Strategic Plan FY 2005 – 2010

• Printer-friendly HRSA Strategic Plan FY 2005-2010

Budget and Performance Crosswalk
Details of Performance Analysis (PART Recommendations)

• Providing support to nearly 3,600 health center sites serving about 12.5 million people;
• Funding care and treatment services for an estimated 533,000 people living with HIV/AIDS;
• Assisting States and communities, including rural and border areas, and health care organizations in improving services to women and children;
• Overseeing the national system that allocates organs, tissue, and blood stem cells for transplant;
• Working with academic health centers and other training programs to enhance the diversity and distribution of the Nation’s health care workforce;
• Implementing comprehensive systems of services in communities to meet the many needs of children and youth with special health care needs and their families; and
• Participating in global health initiatives such as the President’s Emergency Plan for AIDS Relief.

GOAL 1: Reduce the major threats to the health and well-being of Americans.
GOAL 2: Enhance the ability of the Nation’s health care system to effectively respond to bioterrorism and other public health challenges.
GOAL 3: Increase the percentage of the Nation’s children and adults who have access to health care services, and expand consumer choices.
GOAL 4: Enhance the capacity and productivity of the Nation’s health science research enterprise.
GOAL 5: Improve the quality of health care services.
GOAL 6: Improve the economic and social well-being of individuals, families and communities, especially those most in need.
GOAL 7: Improve the stability and health development of our Nation’s children and youth.
GOAL 8: Achieve excellence in management practices.

From year to year, HRSA’s Strategic Plan is a dynamic and flexible document. Adjustments and changes in direction are inevitable as the Agency moves forward over time with the many complex and varied problems it is seeking to address. New information from customers and the scientific community, along with an annual summary of the Agency’s accomplishments toward achieving its goals, is factored into the Agency’s planning process each year. The Plan provides a framework to assist HRSA in focusing on the highest priority health care issues, meeting the needs of its customers, and assuring effective use of taxpayer dollars.
HRSA’s Strategic Plan begins with a brief background/overview of the Agency and then describes its vision, mission, strategic goals, objectives and strategies. The Plan then includes several sections describing HRSA’s organizational infrastructure, including its operating units, management improvements, challenges posed by a rapidly changing health care system, and evaluation activities undertaken to further inform its planning process. Finally, ongoing partnerships and collaborative activities with other organizations are described.

It should be noted that the Strategic Plan is not a depository for all actions that the Agency might take to achieve an objective. Therefore, implementation strategies under each objective are merely illustrative and not meant as a catalogue of all potential implementation plans; they illustrate the general direction the Agency plans to take. In addition, there are many circumstances in which individuals, families, and communities have needs that go beyond the individual HRSA programs. To help facilitate meeting their needs, HRSA works with a wide range of Federal, State, tribal, and local service providers to coordinate the planning and delivery of services in a way that maximizes resources and provides an integrated approach to health care.

The Plan was developed through a collaborative process maximizing the expertise, experience and perspective of HRSA staff. A staff workgroup with Agency-wide representation developed an initial draft which was reviewed by senior Agency staff. In line with the requirements of the Government Performance and Results Act (GPRA), HRSA’s Strategic Plan is supplemented by Annual Performance Plans and Reports, Office of Management and Budget (OMB) Program Assessment Rating Tools (PART) review, evaluation and grant review activities. Progress and findings from these activities have and will continue to assist HRSA in the ongoing revision of its Strategic Plan.

As the Access Agency, HRSA’s programs reach into every corner of America providing health care services relied upon by millions of people. HRSA works to expand access to high-quality, culturally competent health care; improve health outcomes among America’s minority communities; and enhance direct medical care through the use of information and telehealth technology.

Assuring a safety net for individuals and families who live outside the economic and medical mainstream is a key HRSA role. Our portfolio of programs and initiatives are designed to increase access to care, improve quality, and safeguard the health and well-being of the Nation’s most vulnerable populations.

Building upon this foundation, HRSA has recently implemented two Presidential initiatives of critical importance: the 5-year President’s Health Center Initiative, which will significantly affect 1,200 communities with new access points or expanded health center sites in order to serve an additional 6.1 million patients annually by 2006; and reforming and expanding the National Health Service Corps, which increases staffing levels within many of the Nation’s neediest communities.

The United States still faces significant challenges with regard to assuring access to care. Among these challenges, HRSA’s programs address the following health care problems and issues:

• 45 million Americans lack health insurance—many of whom are racial and ethnic minorities;
• Approximately 50 million people live in communities—rural and poor urban neighborhoods—without sufficient access to primary health care;
• African American infants are 2.4 times as likely as white infants to die before their first birthday;
• An estimated 850,000 to 950,000 people are living with HIV in the U.S., with approximately 40,000 new infections occurring in the U.S. every year;
• Over 83,000 Americans are waiting for an organ transplant; and
• 12.8 percent or 9.4 million children are estimated to have special health care needs.

