[Federal Register Volume 65, Number 24 (Friday, February 4, 2000)]
[Notices]
[Pages 5647-5649]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 00-2567]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration


Availability of Funds for Grants for the Community Access Program

AGENCY:  Health Resources and Services Administration, HHS.

ACTION:  Notice of availability of funds.

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SUMMARY:  The Health Resources and Services Administration (HRSA) 
announces the availability of $25 million to assist communities and 
their safety net providers in developing integrated health care 
delivery systems that serve the uninsured and underinsured with greater 
efficiency and improved quality of care. The $25 million in available 
funding has been appropriated under the FY 2000 HHS Appropriations Act.
    In FY 2000, HRSA will provide funding for approximately 20 
communities to further their development of integrated delivery systems 
for the uninsured and underinsured. Grants will vary in size, based on 
the scope of the project and the size of the service area.
    During the first year of funding for this program, HRSA will 
support infrastructure development in communities that have already 
begun to reorganize and integrate their health care delivery systems. 
FY 2000 funding is not intended to support those communities that have 
not yet begun the planning and development of necessary organizational 
structure.
    Up to 100 communities may ultimately be funded as part of this 
national program targeted by the Administration to spend $1 billion 
over five years. FY 2000 funded communities may be eligible for 
available FY 2001 funding (assuming continued appropriations) to 
support further infrastructure development and filling service gaps. In 
addition, using the experiences of the FY 2000 funded communities as 
potential models for adaptation, FY 2001 funding is anticipated for 
support of new communities for planning and system development. Thus, 
communities that have not yet begun the planning and development of 
necessary organizational structure should have an opportunity to apply 
in FY 2001.
    Over the years that the program is funded, funds are anticipated to 
be available to fill service gaps within coordinated systems of care.
    This program shares some of the same goals of the W.K. Kellogg 
Foundation's Community Voices Program and the Robert Wood Johnson 
Foundation's Communities in Charge Program. Thus, CAP will take into 
account the experiences of these foundations as well as other programs 
that promote the integration of services to the uninsured and 
underinsured.

DATES:  The timeline for application submission, review, and award are 
as follows:
    February 10, 2000: Application kits and additional guidance will be 
available through the HRSA Grants Application Center (GAC).
    March 7-16, 2000: There will be a series of six pre-application 
workshops conducted across the country: Boston, MA--March 7, 2000; 
Atlanta, GA--March 8, 2000; Chicago, IL--March 9, 2000; Dallas, TX--
March 14, 2000; Los Angeles, CA--March 15, 2000; Seattle, WA March 16, 
2000.
    June 1, 2000: Applications due.
    July 3-17, 2000: Applications reviewed.
    August 2000: Site visits to selected applicants.
    September 2000: Grant awards announced.

ADDRESSES:  To receive a complete application kit (i.e., application 
instructions, necessary forms, and application review criteria), 
contact the HRSA GAC at: HRSA GAC, 1815 N. Fort Meyer Drive, Suite 300, 
Arlington, VA 22209, Phone: 1-877-HRSA-123, Fax: 1-877-HRSA-345, E-
Mail: [email protected]

FOR FURTHER INFORMATION CONTACT:  For further information, contact the 
Community Access Program Office: Community Access Program Office, 
Health Resources and Services Administration, Parklawn Building, Suite 
9A-30, 5600 Fishers Lane, Rockville, MD 20857, Phone: (301) 443-0536, 
Fax: (301) 443-0248.

SUPPLEMENTARY INFORMATION:  In 1998, 44.5 million people in the United 
States did not have health insurance. Of these, 24.6 million were 
employed--18.7 million worked full time and 5.9 million worked part 
time.
    The uninsured and underinsured often have complex medical needs, 
remain outside organized systems of care, and have insufficient 
resources to obtain care. They may defer care or not receive needed 
services, and they are about half as likely to receive a routine check-
up as insured adults. The uninsured and underinsured also rely heavily 
on expensive emergency rooms, and because they lack a routine source of 
care, they often do not receive needed follow-up services.
    Many of the uninsured and underinsured rely on the nation's 
institutions, systems, and individual health professionals that provide 
a significant volume of health care services without regard for ability 
to pay. In many communities, these providers are struggling to care for 
the increasing numbers of uninsured and underinsured individuals. They 
face many challenges such as an uneven distribution of the burden of 
uncompensated care, the fragmentation of services for the uninsured, 
insufficient numbers of certain types of providers, reduced Medicaid 
revenues, and a growing need for mental health and substance abuse 
services.
    While integration among these providers is critical to serve the 
uninsured and underinsured with greater efficiency and to improve 
quality of care, many of these providers are so pressured by basic 
caregiving tasks, that they need assistance to coordinate their efforts 
with other providers and to develop integrated community-based systems 
of care.

