Annual Performance Plan and Report

Topics on this page: Goal 1. Objective E | Table of Related Performance Measures | Analysis of Results | Plans for the Future | Objective Progress Update Summary

Goal 1. Objective E: Ensure access to quality, culturally competent care, including long-term services and supports, for vulnerable populations

With the growing diversity of the U.S. population, healthcare providers are increasingly called on to address their patients’ differing social and cultural experiences and language needs. Provision of culturally competent care can increase quality and effectiveness, increase patient satisfaction, improve patient compliance, and reduce racial and ethnic health disparities. A number of HHS programs help make health care more accessible to people whose circumstances call for special attention, including older adults, children, people with disabilities, uninsured populations, persons with limited English proficiency, low income individuals, and those who live in remote areas. The 2013 National Healthcare Disparities Report issued by AHRQ finds that many racial and ethnic minorities have more limited access to care and receive lower quality care.

CMS programs facilitate health services for older adults, people with disabilities, and many low-income adults and children. Service delivery programs in HRSA, IHS, and SAMHSA enhance the availability of care in areas of high need. These HHS components strive to improve the quality of care their programs deliver. AHRQ regularly monitors healthcare quality and disparities, and through its grants and contracts, it focuses on improving how providers deliver care. Given the federal government’s unique legal and political relationship with tribal governments, IHS has a special trust obligation to provide health services for American Indians and Alaska Natives. HHS follows the President’s 2009 tribal consultation policy to partner with tribes to ensure access to quality health care.

ACF, ACL, AHRQ, CDC, CMS, FDA, HRSA, IHS, OASH, OCR, and SAMHSA have significant roles to play in realizing this objective. The Office of the Secretary led this Objective’s assessment as a part of the Strategic Review.

Objective 1.E Table of Related Performance Measures

American Indian and Alaska Native patients with diagnosed diabetes achieve Good Glycemic Control (A1c Less than 8.0%). (Lead Agency - IHS; Measure ID - 2)

Proportion of adults ages 18 and over who are screened for depression. (Lead Agency - IHS; Measure ID - 18)

Implement recommendations from Tribes annually to improve the Tribal consultation process. (Lead Agency - IHS; Measure ID - TOHP-SP)

Increase the likelihood that the most vulnerable people receiving Older Americans Act Home and Community-based and Caregiver Support Services will continue to live in their homes and communities. (Lead Agency - ACL; Measure ID - 2.10)

Increase the number of program participants exposed to substance abuse prevention education services (Lead Agency - SAMHSA; Measure ID - 2.3.56)

Increase the percentage of children receiving Systems of Care mental health services who report positive functioning at 6 month follow-up (Lead Agency - SAMHSA; Measure ID - 3.2.26)

Number of patients served by Health Centers (Lead Agency - HRSA; Measure ID - 1.I.A.1)

Increase the number of people receiving direct services through the Office of Rural Health Policy Outreach Grants. (Lead Agency - HRSA; Measure ID - 29.IV.A.3)

Field strength of the NHSC through scholarship and loan repayment agreements. (Lead Agency - HRSA; Measure ID - 4.I.C.2)

Increase the number of adult volunteer potential donors of blood stem cells from minority race or ethnic groups. (Lead Agency - HRSA; Measure ID - 24.II.A.2)

Reduce infertility among women attending Title X family planning clinics by identifying Chlamydia infection through screening of females ages 15-24. (Lead Agencies – HRSA and OASH; Measure ID - 36.II.B.1)

Percentage of individuals supported by the Bureau of Health Workforce who completed a primary care training program and are currently employed in underserved areas. (Lead Agency - HRSA; Measure ID - 6.I.C.2)

Proportion of persons served by the Ryan White HIV/AIDS Programs who are racial/ethnic minorities. (Lead Agency - HRSA; Measure ID - 16.I.A.1)

Analysis of Results

IHS, which incorporates tribal consultation to improve services for American Indians and Alaska Natives, has focused on some key health related issues for vulnerable tribal members. These include increasing the number of adults screened for depression when visiting IHS facilities and helping diabetic patients maintain good glycemic control. As a result of a more focused educational campaign conveying the benefits of early identification of depression, depression screening within IHS-operated facilities increased to 66 percent in FY 2014, missing its target by 0.9 percent but improving on the previous year’s result. During 2012-2013 and 2013-2014, the denominator increased 1.5 percent each year for a cumulative total of 16,490 new patients. The large increase in the denominator is one contributing factor to missing the FY 2014 target. Other contributing factors are a combination of staff turnover, recruitment of new staff unfamiliar with depression screening processes, and decreases in depression screening numbers among certain IHS Service Areas.

