Title X Overview

1. Title X Overview Di Petsche, Iowa Department of Public Health Leila Schlenker, Family Planning Council of Iowa

2. OBJECTIVES 1. Identify the funding source of the federal family planning program 2. Explain 3 requirements of Title X 3. Identify some terminology unique to Title X

3. What is Title X? • Created in 1970 as part of the Public Health Services Act. • The only federal program dedicated to family planning and reproductive health care. • Mission: To provide individuals with information as a means to exercise personal choice in determining the number and spacing of their children.

4. US Department of Health and Human Services Office of Public Health & Sciences Office of Population Affairs Office of Family Planning DHHS Region VII Office (Kansas City) IA, KS, MO, NE FPCI IDPH Central Iowa Family Planning Edgerton Women’s Health Center Hillcrest Family Services Planned Parenthood of the Heartland Trinity Muscatine Public Health Webster County Health Department Women’s Health Services Allen Women’s Health New Opportunities Crawford County Home Health North Iowa Community Action Northeast Iowa Community Action Southern Iowa Family Planning St. Luke’s Family Health Center

5. Title X Services in Iowa • FPCI’s Title X service area covers 55 of Iowa’s 99 counties. • IDPH Title X service area covers 45 of Iowa’s 99 counties. • Both grantees cover Polk County

7. Title X Clinic Sites - FPCI Family Planning Council of Iowa • Central Iowa Family Planning -- Marshalltown -- Toledo -- Grinnell • Edgerton Women’s Health Center -- Davenport • Hillcrest Family Services -- Dubuque • Planned Parenthood of the Heartland -- Des Moines x 3 -- Iowa City -- Ames -- Council Bluffs -- Burlington -- Keokuk -- Sioux City • Trinity Muscatine -- Muscatine • Women’s Health Services -- Clinton -- Maquoketa • Webster County Health Department -- Fort Dodge --Humboldt --Webster City --Clarion

8. Title X Clinic Sites- IDPH Iowa Department of Public Health • Allen Memorial Hospital -- Waterloo -- Independence • Crawford Co. Public Health -- Denison -- Onawa -- Atlantic -- Logan -- Harlan • New Opportunities -- Carroll -- Ankeny (DMACC) -- Des Moines • North Iowa Community Action -- Mason City -- Hampton

9. Title X Clinic Sites - IDPH Iowa Department of Public Health • Northeast Iowa Community Action -- Decorah • St. Luke’s Family Health Center -- Cedar Rapids x 3 (Kirkwood) -- Anamosa -- Vinton -- Monticello -- Mt Vernon x 2 (Cornell) • Southern Iowa Family Planning -- Ottumwa -- Centerville -- Bloomfield -- Fairfield -- Sigourney -- Chariton -- Oskaloosa -- Albia -- Keosauqua -- Corydon

10. Impact of Title X • In 2012, Title X enabled women to avoid 1.1 million unintended pregnancies, 48% (526,900) of which would have likely resulted in unplanned births, and 36% (362,500) would have likely have ended in termination. • Nationally, for every $1.00 spent to provide services in publicly funded family planning clinics, approximately $5.68 in Medicaid expenses on births are averted(2010) • In Iowa, for every $1.00 spent to provide services in publicly funded family planning clinics, $3.78 in Medicaid expenses on births are averted (2009)

11. The National Picture2012 Title X User Characteristics* • 92% female • 19 % under age 20 • 51 % age 20 – 29 • 28 % Hispanic or Latino (all races) • 20 % Black or African American • 5 % More than one race • 71 % < 100% of Federal Poverty Level • 90 % <200% of Federal Poverty Level • 64 % uninsured *2013 National Title X FPAR Report (2012 Summary)

12. Title X in Iowa 2012

13. Title X Program Guidelines & Program Instructions • Title X Program Guidelines for Project Grants for Family Planning Services was developed by the Office of Population Affairs (OPA), U.S. Department of Health & Human Services (DHHS), to assist current and prospective grantees in understanding and utilizing the family planning services grants program authorized by Title X of the Public Health Services Act, 42 U.S.C. 300, et seq. • The Office of Population Affairs also provides more detailed guidance, updated clinical information, and clarification of specific program issues in the form of periodicProgram Instructions.

14. Title X Program Guidelines…Definitions • Granteeis the organization that receives a federal grant and assumes legal and financial responsibility for good stewardship of public funds. • Sub-Recipients or contractors receive grantee funds, through formal agreements with the grantee, and whose purpose is to carry out the project of direct services to clients. Some have multiple service sites or clinics to cover specific geographic areas. • "The project" refers to activities defined by the grantee and supported by the budget described in the grant application.

15. Title X Compliance Issues As the Title X Grantees for Iowa, FPCI and IDPH are responsible to the Federal government for administering the program. The Grantees: • assure that services are available for low-income Iowans. • monitor sub-recipient performance by reviewing monthly, quarterly, and annual reports. • conduct regular site reviews of sub-recipient clinic sites and programs. • assure that funds are spent according to federal guidelines and requirements.