The Community Access Program

Program Purpose

    The purpose of this program is to assist communities and consortia 
of

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health care providers to develop the infrastructure necessary to fully 
develop or strengthen integrated health systems of care that coordinate 
health services for the uninsured and underinsured.

Program Goal

    The coordination of services through the CAP grant will allow the 
uninsured and underinsured to receive efficient and higher quality care 
and gain entry into a comprehensive system of care. The system will be 
characterized by effective collaboration, information sharing, and 
clinical and financial coordination among all levels of care in the 
community network. The system will be committed to continuous 
performance improvement, implementation of best practices, staff 
development, and real-time feedback of outcomes of care. Care 
management (e.g., case, disease) will be applied across the continuum 
for those with chronic illnesses, high-risk individuals, and high 
utilizers. The system will also strive to provide universal access to 
the target population, and to improve the health status of the 
community population.
    This vision requires a re-thinking of the relationships, 
priorities, and desired outcomes for local or regional care delivery. 
It means adopting the philosophy that care for the ill and injured 
occurs within the context of a comprehensive system design of 
population health improvement.
    The community being served should be actively involved in the 
system design. Broad understanding, two-way learning between providers 
and community, and participation in priority setting and governance by 
the community are essential components of this vision. This will reduce 
out migration for services in rural areas and assure sustainability of 
the system.

Program Description

    In implementing a system of coordinated care for the uninsured and 
underinsured in a community, we are seeking to fund a variety of 
program models in communities that have an established track record for 
building partnerships and that have completed the basic planning 
necessary to implement a system. The successful applicant will design a 
program that builds upon its current capacities and strengths; brings 
the major players in the political and health delivery systems to the 
table; uses the federal funds available to plan a transition to an 
expanded and innovative approach that will ultimately be competitive 
within its own market; and, in any event, will sustain the delivery of 
services and funding after these federal grants no longer exist. The 
successful applicant will work with its county board, city council, 
state legislature, and state health programs to assure the coordination 
and efficient use of all available resources to achieve program goals.
    There is no one successful model that we are trying to replicate. 
Rather, there are several models that already exist and that each 
community may draw from in creating a program to address its own needs.
    In surveying innovative community approaches to the provision of 
safety net services, we have come across communities that have:
     combined the development of managed care networks for the 
indigent funded through local tax increases and the redirection of 
funds towards the care network and away from the support of tertiary 
care at public hospitals;
     Redistributed caseload to private providers because of the 
forced closure of public hospitals;
     Coordinated the provision of care through public 
hospitals, public health departments, and community health centers;
     Linked hospital and clinic services through state of the 
art data systems and are able to create seamless transitions between 
Medicaid, uninsured, and insured status for low income populations;
     Linked behavioral and acute care service provision; and
     Created networks to allocate uncompensated ambulatory care 
loads among physicians.
    We are looking for applicants with clear goals, an operational plan 
for meeting those goals, a history of commitment to serving indigent 
populations, and enough of a track record to indicate a fair chance at 
being successful. Innovative proposals for sustaining the service 
delivery component of projects could include state redirection of DSH 
funds or general assistance funds, creative use of local or state 
taxing authorities, use of tobacco settlement funds, and creative 
partnerships with the provider and business communities. Applications 
will be judged from the perspective of whether the financing proposed 
is realistic--given state and community resources--and appropriate to 
the project proposed.

Funded Projects Will Contain Several Common Elements

    Community Need: Communities funded through this program will have 
high or increasing rates of uninsured and underinsured and will have 
identified specific organizational needs within existing delivery 
systems. A ``community'' for the purpose of this program may be based 
on geography or a population group (e.g., the homeless) as defined by 
the people in the community.
    Collaboration Among Safety Net Providers: The proposed system 
should build upon current investments in communities for serving these 
populations and include the safety net providers who have traditionally 
provided services without regard to the ability to pay. The coalition 
should be built upon formal arrangements among the partners that define 
the extent of the commitment and involvement in policy development and 
decision-making from each partner.
    Comprehensive Services: The proposed system will include all 
partners necessary to assure access to a full range of services, 
including mental health and substance abuse treatment. It is 
anticipated that the health services (prevention, primary, and 
specialty) provided by Federally-supported programs that are present in 
the community will be part of this coalition of providers.
    Coordination with Public Insurance Programs: The proposed system 
will demonstrate coordination with state (e.g., memorandum of 
agreements) programs to ensure that eligible beneficiaries are enrolled 
in public insurance programs (e.g., S-CHIP, Medicaid).
    Community Involvement: There is strong community support for these 
efforts that provide a broad foundation of assistance to the provider 
community undertaking this project. Management and governance 
structures are in place that assure accountability to funders and 
define the community role in setting policy. The community involvement 
in the development, implementation, and governance of the project will 
be evident. This should include the leadership within the appropriate 
legislative and executive bodies, providers identified above, health 
plans and payers, and community leaders.
    Sustainability: A plan for long-term sustainability is designed and 
has community consensus. There is evidence that the program is capable 
of leveraging other sources of funds and integrating current funding 
sources in a way to assure long-term sustainability of the project.

