Detailed Information on the
Healthy Start Assessment

Identifying and validating barriers to early and adequate prenatal care in order to plan strategies to improve access

Developing training activities for Healthy Start grantees to assure the ongoing quality of grantee data

Synthesizing emerging community-based best practices that contribute to improved perinatal outcomes, for future dissemination to the Healthy Start communities

Exploring mechanisms with national evaluators to provide a detailed report on the progress of all Healthy Start grantees on the annual and long-term measures

Measure: Reduce the infant mortality rates (IMR) among Healthy Start program clients. (Number of infant deaths per1,000 Live Births in among Healthy Start clients)

Explanation:Number of infant deaths per1,000 Live Births in among Healthy Start clients

Measure: Reduce the neonatal mortality rate among Healthy Start program clients. (Number of neonatal deaths per 1,000 Live Births among HS Program clients)

Explanation:Number of neonatal deaths per 1,000 Live Births among Healthy Start Program clients

Measure: Reduce the post-neonatal mortality rate among Healthy Start program clients. (Number of post-neonatal deaths per 1,000 Live Births among Healthy Start clients)

Explanation:Number of post-neonatal deaths per 1,000 Live Births among Healthy Start clients

Measure: Decrease annually the percentage of low birth weight infants born to Healthy Start program participants.

Explanation:

Measure: Increase annually the percentage of women participating in Healthy Start who have a prenatal care visit in the first trimester

Explanation:

Measure: INCREASE annually the number of community members (providers and consumers, residents) participating in infant mortality awareness public health information/ and education activities.

Explanation:* Some of the difference in the large increase reported between 2003 and 2004 is due to improvements in data collection and reporting. **As of June 21, 2006, 12 Healthy Start grantees have not submitted all of their 2005 data; subsequently the 2005 actual number of community members participating in Healthy Start public health information activities will be higher than the number displayed below. In addition, the data that has been provided (by 85 of the 97 grantees) is being reviewed for errors and other discrepancies. Therefore, as stated above, the Actual number provided for 2005 is preliminary and will be finalized later in 2006.

Measure: Increase the number of persons served by the Healthy Start program with a (relatively) constant level of funding.

Explanation:

Is the program purpose clear?

Explanation: The purpose of the program is to reduce the rate of infant mortality and improve perinatal outcomes through grants to project areas with high annual rates of infant mortality, as clearly stated in the Public Health Service Act (See Tab 1.1.1) and in the grant guidance.

Evidence: 1) Title III, Part D, Section 330H of the Public Health Service Act; 42 United States Code (USC) 254 c-8; 2) FY2006 Eliminating Disparities in Perinatal Health New Competing Application Program Guidance, page 4.

Does the program address a specific and existing problem, interest, or need?

Explanation: The program addresses the specific and existing public health problem of infant mortality. The United States (US) ranks 27th in infant mortality among industrialized nations. In 2002, the infant mortality rate (IMR) in the US was 7 per 1000 live births, an increase from the 6.8 IMR in 2001. The IMR dropped slightly to 6.85 in 2003. The Healthy People 2010 target is 4.5 per 1000 live births. There is consensus that eliminating racial/ethnic disparities in birth outcomes is key to the continued reduction in the overall rate of infant mortality in the United States. Blacks, American Indian/Alaska Natives, and Puerto Ricans, in descending order, have notably higher rates of infant mortality than other races/ethnicities. Moreover, the Institute of Medicine's (IOM) 2003 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, proposes that the sources of racial/ethnic disparities in health are "complex rooted in historic and contemporary inequities, and involve many participants at several levels, including health systems, health professionals, and patients" (Institute of Medicine 2003). IOM furthermore notes that many factors other than socioeconomic and clinical ones contribute to the problem, such as behavior and attitudes, cultural and language barriers for both participants and providers and within health systems.

Evidence: 1) Abt Associates, Inc. and Mathematica Policy Research, Inc. 2006. Racial and Ethnic Disparities in Infant Mortality: Evidence of Trends, Risk Factors, and Intervention Strategies. Cambridge, MA 2) FY2006 Eliminating Disparities in Perinatal Health New Competing Application Program Guidance, page 4, 10. 3) National Center for Health Statistics- http://www.cdc.gov/nchs/pressroom/04facts/infant.htm 4) Healthy People 2010 Objectives- http://www.healthypeople.gov/document/html/objectives/16-01.htm

Is the program designed so that it is not redundant or duplicative of any other Federal, state, local or private effort?

Explanation: The Federal Healthy Start program is not redundant or duplicative of any other Federal, State, local or private effort. The program is unique in that it both 1) provides direct services (home visits) to high-risk pregnant women and 2) works to reduce or eliminate gaps in health care and support services community-wide. Healthy Start projects are required to coordinate Healthy Start funded services and activities with State and local agencies administering Maternal and Child Health (MCH) Block grant programs under Title V of the Social Security Act. Coordination between each Healthy Start project and Title V programs eliminates duplication, and promotes cooperation, integration and dissemination of information with statewide systems and with other community services funded under the MCH Block grant. For similar reasons, projects must demonstrate established linkages with key state and local services and resources, such as Title XIX, Title XXI, WIC, Enterprise Communities/Empowerment Zones, community and migrant health centers and Indian/Tribal Health Services (See Tab 1.3.1). Healthy Start's service delivery model also differs in a few important ways from other programs. Some government-supported programs provide services only to pregnant women, while others focus on only infants, and/or low-income populations below the federal poverty level. Others public programs focus on specified services such as clinical care, or nutrition support, and at times these services are not well coordinated with other health resources in the areas in which they operate. Healthy Start projects work to target the highest risk communities and use outreach and case management to maintain women and their infant in care through two years after the end of each pregnancy. Research has demonstrated that following women and their infants over (at least) two years tends to improve and sustain positive health behaviors and outcomes. Each Healthy Start project is required to implement a core set of services including: outreach; case management; health education; interconceptional care; and screening for depression. In addition, projects must develop and implement four core systems efforts: development of a local health systems action plan; a consortium of key community stake holders including consumers; collaboration with the State Title V program; and a sustainability plan.

