The Health Center Program: Change in Scope

Sample Change in Scope Request & Instructions

Submit all requests using the HRSA Electronic Handbooks.

Instructions

For adding a site/service or relocating a site, the following information should be provided:

• Cover Page
• Completed Exhibit B (Current Services Provided and Service Sites) of the grant application
• One-year budget specific for the change, showing the projected number of encounters, payer mix, revenue and expense projections, sources of support, and sustainability.
  If any of the sources of funding are not projected to continue beyond an initial period of time (i.e., beyond the first year of the project), please describe what sources will support the change in scope in the future.
  The revenue and expense projections must be at a level of detail that clearly shows no additional Section 330 funding is required for the change.
  For an example of calculations to be included in a revenue projection, please refer to the grant application Form 3 entitled "Income Analysis Format."
• One-year total budget (for the entire scope of project including the requested change), showing the projected total number of encounters, payer mix, and revenue and expense projections. Again, the revenue and expense projections must be at a level of detail that clearly shows no additional section 330 funding is required for the change.
• Completed and signed Change in Scope Assurances Checklist
• A brief narrative (maximum of 6 pages for adding or relocating a site; maximum of 3 pages for adding a service) describing the change in scope that is being proposed, why it is being proposed and addressing the following:
  • The latest community needs assessment that illustrates a need for the new site/service in the community.
  • If no needs assessment was completed, an explanation of how the need for the new site/service was determined.
  • The impact of the change on the total organization, including a description of the service delivery system and how the appropriateness and quality of care are maintained for the new site or service.
• If the target population for the new site/service is different from that currently served by the health center, what is the target population of the new site/service? Include the following information:
  • Number of patients expected to be seen annually at the new site or expected to utilize the service.
  • Information demonstrating the need of the target population.
  • Percentage of individuals below 200 percent of the Federal Poverty Level.
  • Percentage of uninsured individuals.
  • Health disparities present in the target population.
  • Any additional information that will document the need, such as unemployment rate, percentage of minority/special populations, ratio of primary care physicians to population, etc.).
• If the service area of the new site/service is different from that currently served by the health center, what is the service area for the new site/service? Include the following information:
  • List of census tracts, counties, minor civil divisions, etc., in the new service area.
  • List of other existing entities that provide primary care services to the same target population and/or in the same geographic service area. Highlight the safety net providers i.e., other BPHC-supported health centers, rural health clinics, FQHC Look-Alikes, and other related entities that are serving the same geographic area or target population.
  • Description of coordinated/collaborative efforts with these entities.
  • Letters of support from safety net providers in the area.
  • Description of Board representation from the new service area.
• If adding or relocating a site: How will the new site be staffed, and what services will be provided? Include the following information:
  • Number and types of providers.
  • If not all required primary care services that the health center offers its patients at other sites are being provided, how will access to these services be assured? For example, if the new site will provide only dental or mental health services, how will access to comprehensive services be assured?
• If adding a service:
  • If it is a specialty or non-primary care service, how does it complement primary care services and the health care needs of the users and community?
  • If it has traditionally been the financial responsibility of a local, county, or State government, why is the health center assuming responsibility for the service?

To Request the Reduction of a Site/Service

For dropping a site or service, the following information should be provided:

• Cover Page
• Completed Exhibit B (Current Services Provided and Service Sites) of the grant application.
• One-year budget specific for the change, showing the impact on payer mix, revenue projections, and expense projections.
• One-year total budget (for the entire scope of project including the requested change), showing the projected number of encounters, payer mix, and revenue and expense projections.
• Completed and signed Change in Scope Assurances Checklist.
• A brief narrative (maximum of three pages for dropping a site; maximum of two pages for dropping a service) describing the change in scope that is being proposed, why it is being porposed and addressing the following:
  • Describe the target population currently served by the site/service.
  • Number of annual users.
  • Number of annual patient encounters.
  • Describe any other access to health care issues of the population (i.e., number of uninsured and low-income individuals, health disparities, etc.).
  • What is the impact on this target population from dropping the site/service?
  • Describe how access to care has been assured for patients currently served by the site/service.
  • Include a list of other providers in the area who can deliver services to the Population and the contact made with them.
  • What effect does dropping the site/service have on the required services provided? Please address how the appropriateness and quality of care will be maintained.