Eligible Applicants

    To encourage the development of various types of system integration 
models, this program seeks a variety of

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applicants representing all types of communities. Applicants who 
receive funding may be large health care systems or small 
organizations. Applications are encouraged from large urban areas, 
small rural communities, and tribal organizations.
    Applications may be submitted by public, private, and non-profit 
entities that demonstrate a commitment to and experience with providing 
a continuum of care to uninsured individuals. Each applicant must 
represent a community-wide coalition that is committed to the project 
and includes safety net providers (where they exist) who have 
traditionally provided care to the community's uninsured and 
underinsured regardless of ability to pay. The community-wide coalition 
must consist of partners from all levels of care (i.e., primary, 
secondary, tertiary) and partners who represent a range of services 
(e.g., mental health and substance abuse treatment, maternal and child 
health care, oral health, HIV/AIDS).
    Examples of eligible applicants who may apply on behalf of the 
community-wide coalition include but are not limited to:
     A consortium or network of providers (e.g., public and 
charitable hospitals; community, migrant, homeless, public housing, and 
school-based health centers; rural health clinics; free health clinics; 
teaching hospitals and health professions education schools)
     Local government agencies (e.g., local public health 
departments with service delivery components)
     Tribal governments
     Managed care plans or other payers (e.g., HMOs, insurance 
companies)
    Agencies of State governments, multi-state health systems, or 
special interest groups may submit applications on behalf of multiple 
communities if they demonstrate the ability to coordinate community 
health care delivery systems and bring resources to the community.
    Competing applications for the same patient population will not be 
considered for funding; therefore, applicants from the same community 
are required to collaborate.

Funding Criteria

     Review criteria that will be used to evaluate applications 
include:
     Evidence of progress towards integration prior to 
application for funding
     Evidence that the target population has a high or 
increasing rate of uninsurance
     Evidence of established partnerships among a broad-based 
community consortium
     Appropriateness and quality of clinical services to be 
provided
     Commitments from local government agencies, public and 
private health care providers, community leaders
     Demonstration of existing and sustainable public and 
private funding sources
     Accountable management and budget plan
     Commitment to self evaluation and participation in a 
national evaluation

Program Expectations

    Funding through this initiative may be used to support a variety of 
projects that would improve access to all levels of care for the 
uninsured and underinsured. While each community should design a 
program that best addresses the needs of the uninsured and 
underinsured, and the providers in their community, funding is intended 
to encourage safety net providers to develop coordinated care systems 
for the community's uninsured and underinsured.
    Examples of activities that could be supported with this funding 
include:
     Offering a comprehensive delivery system for the uninsured 
and underinsured through a network of safety net providers. [Single 
registration, eligibility systems]
     Integrating preventive, mental health, substance abuse, 
HIV/AIDS, and maternal and child health services within the system. 
[Block grant funded services, other DHHS programs, state and local 
programs]
     Developing a shared information system among the 
community's safety net providers. [Tracking, case management, medical 
records, financial records]
     Developing and incorporating shared clinical protocols, 
quality improvement systems, utilization management systems, and error 
prevention systems.
     Sharing core management functions. [Finance, purchasing, 
appointment systems]
     Coordinating and strengthening priority services to 
specific targeted patient groups.
     Developing affordable pharmaceutical services.

Use of Grant Funds

    Funding provided through this program may NOT be used to substitute 
for or duplicate funds currently supporting similar activities. Grant 
funds may support costs such as:
     Project staff salaries
     Consultant support
     Management information systems (e.g., hardware and 
software)
     Project-related travel
     Other direct expenses necessary for the integration of 
administrative, clinical, information system, or financial functions
     Program evaluation activities
    With appropriate justification on why funds are needed to support 
the following costs, up to 15 percent of grant funds may be used for:
     Alteration or renovation of facilities
     Primary care site development
     Service expansions or direct patient care
    Grant funds may NOT be used for:
     Construction
     Reserve requirements for state insurance licensure

Expected Results

    The integration and coordination of services among a community's 
safety net providers are expected to result in:
     A system of care that provides coordinated coverage to the 
target population.
     Increased access to primary care resulting in a reduction 
in hospital admissions for ambulatory sensitive conditions among the 
uninsured and underinsured.
     Elimination of unnecessary, duplicate functions in service 
delivery and administrative functions, resulting in savings to reinvest 
in the system.
     Increased numbers of low-income uninsured people with 
access to a full range of health services.

    Dated: January 31, 2000.
Claude Earl Fox,
Administrator.
[FR Doc. 00-2567 Filed 2-3-00; 8:45 am]
BILLING CODE 4160-15-U