HRSA Vision
HRSA envisions optimal health for all, supported by a health care system that assures access to comprehensive, culturally competent, quality care.

Mission
HRSA provides national leadership, program resources and services needed to improve access to culturally competent, quality health care.

Goals
As the Nation’s Access Agency, HRSA focuses on uninsured, underserved, and special needs populations in its goals and program activities:

• Put People First
  First and foremost, all our actions must benefit America’s people who are uninsured, underserved, vulnerable and living with special needs.
• Deliver Results
  Deliver results that are useful to the people and communities directly served by HRSA’s programs and to the taxpayers who pay for these programs.
• Be Accountable
  Be accountable for HRSA’s programs and the efficiency and quality of services provided.
• Focus on Prevention
  Focus on health promotion and prevention of disease, illness, and social problems, including prevention and correction of unlawful discrimination in providing health and human services.
• Create Collaborations
  Create useful, effective forms of collaboration with partners, within and beyond the health sector, in regulation, research, service delivery and evaluation, and management.
• Provide Information
  Provide accurate, reliable, understandable, and timely information to our partners, customers and the public.
• Apply Evidence Based Scientific Knowledge
  Apply the most current scientific knowledge when making decisions that affect public well-being.
• Foster Flexibility and Innovation
  Foster flexibility and encourage innovation in the effective delivery of health and human services programs.
• Establish a Respectful and Supportive Work Environment
  Encourage creativity, diversity, innovation, teamwork, accountability, continuous learning, a continuous quality improvement loop inclusive of all employees, a sense of urgency, enthusiasm, trust, celebration of achievement, and the highest ethical standards.
• Maintain a Work Place that is Free from Discrimination
  Maintain a work environment that is free from discrimination in any of the Agency’s policies, procedures or practices.
• Work as One HHS
  Actively participate in the Department’s effort to work as a single entity through a “One HHS” approach to management. With a statutory emphasis on special needs, underserved, and vulnerable populations, HRSA works to accomplish its mission through the separate and collaborative efforts of its Bureaus and Offices.

• Increase the number of available access points providing care to underserved, vulnerable and special needs populations.
• Increase the range of services available through access points and other program efforts to include such expanded services as mental health, genetic, oral health, substance abuse, chronic disease management, and preventive services.
• Enhance and expand services that address and target populations with particular needs (e.g., older adults; people who are homeless or living with HIV/AIDS).
• Promote incorporation of distance learning and telehealth into HRSA-funded grantee sites.

• Increase recruitment, training, distribution, and retention of under-represented minorities into the health care professions.
• Provide training opportunities and technical assistance for existing health care workers to reduce potential barriers to care (e.g., cultural competence; health literacy; limited English proficient (LEP) clients).
• Facilitate the infusion of cultural competence into health professions training.
• Promote training in cross-cultural communication for providers.
• Promote distance learning and the use of information technology and telehealth by HRSA-funded grantees.

• Identify and address the health professions workforce shortages, with periodic updates of Health Professions Shortage Area (HPSA) designations.
• Increase recruitment of health care workers willing to enter practice in underserved, rural, and border areas.
• Increase retention of health care workers currently working in underserved, rural and border areas.

Objective 1.4: Promote access to health insurance and maximize use of available reimbursements for health care services
How We Will Accomplish Our Objective

• Provide technical assistance to HRSA grantees and programs regarding ability to maximize appropriate third party reimbursement or prospective payment for service.
• Encourage grantees to facilitate the enrollment of eligible individuals into Medicaid, SCHIP, Medicare and other appropriate health insurance programs.
• Promote health care financing systems and approaches that increase access to care by reducing barriers to payment.

• Increase participation of eligible underserved, vulnerable, and special needs individuals receiving comprehensive, culturally competent, quality primary health care services.
• Target available Ryan White CARE Act resources to underserved communities, uninsured and underinsured people disproportionately impacted by HIV/AIDS.
• Promote utilization of HRSA funded health care services by underserved maternal and child populations, including children with special health care needs.
• Increase organ and blood stem cell donation and access to transplantation.
• Target available genetic service resources to underserved and underinsured communities to assure equal access to those subspecialty services.
• Support community and grantee efforts to identify underserved, vulnerable and special needs populations.

• Increase participation of eligible individuals receiving care through HRSA funded programs having preventive and chronic disease management services (e.g., routine screening such as newborn screening for congenital disorders, immunization, prenatal care, utilization of family history, health counseling, etc.).
• Increase use of effective complementary and alternative therapies by health care providers.
• Identify and share solutions for increasing prevention and disease management services with grantees, program officials and policy/decision makers.
• Promote the Health Disparities Collaborative approach to disease management throughout the health center system.

