Title X The National Family Planning Program The Basics Title X 101

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Title X The National Family Planning
Program The Basics (Title X 101)
Office of Population Affairs

• Susan B. Moskosky, MS, RNC
• Director, Office of Family Planning
• Office of Population Affairs
• August 6, 2007

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Office of Population Affairs (OPA)
Purpose

• Focal point for the department on reproductive
  health issues(e.g, family planning, adolescent
  pregnancy, etc.)

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US Department of Health Human Services
Secretary Mike Leavitt
Assistant Secretary - Dr. John O. Agwunobi, MD,
MPH, MBA
Office of Public Health and Science (OPHS)
Programs

• Office of Minority Health Office of HIV/AIDS
  Policy
• Office of Population Affairs Office of
  Research Integrity
• Office of Womens Health National Vaccine
  Program
• Office of Regional Health Administrators
• Presidents Council on Physical Fitness
• Office of the Surgeon General
• Office of Military Liaison and Veterans Affairs
• Office of Disease Prevention and Health
  Promotion

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Office of Population Affairs

• Office of Family Planning
• Supports grants to public / private
  not-for-profits for family planning services -
  services program is Regionally administered
  (RHA/RPC)
• Office of Adolescent Pregnancy
• Supports adolescent pregnancy prevention and care
  demonstration grants administered Centrally
• Office of Research and Evaluation
• Supports a focused approach to OPA sponsored
  research and special projects

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Office of Population Affairs (OPA)
Two Appropriations
Title X
Provides funds to public / private not for
profits for family planning services
Susan B. Moskosky, Director, OFP
Title XX
Provides funds for adolescent pregnancy
prevention and care grants
Title X Introduced by Congressman George Bush
Johanna Nestor, Director, OAPP
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May 2007
Office of Population Affairs
Vacant Deputy Assistant Secretary for Population
Affairs
Evelyn Kappeler Acting Director
Immediate Office Vacant Susan Dunnell Vacant Progr
am Analyst Management Analyst Special
Assistant Brad Hendrick Evelyn
Kappeler Vacant Policy Analyst Senior Policy
Analyst Information Sys. Mgr. Terresa
Williams Vacant Inyang Isong Staff
Assistant Writer/Editor Medical Officer
Office of Family Planning Susan Moskosky Director
Office of Adolescent Pregnancy Programs Johanna
Nestor Director
Office of Research Evaluation Patricia
Thompson Director
La Quinta Bruster Jacqueline Crump-McCain Staff
Assistant Program Analyst Jo Anne
Jensen Vacant Medical Education Program Analyst
Specialist Alicia Richmond-Scott Allison
Roper Program Analyst Project Officer Vacant Les
lie Raneri Project Officer Project Officer
Charmaine Anderson Charon Flowers Staff
Assistant Health Education
Specialist Jule Hallerdin Nurse Consultant
David Johnson Public Health Advisor George
Jones Program Development Elizabeth
Phillips Specialist Program Analyst
Kathleen Woodall Public Health Analyst
Barbara Cohen Statistician Eugenia
Eckard Statistician Vacant Public Health
Analyst
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Title X History

• Created in 1970
• Amended the Public Health Service Act to provide
  for special project grants for the provision of
  family planning services, and related research,
  training, and technical assistance - cited as
  Family Planning Amendments of 1970
• Context - concern over population issues

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Authority and Structure of Title X

• Five Major Provisions of the Law
• 1001 Title X Services - Heart of Title X
• More than 4,400 clinics in the system
• 1003 Title X Training
• General Training Center in each Region
• Clinical Training Grantee
• Male Family Planning Training Center
• National Family Planning Training Center
• 1004 Title X Research
• Evaluation Activities, Service Delivery
  Improvement Research
• 1005 Title X Information and Education
• Title X Clearinghouse, publications, clinic
  directory
• 1008 Prohibition on Abortion