Good glycemic control among diabetic patients can help prevent associated health problems caused by diabetes. Glycemic control requires frequent medical visits, medications, and laboratory testing for blood sugar control. In FY 2013, IHS implemented new clinical standards of care, changing the glycemic control measure threshold. The FY 2014 result is 48.6 percent, exceeding the baseline target set in FY 2013. To strengthen the federal/tribal partnership, IHS engages American Indian and Alaska Native Tribes in open, continuous, and meaningful consultation. Out of this process in FY 2014, IHS implemented nine recommendations, exceeding the target. These included budgeting and contracting improvements and enhanced communication and deliberation opportunities. The substantial increases above the annual target in both FY 2011 and FY 2014 reflect the improvements made as a result of technology in communications with Tribes and the Agency's responsiveness to the implementation of the Affordable Care Act, the Indian Health Care Improvement Act reauthorization, and to congressional oversight.

Community based services and assistance to caregivers are crucial to enabling frail elderly clients to delay or defer nursing home placement. According to Genworth 2014 Cost of Care Survey the average cost in the US for a semi-private room in a nursing home is $77,380 per year. For many people, that level of annual expenditure for care cannot be obtained without spending down savings and liquidating other assets. Seeking alternatives to this level of costly care, while providing quality care in familiar surroundings for elderly individuals, is something that many senior citizens and family members prefer. ACL uses a “nursing home predictor” index which measures the prevalence of characteristics that frequently lead to nursing home placement. In FY 2013, the results showed continuous improvement with a resulting score of 64.2. Performance for FY 2013 shows a nearly 38 percent improvement over the FY 2003 baseline. As the score on the index increases it indicates an increase in the proportion of the high risk elderly population served through ACL funded services in the community. Since FY 2003, the index has increased substantially, demonstrating that in tight economic times ACL is succeeding in targeting community services and diverting individuals from more costly care.

SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.  SAMHSA’s Children's Mental Health Services program seeks to increase the percentage of children receiving systems of care mental health services who report positive functioning at 6 month follow-up.  A "system of care" is a strategic approach to the delivery of services and supports that incorporates family-driven, youth-guided, strength-based, and culturally and linguistically competent care.  This occurs through collaboration across agencies, families, and youth, while positive functioning relates to the general ability of the child to perform routine life activities.  In FY 2014, the percentage of children reporting positive functioning declined slightly to 62.5 percent, missing the target due to reduced resources, attrition rates, and difficulties acquiring enrollees.  Children’s mental health experts consider a target performance level of approximately 60 percent to be appropriate, given the serious mental health issues of children served by this program.  

Increased awareness of the consequences of substance abuse and risky sexual behaviors reduces the likelihood that those at highest risk and who are hardest to treat will engage in behaviors that place them at risk of HIV/AIDS transmission.  The goal of the Minority AIDS Initiative (MAI) is to prevent and reduce the onset of substance abuse and transmission of HIV among at-risk minority populations by delivering evidence-based substance abuse and HIV prevention interventions, including testing.  SAMHSA monitors the numbers of individuals receiving education in the areas of substance abuse prevention and health promotion, thus enhancing protective factors against substance abuse, and transmission of HIV and other sexually transmitted diseases.  In FY 2013, 6,437 program participants received substance abuse prevention education services, exceeding the target.  This result reflects a slight decline from the previous year due to the transition of cohorts within the program.

HRSA plays a vital role in ensuring access to quality, culturally competent care for vulnerable populations through its mission to improve health and achieve health equity through access to quality services. Health centers are community-based, patient-directed organizations that serve populations lacking access to high quality, comprehensive, cost-effective primary health care. Health centers served 21.7 million patients in FY 2013. This is 0.6 million more than the patients served in FY 2012 and represents a greater than 75 percent increase within a ten year period. Through the Office of Rural Health Policy, HRSA improves access to care in rural communities by utilizing Outreach grants that focus on community coalitions and partnerships. In FY 2013, 703,070 persons received direct services supported by these grant programs, exceeding the target substantially.

