Presentation to the National Advisory Council on Migrant Health

1. Presentation to the National Advisory Council on Migrant Health Analyzing Issues, Barriers, Examples, and Opportunities in Migrant Health Presented by: Bobbi Ryder National Center for Farmworker Health February 5, 2007

2. Analyzing Issues, Barriers, Examples and Opportunities: Summary Of Input Source • This presentation Analyzing Challenges, Barriers and Opportunities in Migrant Health was prepared in response to a request by the OMSP for a presentation to the National Advisory Council on Migrant Health • Content is based on meetings held in November 2005 and 2006 consisting of representatives of Migrant Health Center grantees, State Primary Association staff, Central Office Grantees and Office of Minority and Special Population staff. • Documents reviewed include letters to HRSA commenting on policy tools and transcripts of the last three hearings of the National Advisory Council on Migrant Health

3. Issues, Barriers Examples, and Opportunities in Migrant Health GRANTS MAKING GRANTS ADMINISTRATION LEADERSHIP ACCOUNTABILITY

4. ISSUES Process has been designed for larger CHC network of health centers and does not work effectively for current and potential MHC applicants Barriers Types of Requests for Proposals (RFPs) Criteria for establishing need (Need for Assistance Worksheet) Review Committees are not migrant cognizant EXAMPLES An existing health center with insufficient physical space, provider capacity, and excess demand cannot address that need through a NAP application but could do so through an EMP or SE PIN A NAP opportunity to serve a new MSFW population in a currently un-served area is not a viable business opportunity for an uninsured population with a max of $200 per user per year of federal funding available. GRANTS MAKING

5. GRANTS MAKING OPPORTUNITIES • Assure that there is a true “spirit of partnership” in place between the grantees and the federal government and a consensus on the meaning and definition of partnership • Assure that there are communication vehicles (such as workgroups) in place to allow for information exchange between grantees and federal government • How to best get new funding to areas of need • Mutual understanding as to what is do-able within the confines of each other’s limitations • Open discussion of barriers and how to overcome them in order to increase access

6. GRANTS MAKING EXAMPLES of OPPORTUNITIES • Offering a PIN with the choice of a New Access Point (NAP), Expanded Medical Capacity (EMC), or Service Expansion (SE) monies to allow existing health centers with infrastructure in place to serve a previously un-served MSFW population • Offering opportunities for developmental grants would support NAP applications in the future. • Offering a Special Populations PIN in which applicants do not have to choose between serving their migratory farmworker population and their area resident population • Assure that Review Teams include individuals with expertise in Migrant Health as primary readers on MH Applications

7. ISSUES Program admin structure is not designed for special populations Grantees that do not fit the medical model have been singled out or forced to change their service delivery tactics to conform EXAMPLES Performance reviewers who are unfamiliar with the unique characteristics of a voucher program model often cite the services as inferior An effective health care plan for a mobile population is significantly different from that of a health center serving a year round non-farmworking population Occupational and migration related risks and diagnoses are not reflected among selected diagnoses for the UDS Performance reviewers are not trained to verify farmworker status is established at the local level GRANTS ADMINISTRATION

8. GRANTS ADMINISTRATION OPPORTUNITIES • Assure that in the administration of the consolidated 330 model, the distinctions essential to serving the MSFW population are respected by putting into place performance measures and indicators that are: • Relevant to the population • Designed to overcome the barriers that the current processes have created • Increase access to comprehensive care

9. GRANTS ADMINISTRATION EXAMPLES of OPPORTUNITIES • Training of Project Officers and Performance Reviewers to be able to assure that the grantee is serving farmworkers • Assessment of service delivery configuration to assure that it is appropriate to the needs of a seasonal population, ie staffing, location, hours of operations • Practice management systems to assure that they address the needs of the population, such as triage and urgent care

10. ISSUES The MHP is at risk of becoming an afterthought through lack of field knowledge and experience at the federal and local level Gradual loss of leaders through aging, turnover, re-organization, consolidation and attrition of leaders at the national and local levels, among grantors and grantees The need for professionals who have experience and knowledge of the needs of the population and the expertise to design, implement, and oversee effective programs EXAMPLES Where seasoned MHP staff and boards are committed to serving the community, access is good and quality is assured Where federal employees with an understanding of the population and the unique service delivery challenges are in positions of responsibility, MHP needs are incorporated into grants administration and program needs are considered in administrative policy LEADERSHIP