• Ensure HRSA funded programs providing clinical services meet or exceed accepted quality and accreditation standards.
• Ensure HRSA funded programs implement and maintain a proactive system to identify, monitor and correct medical errors/sentinel events.
• Assure HRSA funded programs providing clinical care implement appropriate follow-up and referral services.
• Ensure that HRSA funded programs providing clinical care have demonstrated ability to deliver culturally competent care.
• Promote and support performance improvement efforts of HRSA grantees, providing performance reviews and assistance.

• Ensure HRSA funded programs providing clinical services develop and implement a quality management and improvement program.
• Improve key health status indicators that reflect quality of safety net programs.
• Develop and implement patient-centered standardized tools that HRSA grantees can use to improve quality of health care. ? Enhance monitoring and compliance of Title VI of the Civil Rights Act of 1964.
• Increase awareness and utilization of National Practitioner Data Bank (NPDB) and Health-care Integrity and Protection Data Bank (HIPDB) by health care delivery sites.
• Increase awareness of HRSA grantees about issues relevant to consumer and patient protections, rights and responsibilities.

• Develop appropriate health care information in collaboration with family, faith-based and community partners that takes into consideration cultural values, linguistic differences, and health literacy.
• Disseminate health care information materials in collaboration with family and community partners that take into consideration cultural values, linguistic differences, and health literacy.

• Identify and document best/innovative practice models of HRSA grantees.
• Disseminate best/innovative best practices among HRSA grantees.
• Encourage adoption and utilization of appropriate evidence-based clinical practice guidelines by HRSA grantees providing clinical services

• Focus HRSA program efforts to reduce incidence of low birth weight for populations that are disproportionately affected.
• Focus HRSA program efforts to reduce infant mortality for populations that are disproportionately affected.
• Direct HRSA program efforts to increase the percentage of children who are screened early and continuously for special health care needs and linked to medical homes, appropriate follow-up and early intervention.
• Focus HRSA program efforts to reduce deaths due to AIDS in populations that are disproportionately affected.

• Establish outreach/partnering efforts related to raising awareness about major health risks, including genetic and environmental risk factors, and how to reduce these risks.
• Partner with minority institutions, faith-based and other community-based organizations to help reach diverse populations most affected by health disparities concerning major health risks and prevention in their communities.
• Direct HRSA program efforts to increase organ and blood stem cell donation and the
  likelihood of receiving a transplant among minorities.

• Assure that program and grant guidances reflect an emphasis on promoting cultural competency.
• Support cultural competence training for HRSA program staff, grantees, and provider community.

• Inform policy decisions by using the most current public health and health care data available, including global, national and State trend data.
• Provide technical assistance to States related to the health care workforce, including projected supply and demand.
• Improve the performance of HRSA funded programs, providing performance reviews, analyzing performance trends/issues and providing feedback on the impact of policies on program implementation and performance within communities and States.

• Increase coordination among public health and private sector organizations to improve impact of HRSA programs.
• Help assure a coordinated approach in addressing public health developmental issues in U.S. territories and other U.S.-associated island jurisdictions.
• Assure the development of a strategic, coordinated approach that addresses technical assistance for global health issues, especially HIV/AIDS, maternal and child health, health workforce, and other areas of HRSA expertise.
• Increase capacity of the public health and health care systems in rural and border areas.
• Promote and support cross-program, performance improvement efforts within communities and States through State/community strategic partnership reviews.
• Increase collaboration between HRSA-funded programs and State governments.

• Enhance the provision of clinical services at grantee delivery sites with distance learning programs, electronic transmission of medical data or electronic links with experts in distant communities.
• Increase technical assistance (e.g., guidance, manuals, training) to HRSA grantees related to management information systems, including hardware and software issues.
• Develop, monitor and evaluate electronic resources (e.g., web sites, list servs, data systems) for HRSA grantees and funded programs.
• Promote integration of public and community-based child health information systems to facilitate the assessment for and prompt provision of requisite services to ensure an optimal healthy start for all children and improve the health of children.
• Support development of electronic health records.
• Collaborate with the President’s Health Information Technology initiative.

• Promote collaboration and establishment of comprehensive health care systems (hospitals, health centers, trauma, emergency medical services, and poison control centers) to plan for evacuations, triage and treatment of mass casualties, including for those with special health needs (e.g., those at home on ventilators) and increase their capacity in the event of bioterrorism or other public health emergencies.
• Enhance the ability of the Nation's health care system to effectively detect and report bio-events and respond to bioterrorism and other public health emergencies.
• Develop education and training programs for healthcare professionals to effectively respond to bioterrorism and other public health emergencies.
• Promote the establishment of secure and redundant communication systems to ensure connectivity among professionals to effectively respond to bioterrorism and other public health emergencies.
• Enhance the capability for special needs populations to have access to lifesaving medications, equipment, and medical services during public health emergencies.

