Form 4 Checklist for Adding a New Target Population - Clean

Checklist for Adding a New Target Population

Assurances:

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

• I certify that the following statements related to the preparation of this Change in Scope (CIS) request are true, complete and accurate:

• This CIS request is complete and responsive to all applicable criteria relating to the CIS checklist. Refer to http://www.bphc.hrsa.gov/programrequirements/scope.html for all applicable policies and guidance.

• The health center consulted with its Project Officer prior to submitting this CIS request.

• The proposed CIS implementation date is at least 60 days from the submission date to HRSA. Note: HRSA recognizes that there may be circumstances where submitting a CIS request at least 60 days in advance of the desired implementation date may not be possible; however, the goal is to minimize these occurrences through careful planning.

• The health center’s governing board approved this CIS request prior to submission to HRSA, as documented in board minutes (must be made available upon request).

• The health center has examined the potential impact of this CIS under the requirements of other programs as applicable (e.g., 340B Program, FTCA). Refer to: https://www.bphc.hrsa.gov/programrequirements/pdf/potentialimpactofcisactions.pdf

• The health center understands that HRSA will consider its current compliance with Health Center Program requirements and regulations (i.e., the status and number of any progressive action conditions) when making a decision on this CIS request. See Health Center Program Compliance Manual, Chapter 2: Health Center Program Oversight for more information on progressive action. Refer to: https://bphc.hrsa.gov/programrequirements/compliancemanual/index.html

• I will ensure the health center complies with the following statements related to the implementation of this Change in Scope (CIS) request, if approved:

• All Health Center Program requirements (http://www.bphc.hrsa.gov/programrequirements/index.html) will apply to this CIS. Note: Compliance with Health Center Program requirements across sites and services will be assessed through all appropriate means, including site visits and application reviews.

• This CIS will be undertaken directly by or on behalf of the health center for the benefit of the current or proposed health center patient population, and the health center’s governing board will retain oversight over the provision of any services and/or sites.

• This CIS will be accomplished without additional Health Center Program Federal award funding (for awardees only) and will not shift resources away from carrying out the current HRSA-approved scope of project.

• The impact of this CIS will be reflected in the total budget submitted with the health center’s next annual competing or non-competing or designation application.

• This CIS will be implemented and verified within 120 days of receiving the NoA or HRSA notification approving the change.

• This CIS will not diminish the patient population’s access to and quality of services currently provided by the health center.

• The health center will take all applicable steps related to the requirements of other programs impacted by this change in scope request. Refer to https://www.bphc.hrsa.gov/programrequirements/pdf/potentialimpactofcisactions.pdf

Change in Scope Questions:

1. OVERVIEW

Required Attachment: UDS Mapper Map & Data Table

Optional Attachment: Other Supporting Need Documentation

NOTE: The UDS Mapper Map and Data Table are required and should be used to support the explanations provided in this CIS request; upload any additional need data/documentation as necessary. HRSA will use UDS Mapper data to assess unmet need and service area overlap. If UDS Mapper Map and Data Table are not yet available, attach other relevant and comparable documentation which supports this request. UDS Mapper: http://www.udsmapper.org. For a UDS Mapper sample to support a CIS request, click here (placeholder for external resource).

1. The proposed change will add the following target population(s) to the health center’s scope of project (check all that apply):

• 330(e) General medically underserved population

• 330(g) Migratory and seasonal agricultural workers

• 330(h) Individuals experiencing homelessness

• 330(i) Residents of public housing

2. Patient Data: Provide the number and proportion of patients that your health center has served at sites within the current approved scope of project (Form 5B) from the proposed new target population(s) over the past three complete calendar years.

Year	Number of Patients from New Target Population(s) Served Annually by Health Center	New Target Population(s) Patients as a Percentage of Total health Center Patients Served Annually
		_%
		_%
		-%

3. Proposed Reallocation of Section 330 Funds: Describe how you propose that your current section 330 funding be reallocated to support services to the new target population(s).

Section 330 Funding	Current Annual (Federal) Section 330 Funding Allocation  (Based on Current 12 Month Budget Period)	Proposed Annual (Federal) Section 330 Funding Reallocation  (Based on Current 12 Month Budget Period) The sum of the proposed subprogram funding amounts must be equal to the total annual funding amount.	Projected Number of Patients to be Served in 12 Month Period following CIS Approval
330 (e ) CHC	$	$
330 (g) MHC	$	$
330 (h) HCH	$	$
330 (i) PHPC	$	$
Total Section 330 Funding/ Total Patients	$	$

2. MAINTENANCE OF APPROVED SCOPE OF PROJECT

Clearly describe in narrative format the health center’s plan for maintaining its current scope of project (i.e., sites and services) for the existing patient population(s). Specifically address how the health center is prepared to meet the primary care needs of the new target population while also assuring that resources will not be reduced for providing services to the current patient population.

Requires narrative response.