16. Title X Services • A variety of birth control methods and supplies • Tests and treatment for sexually transmitted diseases • HIV/AIDs education and testing • Basic infertility services. • Breast and Cervical Cancer screening • Testicular Cancer screening • Pregnancy tests and options counseling • Health education on sexuality and related topics • Reproductive Life Planning

17. Title X Priorities* 1. Assuring the delivery of quality family planning and related preventive health services 2. . Providing access to a broad range of acceptable and effective family planning methods and related preventive health services in accordance with Title X program requirements and nationally recognized standards of care. 3. Assessing clients’ reproductive life plan as part of determining the need for family planning services, and providing preconception services as appropriate; 4. Addressing the comprehensive family planning and other health needs of individuals, families, and communities through outreach to hard-to-reach and/or vulnerable populations. 5. Identifying specific strategies for adapting delivery of family planning and reproductive health services to a changing health care environment including addressing provisions of the Affordable Care Act (ACA). *found on OPA website

18. Title X Informed by: Title X Statute Title X Regulations Grants Policy Statement Informed by: CDC ACOG ACS USPTF & others

19. Legal Issues for Title X Participants • Voluntary Participation • Use of project services by an individual must be voluntary. • Coercion must not occur with clients receiving services or to use or not use particular methods can be occurring within a project site. • Coercion of abortion or sterilization must not take place. • Confidentiality • Clients must be assured of confidentiality. All providers must be HIPPA compliant. • Conflict of Interest • No personal gain may occur from working within a Title X program. • No funds may be used to support lobbying efforts.

20. Section 1007 The acceptance by any individual of family planning services…shall be voluntary and shall not be a prerequisite to eligibility for or receipt of any other service…

21. Section 1008 Prohibition on Abortion None of the funds shall be used in programs where abortion is a method of family planning

22. What does voluntary Participation mean?

23. What does providing confidential services mean?

24. Title X Grantees & Clinic Sites must comply with Federal Requirements • Cannot deny services or subject any client to any variation in services due to their inability to pay. • Title X must be the last payer for services. • Must provide specific services to adolescents.

25. Title X Grantees & Sub-Recipients must comply with Federal Requirements • Educational materials used for clients must be reviewed and approved by an Information & Education Committee. This committee of 5-9 members must be broadly representative of the community.

26. Title X Grantees & Sub-Recipients must comply with Federal Requirements • Must provide an opportunity for participation in the development, implementation, and evaluation of the project by persons broadly representative of all significant elements of the population to be served. • You may use your I & E Committee, Board of Directors, or establish an advisory or community group for this purpose, however, the community participation function {development, implementation and evaluation of project} should be tracked and documented separately from I & E activities.

27. Title X Grantees & Sub-Recipients must comply with Federal Requirements • Providers of services must be qualified to provide services. • Clinical and educational services are prescribed by the program requirements. • All sub-recipients must comply with Federal anti-trafficking laws, including the Trafficking Victims Act of 2000. Sub-recipients must have a written policy regarding training staff on human trafficking.

28. Title X Clinic Fee Collections • Charges based on costs and placed on a sliding fee scale • Request donations • Bill Medicaid • Bill private insurance • Clients charged based on sliding fee scale

29. Title X Client Eligibility • Income below 100% of poverty, free services • Income 101 – 250% of poverty, sliding scale • 250% + of poverty, full fee • Income level of no-contact minors determined on their income only (not parents’ income)

30. Fiscal Requirements – Billing/Collections Third party payers are billed at full fee. Clinic must be reimbursed prior to billing the client any remaining amount of client responsibility. Reasonable efforts to collect without jeopardizing confidentiality

31. Required Title X Services • Medical Services • Health Education • Community Participation, Education and Outreach

32. Framework for Family Planning, Related and Other Preventive Services

33. FamilyPlanningServices A constellation of services that include: • Contraceptive services • Pregnancy diagnosis & counseling • Achieving pregnancy • Basic infertility services • Preconception health • Prevent STIs

34. Key Title X Clinical Expectations Project operates under a qualified medical director Maintain written protocols for clinical care per national standard, e.g., CDC, USPSTF, ACOG (per OPA Program Instruction 09-01) Services must be based on those protocols Grantee responsible for ensuring pertinent clinical protocols and services in its clinics Compliance with state pharmacy regulations Written plans for clinical emergency management Appropriate CLIA laboratory certification QA Process & Monitoring – ensure adequate documentation of these activities *All plans must be location specific – need to enlarge to above 18

35. Reproductive Life Planning • The RLP is a conversation about an individual’s life goals, including reproductive goals, that prompts both non-sexually active and sexually active individuals to think of themselves in relationship to their life and parenting goals. • The plan can be started at any age and can be changed whenever the individual wants as his/her life changes!