Evidence: 1) Health Resources and Services Administration, Maternal And Child Health Bureau, Healthy Start Program, (2005) Eliminating Disparities In Perinatal Health (General Population) HRSA-06-103, Open Competition Program Guidance-Fiscal Year 2006. page 1. 2) Title III, Part D, Section 330H of the Public Health Service Act; 42 United States Code (USC) 254 c-8.

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: The Healthy Start program has no major design flaws that prevent it from meeting its defined objectives and performance goals. There is no evidence that another approach or mechanism would be more efficient. Every project receiving federal Healthy Start funds must ensure the availability, within the project area, of the following Core Services: ?? Outreach and Client Recruitment ?? Case Management ?? Health Education ?? Interconceptional Care ?? Depression Screening and Referral These Core Services help lead to the project's achievement of core program goals in a clearly organized, effective, and efficient manner. In addition to the Core Services, Healthy Start requires each project to work on activities that will ensure that the project: ?? works collaboratively with others in the community and State ?? provides evidence of being sustainable beyond the time when federal funding is available ?? works within the community to establish and maintain a system of care that makes comprehensive perinatal care understood and available ?? provides sound management of resources. These activities can be grouped as the following four Systems Services: 1) Local Health Systems Action Plan for Comprehensive Perinatal Care 2) Consortium 3) Collaboration and Coordination Linkages with Title V and Others 4) Sustainability

Evidence: The following independently conducted evaluations support that the Healthy Start program is free from major design flaws that limit the program's effectiveness or efficiency: Abt Associates, Inc. and Mathematica Policy Research, Inc. (2006); Mathematica Policy Research, Inc. (2000); and, Kotelchuck and Fine (2000). Furthermore, a study by Abt Associates and Mathematica Policy Research, Inc. (2006) entitled Racial and Ethnic Disparities in Infant Mortality: Evidence of Trends, Risk Factors, and Intervention Strategies provides an evidence base to support the targeted interventions implemented by the national Healthy Start program.

Is the program design effectively targeted so that resources will address the program's purpose directly and will reach intended beneficiaries?

Explanation: Healthy Start is designed in a manner that targets resources to effectively meet the program's purpose. The Healthy Start program is structured so that resources reach the intended beneficiaries. The program can demonstrate that the correct beneficiaries are being targeted, and that activities that are funded by the Healthy Start program would not have otherwise been funded by other agencies or entities. Funding is made available to community-based projects that: ?? Meet eligibility criteria, specifically the long-term measure of having an infant mortality rate that is one and a half times the national average. Since the beginning of the Healthy Start program, the nation has seen a shift in infant mortality rates. The same shifts have also occurred within the Healthy Start communities. As the overall infant mortality rate has decreased nationwide, Healthy Start has adjusted to allow the projects to focus resources and activities on subsets and subpopulations within their community, including focusing on neonatal and post neonatal mortality rates. Instead of focusing its activities on the entire community's infant mortality rate, Healthy Start allows a project to focus on those people within the community that have the highest infant, post neonatal, and/or neonatal mortality rates and/or the greatest health disparities. ?? Have an existing or proposed active consortium of stakeholders with the expressed purpose of addressing issues related to infant mortality reduction or eliminating disparities in perinatal health. ?? Have a feasible plan to reduce barriers, improve the comprehensiveness and quality of the local perinatal system of care, and work towards eliminating existing disparities in perinatal health. Healthy Start is designed to ensure that resources support specific program purposes while reaching its target population. Healthy Start targets its services and activities to meet the unique needs and requirements of its population. Towards this end, Healthy Start works to fill gaps in the disparate community, particularly its health care system. By regularly conducting needs assessments, and through the use of their Local Health System Action Plan, the projects are able to better identify these gaps, and then target their activities to fill the needs of their community. Furthermore, projects are required to coordinate their Healthy Start funded services and activities with the State and local agencies that administer MCH block grant programs under Title V of the Social Security Act. Moreover, the projects must demonstrate established linkages with key State and local services and resources, such as Title XIX, Title XXI, WIC, Enterprise Communities/ Empowerment Zones, federally funded community and migrant health centers, and Indian/Tribal Health Services - again with the aim to prevent the duplication of services and to ensure that Healthy Start funds are used to fill gaps in the community's health care system. These linkages also assure that the program design effectively targets resources that address the intended target population's needs.

Evidence: 1) Title III, Part D, Section 330H of the Public Health Service Act; 42 United States Code (USC) 254 c-8. 2) FY2006 Eliminating Disparities in Perinatal Health New Competing Application Program Guidance. Page 1.

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: Between 2001 and 2002, the infant mortality rate (IMR or the number of deaths to infants under 1 year of age per 1,000 live births) in the U.S. increased from 6.8 to 7.0. The rise in the IMR was concentrated in the neonatal period (0-27 days), particularly in the early neonatal period (0-6 days). The IMR in the post-neonatal period (28 days to under 1 year of age) remained unchanged. Because a change in the overall IMR could be the result of a change at a specific period during the first year of life (e.g., neonatal vs. post-neonatal period), the long-term outcome measures for Healthy Start capture the overall IMR as well as the subset of neonatal and post-neonatal mortality.

