[Federal Register Volume 59, Number 111 (Friday, June 10, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-14088]


[[Page Unknown]]

[Federal Register: June 10, 1994]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
[PN 2243]
RIN 0905-ZA 63

 

Special Projects of National Significance

AGENCY: Health Resources and Services Administration.

ACTION: Notice of availability of funds.

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SUMMARY: The Health Resources and Services Administration (HRSA) 
announces the availability of up to $10.5 million in fiscal year (FY) 
1994 funds to be awarded as cooperative agreements under the Special 
Projects of National Significance (SPNS) program. The SPNS program, 
authorized by section 2618(a) of the Public Health Service Act, 
receives its appropriation of funds through Public Law 103-112. Project 
periods can be from three to five years, subject to Congressional 
reauthorization in FY 1996 of the Ryan White CARE Act. This 
announcement solicits two types of applications: (1) HIV service 
delivery model demonstration projects, or (2) HIV service delivery 
model demonstration projects in conjunction with an evaluation and 
dissemination center. The SPNS program, in collaboration with the 
evaluation and dissemination center(s), will sponsor multi-site program 
evaluation studies. All HIV service delivery model demonstration 
projects agree, as a condition of grant award, to participate in these 
studies. Awards will be made to achieve population and geographic 
diversity.
    The SPNS program is designed to demonstrate and evaluate innovative 
and potentially replicable HIV service delivery models. The authorizing 
legislation specifies three SPNS program objectives: (1) To support the 
development of innovative models of HIV care; (2) to evaluate the 
effectiveness of innovative program designs; and (3) to promote 
replication of effective models. Therefore, crucial factors in 
appraising proposals for the HIV service delivery model demonstration 
projects will include the applicant's plan for conducting an evaluation 
of the model, the program's potential to improve access to, 
coordination of, and quality of, HIV service delivery, and a plan for 
disseminating findings about the model's effectiveness.
    Because of the complexity of this program, a cooperative agreement 
mechanism is being utilized to allow for substantial Federal 
programmatic participation in the conduct of the program, and to 
facilitate communication and coordination in the overall implementation 
and evaluation of the program. A steering committee will be established 
to facilitate coordination and cooperation among the service 
demonstration projects and the evaluation and dissemination center(s), 
and to oversee the cooperative agreements.

DATES: Applications for these announced cooperative agreements must be 
received in the Grants Management Office by the close of business July 
20, 1994, to be considered for competition. An advance notice of the 
application deadline date for the Special Projects of National 
Significance for FY 1994 was published in the Federal Register on April 
26, 1994 at 59 FR 21769. Applications will meet the deadline if they 
are either (1) Received on or before the deadline date or (2) 
postmarked on or before the deadline date, and received in time for 
submission to the objective review panel. A legibly dated receipt from 
a commercial carrier or U.S. Postal Service will be accepted in lieu of 
a postmark. Private metered postmarks shall not be accepted as proof of 
timely mailing. Applications received after the deadline will be 
returned.

ADDRESSES: Grant applications, guidance materials, and additional 
information regarding business, administrative and fiscal issues 
related to the awarding of grants under this Notice may be requested 
from Ms. Glenna Wilcom, Grants Management Officer, Bureau of Health 
Resources Development, Health Resources and Services Administration, 
5600 Fishers Lane, room 7-15, Rockville, MD 20857. The telephone number 
is (301) 443-2280 and the FAX number is (301) 594-6096. Applicants for 
grants will use Form PHS 5161-1, approved under OMB Control No. 0937-
0189. Completed applications should be sent to the Grants Management 
Officer.

FOR FURTHER INFORMATION CONTACT: Additional technical information may 
be obtained from Mr. George Sonsel or Mr. Russell Brady, SPNS Branch, 
Office of Science and Epidemiology, Bureau of Health Resources 
Development, Health Resources and Services Administration, 5600 Fishers 
Lane, room 7A-19, Rockville, MD 20857. The telephone number is (301) 
443-9976 and the FAX number is (301) 594-2511.

