Remarks to the National Association of Community Health Centers

by HRSA Administrator Elizabeth M. Duke

August 27, 2007
Dallas, Texas

Let me say that I’m delighted to be here. Thank you for inviting me to speak with all of you again.

I’d like to begin by introducing my HRSA colleagues who joined me on stage:

• Jim Macrae, associate administrator of Primary Health Care, and Don Weaver, deputy associate administrator;
• Steve Smith, my senior advisor;
• Cheryl Austein-Casnoff, associate administrator for Health Information Technology; and
• Rick Smith, associate administrator of the new Bureau of Clinician Recruitment and Service and director of the National Health Service Corps. I’ll talk more about the new bureau in a few minutes.

I plan to cover a number of topics today:

• The status of President Bush’s Health Center Initiative;
• The President’s new High Poverty Counties Initiative;
• New health information technology grants;
• OMB’s most recent assessment of the health center program;
• An update on quality and patient safety initiatives from our Center for Quality;
• Our latest efforts to help rebuild the delivery of primary health care in New Orleans and other areas devastated by Hurricane Katrina and Hurricane Rita two years ago;
• Our efforts to implement the new Ryan White legislation; and
• Recent internal changes at HRSA.

Those are the topics, one after another. They may sound dry as I recite the list, but in truth they reflect a great story that all of us, working together, have written over the past six years.

It’s a story that reflects the push and pull and give and take of our aging but still vibrant democracy. It’s a story of clashing views but also, more importantly, of compromise for the common good. It’s a story of talking and listening and learning.

Above all, it’s a story of citizens and government bureaucrats who have dedicated their careers to serving the less fortunate among them.

And it’s their dedication – your dedication, our dedication – that, in the end, makes our story not just triumphant but heroic.

Most people think of heroism as a sudden act of physical bravery that rescues people facing imminent danger.

But I would contend that there is heroism in setting distant, ambitious goals and slogging it out, one step in front of the other, one day after another, until the years run together. And finally, after years of pushing steadily ahead by thousands of people who show up to work everyday and do their best – finally, the goal is not just in sight, we can almost touch it! But we have more to do, and we can do it – together!

That said, let me start, as I normally do, by giving you an update on President Bush’s Health Center Initiative.

These are exciting days to be in the health center movement, because we are – all of us – nearing the historic completion of the President’s Initiative. We can almost touch it!

In the last five years, we have created more than 1,100 new and expanded access points across the country, moving us very, very close to the President’s original goal of 1,200 new sites.

Most importantly, of course, the expansion has dramatically increased the number of patients served:

• In 2006 the number of patients served topped the 15 million mark for the first time. Between 2001 and 2006, the number of patients treated at health centers has increased by over 4.7 million. That’s almost a 50 percent increase in just five years – by any reckoning that’s a remarkable management achievement!

And we have managed that expansion while remaining true to our mission. America’s neediest communities continue to be the prime beneficiaries of our work:

• Over 92 percent of our patients have incomes below 200 percent of the poverty line.
  
  
• Nearly 6 million patients are uninsured – that’s up 50 percent from the 4 million uninsured patients that were treated in 2001.
  
  
• And almost two-thirds (64 percent) of our patients are from racial or ethnic minority groups.

Health centers also are serving more people who are homeless and who are migrant and seasonal farmworkers:

• The number of homeless patients served during the 2001-2006 time period rose by over 255,000, a 45 percent increase.
  
  
• And the number of migrant and seasonal farmworkers increased by almost 120,000, or 18 percent, over the same period.

Even better, while the number of patients has increased, so has the range of services health centers offer. We are providing more comprehensive services than ever before:

• In 2006, almost 2.6 million patients received dental services. That’s an increase of more than 80 percent over the 1.4 million dental patients served in 2001.
  
  
• Even more striking gains are registered among patients who received mental health services. In 2006, 470,000 patients came to health centers for mental health care. That’s an increase of almost 170 percent over the 176,000 patients who received such care in 2001!

Perhaps the best thing about our joint success in implementing the President’s growth initiative is that it sparked another Presidential Initiative to extend the benefits of health center care to the hardest-to-penetrate, poorest areas of the country.

And today I am proud to announce the first set of grants under President Bush’s new High Poverty Counties Initiative. A press release listing the awardees will be available on hrsa.gov later today. Some are grants to existing grantees to expand satellites into neighboring poor counties and others are to entirely new grantees. Here’s the total:

• Seventy-four grants worth $37 million will establish New Access Points in low-income counties. The grants will touch poor communities across America, bringing the promise of better access to health care to places like Candler County in southeast Georgia; Morgan County in Ohio’s Appalachia region; rural Fremont County in Idaho, near Yellowstone National Park; and to Callahan County in the north central plains of Texas. These grants will bring new hope to people there and in 70 other counties.
  