Evidence: The specific long-term outcome measures of the Healthy Start program are: 1) Reduce the infant mortality rate among Healthy Start program participants 2) Reduce the neonatal mortality rate among Healthy Start program participants 3) Reduce the post-neonatal mortality rate among Healthy Start program participants

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation: The program has ambitious targets and timeframes for its long-term measures. To reduce the factors that contribute to the Nation's high infant mortality rate, particularly among African-American and other populations, Healthy Start (HS) provides services tailored to the needs of high risk pregnant women, infants and mothers in geographically, racially, ethnically, and linguistically diverse communities with exceptionally high rates of infant mortality. The program's mission is to achieve the Healthy People (HP) 2010 Objectives in infant, neonatal and post-neonatal mortality for all Healthy Start program participants. In establishing targets for this objective, Healthy People utilized a method described as "better than the best." Given the characteristics of the Healthy Start participants and their vulnerable communities, it is sufficiently ambitious to decrease infant, neonatal and post-neonatal mortality at a rate equal to the rate that it will take the nation to achieve the Healthy People 2010 Objectives for infant, neonatal and post-neonatal mortality. In January 2006, the Center for Disease Control and Prevention's (CDC) National Center for Health Statistics (NCHS) released 2003 final mortality data for the United States (See evidence. The 2003 infant mortality rate for the nation has dropped to 6.85; the neonatal mortality rate is 4.62 and the post-neonatal is 2.23. To achieve the HP 2010 objective, the national infant mortality rate must decline by a rate of 0.049 annually.

Evidence: To achieve the HP 2010 objective, the national infant mortality rate must decline by a rate of 0.049 annually. Applying this rate of decline to Healthy Start, the targets for Healthy Start's three long-term measures are as follows: 1) Reduce the IMR among HS program participants to 4.28 infant deaths per 1,000 live births MEASURE HS 2004 BASELINE HS 2013 TARGET Infant Mortality Rate per 7.65 4.28 1,000 Live Births in HS Program Participants 2) Reduce the neonatal mortality rate among HS program participants to 2.7 neonatal deaths per 1,000 live births MEASURE HS 2004 BASELINE HS 2013 TARGET Neonatal Mortality Rate per 4.83 2.70 1,000 Live Births in HS Program Participants 3) Reduce the post-neonatal mortality rate among HS program participants to 1.58 post-neonatal deaths per 1,000 live births. MEASURE HS 2004 BASELINE HS 2013 TARGET Post-Neonatal Mortality Rate 2.82 1.58 per 1,000 Live Births In HS Program Participants

Does the program have a limited number of specific annual performance measures that can demonstrate progress toward achieving the program's long-term goals?

Explanation: Healthy Start (HS) has developed annual performance measures for GPRA that demonstrate progress toward achieving the program's long-term goals. The measures reflect program goals, factors contributing to infant mortality, and the intervention developed by the program. Interventions are categorized as: core services for risk assessment, risk reduction/prevention; core systems improvements to address access to quality care; and, community mobilization to address the gaps and barriers in the local health care system and broader service areas, as appropriate.

Evidence: The Healthy Start Program's Annual Performance Measures are: 1) The percentage of live singleton births weighing less than 2,500 grams among all live births to HS program participants. This measure reflects a major factor contributing to IMR and intermediate output of Healthy Start's core services for risk reduction and prevention. 2) The percentage of HS pregnant program participants who have a prenatal care visit in the first trimester. This measure reflects issues related to access to care in the community and output of Healthy Start's outreach activities. 3) The number of community members (providers and consumers, residents) participating in infant mortality awareness public health information/ and education activities. This measure reflects factors contributing to infant mortality at the community level and the community mobilization needed to achieve desired community-based system changes.

Does the program have baselines and ambitious targets for its annual measures?

Explanation: Baselines and ambitious targets have been developed for all annual performance measures.

Evidence: Healthy Start's annual performance goals, targets and timeframes are as follows: MEASURE HS 2004 BASELINE HS 2008 TARGET The percentage of live 9.3% 8.9% singleton births weighing less than 2,500 grams among all live births to HS program participants. The percentage of HS 70% 75% pregnant program participants who have a prenatal care visit in the first trimester of pregnancy. The number of persons 366,978 410,000 served with constant funding. The number of community 300,000 340,000 members (providers and consumers, residents) participating in infant mortality awareness public health information/ and education activities.

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) commit to and work toward the annual and/or long-term goals of the program?

Explanation: All partners commit to and work toward the annual and/or long-term goals of the program as detailed in the program guidance. Since February 2003, under MCHB's Discretionary Grants Information System (DGIS), Healthy Start grants report on a set of performance indicators reflecting the nine program elements (direct outreach services and client recruitment; case management; health education services; screening and referral for maternal depression; continuity of care through for the women and her infant for two year's following delivery (interconceptional care); utilization of community consortia and provider councils to mobilize key stakeholders and advise local grantees; development of a local health action plan; collaboration and coordination with Title V services; and development of a plan for continuation of services and project work beyond the grant period). Grantees use these indicators to monitor and improve their project's various services and interventions. They include program focused measures reflecting both services and systems building core activities (i.e., the number of Healthy Start participants identified and linked to medical home/primary health care as well as to other necessary services; the extent to which each of the system building interventions are accomplished.) There are also indicators describing participant characteristics and service utilization. In addition, there are a set of performance indicators considered common to all Healthy Start grantees from the current State Title V MCH reporting requirements that reflect program outcomes (infant mortality). All MCHB discretionary grant projects, including Healthy Start, are also expected to have a carefully designed and well planned evaluation protocol capable of demonstrating and documenting measurable progress toward achieving the stated goals. Required program tracking provides ongoing monitoring of the project on different aspects of the project's administration, fiscal and contract management, consortium, service delivery, collaboration/partnerships, impact on both perinatal indicators and on the community, and sustainability. The local evaluation, required performance measures and other outputs of program tracking are invaluable to the projects in justifying proposed project modifications, communicating and marketing the project to the community/public as well as to interested funding agencies and policy making agencies for sustainability and state wide policy development.