SUPPLEMENTARY INFORMATION:

Background and Objectives

    The SPNS program endeavors to advance knowledge and skills in HIV 
service delivery, stimulate the design of innovative models of care, 
and support the development of effective delivery systems for these 
services. SPNS accomplishes its purpose through funding and technical 
support of innovative HIV service delivery models. For purposes of this 
announcement, models seeking SPNS support must address at least one of 
the four (4) new service delivery system categories described below. 
Additional funding will be provided to one or more interested grantees 
to establish, either on site or by subcontract, evaluation and 
dissemination center(s) to provide technical assistance to grantees in 
the design and implementation of evaluation studies and dissemination 
activities, in collaboration with the SPNS program and the funded 
applicants.
    In establishing the current special project categories, 
consideration was given to the priority service areas identified in the 
concept paper, ``Future Directions: Increasing Knowledge about Health 
and Support Service Delivery to People with HIV Disease.'' This 
document was developed through interviews with, and written comments 
from, key HRSA staff and experts inside and outside the U.S. Public 
Health Service, and through a review of relevant HIV-related service 
delivery, research, evaluation, policy, and planning documents.

Descriptions: HIV Service Delivery Model Categories

    The Special Project Categories for FY 1994 will support the 
implementation and evaluation of innovative HIV service delivery 
models. SPNS funds cannot be used for expenses related to the provision 
of medical care; supportive services; or any other expenses currently 
reimbursed, subsidized or eligible for reimbursement through third 
party payors, grants awarded under Titles I-IV of the Ryan White CARE 
Act, or other grant and foundation sources. Applicants may not submit 
proposals for more than one subcategory in a category.
    Proposals will be accepted for HIV service delivery model projects 
that demonstrate and evaluate:
    (1) Comprehensive primary care service delivery systems for people 
with HIV within one of the distinct environments or settings described 
in the six following sub-categories.
    (a) Develop and evaluate the effectiveness of including new or 
existing support services as part of the basic benefits of a managed 
care plan or a comprehensive, coordinated care system.
    Because one of the potential strengths of managed care plans or 
coordinated care systems is their capacity to coordinate the services 
of several providers, the proposed service delivery model must test its 
ability to meet the wide range of service needs required by individuals 
with HIV. These service needs, in addition to primary care, may 
include, but are not limited to, specialty medical care, mental health 
services, substance abuse treatment, and/or assistance with locating 
housing, transportation, child care, etc. Grantees must evaluate 
changes in: (1) Patient adherence to medical treatment plans; (2) 
access to and use of medical and support services; (3) costs per-
patient of providing both medical and support services; and (4) patient 
satisfaction with services.
    (b) Test the feasibility of providing comprehensive HIV services 
under a capitated reimbursement system (including, but not limited to, 
Ryan White CARE Act Title I and Title II funds).
    Grantees must evaluate patterns of utilization of medical and 
support services under a capitated system, compare the costs of 
delivering services under a capitated reimbursement system with a fee-
for-service system, and evaluate client satisfaction.
    (c) Add primary care services to an intermediate level of care, i. 
e., subsidized housing, residential care, shelter, partial 
hospitalization, or other type of ``step down'' setting, for 
individuals with HIV disease.
    Grantees must evaluate the effectiveness of primary care services 
provided in this environment on reducing dependence on inpatient 
hospitalization, increasing the continuity of medical care, and 
improving client satisfaction.
    (d) Develop, in a geographically defined rural area, a 
comprehensive continuum of care for the purpose of increasing 
accessibility and quality of primary and specialty medical care to its 
residents with HIV disease.
    Grantees must explain how the proposed model accommodates the needs 
of the residents with HIV disease in relation to the health service 
delivery system characteristics of the area. Based on the needs of the 
area, models that supplement primary medical care with case management, 
psychosocial support, and other non-medical support services are 
encouraged.
    (e) Develop a service delivery model for adolescents and young 
adults (up to age 25) with CDC-defined Stage III or IV HIV disease that 
effectively manages their medical and, when appropriate, substance 
abuse treatment needs.
    Grantees should evaluate the model's effectiveness in meeting the 
full range of physical, psychological, social, and spiritual needs of 
adolescents and young adults who are seriously or terminally ill.
    (f) Develop a service delivery model for women with HIV disease 
that emphasizes the coordination of services from outreach, counseling 
and HIV testing, including expanded counseling and testing during 
pregnancy, through early intervention and care, including appropriate 
therapeutic drug regimens, for asymptomatic and symptomatic disease, 
and for prevention of transmission of HIV during pregnancy and 
delivery.
    Grantees must describe how the proposed model is using innovative 