  
• I’m also happy to announce another 25 awards worth $2 million to fund planning grants to help organizations in other low-income counties apply for future New Access Point grants.

These High Poverty Counties grants will put health center sites in more low-income counties than ever before. They will stretch America’s health care safety net to places it’s never been. These grants are exactly the kind of work HRSA should be doing. And I want to make clear that we funded these grants under the standards we apply to our other health center grants.

I’m very happy to share news of these new grants with the very people who will implement them. Our partnership with you in these high poverty counties means that 300,000 people in some of the poorest communities in the country will gain access to primary health care, many for the first time. That’s a great thing for them, and it’s a big step forward for America.

Congratulations to all of you who competed for and won grants.

At HRSA, we’re proud that the High Poverty County Initiative emerged from a question we first asked ourselves. If you have heard this story before, I ask your patience. But I love to tell it because it is a wonderful story of how hard work, good data collection and fortuitous timing can combine to make policy in Washington.

One day some years back I was given a line in a speech draft which said that health centers had penetrated into 92 percent of the poorest counties in America.

We were rightly proud of that statistic. But then we turned it around and looked at it from the other end of the equation. Who were these 8 percent? Where were they? Why did they have no health center?

We began investigating how to reach them. Then one day, through a chance meeting, we discussed our research with an old friend who was working in the White House. He was intrigued and asked for more data and a plan for reaching those 8 percent. Eventually, after passing through reviews at the Department, the Office of Management and Budget, and ultimately at the White House, a proposal to reach them emerged.

A few years ago, President Bush put the proposal – now called the High Poverty Counties Initiative – in a State of the Union address. It was included in successive budget proposals until it was funded in HRSA’s FY 2007 appropriation.

And today we announce the first grants. Grants that began with a question which turned into an investigation. That study then morphed into a policy proposal which Congress, in its collective wisdom, decided to support and fund. So it’s a great day. It really is. And in large part it’s due to the work that all of you in this room do. All of you who slog it out, one step in front of the other, one day after another, because you are dedicated to serving the underserved.

Eventually that good work gets recognized. Respect grows. Word gets out. In communities everywhere across America, on Capitol Hill, and in the White House, too.

In fact, we recently received some very good news about the health center program from the Office of Management and Budget. I have to couch this by telling you that this news should be considered “tentative” until an official announcement is made next month.

The good news is that OMB’s 2007 assessment of the health center program gave it a score of 90 – and believe me, that’s about as good as it gets from OMB. That score gave health centers a rating of “Effective,” the highest a federal program can receive. That 90 grade continues OMB’s 2002 top rating of the program, when it was also given the “Effective” ranking.

Only 17 percent of nearly 1,000 Federal programs surveyed to date have received that ranking. According to OMB, only programs that set ambitious goals, achieve results, are well-managed and improve efficiency may qualify for it.

The Administration uses OMB’s assessment when making budget decisions and when it implements management strategies to improve programs’ performance. So an “effective” rating is very good news for any program that gets it.

The bottom line is that OMB’s findings coincide with the views we all share – health centers are a “smart investment” for the nation.

And that smart investment doesn’t end with the High Poverty Counties grants. I’m also happy to be able to share with you today the award of:

• 41 New Access Point grants worth $20 million; and
• 4 Expanded Medical Capacity grants worth more than $1 million.

An estimated 235,000 people will gain access to care from these grants.

These awards, like those announced in May, were open to all applicants and were rated by the same rigorous standards as the earlier NAPs. The 17 states and the District of Columbia which were not eligible for the High Poverty Counties grants got 32 percent of today’s NAP awards (13 of 41 grants), as they got 42 percent of the May NAP awards (36 of 86 grants). Congratulations!!

Additionally, I’m delighted to announce more than $31 million in grants to fund 46 Health Information Technology projects at health centers and health center networks.

Today’s grants are key elements of our drive to help our grantees reach the President’s goal to create and use electronic health records for most Americans by 2014. We feel confident that the widespread adoption of Electronic Health Records will help health care professionals improve their ability to track and analyze their patients’ health information and, thus, improve the quality of their care.

Today’s HIT awards include:

• 25 grants worth more than $27 million, which will support the implementation of Electronic Health Records at health centers and in networks that link multiple health center grantees.
  
  In Chicago, the ACCESS Community Health Network plans to use its $1.4 million grant to implement an EHR system. That new system will improve continuity of care and health outcomes for 200,000 patients who receive care at multiple sites.
  
  
• Another 13 grants worth $3 million will help health center networks implement HIT innovations other than electronic health records. These may include such things as electronic prescribing, using telehealth, and creating interoperability with partners.
  
