding resources, via Memorandums of Agreement (MOAs) or other means, with the Lead Cluster PCA.
• The formation of performance-based partnerships with organizations on any activities or performance measures included in the PCA's BPHC workplan. Examples of such partnerships include joint projects improving quality of care, presenting at each other's annual meetings, and joint representation on task groups. Potential partner groups include:
  • State-level organizations that represent the interests of special population programs and/or minorities, such as the National Assembly of School Based Health Centers (State-based and/or national), National Health Care for the Homeless Council, State association of county health departments (the parent organizations of many special population programs)
  • Organizations that share similar missions and/or commitment to the underserved (e.g., faith-based organizations, National Association of Community Health Centers, clinical and integrated service networks, other HRSA programs such as State Offices of Rural Health, Title V and other Maternal and Child Health programs, Area Health Education Centers, etc.).
• A formal MOA among the PCA, PCO and the HRSA Field Office (FO). The purpose of the MOA is to increase collaboration, effectiveness, and efficiency, and to avoid duplication. Areas addressed should include, but are not limited to, statewide and regional assessment, planning, community development, and technical assistance. The MOA should specify key joint/individual responsibilities and expectations.

A2. Technical Assistance and Training

Coordinates with the HRSA FO and other State organizations to link training needs of all BPHC-supported programs with the appropriate technical assistance (TA) and training. Training needs may include managed care, practice management, board development, workforce recruitment and retention, and clinical quality/outcomes. It is not expected the PCA provide all training. However, any activity, TA or training for which the PCA uses BPHC funds should be available to all BPHC supported programs regardless of PCA membership status. Training and TA capability and effectiveness will be evidenced by:

• An annual process to survey all types of BPHC-supported programs regarding their training and technical assistance needs. Such issues may include board training and development, practice perations/systems efficiencies, maximizing reimbursement, health professional recruitment and retention, entor program for leadership, buddy system/mentorship for new health centers, organizational self assessment, and grant writing. The PCA may be asked to share results of the surveys with BPHC or the Field Office for planning purposes.
• A marketing and outreach process to encourage participation of all Bureau- supported programs in applicable training sessions/TA.
• An evaluation process that measures effectiveness of the training/TA and to ensure responsiveness to topical issues.
• Reports on the numbers and types of participants at PCA sponsored
  training sessions.
• Collaboration with HRSA FO staff to provide TA or training, as requested, to assist "at risk sites" with Primary Care Effectiveness Reviews, Federal Tort Claims Act issues, grant applications, etc.
• Collaboration with HRSA FO and other State organizations, as well as health center networks and managed care plans, to plan training and TA, where appropriate.
• Training and TA is provided on topics related to one or more of the critical elements of managing the growth of health centers, as listed below:
  • Verification of need
  • Community development
  • Board development
  • Human resource requirements
  • Information systems
  • Outreach to special populations
  • Facilities and technology
  • Leveraging resources
  • Administrative and Clinical Leadership development.

A3. Excellence in Practice

Commits to Excellence in Practice as an organizational priority, as evidenced by:

• The development and implementation of an action plan to increase the participation of health centers in the health disparities collaborative. This action plan should be included as part of the workplan prepared for BPHC.
• At least one of the following:
  • The presence of clinicians on the PCA board of directors or
  • The presence of a clinical committee that reports directly to the board or
  • The existence of a clinical network that influences programs and policies of the PCA.

A4. Effective Use of Data and Organizational Planning

Effectively uses data and planning to increase access and reduce disparities, as evidenced by:

• Use of a relational database, such as Access, that can be manipulated to reflect new developments in marketplace and statewide data. This can be done over the next 2-3 years and will include, at a minimum, the data elements included in the Marketplace Analysis.
• A 3-5 year PCA Strategic Plan that:
  • guides the association's work priorities, $ fully reflects the mission of increasing access and decreasing disparities, and $ is updated annually to address changing resources and capacity.
• An Annual PCA Operational Plan or other annual planning process that:
  • seeks to achieve the goals of the Organizational Strategic Plan $ clearly defines measurable objectives, activities, and outcomes tobe accomplished
  • is sufficiently flexible to respond to emerging issues
  • incorporates all activities included the workplan prepared for BPHC
• Identification of best practices for monitoring progress and effectiveness of its strategic and operational plans. It also shares these practices with others and implement lessons learned in its future planning processes.