features to reach pregnant women and women at high risk (e.g., 
substance abusing women) who have been reluctant to become engaged in 
traditional counseling/testing services, and how these women will be 
engaged and retained in care systems for themselves during and after 
pregnancy. Priority will be given to applicants in States or cities 
which have made the decision to ``routinely recommend'' that women 
(during pregnancy and/or whenever they receive primary care services) 
learn their HIV infection status for the purposes of improving their 
own care and health status; preventing transmission to their infants 
during pregnancy; and preventing transmission during breastfeeding. The 
funds will be used primarily to support system development and 
organizing and training providers. The intent of this sub-category is 
to foster systems of care for women with HIV; to encourage more women 
to know their infection status; to encourage States and cities to 
develop plans for accomplishing this; and to assess the reasons for and 
impact of the various decisions women make regarding HIV testing, use 
of AZT during pregnancy, and adherence to follow-up care decisions made 
jointly with providers.
    (2) Coordinated delivery of HIV health and support services to 
specific mobile populations in the United States, ensuring the delivery 
of continuous services throughout the course of HIV disease.
    For the purposes of this category, mobile populations are defined 
as border populations; populations with migration patterns primarily 
between the continental United States and its territories and 
commonwealths and between the United States and other countries; 
migrant farm labor workers; and, undocumented workers and residents. 
Examples of services needed by these populations include primary 
medical care, mental health services, and advocacy or other legal 
support services that address AIDS discrimination and access to care. 
Special attention must be paid to ensuring and documenting continuity 
of care for clients that receive care from providers located in 
different geographical locations. SPNS is seeking innovative methods of 
interagency communication and for tracking referrals between providers 
so that longitudinal follow-up of clients from provider to provider 
will be possible. Grantees must evaluate their success at ensuring 
continuity of medical care and access to needed support services.
    (3) Reduction of cultural, linguistic, and/or organizational 
barriers to care in a geographically defined area (e.g., neighborhood, 
community, region, state).
    Grantees must have the capacity to analyze reductions in 
organizational barriers to accessing care. AIDS service providers and 
other community-based organizations located in the geographic area and 
staffed by the cultural and/or linguistic group to be served by the 
proposed service delivery model are encouraged to apply under this 
category. Grantees submitting a proposal under Category #3 must address 
one of the following four populations:
    (a) An underserved population group experiencing significant 
barriers to care (e.g., men of color, HIV infected women, AIDS 
survivors, etc.) by addressing their access to care issues through 
organizational collaboration and inclusion in policy development.
    The grantee chooses the target population in this sub-category 
based on documented evidence that this population affected by HIV 
disease is not receiving services. At a minimum, collaboration among 
providers must include all Ryan White CARE Act-funded grantees in the 
area that serve the targeted population.
    (b) An ethnic group facing both linguistic and cultural barriers.
    A critical component of a proposed model in this sub-category must 
be the involvement of individuals and/or community-based organizations 
with established service relationships with the targeted special 
population.
    (c) Active substance abusers utilizing primary care on an 
intermittent basis or who do not adhere to their treatment regiment.
    Models for expanding enrollment and enhancing retention of HIV 
infected substance users, particularly active users, in primary care 
may include methods of increasing primary care providers' knowledge, 
receptiveness, and skill in treating this population.
    (d) Individuals or special populations experiencing HIV-based 
discrimination in health care, employment, and/or housing, that 
inhibits their receipt and/or utilization of health care services.
    Grantees must demonstrate and evaluate how innovative advocacy 
services targeting HIV discrimination impacts access to and utilization 
of appropriate health care for people whose needs are already 
complicated by cultural, linguistic or organizational issues.
    (4) Provider training and education models that develop, test, and 
evaluate strategies for increasing, improving or updating knowledge 
about HIV disease and its treatment for providers in rural areas, 
correctional facilities or mental health services programs and 
facilities.
    Grantees should collaborate, when feasible, with existing AIDS 
Education and Training Centers (AETC) and other training centers 
already providing education services to a wide variety of health care 
providers. Adoption, or adaptation to local conditions, of existing 
training models with outcome oriented evaluation is encouraged. The 
project's evaluation must specify the extent to which providers 
incorporate new skills and knowledge into their practices, and if there 
are any changes in numbers of people with HIV disease served by the 
provider. Evaluation designs comparing the results between different 
levels or intensity of training are encouraged.