• Develop critical benchmarks to measure system improvement with regard to preparation for bioterrorism and other public health emergencies.
• Assess training needs of health professionals to respond to bioterrorism and other public health emergencies on a periodic basis.

• Conduct ongoing workforce planning, including recruitment and retention of key staff.
• Implement EEOC’s Management Directive-715, which provides policy guidance and standards for establishing and maintaining effective affirmative programs of equal employment opportunity.
• Implement an “emerging internal workforce” recruitment program (e.g., details, developmental assignments, and mentoring programs), the HRSA Scholar’s Program, which targets mission-critical positions in the GS-5,7 and 9 grade levels, and focusing on an active external hiring of highly educated adaptable individuals.
• Participate actively in the HHS Emerging Leaders program.
• Increase employee accountability for achieving measurable results through performance contracts.
• Enhance training and career development opportunities for HRSA employees.
• Conduct studies that examine selected HRSA functions for cost comparisons to identify opportunities for increased efficiency and effectiveness.

• Support development of an electronic grant application and progress report system.
• Provide a secure and trusted IT environment.
• Enhance the quality, availability, and delivery of HRSA information and services to citizens, employees, businesses, and governments.
• Support the Department’s implementation of an enterprise approach to IT infrastructure and common administrative systems that will foster innovation and collaboration.
• Enable and improve the integration of health and human services information.
• Achieve excellence in IT management practices.
• Support development of www.grants.gov

• Implement a new integrated Department-wide financial management system—the Unified Financial Management System (UFMS) that supports financial analysis, performance measurement and operational decision making.
• Comply with the Department’s accelerated annual audit reporting guidelines and standards.
• Conduct assessments of applicant organizations and grantees and resolve audit findings.
• Conduct reviews of HRSA programs, procedures, and activities.
• Conduct an orderly phase-out of HRSA’s active loan portfolio.

• Develop policies and procedures to ensure consistent administration of grants.
• Document program performance improvement by HRSA grantees reviewed by HRSA’s Office of Performance Review (OPR) or by a nationally recognized accrediting body.
• Implement objective review requirements applicable to competitive grants and cooperative agreements.
• Plan, award, and manage the Agency’s portfolio of grants and cooperative agreements.
• Consolidate HRSA grants processing with NIH.

• Support collaborative efforts within the Agency designed to address cross-cutting policy issues.
• Develop bilateral and multicultural working relationships to enhance HRSA’s knowledge base and the dissemination of information in support of its global and domestic activities.

The Bureau of Health Professions (BHPr) provides national leadership in coordinating, evaluating, and supporting the development and utilization of the Nation’s health personnel. The Bureau also manages the National Health Service Corps and the National Practitioner Data Bank.

The Bureau of Primary Health Care (BPHC) provides national leadership in assessing the Nation’s health care needs of underserved populations and in assisting communities to provide primary health care services to the underserved in moving toward eliminating health disparities. The major program component is the Consolidated Health Center Program. The Bureau also administers the Black Lung Clinics program, the Native Hawaiian Health Care Program, the Healthy Communities Access Program, the Radiation Exposure Screening and Education Program, and the National Hansen’s Disease Program.

Healthcare Systems Bureau (HSB) provides national leadership and direction in several key functional areas: 1) the procurement, allocation and transplantation of human organs and blood stem cell; 2) the facilitation of the development of State, territorial, and municipal preparedness programs to enhance the capacity of the Nation’s hospitals and other healthcare entities to respond to mass casualty incidents caused by terrorism and other public health emergencies; 3) the provision of programmatic, financial and architectural/engineering support for healthcare facilities construction/renovation programs; 4) the reduction in numbers of uninsured persons through the State Planning Grants Program; and 5) the management and operation of the national programs for childhood vaccine and smallpox vaccine injury compensation.

The HIV/AIDS Bureau (HAB) provides leadership in the delivery of high quality clinical care and supporting services for uninsured and underinsured individuals living with and families affected by HIV/AIDS. It includes the Office for Advancement of Telehealth, the HRSA-wide developer of telehealth, including the use of electronic information and telecommunications technologies for all types of health-related activities. It also includes HRSA’s Center for Quality which strengthens and improves the quality of health care, especially related to Agency programs and service populations.