B. Assessment

OUTCOME: Demonstrates collaboration between the PCA, PCO and other State and local agencies to conduct an overall statewide primary care needs assessment. The assessment will identify communities and populations with the greatest unmet health needs and health disparities which will serve as the basis for Statewide Strategic Planning and Community Development.

B1. Assessment of Unmet Needs and Health Disparities (The PCO is the lead in this activity)

• Supports the PCO (via an MOA or other means) as the lead in the assessment of the State's unmet primary care needs and the identification of health disparities. These analyses will be used as a basis for Marketplace Analysis, statewide strategic planning, and community development activities, and will identify communities and populations that:
  • Lack access to preventive and primary care services.
  • Experience major health disparities.
  • Experience a shortage of primary care providers and other staff.
  • Demonstrate the highest need for health services, such as levels of BPHC Policy Information Notice 2002-02
  • poverty, infant mortality, low-birth weight, life expectancy, shortage designations, percent or number unserved and underserved. Have a high number of individuals with special needs (e.g., homeless persons, public housing residents, low-income school children).
• Provides technical assistance in identifying potential Health Professional Shortage Areas (HPSAs), assists in the preparation of designation applications, and reviews the annual HPSA list with health centers.
• Educates health centers and other partners about the importance of maintaining designations.

B2. Assessment of Market Forces (The PCA is the lead in this activity)

• Conducts and effectively uses a statewide Marketplace Analysis at least every 3 years (more frequently, depending on changes in the health care environment) and continuously uses it to:
  • Identify the major characteristics of and developments in the State's major market places as they relate to the underserved and the safety net.
  • Identify hard-to-reach populations (e.g., homeless, immigrants, seasonal farmworkers, low-income students) and existing resources to serve them.
  • Based on new marketplace forces, make any necessary adjustments to the Statewide Strategic Plan (SSP) (see below) and/or organization's strategic planning process.

B3. Assessment of Health Policy Environment

• Monitor and report to HRSA on important developments regarding the:
  • Development and implementation of State programs and policies that affect the need for and availability of primary care services for the underserved. This includes Medicaid, managed care, the prospective payment system, child health insurance, the uninsured, health workforce and other key issues affecting the underserved and their providers of care.
  • Impact of Federal/State legislation and policy developments on the underserved and safety net (especially BPHC-supported programs).
  • The PCA's role, if any, in the development/implementation of legislation/policies

C. Statewide Strategic Planning

OUTCOME: The PCA has the lead for this activity. This is a phased in expectation over the next 1-2 years and will apply to States, based on when they begin the Statewide Strategic Planning process.

• C1. Required of all PCAs once they have begun SSP. In the first phase of SSP, the PCA will concentrate its efforts on facilitating the managed growth of health centers through the development of a 3-5 year Health Center Growth and Resource Plan representing all BPHC programs. This Health Center Growth and Resources Plan will include, at a minimum
  • Growth targets for the next 3-5 years for increased number of people to be served
  • Priority locations/ communities for:
  • locating new health centers (based on need)
  • expanding current health centers (based on need and organizational readiness criteria referenced in the SSP guidebook)
  • targeted community development (to prepare the community for a health center site)
  • Resource requirements:
  • staffing requirements (clinical, administrative, financial, technology)
  • capital, operational costs
  • services needed, including behavioral health, oral health, and pharmacy
  • Identification of partners and contributions, either financial, in-kind, or technical assistance, to assist with growth efforts (other providers, businesses, faith-based organizations, etc.).
  • At least two measurable objectives included in the organization's strategic planning process to demonstrate that statewide strategic planning is a priority. Objectives must:
  • identify geographic and/or population priorities in a given year
  • assist in targeting community/systems development efforts, new start/expansion application assistance or other technical assistance
  • result in Letters of Intent for BPHC funding opportunities incorporate critical elements of managed growth, such as verification of need, community/board development, human resources, information systems, technology, outreach to special populations, clinical systems.
  • incorporate critical elements of managed growth, such as
    verification of need, community/board development, human
    resources, information systems, technology, outreach to special
    populations, clinical systems.