Evidence: 1) Health Resources and Services Administration, Maternal and Child Health Bureau, Healthy Start Program, Grantees Final Report- Healthy Start Impact Summary Guidance. 2) Health Resources and Services Administration, Maternal And Child Health Bureau, Healthy Start Program,(2005) Eliminating Disparities In Perinatal Health (General Population) HRSA-06-103, Open Competition Program Guidance-Fiscal Year 2006., pp.13-15 and pp.59- 60 Appendix G (Performance Measures); p.6-7 Core Systems and Efforts (Collaboration and Coordination Linkages); p.8-9 Project's Local Evaluation.

Are independent evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: Healthy Start conducts and supports non-biased and independent evaluations on a regular and as-needed basis to address information related to performance. These evaluations are of sufficient scope to improve planning with respect to the effectiveness of the program. For example, the program is currently undergoing a four year comprehensive independent National Evaluation. The evaluation is being conducted by Abt Associates, Inc. and Mathematica Policy Research, Inc. The current independent National Evaluation of the Healthy Start program is designed to answer the following four questions: ?? What are the features of the individual Healthy Start projects? By features, it is meant the characteristics of a project that reflect how the project operates ?? What results have Healthy Start projects achieved? By results, it is meant intermediate outcomes a project has achieved. ?? Is there an association or link between certain Healthy Start program features and the achievement of program results? ?? What types of Healthy Start features are associated with improved perinatal outcomes? This report is currently under review by HRSA. By the end of Calendar Year 2006, the ongoing national evaluation will result in a final Phase I report and chart book, as well as an interim report for Phase II (which is based on Case Studies of eight Healthy Start projects and Healthy Start Participant survey that has just received OMB approval). Findings from the national evaluation will be presented at national conferences as well as in peer-reviewed journals. There have also been two additional large-scale program-wide independent evaluation studies in the past: ?? In 1997 Mathematica Policy Research, Inc. submitted their final reports for the HRSA-sponsored national evaluation designed to study the implementation of the Healthy Start demonstration phase (1991-1996). This evaluation yielded a number of publications including: Devaney, et al's., Reducing Infant Mortality: Lessons Learned from Healthy Start (2000) ?? In 2000, The Healthy Start Initiative: Strategic Assessment and Policy Options was conducted by Kotelchuck and Fine for the Health Resources and Services Administration.

Evidence: 1) Abt Associates, Inc. and Mathematica Policy Research, Inc. 2006. Evaluation of the Implementation of Maternal and Child Health Bureau's National Healthy Start Program - Phase I. Evaluation Final Report. Cambridge, MA. 2) Devaney, Howell, McCormick, and Moreno. 2000. Reducing Infant Mortality: Lessons Learned from Healthy Start. Mathematica Policy Research. Washington, DC. 3) Kotelchuck and Fine. 2000. The Healthy Start Initiative: Strategic Assessment and Policy Options. Prepared for the Office of the Administrator, Health Resources and Services Administration. Washington, DC. 4) Thompson, et al., 2000. Community Involvement in the Federal Healthy Start Program. PolicyLink. Oakland, CA. 5) Abt Associates, Inc. and Mathematica Policy Research, Inc. 2006. Racial and Ethnic Disparities in Infant Mortality: Evidence of Trends, Risk Factors, and Intervention Strategies. Cambridge, MA.

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: Budgets are not explicitly tied to accomplishments of annual and long-term goals. The relationship between annual and long-term targets and budget resources is not clear.

Evidence: The budget justifications the Healthy Start program's activities are included in the Health Resources Administration Fiscal Year 2007 Justification of Estimates for Appropriation Committees.

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: The Healthy Start program has no current strategic planning deficiencies. When such deficiencies are identified there is a mechanism to address them both programmatically and through program management. The HS program has performance measures with baselines and targets. These are the program's GPRA measures. GPRA measures and the Healthy Start program accomplishments are reported as part of the annual budget process.

Evidence: 1) Kotelchuck and Fine. 2000. The Healthy Start Initiative: Strategic Assessment and Policy Options. Prepared for the Office of the Administrator, Health Resources and Services Administration. Washington, DC; 2) The Maternal and Child Health Bureau, Strategic Plan Fiscal Years 2003-2007.