The Maternal and Child Health Bureau (MCHB) provides national leadership, in partnership with key stakeholders, to improve the physical and mental health, safety and well-being of the maternal and child health (MCH) population. The MCH population includes all of the Nation’s women, infants, children, adolescents, and their families (including fathers), and children with special health care needs. The Bureau also manages the HRSA Office of Women’s Health.

The Office of Rural Health Policy (ORHP) serves as a focal point within the Department and as a principle source of advice to the Administrator and Secretary for coordinating efforts to strengthen and improve the delivery of health services to populations in the Nation’s rural areas and border areas.

The Office of Performance Review (OPR) serves as the Agency’s focal point for reviewing and enhancing the performance of HRSA supported programs within communities and States to improve access to quality health care and reduce health disparities. Through an Agency-wide performance review process, OPR strives to improve program administration through

1. the assurance of efficient and effective use of resources;
2. promotion of effective coordination; and
3. reduction of barriers to performance.

The Office of Administration and Financial Management (OAFM) provides Agency-wide leadership, program direction, and coordination to all phases of management including financial management, policy and regulations, and administrative management.

The Office of Planning and Evaluation (OPE) coordinates the Agency’s strategic, evaluation, and research planning activities; prepares policy analysis papers; analyzes budgetary data with regard to planning guidelines; assesses the information needs of the Agency; and serves as the focal point for health systems organization and financing issues with particular emphasis on the Agency’s relationship with the Centers for Medicare and Medicaid Services and safety net providers.

The Office of Minority Health (OMH) provides leadership and guidance to the Agency in assisting it to improve the health status of racial/ethnic minorities.

The Office of Legislation (OL) serves as the Administrator’s primary staff unit and principal source of advice on legislative affairs.

The Office of Communications (OC) builds support for HRSA’s activities by explaining to the American public, the press and health care organizations how the Agency’s programs expand access to comprehensive, quality health care for all.

The Office of Federal Assistance Management (OFAM) provides national leadership, oversight, and financial integrity assurances for the administration of HRSA’s Federal assistance programs; provides leadership, direction and coordination to all phases of grants policy, administration and independent review.

The Office of Information Technology (OIT) delivers innovative information technology tools and essential services to enable HRSA and its customers to be continually more effective.

The Office of Equal Opportunity and Civil Rights (OEOCR) ensures that all of HRSA employees’ and applicants’ rights are protected in every aspect of their employment and protects the rights of all beneficiaries who use the programs and services funded by HRSA.

The Office of International Health Affairs (OIHA) serves as a focal point within HRSA for leadership, coordination, and advancement of international health activities relating to health care services for vulnerable and at-risk populations and for training programs for health professionals.

Management Improvement
To accomplish the program goals and objectives in its Strategic Plan, HRSA must achieve excellence in management through ongoing improvements in management practices. To this end, HRSA is directing strategies to accomplish the management objectives outlined in the HHS Strategic Plan, including those objectives that are consistent with the President’s Management Agenda (Competitive Sourcing, Strategic Management of Human Capital, Improved Financial Performance, Expanded Electronic Government, and Budget and Performance Integration).

Support a Unified HHS Committed to Functioning as One Department
To support the unification of HHS, HRSA is an active participant in several ongoing activities including:

1. consolidation of HHS operations, including facilities management, human resources and administrative services;
2. coordination with other HHS agencies to better leverage collective resources;
3. reduction in management to speed decision making;
4. establishment of uniform information systems to standardize enterprise functions (e.g., financial systems; electronic communications); and
5. implementation of initiatives to consolidate acquisitions and utilize strategic purchasing.

Improve the Strategic Management of Human Capital
By fiscal year (FY) 2006, 37 percent of HRSA’s civilian workforce and 49 percent of our Commissioned Corps workforce will be eligible to retire. HRSA is addressing this anticipated change in its workforce through its strategic management of human capital. Current and ongoing activities in this area include:

1. ongoing workforce planning, including the recruitment and retention of key staff;
2. implementation of EEOC’s Management Directive-715 which provides policy guidance and standards for establishing and maintaining effective affirmative programs of equal employment opportunity;
3. implementation of an “emerging internal workforce” recruitment program (e.g., details, developmental assignments, and mentoring programs), the HRSA Scholar’s Program, which targets mission-critical positions in the GS-5,7 and 9 grade levels, and focusing on an active external hiring of highly educated adaptable individuals;
4. increase in employee accountability for achieving measurable results through performance contracts;
5. enhancement of training and career development opportunities for HRSA employees; and
6. conduct of studies that examine selected HRSA functions for cost comparisons to identify opportunities for increased efficiency and effectiveness.