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Title X and Grants

• Title X is primarily a grant-making program
• Authority under four of the five main provisions
  of the Act to award grants and/or contracts
• Section 1001 - Services
• Section 1003 - Training
• Section 1004 - Research
• Section 1005 - Information and Education
• All Discretionary Grants
• All grants and other activities support Service
  grants funded under Section 1001

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Hierarchy of Authority

• Statute and Regulations Force of Law
• Appropriations Language expectations Congress
  establishes for the Title X program each year
• Program Instructions Respond to emerging
  issues or clarify program requirements may
  supersede Program Guidelines
• Title X Program Guidelines Provide guidance for
  service program implementation
• Program Announcements Outline expectations and
  requirements for specific grant opportunities
  within the authority established by Title X

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Program Structure - Title X is a De-Centralized
Program

• Authority for program operations is delegated to
  the Regional Health Administrator in the ten PHS
  Regions through a memorandum of understanding
  (MOU)
• Regional Program Consultants carry-out program
  activities, including oversight, for the
  applicable PHS Region
• Central Office - Office of Family Planning/OPA
  in Rockville, MD - policy office

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Public Health Service Regions
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Funding

• Title X Part of the Labor/ HHS Appropriations
• - operationally, OPA/OFP is part of the
  Office of the Secretary of Health, Office of the
  Assistant Secretary, OPHS
• - although Title X is NOT a HRSA program, the
  budget line is part of the HRSA budget

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Funding History - Key Years

• 1971 6,000,000
• 1981 161,671,000
• 1983 124,088,000
• 1991 144,311,000
• 2001 253,932,000
• 2002 265,000,000
• 2003 273,000,000
• 2004 280,000,000
• 2005 285,963,000
• 2006 283,103,000
• 2007 283,146,000 (year long CR)

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Money

• 2007 Budget
• Year Long C.R. at 2006 Level (283 million)
• FY 2006 Appropriations Language applies
• Priority is maintenance of family planning
  clinical services

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Money

• 2008 Budget Appropriations Discussions
• Senate Level - 300 Million
• House Level - 311 Million

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2006 Appropriations Language

• Weldon Language - Applies to all Labor, Health
  and Human Services, Education, and related
  agencies
• Prohibits subjecting any institution or
  individual health care entity to discrimination
  on the basis that the entity does not provide,
  pay for, provide coverage of, or refer for
  abortions

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2006 Appropriations Language

• Prohibition on use of funds for any activity in
  support of or in opposition to any legislative
  proposal or candidate (includes distribution of
  literature)
• Compliance with State laws requiring notification
  or reporting of child abuse, child molestation,
  sexual abuse, rape, or incest

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2006 Appropriations Language

• Certification of encouragement of family
  involvement, and provision of counseling to
  minors on resisting coercion
• Disbursement of Funds to Regional Offices
• Same manner and time frame as 2006
• Same percentage of appropriated funds as 2006 (90
  percent)
• Regional Offices should retain authority for
  review, award and administration of family
  planning funds.

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2008 Appropriations Language

• Same language as in previous years
• 90 of appropriation to be used for 1001
  activities
• Nondirective pregnancy counseling
• Certification of encouraging family involvement
  and counseling minors on resisting attempts to
  engage them in coercive sexual activities
• Not exempt from State law requiring notification
  or reporting of child abuse, child molestation,
  sexual abuse, rape, or incest
• No funds used to support legislative proposals or
  candidates
• Weldon language

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Title X Program Priorities

• Established annually and published in the Family
  Planning Services Federal Register announcement
• Overarching goals for the Title X Program
• Derive from Title X Statute, Regulations, and
  Departmental Priorities
• Regional Office and Grantee work plans should
  address

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Title X Program Priorities 2008

• Assuring ongoing high quality family planning and
  related preventive health services that will
  improve the overall health of individuals, with
  priority for services to individuals from
  low-income families

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Program Priorities 2008

• Assuring access to a broad range of acceptable
  and effective family planning methods and related
  preventive health services that include natural
  family planning methods, infertility services,
  and services for adolescents highly effective
  contraceptive methods breast and cervical cancer
  screening and prevention services that correspond
  with nationally recognized standards of care STD
  and HIV prevention education, counseling,
  testing, and referral adolescent abstinence
  counseling and other preventive health services.
  The broad range of services does not include
  abortion as a method of family planning.