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: Since the Healthy Start Program's inception grantees have been required to report on objectives that were outlined in their competitive application. Since February 2003, under MCHB's Discretionary Grants Information System (DGIS), Healthy Start grantees report on a set of performance indicators reflecting the nine program elements (direct outreach services and client recruitment; case management; health education services; screening and referral for maternal depression; continuity of care through for the women and her infant for two year's following delivery (interconceptional care); utilization of community consortia and provider councils to mobilize key stakeholders and advise local grantees; development of a local health action plan; collaboration and coordination with Title V services; and development of a plan for continuation of services and project work beyond the grant period). Grantees use these indicators to monitor and improve their project's various services and interventions. The Healthy Start program uses grantee performance data to improve the overall management of the program. At a minimum, the reports generated by the Healthy Start grantees are used: (1) in the annual budget process (2) to measure the progress of the HS programs long term and short term goals (3) to monitor the progress of the target population in meeting the Healthy People 2010 National goals, and (4) to monitor the achievements of the grantees. Since 1991, evaluation of program performance has been assessed annually and as a result, program requirements have evolved to what is now in effect, the implementation of a set of core services, and the building of a set of core systems that serves to improve the overall perinatal delivery system.

Evidence: 1) Health Resources and Services Administration, Maternal And Child Health Bureau, Healthy Start Program,(2005) Eliminating Disparities In Perinatal Health (General Population) HRSA-06-103, Open Competition Program Guidance-Fiscal Year 2006., pages 2) Health Resources and Services Administration, Maternal and Child Health Bureau, Discretionary Grant Information System www.perfdata.hrsa.gov/mchb/dgisreports/DGISReportsDesc.htm

Are Federal managers and program partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) held accountable for cost, schedule and performance results?

Explanation: All Federal managers on performance plans and program partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) are held accountable for cost, schedule and performance results. From HRSA's Administrator through the Associate Administrator for Maternal and Child Health to every staff member involved in the Healthy Start program, annual performance outputs, standards, and reviews address results of the Healthy Start Program. Furthermore, all grantees commit to and work toward the annual and/or long-term goals of the program as detailed in the program guidance. Under MCHB's Discretionary Grants Information System (DGIS), Healthy Start grants report annually on a set of performance indicators reflecting the cores services and system interventions of the program as well as outcome measures (which included neonatal and post neonatal infant mortality and the programs annual performance measures, (entry into prenatal care, LBW, and community participation in infant mortality reduction awareness activities).

Evidence: 1) Associate Administrator for Maternal and Child Health 2006 SES Plan 2) Director Division of Healthy Start and Perinatal Services, 2006 PEP Plan 3) 2006 Project Officers Performance Plans 4) U.S. Department Of Health And Human Services, Health Administration, Maternal And Child Health Bureau, Healthy Start Program,(2005) Eliminating Disparities In Perinatal Health (General Population) HRSA-06-103, Open Competition Program Guidance-Fiscal Year 2006., pages 22-23; 5) U.S. Department Of Health And Human Services, Health Administration, Maternal And Child Health Bureau, Healthy Start Program,(2005) Eliminating Disparities In Perinatal Health (General Population) HRSA-06-103, Open Competition Program Guidance-Fiscal Year 2006., Appendix 2, PM18-20 and Section C, Major Service Table.

Are funds (Federal and partners') obligated in a timely manner, spent for the intended purpose and accurately reported?

Explanation: The Healthy Start program works with HRSA'S Office of Financial Accountability and Management, Division of Grants Management Operations to assure that grants are administered in accordance with planned schedules and spent for intended purposes. By statute, at least 94 % of the Healthy Start appropriation is awarded as grants to state, local and community based organizations. As stated in the Healthy Start: Eliminating Disparities in Perinatal Health guidance for the continuation application Grantees are required to report their actual expenditures by category and future funding plans. The budgets and plans are submitted within the Discretionary Grant Information System (DGIS). The Project Officers and the Grants Management Specialist review these budgets. A copy of their most recent audit is also submitted with the continuation applications. The audits are sent to the Federal Audit Clearing House for review. If there are any discrepancies or unsatisfactory audits the Division of Grants Management Operations is notified. They in turn notify the Healthy Start program. Conditions are then placed on the Notice of Grant Award and grantees are required to correct the deficiencies within a reasonable period of time. Grantees are required to submit a Financial Status Report within 90 days after the end of the each budget period. It is within the FSR that grantees report any unobligated balances.

Evidence: Health Resources and Services Administration, Maternal And Child Health Bureau, Healthy Start Program, (2005) Eliminating Disparities In Perinatal Health (General Population) HRSA-06-103, Open Competition Program Guidance-Fiscal Year 2006. pages 93-107.

Does the program have procedures (e.g. competitive sourcing/cost comparisons, IT improvements, appropriate incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: The MCHB has implemented several information technology improvements including a web-based application for grantees. It is expected that this process will reduce the time and effort that Healthy Start and other grantees will need to prepare and submit their grant applications. The MCHB is in the process of implementing a Discretionary Grant Information System (DGIS) to automate and reduce the effort for grantees to report required progress on performance. The DGIS was developed to collect the data and includes a set of financial and program forms and 37 performance measures of which Healthy Start responds to twelve (12) to monitor discretionary grant programs. This system is similar to the MCHB Title V Information System. The centralized acquisitions office utilizes the Federal Acquisitions Requirements (FAR) and the Health and Human Services Acquisitions Requirements (HHSAR) to achieve efficiency and cost-effectiveness for all of Healthy Start's competitive sourcing. FAR and HHSAR procedures are designed to ensure that the best value is obtained for the government. An example of an efficiently outsourced activity is the Healthy Start National Evaluation, Phase I. The contractor selected for this task order underwent a 'double competition' before being awarded the contract: first, the contractor successfully competed to be listed on HHS' Program Support Center's (PSC) Indefinite Deliverable/Indefinite Quality (IDIQ) schedule; and then, the contractor was selected using a peer review method from several competitive proposals reviewed from IDIQ contractors. The program has maintained its level of Federal FTE totals during an extended period of program budget growth through improvement in efficiency of Federal program execution. Specific examples of procedures already in place include contracted technical assistance. Further, the Healthy Start program airs nine to twelve webcasts each year that have an enhanced capacity to reach 300 connections during the live broadcasts; each connection can accommodate unlimited participants. Because webcasts are archived, they can be used by an unlimited number of viewers twenty-four hours per day, seven days per week at the viewer's convenience. The program has also archived all work products, protocols, training documents, consumer, provider, and community information materials and other resources developed by each grantee at a virtual library since the inception of the Healthy Start program in 1991.