Enhance the Efficiency and Effectiveness of Competitive Sourcing
HRSA is enhancing its competitive sourcing activities through the development of a competitive sourcing plan which determines studies to be done of commercial functions each year. The implementation of this plan allows HRSA to set FTE targets and develop studies for its commercial functions as identified in the annual HRSA FAIR Act Inventory process. This enables HRSA to identify performance efficiencies and continuous improvement for the studied functions. Contracts resulting from the studies for either public or private entities are performance based and include a process for vigorous monitoring and measuring of the contractor’s performance.

Improve Financial Management
HRSA continues an ongoing improvement in its financial management through several major efforts:

1. implementation of a new integrated Department-wide financial management system—the Unified Financial Management System (UFMS) that supports financial analysis, performance measurement and operational decision making;
2. compliance with the Department’s accelerated annual audit reporting guidelines and standards; and
3. standardization of processes and procedures related to grant awards, management, and oversight within the Agency, including reduction of payment errors.

Enhance Use of Electronic Commerce in Service Delivery and Record Keeping
HRSA uses electronic commerce both internally for archival and record keeping and externally to improve communication with its grantees and other interested parties. By enhancing the use of electronic resources, HRSA is making it easier for entities to apply for grants and ultimately bring primary health care services to individuals and families, especially those in underserved areas.

In addition, HRSA supports all e-government initiatives with e-government productivity measures, strong Information Technology (IT) security, and integrated enterprise architecture. Finally, HRSA implements the HHS IT Strategic Plan, with its goals to: provide a secure and trusted IT environment; enhance the quality, availability, and delivery of HRSA information and services to citizens, employees, businesses, and governments; support the Department’s implementation of an enterprise approach to IT infrastructure and common administrative systems that will foster innovation and collaboration; enable and improve the integration of health and human services information; and achieve excellence in IT management practices.

Achieve Integration of Budget and Performance Information
HRSA continues to integrate more closely performance and budget information so that program results inform budget decisions. Along with HHS, HRSA has developed a fully integrated fiscal year (FY) 2006 performance budget.

Reduce Regulatory Burden on Providers and Consumers
In an effort to reduce regulatory burden, HRSA will examine the findings and recommendations from the Advisory Committee on Regulatory Reform. It will also solicit advice from stakeholders to identify confusing regulations, strategies and seek suggestions to clarify and simplify these regulations. HRSA has also initiated an Agency wide performance review process to eliminate multiple on-site reviews for grantees with one or more HRSA funded programs, placing a greater focus on program performance and outcomes.

Challenges and External Factors
There are many factors that pose challenges to the effective implementation and accomplishment of HRSA’s goals. The factors/issues described in this section highlight the challenges posed by the overall environment within which HRSA is striving to improve the health of all Americans. The Agency has and will continue to address these challenges as it moves forward to accomplish its mission.

Demographic Trends
Changes in the demographics of the Nation’s population have an impact on the delivery of health care services, both overall and through the health care safety net. The U.S. population is aging; current estimates indicate a 150 percent increase in the number of individuals over 65 by the year 2020. With improvements in medical care, the life expectancy of these individuals is longer. Although life expectancy at birth is 77 years, if an individual lives to 65, his/her life expectancy increases to 83. Both the aging of the population and the increase in life expectancy pose significant challenges to the delivery of medical care in the 21st century. In addition, the increasing diversity (racial, ethnic, linguistic, and literacy rates) and mobility of the population both at a State and national level pose additional challenges in rural, urban and border areas to the delivery of health care.

Changing Disease Burden
There is a current and ongoing change in the nature and impact of both chronic and infectious disease both globally and in the United States. These changes are reflected in several factors including: 1) the increasing prevalence of chronic and infectious diseases; 2) the emergence and re-emergence of infectious diseases; 3) the changing demographics of disease; 4) the distribution of disease; 5) the prevalence of injuries; and 6) the increasing understanding of genetic risk, environmental and lifestyle factors that impact the prevalence of chronic diseases. For example, in 2000, 47 percent of all AIDS cases reported in the U.S. were among African-Americans, and the rate of new AIDS cases among African-Americans was almost 10 times higher than among non-Hispanic whites. These changes affect both the need for services and the types of services provided with an increasing need to focus on prevention, awareness and behavioral issues.

Increasing Complexity and Changing Demands of the Health Care Care Delivery System
The delivery of health care in the United States has become increasingly complex in recent years. The need to optimize decreasing resources has resulted in an increased focus on outpatient and home health care services with a resulting decrease in inpatient services. In addition, there are a number of trends that have affected health care delivery including:

1. improved detection of medical errors and increased emphasis on the correction and prevention of errors;
2. increased concerns regarding medical liability and malpractice, including risk management and potential tort reform;
3. decreased access to specialty care, especially for low-income and uninsured populations as well as overall increase in the number of uninsured;
4. increased flexibility at the state and community level to design health care programs to meet their own needs and priorities, resulting in a changing role for the Federal government in the delivery of health care services;
5. increased globalization of health care issues and involvement of the Federal government in international health (e.g., AIDS, SARS);
6. increasing pressures on revenue sources, such as Medicaid and other local/State programs that will require exploring innovative approaches to financing, such as pay-for-performance and Medicare modifications;
7. increasing costs of health care; and
8. increased need to integrate genetic medicine into primary care clinical practice.