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Program Priorities 2008

• Assuring compliance with State laws requiring
  notification or reporting of child abuse, child
  molestation, sexual abuse, rape, or incest
• Encouraging participation of families, parents,
  and/or legal guardians in the decision of minors
  to seek family planning services and providing
  counseling to minors on how to resist attempts to
  coerce minors into engaging in sexual activities

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Program Priorities 2008

• Addressing the comprehensive family planning and
  other health needs of individuals, families, and
  communities through outreach to hard-to-reach
  and/or vulnerable populations, and partnering
  with other community-based health and social
  service providers that provide needed services.

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Key Issues Focus on Quality

• Cost of contraceptives and other pharmaceuticals
• Efficiency and effectiveness
• Management and decision-making through
  performance measures and accountability for
  outcomes
• Linkages and partnerships
• Addressing CDC Revised Recommendations for HIV
  Testing.. In Health Care Settings
• Use of electronic technologies

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Key Issues - 2008

• Data collection for monitoring performance
• Translation of research outcomes into practice
• Utilizing practice guidelines and
  recommendations, developed by recognized national
  professional organizations and Federal agencies

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Section 1001 - Services

• At least 90 of appropriation must be used for
  clinical service programs (Section 1001)
• Scope of the service project is defined in the
  application for funds

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Scope of Title X Services

• Voluntary
• Confidential - regardless of age (State laws
  regarding reporting must be followed)
• Priority low income no charge for services for
  individuals from low income families (lt 100
  FPL) sliding fee schedule between 101 250 FPL
  
• Any individual desiring services - Male and
  Female
• Under the direction of a physician with training
  or experience in FP
• Most hands-on services provided by NPs, CNMs, PAs

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Scope of Title X Services

• Broad Range of Acceptable and Effective FP
  services
• Education and counseling related to FP
• Physical Exam and clinical procedures as
  indicated for method
• Laboratory tests as indicated for method
• Contraceptive method
• Level 1 Infertility services

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Scope of Title X Services

• Related Preventive Health Services
• HIV Prevention Education (ABC messages)
• Breast and Cervical Cancer Screening
• Lab screening for prevention
• lipids, Hepatitis B testing, urinalysis, anemia
  screening, etc.
• STD Screening and Treatment
• HIV Counseling, Testing and Referral
• Referral and Follow-up

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Title X Clinical Care

• Protocols for Clinical Services Should be Based
  on Current, Nationally Recognized Standards for
  Practice and/or Clinical Care
• Agency Protocols Should Note Which Federal and/or
  Professional Organizations Recommendation(s)
  Have Been Used for Development of Specific
  Clinical Protocols
• Relevance to Program Review Findings

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Nationally Recognized Organizations (Examples)

• American Cancer Society
• U.S. Preventive Services Task Force
• Centers for Disease Control and Prevention
• American College of Obstetricians and
  Gynecologists
• American Academy of Pediatrics
• American Academy of Family Physicians

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Section 1001 Services

• In 2006, Title X made up an average of 24 of
  total project revenues (has decreased over time)
  
• Other Sources Revenue - Medicaid, Medicaid
  waivers, other Federal, State and Local, private
  funds, and client fees (proportional contribution
  of other revenue sources has increased over time)
• All activities and other revenue described in the
  application for Title X funds are considered part
  of the project and must comply with all Title X
  requirements

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Family Planning Annual Report (FPAR)

• The only source of annual uniform reporting by
  all Title X Service Grantees.
• FPAR data are reported and presented in summary
  form to protect the confidentiality of persons
  that receive Title X services.
• FPAR data undergo both electronic and manual
  validations.
• http//opa.osophs.dhhs.gov/

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Family Planning Annual Report (FPAR)

• Key Term
• Family Planning User- A Family planning user is
  an individual who has at least one family
  planning encounter at Title X service site during
  the reporting period. The same individual may be
  counted as a family planning user only once
  during a reporting period.