Evidence: As outlined in HRSA's justification for the President's 2007 Budget, the Healthy Start Program's efficiency measure is: The number of persons served with constant funding. In FY 2002, the Healthy Start appropriation was $98, 952,000 and 288,880 participants were served overall. In FY 2004, the appropriation was $97,751,000 and the number of participants served increased to 410,086. Average cost per participant decreased from $343 dollars per participant in FY2002 to $238 dollars per participant in FY2004. Other Evidence for 3.4 1) Health Resources and Services Administration, Maternal and Child Health Bureau, Discretionary Grant Information System www.perfdata.hrsa.gov/mchb/dgisreports/DGISReportsDesc.htm 2) Health Resources and Services Administration, Maternal and Child Health Bureau, Healthy Start Program, (2005) Eliminating Disparities In Perinatal Health (General Population) HRSA-06-103, Open Competition Program Guidance-Fiscal Year 2006. Appendix G: Program Specific Information - MCH Performance Measures, page 59-60 3) Health Resources and Services Administration, Maternal and Child Health Bureau website. www.mchb.hrsa.gov/TVIS 4) Maternal and Child Health Virtual Library: www.mchlibrary.info 5) Evaluation of the Implementation and Outcomes of the Maternal and Child Health Bureau's National Healthy Start Program- Task Order # 43

Does the program collaborate and coordinate effectively with related programs?

Explanation: The Federal Healthy Start program both coordinates and collaborates effectively with other federal programs such as CDC's National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Division of Reproductive Health (DRH); HRSA's Bureau of Primary Health Care's (BPHC) Perinatal and Patient Safety Health Disparities Collaborative Pilot Project (Perinatal Pilot); Maternal and Child Health Bureau's (MCHB) State Title V Block grant program; the Alliance for Information on Maternal and Child Health; CityMatCH's Perinatal Period of Risk (PPOR); The Association of Maternal and Child Health Programs (AMCHP); HRSA's HIV/AIDS Bureau; HRSA's Office of Women's Health and Office of Minority Health; and National Institutes of Health (NIH), National Institute of Child Health and Human Development (See Tab 3.5.1). Healthy Start grantees are required to coordinate their services and activities with the State and local agencies that administer Maternal and Child Health (MCH) Block Grant programs under Title V of the Social Security Act. Other state and local programs that the Healthy Start projects must demonstrate established linkages with include Title XIX, Title XXI, WIC, Enterprise Communities/Empowerment Zones, federally funded community and migrant health centers and Indian/Tribal Health Services (See Tab 3.5.1). As evidence of the scope of their collaborative efforts, Healthy Start grantees are required to submit letters of support from their State Title V agency and any formal agreements and letters of understanding with appropriate, actual or anticipated agencies or contractors (See Tab 3.5.2). Each of these collaborations has improved communications and the transfer of public health knowledge, practice, and expertise between Healthy Start and the partnering program(s). For example, through Healthy Start's 3-year collaboration with BPHC on their Perinatal Pilot, the Federally funded community health centers (CHCs), State Title V Agency and the Healthy Start projects in the pilot project areas meet to improve maternal and infant care and health outcomes in the CHCs. Prior to the Perinatal Pilot, the majority of participating CHCs had minimal or no contact with their local Healthy Start program. During and since the Perinatal Pilot, the CHCs frequently contact their local Healthy Start projects to benefit from their experience in solving perinatal care delivery issues.

Evidence: 1) Excerpts from FY 2005 Division of Healthy Start and Perinatal Services-Inter Agency Agreements; 2) Health Resources and Services Administration, Maternal And Child Health Bureau, Healthy Start Program, (2005) Eliminating Disparities In Perinatal Health (General Population) HRSA-06-103, Open Competition Program Guidance-Fiscal Year 2006. pages 1, 10, 11.

Does the program use strong financial management practices?

Explanation: In 2005, HHS received a material control weakness for its financial systems and processes. HRSA contributed to the material internal control weakness identified in the 2005 HHS audit. HHS is in the process of resolving these weaknesses by replacing existing accounting systems within HHS with the Unified Financial Management System (UFMS). UFMS is scheduled to be operational for HRSA in October 2006.

Evidence: Since 2003, HRSA has been not been included in a consolidated HHS audit. In a 2005 audit of HHS, Ernest and Young found a material weakness in HHS financial systems and processes. In particular, the audit found: Documentation regarding significant accounting events, recording of non-routine transactions and post-closing adjustments, as well as correction and other adjustments made in connection with data conversion issues must be strengthened. Processes to prepare financial statements need improvement. Financial systems are not FFMIA compliant. Weaknesses were identified in Department/Operating Division Periodic Analysis, Oversight and Reconciliations In addition, the audit found PSC's DFP CORE accounting system, which supports the activities of HRSA, did not facilitate the preparation of timely financial statements and did not have an efficient mechanism in place to compile accounting statements.

Has the program taken meaningful steps to address its management deficiencies?