Rapid Rate of Technological Innovation in Health Care
The increasing pace of technological advances, including transmission of medical data, use of telecommunication to deliver health care information, and use of the Internet, affects the delivery of health care services. In addition to facilitating exchange of information and referral to services, these technological advances help to assure access to care for underserved areas (e.g., rural and border areas). They also present challenges to the infrastructure of the health care delivery system and skills/training required of health care providers and support staff.

Biotechnology and Biomedical Advances
Dramatic advances in biotechnology and biomedicine, including therapeutics (e.g. gene therapy), treatment modalities (e.g., drugs to combat HIV/AIDS), understanding of genetic risk, and lifestyle factors, affect the delivery of health care in the United States. The potential variation across different types of health care delivery systems in the United States is an additional challenge to obtaining the maximum benefit from these advances.

Health Care Workforce
There are a number of challenges posed by the current status of the Nation’s health care workforce on the health care delivery system overall and the health care safety net in particular. These challenges include a nationwide shortage of health care professionals, especially nurses, but also pharmacists, allied and public health workforce, dentists and physicians who are pediatric sub-specialists. The shortage of physicians in certain areas is exacerbated by increasing rates of malpractice insurance that is limiting scopes of practice for many physicians (e.g., obstetric services). There is particularly a problem with the recruitment and retention of health care professionals to underserved areas, including rural and border areas. Recruitment and retention issues create additional financial burdens on health care safety net providers in their attempt to retain qualified personnel.

Bioterrorism Preparedness and Response
The need for the Nation to prepare for an act of bioterrorism presents several challenges to the current health care deliver system and public health infra structure. The principle challenge lies in the need to strengthen state and local infrastructures required to respond during a national, State or local emergency. Two key components of this infrastructure are the communication system(s) among local, State, and national agencies as well as practitioners trained to respond to bioterrorism.

Quality of Health Care Services
Improving the quality of health care services includes the implementation of a variety of strategies to improve health outcomes. These strategies parallel the goals in the Department's health care quality initiative. The agenda for addressing this important area includes reducing medical errors, increasing the appropriate use of effective health care services, increasing consumer and patient use of health care quality information, and improving consumer and patient protections.

Performance Measures
Achieving high performance in pursuing its mission is a major priority for HRSA. The Agency measures its progress by monitoring a variety of performance measures that are linked to the goals and objectives set out in this Strategic Plan. Thus the Strategic Plan provides a performance management framework for HRSA. The performance measures have been designed over several years and are regularly refined and updated, as appropriate, to reflect programmatic changes, improvements in data collection capability, and enhanced measurement rigor.

HRSA’s performance measures include, but are not limited to, those reported in compliance with the Government Performance and Results Act (GPRA) and included in the Agency’s annual performance budget. The measures relate to key program outputs as well as outcomes. As the Nation’s Access Agency, HRSA monitors outcomes of various types including: the health status, health behaviors and specific care received by the population, the extent of access to and utilization of services by the population, and the development and distribution of essential safety-net providers and systems of care.

More information on HRSA’s performance measures is available on the HRSA Web site in the specific Bureau, Office or program sections and in the “About HRSA” section, which includes the Agency’s GPRA measures.

Program Evaluation: Assessing the Results
The purposes of the HRSA evaluation program are to enhance performance planning and reporting, strengthen budget and legislative development, and improve program management. HRSA’s evaluation priorities align closely with the HHS evaluation strategy and its five priority areas for evaluation activities:

• Assessment of the effectiveness of programs and strategies used to achieve public health and human service goals and objectives.
• Assessment of the health and human services environment to understand how changes in the environment affect the public programs and strategies.
• Improvement in the management of public health and human service programs.
• Development of performance measures and data systems for measuring progress toward achieving the public health and human service goals and objectives.
• Support for maintaining and improving the infrastructure needed to evaluate programs.

Effectiveness of Programs and Strategies
An evaluation of program effectiveness assesses intermediate and longer-term outcomes or impact of programs in relation to their intended goals. Types of evaluation activity examining the effectiveness of HRSA programs include:

1. impact of programs on utilization, cost of care, and patient outcomes;
   
2. effectiveness of technical assistance; and
3. effectiveness of distance learning on enhancement of knowledge and skills.