Review Criteria: HIV Service Delivery Models

    All applications for HIV Service Delivery Model cooperative 
agreements described under Category (1) through (4) above and submitted 
to the SPNS program will be reviewed and rated by an objective review 
panel. Factors for the technical review of applications are as follows:
    Factor 1 (10 points). Adequacy of justification of need within the 
community and target population for the proposed program.
    Factor 2 (25 points). The feasibility, clarity of the description, 
appropriateness, innovative quality, and potential for replication and 
dissemination of the proposed model.
    Factor 3 (15 points). Comprehensiveness of the program plan as 
described in clearly stated goals, time-limited and measurable 
objectives for each goal, activities for each objective, and a time 
line that shows the scheduled production of materials that corresponds 
to milestones stated in the objectives and program evaluation.
    Factor 4 (20 points). Thoroughness, feasibility and appropriateness 
of the project's capability to conduct and collaborate on a 
comprehensive evaluation design and a plan for dissemination of the 
project's findings.
    Factor 5 (15 points). Competency of the applicant organization in 
fiscal and program management as evidenced by (a) the consistency 
between the proposed level of effort and the budget justification; (b) 
skill level and time commitment required in the personnel 
specifications; (c) the level of resources being proposed to conduct a 
quality evaluation of the project; and (d) appropriate confidential 
handling of medical, social service, and epidemiological data of 
clients served.
    Factor 6 (15 points). Extensiveness of coordination and 
collaboration with related HIV activities within the project's 
catchment area as documented by the applicant.

Additional Funding for SPNS Evaluation & Dissemination Center(s)

    In addition to the funds provided to successful applicants for 
development of service delivery model demonstration projects, 
additional funds will be provided to one or more successful applicants 
to establish, either on site or by subcontract, evaluation and 
dissemination center(s) to work with all of the SPNS grantees funded 
under the HIV Service Delivery Models Categories [1] through [4]. The 
Center(s) will have two primary responsibilities: (1) to provide 
technical assistance to SPNS grantees in designing and implementing 
evaluation studies and dissemination activities for their individual 
projects; and, (2) to develop and coordinate the implementation of 
cross-cutting evaluations within groups of similar projects. HRSA staff 
will offer advice and guidance and participate in each of these areas 
as well as monitor the Center's work to assure its progress is in 
accordance with program objectives and Federal requirements. HRSA staff 
may accomplish this task, in part, through an advisory panel composed 
of Federal employees and external consultants.
    Inclusion of a request for additional funding for the SPNS 
Evaluation and Dissemination Center is not a mandatory requirement of 
the application. Those applications not requesting this additional 
funding will be given equal consideration for service delivery model 
funding. All applications, regardless of inclusion of a request for 
evaluation center funding, will be scored first only on the applicant's 
proposal for the service delivery model. Service delivery model 
applications which are approved for funding will then be reviewed for 
interest in the additional funding. Only then will proposals for an 
evaluation and dissemination be reviewed and scored according to the 
following.

