FY 2023 Annual Performance Plan and Report - Strategic Goal 1: Objective 1.3

Fiscal Year 2023
Released March, 2022

Topics on this page: Objective 1.3: Expand equitable access to comprehensive, community-based, innovative, and culturally-competent healthcare services, while addressing social determinants of health | Objective 1.3 Table of Related Performance Measures

Objective 1.3: Expand equitable access to comprehensive, community-based, innovative, and culturally-competent healthcare services, while addressing social determinants of health

HHS invests in strategies to expand equitable access to comprehensive, community-based, innovative, and culturally- and linguistically-appropriate healthcare services while addressing social determinants of health.  HHS supports community-based healthcare services to meet the diverse healthcare needs of underserved populations while removing barriers to access to advance health equity and reduce disparities.  The Department also works to understand how to best address social determinants of health in its programs.

The Office of the Secretary leads this objective.  The following divisions are responsible for implementing programs under this strategic objective: ACL, AHRQ, ASPE, CDC, CMS, HRSA, IHS, NIH, SAMHSA, OASH, and OCR.  The narrative below provides a brief summary of any past work towards these objectives and strategies planned to improve or maintain performance on these objectives.

Objective 1.3 Table of Related Performance Measures

The Indian Health Service (IHS) Public Health Nursing (PHN) Program provides critical support for health care services in the tribal communities served.  PHNs are licensed, professional nursing staff that support population-focused services to promote healthier communities through community based direct nursing services, community development, and health promotion and disease prevention activities.  The PHN Program expands access to comprehensive, community-based, innovative, and culturally-competent healthcare services.  One way the PHN Program measures this intervention is through monitoring the total number of individual public health encounters documented in the electronic health record and reported by the PHN data mart system with an emphasis on primary, secondary and tertiary prevention activities to individuals, families and community groups.  The FY 2021 target for the PHN Program measure was 330,000 encounters.  The final FY 2021 result of 428,476 patient encounters exceeded the target by 98,476 encounters, a 30 percent increase.  During the IHS COVID-19 pandemic response, PHNs reported critical patient encounters for communicable disease, surveillance, contact tracing, testing, patient monitoring, and vaccination activities.  These efforts resulted in an overall increase in the number of PHN activities reported for community nursing services to address the COVID-19 crisis.  Prior to FY 2020, the PHN program did not meet the established targets due to anticipated Tribal programs migrating away from reporting to the IHS Resource and Patient Management System.  The PHN Program shares data, such as provider productivity and the number of health care delivery services provided, to inform I/T/U decision-making and promote data reporting.  Efforts are underway to improve PHN data reports.

The PHN program uses key evidence-based strategies in delivering services.  PHNs improve care transitions by providing patients with tools and support that promote self-management of their condition as they transition from the hospital/clinical setting to home.  The PHN expertise in communicable disease assessment, outreach, investigation, and surveillance, aids in the management and prevention of the spread of communicable diseases.  PHNs contribute to several primary prevention efforts such as providing community immunization clinics, administering immunizations to homebound AI/AN individuals, and through public health education, encouraging AI/AN people to engage in healthy lifestyles and ultimately live longer lives.  PHNs provide nurse home visiting services via referral for such activities as follows: maternal and pediatric populations, including childhood obesity prevention through breastfeeding promotion, screening for early identification of developmental problems, and parenting education; elder care services including safety assessment and health maintenance care; chronic disease care management; and communicable disease investigation and follow up.  The PHN program works to improve the overall wellness of AI/AN people by using a variety of methods to educate the AI/AN population such as, individual and group patient education sessions, screening activities and referring high-risk patients, and immunizing individuals to prevent illnesses.  PHNs provide valuable preventative health care service to the AI/AN population by promoting healthy lifestyles and providing early treatment for illnesses.

The PATH program serves individuals with serious mental illness (SMI), or with SMI and a co-occurring substance use disorder, who are homeless or at risk of homelessness.  The PATH program offers an array of essential services and supports, including community mental health services.  A significant aspect of the PATH program that may not be supported by traditional mental health programs or funding is extensive outreach activity to build relationships with hard to reach homeless populations and link them to needed services.  PATH providers ensure that the PATH-eligible clients receive treatment and recovery services either through the PATH program, Medicaid or other funding sources.  SAMHSA encourages PATH providers at the local level to work with HUD continuums of care to ensure PATH eligible clients will be prioritized for HUD housing vouchers.  SAMHSA will encourage grantees (states) to provide supportive services for those who are at risk of housing instability.  The combination of linkage to essential services, such as community mental health, and housing supportive services is important for the attainment and maintenance of housing stability for the people served by this program.

Targets were set for FY 2023 based on the FY 2020 target.  The number of people experiencing homelessness has remained steady over the years.

Since FY 2012, ACL has been successful in exceeding this goal.  The FY 2020 result for ACL Measure ID - 2.10 is calculated using data from the 2020 National Survey of Older Americans Act Participants.  The survey was not conducted in 2021 due to the COVID-19 Pandemic.  ACL anticipated receiving a result of 65.68 which is a 3 year weighted average16 .  ACL's Administration on Aging believes this composite index of nursing home predictors will experience modest increases or be maintained over the next few years.  ACL collaborates with the Aging Network to target services to those at high risk of losing their independence.  ACL has consistently strived to exceed this goal by ensuring the most vulnerable participants receive home- and community-based services and caregiver support by collaborating with the Aging Network, promoting community living, and providing person centered services.  These successes are a reflection of ACL’s collaboration with the Aging Network and efforts to target services to those at high risk of losing their independence and thereby promote and enhance community living.

Timely entry into prenatal care is an indicator of both access to and quality of care.  Identifying maternal disease and risks for complications of pregnancy or birth during the first trimester can also help improve birth outcomes.  At HRSA funded health centers, results over the past few years demonstrate improved performance as the percentage of pregnant health center patients that began prenatal care in the first trimester grew from 57.8 percent in 2011 to 73.0 percent in 2020, meeting the program target.  The FY 2023 target was set based on data trends, including a slight reduction in 2020 data.

The purpose of this initiative is to analyze data received from select states regarding policies and procedures of vaccine provider programs to ensure that these services are being provided free of discrimination on the basis of race or national origin, including discrimination against limited English proficient (LEP) persons and underserved racial and ethnic minority communities.  By conducting compliance reviews in select states, OCR will identify corrective actions, where needed, and provide technical assistance to ensure vaccine provider programs are administered in compliance with Title VI of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act.  These compliance reviews will provide initial and historical results to be used in strengthening this measure going forward.

16. This is a composite measure that utilizes data from multiple sources.  One source is the State Program Report.  Another source is the National Survey.  The State Program Report data is submitted annually by grantees (states and territories).  The web-based submissions include multiple data checks for consistency.  The National Survey draws a sample of Area Agencies on Aging to obtain a random sample of clients receiving selected Older Americans Act (OAA) services.  Since the National Survey draws a sample of Area Agencies on Aging to obtain a random sample of clients it is not possible to measure the actual number of vulnerable people who continue to live in their homes after receiving these services.
• back to note 16