36. Opening the RLP Conversation • Where do you see yourself in the next 5 years? The next 10 years? (Married? Single? In school? Working? Living in a home or apartment? • What about education? • How about a career or job you’d want to do? • Do you want to have children (or more children) or do you not want to have children? (remember this answer may change with time) • What things do you think you can do now to help you achieve your parenting goals some day (avoid STIs, eat a healthy diet, taking the right vitamins, exercise, avoid alcohol, substance use and smoking, update your vaccinations, learn your family history)? • Are there things you can do to get ready to have a healthy pregnancy when you are ready (deal with emotional and physical well-being, manage depression, abuse, and stress, avoid or quit smoking, fix your diet, take the right vitamins, begin regular exercise, avoid alcohol and substance abuse) ?

37. You do want to have children. What questions will help you plan that? • If you are having sex or when you start having sex, do you have a plan in place to prevent pregnancy until you are ready to have a baby? Can we help you with that plan? • How many children do you want to have? • At what age do you want to have your first child, or your next child? • Are you using a method of birth control? Are you happy with the method? If not, are there other methods you would be interested in talking about? • If you want to try to become pregnant soon, do you have any health problems, family illness or birth defects or take any medications that could affect you or your baby? • If you get pregnant before you are ready, what will you do? What changes will happen in your life plans?

38. You don’t want to have children. What questions will help you plan that? • If you are having sex or when you start having sex, do you have a plan in place to prevent pregnancy? Do you know where to go for help with that? • If you get pregnant before you are ready, what will you do? What changes will happen in your life plan?

39. Client Education Requirements Help the client to: • Make informed decisions about family planning, including specific methods of contraception and adverse effects. • Perform breast/ testicular self examination, if interested. • Reduce risk of transmission of sexually transmitted diseases and HIV • Pregnancy Options • Understand the importance of recommended screening tests and other procedures involved in the family planning visit. All clients, regardless of age, should receive information about sexual violence, reproductive coercion and human trafficking.

40. Client Counseling • The counseling process assists clients in reaching an informed decisions about reproductive health. • Counseling refers to the dialogue that must cover all aspects of informed consent. • Information for planned return, emergency 24 hour phone numbers, location of emergency services and appropriate referral for additional services.

41. Required Title X Clinical Services • Physical Assessment (according to QFP) • Fertility Regulation – temporary and permanent • Basic Infertility Services • Pregnancy Diagnosis and Counseling • Adolescent Services • STI (including HIV) services

42. Additional services that might be offered by Title X Clinics (not part of or paid for by the Title X Program) • GYN services • Prenatal & postpartum care • Pregnancy termination

43. Care of the Adolescent Patient Adolescent appointments must be made as soon as possible. Adolescents must be given age appropriate information. Abstinence as well as contraceptives and safer sex practices with options to reduce risks for STD/HIV and pregnancy must be discussed with all adolescents. Adolescents must be counseled about the availability of confidential services. Adolescents must be encouraged to include family participation in their decision to seek family planning services. (or to talk to a trusted adult)

44. Care of the Adolescent Patient • Title X projects may NOT require written consent of parents or guardians for the provision of services to minors. • Parents or guardians may not be notified of services obtained by the adolescent. • Counseling must be provided on resisting reproductive coercion • Comply with state child abuse, sexual abuse, child molestation, and incest reporting laws • A provision for the notification of a parent in the event that a life threatening condition is identified must be included in the consent for services. This provision is exercised only if the minor is unwilling or unable to follow up on referrals.

45. Title X Clinics Must Provide FDA Approved Contraceptive Methods • Eligible for participation in the Federal 340B Program • Federal Drug Pricing Bulletin Board • Public Health Drug Pricing • Drug Prices Lower than Medicaid Drug Prices

46. Required Title X Reporting & Monitoring • As a Title X Grantees, IDPH and FPCI are required to monitor, collect, analyze, and report on all Title X services provided by sub-recipients. • In addition to IDPH and FPCI reports, sub-recipients must report on program activities by completing the FPAR ( See Family Planning Annual Report). • Additional monitoring and/or program reports may be requested

47. Required Title X Reporting Family Planning Annual Report (FPAR) • FPAR is Title X’s report on the services provided • Annual report based on the calendar year, • Submitted by grantees to the Office of Population Affairs (OPA) • FPAR consists of 14 tables

48. Training • Purpose of Training • Improve and increase the delivery of Title X family planning services to people, particularly low-income groups, with a high percentage of unmet need for family planning services • Improve family planning service delivery skills of family planning personnel

49. National Training Centers • National Training Center for Coordination and Strategic Initiatives (CAI and Altarum Institute) • National Training Center for Management and Systems Improvement (JSI Denver) • National Training Center for Family Planning Service Delivery (Cardea) • National Training Center for Quality Assurance, Quality Improvement and Evaluation (JSI Boston) • Clinical Training Center for Family Planning (University of Missouri, Kansas City)

50. Training Advisory Committee • Meets three times annually to develop training for Title X staff • Training is based on clinic needs, a needs assessment and on national priorities and key issues • Training is sponsored by FPCI and IDPH