11. LEADERSHIP OPPORTUNITIES • To assure that farmworkers will have access to care in the coming decades, convene a group of MHP experts from both the Federal and MH grantee perspectives to: • Develop a long term plan to support the growth,development and ongoing training of Migrant Health leaders at the federal and local level • Implement the plan in a systems oriented manner that will assure continuity from one federal administration to another

12. LEADERSHIP EXAMPLES of OPPORTUNITIES • Conduct an analysis of requirements to effectively manage the Migrant Health Program at the federal level and assure that the number of staff positions, qualifications and criteria for filling those positions are in place • Develop an organizational structure and placement of the program within the Department that recognizes and supports the intent of Congress • Analyze elements of the most successful MH programs at the local level and formulate recommendations for staffing expertise that is required to sustain effectiveness • Work with training and technical assistance grantees to establish a leadership development initiative

13. ISSUES Need for an improved system of accountability in place at both the national and local levels Lack of adequate checks and balances to assure that the intent of the PHS 329 legislation is being upheld A need for performance measures which are relevant to the unique characteristics of the MHP EXAMPLES The lack of numbers of high quality applications received for MH funding throughout the 5 years of the Presidential Initiative has been questioned as a lack of need on behalf of the population Testimony to the National Advisory Council demonstrates a critical unmet need in the field such as: no MHC in areas of need lack of access to care prohibitively high fees for emergency dental care lack of continuity of care during migration ACCOUNTABILITY

14. ACCOUNTABILITY OPPORTUNITIES • Collectively, we possess the knowledge of health delivery systems, an understanding of the needs of the population and federal administrative constraints and flexibilities • If we possess the will to create positive change on behalf of the farmworker population, we can design a comprehensive system for administration of the MHP that will assure compliance with statutory and regulatory expectations including: • Standards, Indicators and performance measures that are relevant to service delivery for this population • Unique service delivery vehicles • Growth of access in accordance with increased fuding

15. ACCOUNTABILITY EXAMPLES of OPPORTUNITIES • BPHC convene a work group to analyze current obstacles in the administration of the MHP • Using a systems approach, design a coordinated federal and local system of accountability that will assure that federal funding is being used to appropriately serve the MSFW population • Pilot test and formulate recommendations for broad application and policy modification

16. COUNCIL ROLE “The mandate of the National Advisory Council on Migrant Health is to develop recommendations for action on the part of the Secretary of the Department of Health and Human Services (DHHS) to increase the effectiveness of migrant health centers (MHCs) in meeting the primary health care needs of migrant and seasonal farmworkers (MSFWs).” (BPHC Web site)

17. LEGISLATIVE AUTHORITY • Original PHS 329 Legislation enacted in 1962 authorizing the establishment of the Migrant Health Program, and ensuing re-authorizations. • Health Centers Consolidation Act of 1996, consolidating MH, HH and PH grant programs into the PHS 330 (CHC) legislation. • 2004 Reauthorization of the Health Centers Consolidation Act of 1996.

18. REGULATORY AUTHORITY • 42 Code of Federal Regulations (CDFR) Chapter 1, Part 56 (1976) established regulations for operations of PHS 329 authorized MHCs. No new regulations since the 1996 Health Centers Consolidation Act.

19. Legislative Components • Authorization and Re-Authorization or “Act” of Congress • Regulatory Statutes providing detail on administration of legislative Act • Annual Appropriations

20. LEGISLATIVE AUTHORITY • Legislation includes info such as: • Definitions relevant to program operations • Authority to study and provide environmental services • Authority to make both operating and planning grants • Guidelines for setting fees and collections • Board composition and frequency of meeting requirements • Requirements for community collaboration

21. LEGISLATIVE AUTHORITY • Legislation includes info such as: • Requirements for documentation of need and service area selection • Provision of required services • Arrangements for other services • Requirement for proportional funding for Migrant Health within the PHS 330 Program • Annual submission of funding report from Secretary to Congressional committees • Budgeting, auditing, recordkeeping requirements

22. LEGISLATIVE AUTHORITY • These resources are available to you on line through the HRSA and BPHC web sites • Familiarity is required in order to understand the scope of the Council’s responsibility and authority and the intent of Congress in serving the MSFW population.