The Nation’s healthcare workforce is facing a number of significant challenges that are increasing demand, including changing population demographics, demand for health care services arising from increased health insurance coverage, and the imminent retirement of many Baby Boomer health professionals. HRSA’s Bureau of Health Workforce programs are designed to improve the health of the Nation’s communities, especially vulnerable populations, by supporting programs to augment the supply of health care providers who enter practice in underserved areas and increase access to quality health care. The overall percentage of graduates and completers who were directly supported by a Title VII or Title VIII program and went on to practice in a medically underserved community or health professional shortage area was 43 percent in FY 2013, meeting the target. Future targets are lower due to a change in estimation methodology.

The National Health Service Corps addresses the nationwide shortage of health care providers in areas of need by providing recruitment and retention incentives in the form of scholarship and loan repayment support to health professionals committed to a career in primary care and service to underserved communities. In FY 2014, the Corps field strength was 9,242, exceeding the target. Field strength is generally dependent upon variables such as the number of qualified applicants and the mix of scholarship and loan repayment support provided, among others.

HRSA manages the C.W. Bill Young Cell Transplantation Program to increase the number of unrelated blood stem cell transplants facilitated for patients in need. In FY 2014, 3.25 million persons on the donor registry self-identified as belonging to racial/ethnic minority populations, compared to 3.18 million in FY 2013.

More than 1.1 million people in the United States are living with HIV infection, and almost 1 in 6 (15.8 percent) are unaware of their infection. The CDC and HRSA are both striving to improve prevention and treatment results. Though new HIV infections among racial/ethnic minorities overall have been roughly stable, compared with non-racial/ethnic minorities, they continue to account for a higher proportion of cases at all stages of HIV – from new infections to death. The proportion of the Ryan White program’s service population that comprises racial/ethnic minorities is an indicator of access to treatment for populations disproportionately impacted by HIV/AIDS. In FY 2012, 72.6 percent of Ryan White program clients were racial/ethnic minorities. This compares to 67.1 percent of CDC-reported AIDS cases among racial/ethnic minorities, exceeding the target.

Another example of HHS’s support for providing care to a vulnerable population is evident through the provision of family planning and related preventive health services in Title X family planning clinics. Through these clinics, the Title X program implemented by HRSA and OASH screens young women for Chlamydia as part of the full range of family planning and related preventative health services by Title X clinics. An untreated Chlamydia infection can lead to pelvic inflammatory disease and potential infertility. The number of screenings was 1,164,170 in FY 2013.

Plans for the Future

IHS will also meet depression screening goals through promoting increased accountability for achieving targets at the regional and local levels for IHS operated programs, and a more focused educational campaign will be undertaken for Tribally operated programs to convey the benefits of depression screening. The screening tools and results are incorporated into the IHS Electronic Health Record. The system is now deployed and in operation in more than 250 clinical sites across the country. IHS will strive to maintain the FY 2014 baseline of patients with good glycemic control in FY 2015 and 2016; however targets have been reduced to reflect current challenges. Another ongoing goal is to maintain an open, continuous, and meaningful Tribal consultation between American Indian and Alaska Native Tribes and IHS by implementing at least three process improvement recommendations per year.

ACL believes the composite measure of nursing home predictors, which gauges the prevalence of select characteristics of the service population, predictive of nursing home placement, will remain relatively stable or moderately improve over the next few years as the Aging Services Network has achieved very high levels of the targeted characteristics.  Over 80 percent of home-delivered nutrition services participants have three or more limitations in Instruments Activities of Daily Living (IADLS) such as shopping for groceries and preparing meals.  Nearly 80 percent of caregivers report that the supportive services received have helped them provide care longer than would be possible without these services.  ACL will continue to provide high quality technical assistance, work with program resource centers to support the Aging Network and has proposed initiatives and increased resources in the President’s FY2016 budget to continue effective service delivery for caregivers and home and community-based services that are instrumental in the delay or deferral of nursing home placement of the elderly and persons with a disability.

SAMHSA will continue to support systems of care that supports children and youth (including their families) with SMI through collaboration across agencies and providers.  A systems of care approach also promotes access and expands the array of coordinated community-based, culturally and linguistically competent services.  Additional technical assistance is provided to promote improvements.  Through a new implementation grant, new grantees are using a new automated system for reporting.  Performance is expected to improve during FY 2015.

The MAI grantees employ a number of Evidence-Based Interventions (EBI) to address the complex substance abuse and risky behavioral issues associated with HIV/AIDS transmission.  These interventions are of varied duration and intensity lasting from one day to multiple days.  The target for 2014 was reduced because a cohort ended during 2013.  This mature group of 55 grantees will no longer be serving participants.  While a newer cohort of 29 grantees has been funded, they are in an early stage of the grant and are not initially serving as many participants. This is expected when cohorts end and others begin.  Consequently, targets are reduced for FY 2014 - 2016.