Environmental Assessments
Fundamental changes are taking place in the way health services are delivered in the United States. Understanding the impact of these environmental forces on public health programs and consumers is essential for adjusting public health programs and strategies in the future. HRSA’s activities related to environmental assessment include:

1. assessing effects of major policy and market changes on the viability of safety-net providers in community-based systems of care;
2. monitoring trends in supply and demand of health professions; and
3. assessing effects of major legislative changes on the ability of individuals with HIV/AIDS to obtain medication.

Improving Program Management
Effective management of HRSA’s programs is essential for success in achieving its goals and objectives. Program management studies provide assistance in the development, implementation, and continuous improvement of program management activities. Types of activity related to program management include:

1. providing technical assistance to HRSA grantees on civil rights compliance requirements;
2. providing technical assistance to HRSA grantees on the implementation of the Health Insurance Portability and Accountability Act (HIPAA);
3. identifying technical assistance needs for improving the performance of HRSA sub-grantees;
4. assessing and providing recommendations for programmatic and management improvements in HRSA programs; and
5. performance reviews to improve the performance of HRSA funded programs and provide feedback on HRSA policies and their impact on program performance.

Performance Measurement and Data Systems
Evaluation of performance measurement includes technical assistance and training to strengthen the Agency’s capacity to respond to the requirements of the Government Performance and Results Act (GPRA) and the Performance Assessment Rating Tool (PART), and to lay a foundation for assessing program performance over time. Types of HRSA activity related to performance measurement and data systems include:

1. providing technical assistance to HRSA’s programs in the refinement and update of their GPRA/PART performance measures;
2. implementing Maternal and Child Health (MCH) discretionary grant program performance measures and an associated data system for reporting;
3. developing and implementing an enterprise-wide information management system to allow the linkage of grant, program, performance, and budget information for program evaluation and decision-making at all levels of the HRSA organization; and
4. instituting an Agency wide performance review process for reviewing and enhancing the performance of HRSA funded programs within communities and States.

Supporting an Evaluation Infrastructure
The development of an infrastructure to support evaluation activities, including design and programming for tabulations, statistical and numerical analyses of data, modeling, and the acquisition of databases and other statistical information, is critical to conducting high quality evaluations. HRSA supports the acquisition and analysis of several databases including:

1. Area Resource File (ARF);
2. National Nursing Sample Survey;
3. Health Centers Sentinel Network Database for Primary Care Research; and
4. Health Centers Uniform Data System (UDS).

Partnerships and Coordination
A major source of HRSA’s strength is its many linkages and partnerships with other Federal agencies, States, and national and local organizations. Achievement of its mission is dependent on effective partnerships and HRSA continuously seeks new and renewed relationships with external entities to leverage resources, create synergy, and extend capacity to address the health and health system issues and problems confronting the communities we serve. In its revised Strategic Plan, HRSA identifies as a core value underpinning the development and management of its programs the creation of useful, effective forms of collaborations with partners in regulation, research, service delivery, and management.

• Federal partners such as ACF, CDC, SAMHSA, CMS, VA, DOJ, HUD, AHRQ, and IHS. Examples include:
  • HRSA’s and CDC’s partnership efforts focus on a variety of disease prevention and health promotion activities, including immunization efforts, diabetes detection, and improved data collection and analysis.
  • HRSA and CDC have worked closely with the Office of Public Health Emergency Preparedness to implement new programs to improve preparedness for bioterrorism and other mass casualty events.
  • HRSA and CDC collaborate on a great number of HIV/AIDS issues, including prevention, intervention, and continuity of care issues, as well as service delivery research.
  • HRSA and AHRQ partner on various research efforts such as studies of the health care safety net and HIV/AIDS services.
  • HRSA collaborates with SAMHSA to integrate behavioral health/substance abuse screening, early intervention, referral, and follow-up into primary health care settings funded through HRSA grants.
  • HRSA and IHS collaborate to share resources in remote geographic areas.
  • HRSA and DOJ partner in work related to Vaccine Injury Compensation.
  • HRSA, along with several other agencies, is involved in a collaborative effort to increase health literacy.
• State and local government partnerships through such programs as the Maternal and Child Health Block Grant, Ryan White Care Act Programs, State Offices of Rural Health, and National Bioterrorism Hospital Preparedness.
• National associations and organizations linkages, such as with those representing State and local public health agencies, groups of primary health care providers, adults and children with special health care needs, and health professions associations.
• Work with academic institutions, such as the variety of partners working on health professions training, workforce analysis, and health services research and evaluation.
• Links with foundations, such as the Robert Wood Johnson Foundation, the Kellogg Foundation and the Kaiser Family Foundation.
• Linkages with business groups such as the thousands of businesses involved in helping educate employees and members about the urgent need for organ donation.