Explanation: The Unified Financial Management System (UFMS) will improve funds control and monitoring and provide real-time data. In addition to streamlining the accounting process, HHS monitors funds received through annual Independent Financial Audits from grantees.

Evidence: To address management deficiencies, HRSA developed a baseline assessment of grantees to provide information about the overall strengths and weaknesses within the program. In 2005, HRSA implemented a web-based data collection system through the Electronic Handbook on the HRSA GEMS site to improve the data quality and elements collected. HRSA also held a TA conference call with consultants presenting elements of health care and business plans to incorporate program planning and provide HRSA program staff concrete information for grantee goals.

Are grants awarded based on a clear competitive process that includes a qualified assessment of merit?

Explanation: 100 percent of the grants awarded by the Healthy Start program are reviewed, ranked, and awarded according to a competitive process established by the centralized HRSA Division of Independent Review (DIR). This review includes the use of an objective review panel comprised of non-HRSA staff. The review criteria are taken directly from the program application guidance. There are no earmarks and all awards are subject to peer review.

Evidence: 1) Health Resources and Services Administration, Maternal and Child Health Bureau, Healthy Start Program, (2005) Eliminating Disparities In Perinatal Health (General Population) HRSA-06-103, Open Competition Program Guidance-Fiscal Year 2006. 2) Health Resources and Services Administration, Division of Independent Review, Objective Review Manual (HRSA.gov Intranet for complete copy)

Does the program have oversight practices that provide sufficient knowledge of grantee activities?

Explanation: Healthy Start Program project officers conduct annual reviews of grantee continuation applications and periodic on-site reviews. Feedback on the application is provided to the grantee both verbally through conference calls as well as in writing through Program Letters. Written responses to issues identified in the program letter are required from the grantee. Annual grantee meetings are held which provide an opportunity for grantees to present and discuss strategies being utilized by their projects to impact infant mortality reduction. This educational setting also provides the program with the opportunity to provide new information related to the Healthy Start program and discuss any overall issues. This information is compiled in proceedings, slides or handouts which are made available to the grantees for further use. All Healthy Start projects are involved in a National Healthy Start Evaluation which provides information about common performance measurements. Grantees are audited annually by independent accountants. Change of scope requests are reviewed by the program and recommended for approval or disapproval to the HRSA Division of Grants Management Operations. The HRSA Office of Performance Review conducts grantee performance reviews, providing programmatic and business management assessments, recommendations, on-site technical assistance and best practice identification. These reviews are coordinated with the program and results are shared with the grantee.

Evidence: Health Resources and Services Administration, Office of Performance Review description and mission statement; Scope Change Requests (Notice of Grant Award, Standard Term 4.).

Does the program collect grantee performance data on an annual basis and make it available to the public in a transparent and meaningful manner?

Explanation: The process for public viewing of grantee performance data from the DGIS is currently underway and will be available by the end of 2006. When completed, it will be a companion to the Title V Information System (TVIS) that is currently used to display state performance data. In addition, grantees are required to submit an Impact report at the end of the project period. This report details progress over the 4 year project period to included performance data. All impact reports are sent to the Maternal and Child Health Library for placement on the web.

Evidence: 1) Health Resources and Services Administration, Maternal and Child Health Bureau, Discretionary Grant Information System www.perfdata.hrsa.gov/mchb/dgisreports/DGISReportsDesc.htm Contract with Science Applications Information Corporation 2) MCH Virtual Library web site URL: HTTP//mchlibrary.com

Has the program demonstrated adequate progress in achieving its long-term performance goals?

Explanation: The program has demonstrated progress towards achieving its ambitious long-term performance targets as discussed in Section II. To reduce the factors that contribute to the Nation's high infant mortality rate (IMR), particularly among African-American and other disparate populations, Healthy Start (HS) provides intensive services tailored to the needs of high risk pregnant women, infants and mothers in geographically, racially, ethnically, and linguistically diverse communities with exceptionally high rates of infant mortality. To briefly summarize the explanation to questions 2.1 and 2.2, the Healthy Start long-term outcome measures and targets for 2013 are: 1) Reduce the IMR among HS program participants to 4.28 infant deaths per 1,000 live births (HS 2004 Baseline: 7.65 per 1,000 live births to HS program participants); 2) Reduce the neonatal mortality rate among HS program participants to 2.7 neonatal deaths per 1,000 live births (HS 2004 Baseline: 4.83 per 1,000 live births to HS program participants); 3) Reduce the post-neonatal mortality rate among HS program participants to 1.58 post-neonatal deaths per 1,000 live births. (HS 2004 Baseline: 2.82 per 1,000 live births to HS program participants) The Healthy Start program has achieved significant decreases among each of these mortality rates since 1993.

Evidence: In 1997, baseline data on the infant, neonatal and post-neonatal mortality rates between 1991-1993 was gathered from all Healthy Start projects. (deaths per thousand live births) 1991-1993 2004 Infant mortality rate 13 to 28.7 7.65 Neonatal mortality rate 3.1 to 23.8 4.83 Post-neonatal 3.6 to 10.2 2.82 Additional Evidence: 1) Department of Health and Human Services, Fiscal Year 2007, Health Resources and Services Administration, Justification of Estimates for the Appropriations Committee DHHS/HRSA Performance Budget FY 2007, (pages 196-199, 370-371). 2) Projected Infant, Neonatal and Post-Neonatal Mortality Rates Among Healthy Start Participants in 2013. G. Singh. ODIM, MCHB, HRSA, DHHS.