HRSA expects the number of patients served by health centers will increase in the coming years. This is because success in increasing the number of patients served has been due in large part to the development of new health centers, new satellite sites, and expanded capacity at existing clinics. The target for the number of people receiving direct services through Office of Rural Health Policy Outreach Grants are less than current performance given changes in the cohort of grantees. To maintain the quality of services provided, HRSA works with Outreach grantees to ensure they maintain the minimum required number of consortium members. The field strength of the NHSC fluctuates as it is dependent upon variables such as the level of available funding, the number of qualified applicants, and the mix of scholarship and loan repayment support provided. However, the NHSC field strength is expected to reach a historic high of more than 15,000 in FY 2016. Estimates of the percentage of individuals trained by Bureau of Health Workforce Programs working in underserved areas will remain static for the forthcoming years until new data become available that can help in refining targets to better reflect program performance in this area. The C.W. Bill Young Cell Transplantation Program will have an increasing number of racial/ethnic minorities on the donor registry. The Ryan White HIV/AIDS Program will continue its efforts to ensure that the proportion of racial and ethnic minorities served by Ryan White-funded programs exceeds their representation in national AIDS prevalence data.

The number of young women screened for Chlamydia is projected to decline over the coming years, primarily due to policy changes and funding assumptions occurring in some states resulting in shifting funds away from some major providers of family planning services.

Objective Progress Update Summary

HHS demonstrated progress toward this objective as shown by the representative performance measures described in the HHS Annual Performance Plan and Report. Further evidence of progress is described below.

• Early identification of depression allows providers to plan interventions and treatment to improve the mental health and well-being of American Indian and Alaska Native people who experience depression. Screening tools and results are incorporated into the IHS Electronic Health Record. The system is now deployed and in operation in over 250 clinical sites across the country. Depression screening for early detection, diagnosis, and treatment increased from 65.1 percent in FY 2013 to 66.0 percent in FY 2014.
• The ACF Office of Refugee Resettlement (ORR) oversees the Preventive Health program, which funds states to coordinate and promote refugee access to health screening, assessment, training, and medical follow-up services, recognizing that a refugee's medical condition may affect public health as well as prevent a refugee from achieving economic self-sufficiency. In FY 2013, a total of 77,445 health screenings were completed by the ORR Preventive Health program. In addition, the ORR Refugee Social Services program tracks the percentage of refugees entering full-time employment who receive health benefits. In FY 2013 (the most recent results available), nearly 61 percent of refugees entering full-time employment received health benefits.
• Tooth decay is one of the most common and preventable chronic diseases of children aged 6 to 11 years and adolescents aged 12 to 19. Approximately one-fourth of health expenses for children in the U.S. are dental related. CDC works with funded states to implement two evidence-based strategies that have been shown to prevent tooth decay- community water fluoridation and dental sealants. From 2008 to 2010, nine million additional people had access to fluoridated water, saving an estimated $250 million and from 2010 to 2012 an additional 6 million people had access. Evidence shows that school-based dental sealant programs increase the number of children who receive sealants at school, and that dental sealants result in a large reduction (80 percent after 2 years) in tooth decay among school-aged children (5 to 16 years of age). From 2003 to 2008, there was a 60 percent increase in the delivery of school-based sealants in states with CDC funding, which saved an estimated $1 million in Medicaid dental expenditures.
• CMS has launched the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents aimed at reducing avoidable hospitalizations, improving health outcomes, and reducing Medicare and Medicaid expenditures. Through this initiative, CMS has selected seven organizations who, starting in 2013, have implemented evidence-based interventions in over 140 nursing facilities and serving approximately 16,000 beneficiaries each day.
• HRSA researchers assessed racial/ethnic disparities in clinical quality among US health centers, and whether quality measures vary across certain types of health centers. Outcomes of interest included: poor hypertension control among adult patients, poor diabetes control among adult patients, and low birth weight among newborns. Compared with national rates, health centers report minimal racial/ethnic disparities in clinical outcomes. More favorable outcomes are associated with larger patient volume, longer duration of funding, and at least some patients enrolled in managed care.

The Department is continuing to support and execute the programs contributing to this objective, monitoring progress, performance, and program integrity while adjusting to any budgetary constraints or changes to programmatic demands.