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Title X Family Planning Services

• 88 service grantees
• 57 are State, Territorial, Tribal, County, or
  Local Health Agencies
• Remainder are universities and community-based
  not for profit agencies
• 4400 clinics in network
• 0.4 decrease in users between 2003 and 2006

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Client Characteristics 2006

• 4,992,498 total users
• 58 24 yrs. or younger
• 26 19 yrs. or younger
• 52 Racial/Ethnic minority
• 25 Hispanic/Latino
• 67 lt 100 FPL
• 90 lt200 FPL
• Preliminary 2006 Family Planning Annual Report

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Preliminary FPAR Results 2006 A
National Picture

• 4,992,498 Individuals Served (94.5 Female)
• Pap Tests
• 2,324,488 unduplicated users tested (49)
• 10 Abnormal (ASC or higher result)
• Clinical Breast Exams (CBE)
• 2,510,861 unduplicated users who obtained a CBE
  (50)
• 2 referred for evaluation of abnormal findings

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Preliminary 2006 FPAR- National picture Chlamydia

• Title X clinics tested 2,183,125 female users
• Overall 51 of all female users under age 25 were
  tested for Chlamydia
• Among those tested (same proportions as 2005)
• 28 were 19 years and younger
• 35 were 20-24 years
• 37 were 25 years and older

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Preliminary FPAR Results 2006

• Chlamydia
• 2,325,778 tests performed (93.9 Female 6.1
  Male)
• 46.2 of all female family planning users were
  tested for Chlamydia
• 52.5 of all male family planning users were
  tested for Chlamydia
• HIV
• 646,756 confidential HIV tests performed
• 14,280 anonymous HIV tests performed
• 1,337 positive HIV tests (confidential)

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Section 1003 - Training

• Authorizes the Secretary to make grants and enter
  into contracts with public or nonprofit private
  entities and individuals to provide the training
  for personnel to carry out family planning
  service programs described in Section 1001
• Priorities for General training established in
  the MOU with the PHS Regional Offices

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Section 1003 - Training

• 10 General Training Grants one in each PHS
  Region
• 1 Male Training Grant provides training to
  enhance the capacity of service projects to
  provide family planning and related preventive
  health services to males
• 1 Clinical Training Cooperative Agreement
  Curators of the University of Missouri
• 1 National Training Cooperative Agreement in
  process

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Section 1004 - Research

• Authorizes the Secretary to make grants and enter
  into contracts for projects for research in the
  biomedical, contraceptive development,
  behavioral, and program implementation fields
  related to family planning and population.

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1004 Research/Evaluation

• Male Research 15 awards funded in 2003
• Service Delivery Improvement Projects -
  announcement published in FY 2005 awards on
  various topics
• Research Cooperative Agreements - 3 awards
• Contribute to the NSFG and Add Health surveys

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1 Evaluation Activities

• HHS 1 evaluation process has been used to
  conduct focused evaluation studies on targeted
  topics
• Services for clients with limited English
  proficiency in select Title X provider sites
  (Cosmos 2003)
• HIV integration in select Title X provider sites
  (HSR 2003)
• Effective strategies for FIVP services in Title X
  clinics (Battelle, 2003)

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1 Evaluation Activities, continued

• Specific strategies being used to provide health
  care services to couples and/or families who
  access Title X-supported family planning clinics
  (HSR 2004)
• Best practices to encourage parental involvement
  in services for adolescents in Title X and Title
  XX programs (RTI, 2004)
• 2007 1 Projects
• Assessing Utilization of the 340B Drug Pricing
  Program by Title X Providers
• Evaluation of Cultural Competency Strategies in
  Title X

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Section 1005 Informational and Educational
Materials