Review Criteria: Additional Funding for SPNS Evaluation & Dissemination 
Center(s)

    Those successful service delivery model applications which include 
a request for funding for the SPNS Evaluation and Dissemination Center 
(Part B) will be eligible for review and rating by an objective review 
panel of that part of the application. Applications will be considered 
for funding on the basis of overall technical merit as determined 
through the review process, and the proposed center's suitability for 
working with the funded SPNS projects. Factors for the technical review 
of Part B of the applications will include the following:
    Factor 1 (25 points). Qualifications and experience of the 
principal investigator, the proposed staff and consultants in designing 
and conducting health service evaluation studies, disseminating study 
findings and in providing technical assistance on evaluation and 
dissemination issues.
    Factor 2 (30 points). Adequacy of plans for providing technical 
assistance to SPNS grantees on program evaluation and information 
dissemination.
    Factor 3 (25 points). Adequacy of plans for designing and 
implementing cross-cutting evaluations within groups of similar 
projects and for assuring data quality.
    Factor 4 (20 points). Appropriateness of budget, staffing plans, 
facilities and information management resources, and time frame for 
implementing the project's operational and programmatic objectives.

Role of Federal Staff in Cooperative Agreements

    The cooperative agreement mechanism allows for substantial post-
award programmatic participation by SPNS staff in the projects' 
operations. In addition to the project officer's monitoring function, 
SPNS staff will be active participants in the operations of the HIV 
service delivery model demonstration projects and the SPNS evaluation 
and dissemination center. SPNS staff will facilitate the exchange of 
relevant information among the HIV service delivery model projects and 
provide support for training and consultation. SPNS staff will also 
monitor the function and activities of the center, assuring 
satisfactory progress and timely reporting.
    ``Substantial programmatic participation'' means that SPNS staff 
will provide guidance and coordination for certain programmatic 
activities to a degree beyond their customary stewardship 
responsibilities in grants administration. This may include, but is not 
limited to, the following: participating in the design and direction of 
activities to develop cross-cutting evaluation studies; assisting in 
the selection of project director and/or other key staff; assisting in 
the selection of contractors; participating in the analysis of data; 
coordinating or providing training of project staff; participating in 
selection and approval of analysis mechanisms; participating in 
selection of results for publication; and providing assistance in the 
management and technical performance of the project's activities.

Availability of Funds

    Section 2618, subsection (a) of the Public Health Service Act, 
``Special Projects of National Significance,'' permits the Secretary to 
allocate up to ten percent of the funds provided for Part B of Title 
XXVI to award grants directly to public and non-profit private entities 
to promote the statute's objectives. Approximately $9.7 million is 
available in FY 1994, to fund 25 HIV service delivery model 
demonstration projects estimating an average annual project budget of 
$350,000. The evaluation and dissemination center budget will be based 
on the availability of funds in relation to the objective review 
panel's recommendations. Approximately $600,000 is available in FY 1994 
for this Center. The budget and project periods for approved and funded 
projects will begin October 1, 1994.
    Project periods may be requested for up to five years. However, 
recommended support beyond the third year is subject to a determination 
by an objective review panel in conjunction with an assessment by the 
SPNS staff of the project's progress to date. All grants to support 
projects beyond the first budget year will be contingent upon the 
availability of funds, Congressional reauthorization of Ryan White CARE 
Act funding within the second project year, and satisfactory progress 
each year in meeting the project's objectives.
    All grantees funded to support HIV service delivery model 
demonstration projects under this Notice are encouraged to secure and 
show evidence of non-SPNS funding support equal to 20 percent of the 
approved project budget by the fourth project year, and equal to 40 
percent of the approved project budget by the fifth year. Applicants 
are required to submit, in the initial application, budgets for each 
proposed project year.