3. SERVICE AREA ANALYSIS: This section addresses how the proposed addition of this target population(s) will complement and not duplicate existing health services and resources within the service area.

Based on UDS Mapper Map and Data Table information, will the site serve all or part of a service area currently served by another health center grantee or look-alike and/or of another primary care safety net provider (rural health clinic, critical access hospital, health department, etc.)? Yes or No. Checkboxes for Yes options to allow multiple selections; No skips narrative; Any Yes response requires narrative response.

• No

• Yes – the site will serve a newly identified sub-group/underserved population (e.g., people experiencing homelessness, populations with limited English proficiency within the service area), whose health care needs are not being met.

• Yes – the site will serve an area where unmet need exceeds the capacity of the existing health center site(s) and/or other safety net providers.

• Yes – the site will serve a population where the distance and travel time to the nearest safety-net provider site, (e.g., health center grantee or look-alike, rural health clinic, critical access hospital) is a barrier for patients to access care.

• Note: UDS Mapper is the best tool for identifying the nearest Health Center Program grantee or look-alike. Distance should be measured as the distance (in miles) from the address of the proposed service site to the nearest Health Center Program grantee or look-alike service sites. Use the UDS Mapper Distance tool and/or Google Maps to determine (1) the distance in miles between sites and (2) travel time by driving or public transportation, as appropriate (e.g., if at least 30% of the patient population uses public transportation as the main source of transportation to work, provide travel time based on public transport as opposed to providing travel time by car/drive time).

• Distance in miles: _____

• Travel time in minutes: _____

Required for any Yes response: Based on this answer and attached UDS Mapper data and other needs assessment documentation that shows other health centers and service providers and their penetration rates, address any service area overlap and how the proposed site will complement existing services and programs so as to minimize the potential for unnecessary duplication and/or overlap in services, sites or programs.

Requires narrative response.

Note: Upload any relevant letters of support from all health centers serving the same service area in the next section

3. COLLABORATION WITH HEALTH CENTERS AND OTHER SAFETY NET PROVIDERS

For the purposes of this question, collaborative relationships are those that contribute to one or both of the following goals relative to the proposed target population:

(1) maximize access to required and additional services within the scope of the health center project for target population patients that will be served; and/or

(2) promote the continuity of care of target population patients by coordinating with the services and activities of other federally funded, as well as State and local, health services delivery projects and programs serving the same or a similar patient population (e.g., other health centers, rural health clinics, hospitals, health departments).

1. Describe the established and/or proposed collaborative efforts with other health centers and safety net providers (e.g., health departments, rural health clinics, hospitals) within and adjacent (e.g., neighboring ZIP codes) to the service area and how this collaboration will benefit the new target population.

Requires narrative response.

2. Attach documentation of collaboration, including any agreements (e.g., MOA, MOU, contract), relevant and specific to the proposed site which support the response to 4a. If documentation could not be obtained, describe the outreach made to these service area providers concerning this proposed target population and the result of this outreach.

Optional narrative response:

Optional attachment: Documentation of Collaboration

3. PLAN to meet newly applicable program requirements: The addition of a new target population may impact which Health Center Program Requirements apply to the health center. Address how the health center can or will demonstrate compliance with any newly applicable Health Center Program Requirements resulting from the addition of the proposed target population(s). Attach supporting documentation (e.g., existing bylaws that already demonstrate compliance, draft revised bylaws, etc.).

Resources:

• Health Center Program Governance Policy Information Notice 2014-01: http://bphc.hrsa.gov/programrequirements/policies/pin201401.html

• Form 5A: Services Provided - Service Descriptors

http://bphc.hrsa.gov/archive/about/requirements/scope/form5aservicedescriptors.pdf

Newly Applicable Program Requirements (applicable section depends on type of population added)

New Target Population - 330(e): General Underserved Community

Newly Applicable Program Requirement - Board Composition: Document that the health center’s governing board currently meets all of the following board composition requirements. If the board does not yet meet these requirements, describe how and when they will be met:

• The health center governing board is composed of a majority of individuals whom are being served by the center and this majority as a group, represent the individuals being served by the center in terms of demographic factors such as race, ethnicity, and sex.

• The overall governing board has at least 9 but no more than 25 members, as appropriate for the complexity of the organization.

• The non-patient/consumer members of the board are representative of the community in which the center's service area is located and are selected for their expertise in community affairs, local government, finance and banking, legal affairs, trade unions, and other commercial and industrial concerns, or social service agencies within the community.

• No more than one half (50%) of the non-patient/consumer board members derives more than 10% of their annual income from the health care industry.

Plan for Demonstrating Compliance with Program Requirement: Requires narrative response

New Target Population - 330(h): Individuals Experiencing Homelessness

Newly Applicable Program Requirement - Required and Additional Services: Describe how the health center will assure that all appropriate substance abuse services for homeless populations are or will be available (either directly or via a formal written referral arrangement) among their required services.

Plan for Demonstrating Compliance with Program Requirement: Requires narrative response

Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.