• Authorizes the Secretary to make grants and enter
  into contracts to assist in developing and making
  available family planning and population growth
  information to all persons desiring such
  information
• OPA Clearinghouse
• Ph 866-640-PUBS (7827)
• FAX 866-592-FAXX (3299)
• Emailclearinghouse_at_dhhsopa.net   

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Special Focus Activities - HIV

• HIV prevention projects in third year of three
  year project period total 9.3 M investment of
  Minority AIDS Fund and Title X appropriations
• 63 projects at least one in each Region
• Announcement for new funding cycle focus on
  2006 CDC Recommendations for HIV Testing in
  Health Care Settings
• Expanded collaborative activities in 2006
• 4TC (RTCs, AETCs, PTCs, ATTCs) activities MAI
  funds awarded to support joint meeting held in
  October 2006
• Office on Womens Health
• Office of HIV/AIDS Policy 1 evaluation project

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Special Focus Activities - Males

• 15 grants (many Regional projects)
• Grants in 3rd year of a 5 year project period
• Cross-Site Evaluation Activities
• Change of focus
• Seven grantees participating 4 in
  curriculum-based programs, 3 in clinical programs
  
• Male Health Educator Training Institute
• Male Training Grant
• Male Grants and Projects Training Meeting

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Male Training Grant

• University of North Carolina at Greensboro
• P.O. Box 26170
• Greensboro, NC 27402-6170
• Phone [phone]Web Address www.fpmtc.org
• e-mail FPMTC_at_uncg.edu

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Multiple External Evaluations of Title X Program

• Office of the Inspector General Study-
• describes the efforts of the program to address
  State requirements regarding the reporting of
  child abuse, child molestation, sexual abuse,
  rape, and incest for Title X grantees - positive
  findings

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Multiple External Evaluations of Title X Program

• Assistant Secretary for Administration and
  Management Evaluation
• review of the grants management practices,
  policies, and procedures utilized by program and
  grants staff responsible for the award and
  monitoring of the family planning services
  programs - Family Planning Services Program
  review protocol identified as a best practice

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Program Assessment Rating Tool PART

• Comprehensive Office of Management and Budget
  Review
• Links actions to outcomes
• Identifies strengths and weaknesses
• Assesses 4 Areas
• Program Purpose and Design
• Strategic Planning
• Program Management
• Program Results and Accountability

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Performance Measures (cont.)

• Reduce infertility among women attending Title X
  family planning clinics by identifying Chlamydia
  infection through screening of females ages 15-24
• Efficiency Measure
• Maintain the actual cost per Title X family
  planning client below the medical care inflation
  rate

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Performance Measures (PART)

• Increase the number of unintended pregnancies
  averted by providing Title X family planning
  services, with priority for services to low
  income individuals
• Reduce invasive cervical cancer among women
  attending Title X family planning clinics by
  providing Pap tests

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PART

• Title X PARTED in 2005 Result - Moderately
  Effective Rating
• Title X Performance measures incorporated into
  Annual Performance Plan and Budget
• Three outcome one efficiency measure all
  relate to services provided in Title X-funded
  clinics
• Recommendation for Broad-Based, Independent
  Evaluation of Impact of the Title X Program

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PART - Challenge

• Continued increase in healthcare costs combined
  with decreased funding levels make it difficult
  to maintain and achieve future short- and
  long-term performance targets

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In Summary,

• Title X is a decentralized, discretionary grant
  program
• Five major sections of the law services,
  training, research, information and education,
  and prohibition of abortion
• Grants and/or contracts are made under the
  authority of four of the five major sections
• All grants must adhere to Title X requirements

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Summary, continued

• Central Office is primarily the policy office
• Authority for operations related to services and
  regional training projects is delegated to the
  RHA through an MOU
• OFP engages in a number of research and
  evaluation activities
• There is extensive monitoring by both regional
  and central offices, as well as external
  evaluators
• Regional Offices and Central Office communicate
  on an ongoing basis.

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The End

• WHEW!!!
• Questions?????