Eligible Applicants

    The statute, Section 2618 (a) (1), specifies that grants may be 
awarded to public and non-profit private entities to fund special 
programs for the care and treatment of people with HIV disease. 
Eligible entities may include, but are not limited to, State, local, or 
tribal public health, mental health, or substance abuse departments; 
public or non-profit hospitals; community-based service organizations 
(e.g., AIDS service organizations, primary health care clinics, family 
planning centers, AIDS discrimination and advocacy organizations, 
hemophilia centers, community mental health centers, substance abuse 
treatment centers, urban Indian health centers, migrant health centers, 
Ryan White CARE Act Title IIIb clinics, etc.); institutions of higher 
education; and national service provider and/or policy development 
associations/organizations.

Allowable Costs

    The basis for determining allocable and allowable costs to be 
charged to PHS grants is set forth in 45 CFR part 74, Subpart Q and 45 
CFR part 92 for State, local or tribal governments. The four separate 
sets of cost principles prescribed for public and private non-profit 
recipients are: OMB Circular A-87 for State, local or tribal 
governments; OMB Circular A-21 for institutions of higher education; 45 
CFR part 74, Appendix E for hospitals; and OMB Circular A-122 for 
nonprofit organizations.

Reporting and Other Requirements

    A successful applicant under this notice will submit semi-annual 
activity summary reports in accordance with provisions of the general 
regulations which apply under 45 CFR Part 74, Subpart J, ``Monitoring 
and Reporting of Program Performance,'' with the exception of State and 
local governments to which 45 CFR Part 92, Subpart C reporting 
requirements apply. As a condition of all awards funded under this 
Notice, grantees will be required to cooperate with HRSA and the SPNS 
Evaluation and Dissemination center(s) in any multi-site evaluation 
studies sponsored by the SPNS Program.

Healthy People 2000 Objectives

    The Public Health Service urges applicants to address a specific 
objective of the Healthy People 2000 in their work plans. Potential 
applicants may obtain a copy of Healthy People 2000 (Full Report; Stock 
No. 017-001-00473-0) or Healthy People 2000 (Summary Report; Stock No. 
017-001-00473-1) through the Superintendent of Documents, Government 
Printing Office, Washington, DC 20402-9325 (Telephone: (202) 783-3238).

Federal Smoke-Free Compliance

    The Public Health Service strongly encourages all grant recipients 
to provide a smoke-free workplace and promote the non-use of all 
tobacco products. This is consistent with the PHS mission to protect 
and advance the physical and mental health of the American people.

Public Health System Reporting Requirements

    This program is subject to the Public Health System Reporting 
Requirements which have been approved by the Office of Management and 
Budget under No. 937-0195. Under these requirements, any community-
based, non-governmental applicant must prepare and submit a Public 
Health System Impact Statement (PHSIS). The PHSIS is intended to keep 
State and local health officials apprised of proposed health services 
grant applications submitted from within their jurisdictions.
    Community-based, non-governmental applicants are required to 
submit, no later than the Federal due date for receipt of the 
application, the following information to the administrator of the 
State and local health agencies and to the State and local AIDS program 
director in the area(s) to be impacted by the proposal: (1) a copy of 
the face page of the application (SF 424); and, (2) a summary of the 
project, not to exceed one page, which provides: (a) a description of 
the population to be served; (b) a summary of the services to be 
provided; and, (c) a description of the coordination planned with the 
appropriate State or local health agencies. Copies of the letters 
forwarding the PHSIS to these authorities must be contained in the 
application materials submitted to this program.

Executive Order 12372

    The Special Projects of National Significance Grant Program has 
been determined to be a program subject to the provisions of Executive 
Order 12372, concerning intergovernmental review of Federal Programs, 
as implemented by 45 CFR Part 100. Under urgent conditions, the 
Secretary may waive any provision of this regulation. (See 45 CFR part 
100.13.) The Secretary has waived 45 CFR Part 100 due to the compelling 
need to get funds to grantees.
    The OMB Catalog of Federal Domestic Assistance number for the 
Special Projects of National Significance is 93.928.

    Dated: May 3, 1994.
John H. Kelso,
Acting Administrator.
[FR Doc. 94-14088 Filed 6-9-94; 8:45 am]
BILLING CODE 4160-15-P