Does the program (including program partners) achieve its annual performance goals?

Explanation: 1) INCREASE annually the percentage of Healthy Start program participants that have a prenatal care visit in the first trimester a. Historical 1998 41.8% b. Historical 2003 73% b. Baseline 2004 70% d. Target 2008 75% 2) DECREASE annually the percentage of low birth weight infants born to Healthy Start program participants. a. Historical 1991-93 17.3-23.8% - of live births of HS clients b. Baseline 2004 9.3% - of live births of HS clients d. Target 2008 8.9% - of live births of HS clients 3) INCREASE annually the number of community members (providers and consumers, residents) participating in infant mortality awareness public health information/ and education activities. (new) a. Historical 2003 190,000 b. Baseline 2004 300,000** c. 2005 333,225* d. Target 2008 340,000 Data Source: Grantee Annual Reports * As of June 21, 2006, 12 Healthy Start grantees have not submitted all of their 2005. Of the 85 grantees that have submitted 2005 data, their data are being reviewed for errors and other discrepancies. Therefore, the 2005 data are preliminary and will be finalized later in 2006. ** Some of the difference in the large increase reported between 2003 and 2004 is due to improvements in data collection and reporting.

Evidence: 1) Department of Health and Human Services, Fiscal Year 2007, Health Resources and Services Administration, Justification of Estimates for the Appropriations Committee, DHHS/HRSA Performance Budget FY 2007, pages 196-199, 370-371. 2) The Maternal and Child Health Bureau Discretionary Grant Information System

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program goals each year?

Explanation: The historical data associated with Healthy Start efficiency measure demonstrates the program's improved efficiencies or increased cost-effectiveness. The Healthy Start efficiency measure with historical data is as follows: The number of persons served with relatively constant funding. HS funding # of HS participants $ spent/participant FY 2002 $98, 952,000 288,880 $343/HS participant FY 2004 $97,751,000 410,086 $238/HS participant FY 2008 430,000

Evidence: 1) The Department of Health and Human Services, Fiscal Year 2007, Health Resources and Services Administration, Justification of Estimates for the Appropriations Committee (pages 196-200, 370-371) 2) FY 2004 Grantee Reporting Data- Form 5 Major Services.

Does the performance of this program compare favorably to other programs, including government, private, etc., with similar purpose and goals?

Explanation: As stated previously in the answer to question 1.3, the Healthy Start program is unique in that it both 1) provides direct services (home visits) to high-risk pregnant women and 2) works to reduce or eliminate gaps in health care and support services community-wide. Other public and private programs with similar missions to that of Healthy Start tend to focus on providing direct services to high-risk pregnant women without addressing the community wide-gaps in health care and support services. Similarly, there exist many public programs (Federal and State) that work to fill the gaps in health care services among underserved communities, yet do not focus on the specific medical problems and social obstacles associated with high-infant mortality. Because the Healthy Start program attempts to do both of these things it is very difficult to compare its performance with other programs that are more limited or focused in their goals and objectives.

Evidence: Devaney, Howell, McCormick, and Moreno. 2000. Reducing Infant Mortality: Lessons Learned from Healthy Start. Mathematica Policy Research. Washington, DC.

Do independent evaluations of sufficient scope and quality indicate that the program is effective and achieving results?

Explanation: The Healthy Start program has undergone (or is currently undergoing) a number of different independent and comprehensive evaluations, conducted at the national level, including: 1) The continuing Abt Associates Inc.'s and Mathematica Policy Research, Inc.'s Evaluation of the Implementation of the Maternal and Child Health Bureau's National Healthy Start Program 2) 1997 Mathematica Policy Research, Inc.'s evaluation of the Healthy Start program 3) Kotelchuck's and Fine's The Healthy Start Initiative: Strategic Assessment and Policy Options Of these three studies only the Mathematica study provided information on the program's ability to achieve actual health outcome results, such as decreasing preterm birth rates (found in 4 of the original 15 Healthy Start sites), low and very low birth rates (found in 3 of the original 15 Healthy Start sites). It is important to note also that the Mathematica study was conducted in 1997 when there were only 15 Healthy Start sites (part of the initial demonstration project). Today there are 95 Healthy Start sites across the country. The ongoing national evaluation of the Healthy Start program, being conducted by Abt Associates and Mathematica Policy Research, produced a report that re-assesses the various factors responsible for the disparities in perinatal health outcomes among different socio-economic and racial/ethnic groups. Their study has determined that the Healthy Start program has focused its activities and interventions on the correct areas, but does not comment on the effectiveness of these interventions, how effectively they have been implemented, or whether or not these interventions have resulted in improved health outcomes (i.e. decreased infant mortality, decreased pre-term births, decreased low and very low birthweight births) among the HS program's participants.

Evidence: 1) Abt Associates, Inc. and Mathematica Policy Research, Inc. 2006. Evaluation of the Implementation of Maternal and Child Health Bureau's National Healthy Start Program - Phase I. Evaluation Final Report. Cambridge, MA. 2) Abt Associates, Inc. and Mathematica Policy Research, Inc. A Profile of the National Healthy Start Program. Findings from the National Survey of Healthy Start Programs, 2003 2) Devaney, Howell, McCormick, and Moreno. 2000. Reducing Infant Mortality: Lessons Learned from Healthy Start. Mathematica Policy Research. Washington, DC. 3) Kotelchuck and Fine. 2000. The Healthy Start Initiative: Strategic Assessment and Policy Options. Prepared for the Office of the Administrator, Health Resources and Services Administration. Washington, DC.