D. IMPLEMENTATION

OUTCOME: Based on its assessment of the State, market and community environment, the PCA will engage in activities which support BPHC-supported programs and have a measurable and positive effect on the health status of the underserved.

D1. Informing and Educating for Safety Net Policy

• Effectively presents data to inform and educate policy makers about the needs of the underserved and safety net providers, as demonstrated by at least one of the following three items:
  • Active participation in selected State or regional wide commissions and working groups that directly impact provision of services to the medically underserved or reduction of health disparities (i.e., State or regional commission on workforce issues, implementation of State Children's Health Insurance Program, (SCHIP) etc.).
  • State/local dollars and other resources leveraged to help strengthen and expand the safety net.
  • Policies and regulations that are favorable to safety net providers and populations in need, such as positive reimbursement policies, Prospective Payment System, Medicaid/SCHIP enrollment, etc

D2. Expanding the Safety Net through Designations

• Supports the PCO in attaining and/or maintaining Federal designations. The support is demonstrated through the existence of a MOA or similar document with the PCO documenting the types of support that the PCA will provide. This MOA must include at least three of the following five activities:
• Reviewing lists of designated areas and populations and identifying those relevant to ongoing or developing primary care projects for the underserved.
• Assisting these projects and the PCO in obtaining data necessary to demonstrate continued need.
• Community development activities
• The NHSC scholar and loan repayer recruitment
• New Start/Expansion application development

D3. Health Professional Recruitment and Retention

• In collaboration with the PCO, the PCA partners with key institutions and agencies to create and sustain an adequate workforce to support the needs of the State's safety net system, especially for Bureau-supported programs.These partnerships will result in at least one of the following outcomes:
• Recruitment and retention of primary care clinical staff (decreased turnover of clinical staff, increased retention/ length of service or decrease vacancy rates at sites).
• Recruitment and retention of non-clinical and administrative staff, including mid-level management (decreased turnover of clinical staff, increased retention/ length of service or decrease vacancy rates at sites).
• Increased number of NHSC sites in the State; (based on the unmet needs analysis, number of communities identified for which NHSC is an appropriate intervention, either instead of or in conjunction with a health center, etc.).

D4. Network Development

• Stimulate development of horizontally and vertically integrated networks of safety net providers, including but not limited to, health centers, NHSC sites, and special populations programs, for the purpose of:
  • Increasing access (i.e., increasing primary care services; improved continuum of care; increased number of patients served; increased units of services; increased types of services available) or
  • Enhancing efficiency (i.e., economies of scale, practice management efficiencies, decreased cost per unit of service, sharing of expertise and staff among collaborators)

D5. Community Development -Required for PCAs who receive funding for Community Development; optional for other PCAs.

• In communities identified through Needs Assessment, Market Place Analysis and statewide planning results, conduct targeted activities that sustain the existing infrastructure and expand access/services, to include at least three of the following:
  • Coalition building
  • Organizational development
  • Training and TA
  • Recruitment and retention activities
  • Assisting with attaining and maintaining designations
• Demonstrate the success of Community Development activities through the following outcomes:
  • Increased letters of intent for BPHC funding opportunities
  • Community-based service and systems development, resulting in, but not limited to at least one of the following:
    • Increase in new health centers, including sites that serve special populations (homeless, public housing, school-based, etc.) to increase access capacity and services $ Increase in expanded health centers
    • Increase in community-based Integrated Services Development Networks
    • Increase in sites served by NHSC providers
    • Increased patients served
    • Increase in readiness of an organization wishing to expand
    • Community coalitions representing a broad array of partners "in action" to develop coordinated primary care systems, with PCA facilitating a process, depending on community will, environment, need and resources, resulting in, but not limited to, at least one of the following:
      • Additional State/local resources leveraged
      • Enhanced level of service and systems integrationoccurring.
      • Upward movement along the Community Progress Scale.

Issued December 4, 2001 - Last reviewed November 20, 2006