  In Portland, the Oregon Community Health Information Network intends to use its $300,000 grant to expand its existing practice management and EHR system. The Network wants to make sure that primary care, mental health and oral health providers can share diagnoses and treatments provided to its 192,000 clients, and screen for dangerous prescription drug interactions.
  
  
• Finally, 8 grants worth $1 million will help health centers develop plans to adopt EHR or other HIT innovations.

In the fall, I encourage you to be on the lookout for a new online HIT “toolkit” that will be tailored to the needs of the health centers. That resource comes from our Office of Health Information Technology, which Cheryl heads. And her office is also planning the first-ever HRSA-wide HIT meeting in November, so look for that as well.

Over the course of the fall, I’ll try to bring these awards personally to as many of you as possible.

When I last spoke with NACHC members at your Policy and Issues Forum in March in Washington, I spent a good deal of time outlining HRSA’s quality and data strategy and its four points: 1) performance measures; 2) updated program expectations; 3) best practices; and 4) health information technology.

HRSA’s Center for Quality serves as the focal point for developing HRSA’s overall Quality Strategy. Headed by Denise Geolot, the Center is about ready to begin a feasibility study on clinical core measures among grantees in a range of HRSA programs. The study aims to determine grantees’ capacity to collect and report on clinical performance measures and what type and amount of technical assistance HRSA may need to provide to make the system work as it should.

We expect the study will give us insight into which quality improvement strategies work best and which core measures are most likely to improve the quality of clinical care grantees provide.

Of late, Center staff has been busy working to identify “best practices” in quality care. This past April the Center sponsored a meeting in Rockville attended by HRSA’s senior leadership that showcased 25 grantees from several HRSA programs and the gains they’ve made in improving care and health outcomes for the patients they serve. Many of the presentations emphasized the importance of performance measurement in achieving quality care.

We heard some inspiring stories. Dr. Thomas MacKenzie of Denver Health and Hospitals told us about a registry they developed to track pediatric immunizations; it led to what he called “remarkable improvements” in immunization rates.

From New York, we heard from Mario Drummonds with the Northern Manhattan Perinatal Project, a Healthy Start grantee serving 10,000 women. He told us how Healthy Start interventions have pushed the rate of women entering prenatal care in the first trimester from 25 percent in 1990 to 92 percent in 2004. One after another, grantees from South Carolina, Kentucky, Nebraska, Arkansas and other states told similar stories of success.

In June, the Center rolled out a computerized inventory that identifies and summarizes quality-related initiatives administered throughout the entire agency.

The center also is working to launch Phase 1 of a patient safety and clinical pharmacy initiative later this year. That initiative will compile a Patient Safety Inventory -- similar to the quality inventory -- to identify already existing tools and resources, document best practices of high performers, and enroll high performers as faculty in a national improvement initiative.

Now I’d like to switch gears for a moment and talk about HRSA’s efforts to reweave the safety net in New Orleans and other areas that were devastated by Hurricane Katrina two years ago this Wednesday and by Hurricane Rita about a month after that.

In May, HRSA awarded 28 New Access Point and Expanded Medical Capacity grants to organizations in Louisiana, Alabama, Mississippi, and Texas.

I was fortunate to travel to Mississippi and Louisiana to deliver some of those grants myself. In Hattiesburg, I delivered $1.8 million in grants to the Southeast Mississippi Rural Health Initiative to expand care there. Hattiesburg is about an hour north of New Orleans and its population – and the demand for health care – has ballooned since Hurricane Katrina.

CEO Kaye Ray and her staff in Hattiesburg are using those funds to:

• expand operations by hiring additional staff and extending clinic hours;
  
  
• extend access to primary care in Pearl River County; and to
  
  
• provide early intervention HIV/AIDS care and services to medically underserved people in 16 Mississippi counties under a Ryan White grant.

And Kaye also used her center’s participation in a UCLA/Johnson & Johnson program sponsored by HRSA to plan and implement a gorgeous, thoroughly modern Dental Clinic. And last week in Montana we took a grant to Kate McIvor in Helena to support a new access point in nearby Lincoln. Kate is also a UCLA/J&J grad!

Let me pause for a second here to say hi to Joe Dawsey of Coastal Family Health Center in Biloxi, Mississippi, if he’s here today. Joe? I got an email from Joe last week telling me that they’re planning a grand re-opening this fall to celebrate their struggle back from ruin. Hurricane Katrina destroyed 4 out of their 9 clinics, and severely damaged the other 5. Since then, they have re-opened the clinics that could be repaired and operated from temporary sites, providing primary medical and dental services to 30,000 people each year. That’s another heroic story.

I also went to New Orleans in the spring to deliver $2.5 million in New Access Point and Expanded Medical Capacity grants to health centers in New Orleans, Jefferson Parish just west of New Orleans, and Franklin, in deep south central Louisiana. Those funds will open up access to primary care for about 14,000 people.

While we were there we took a tour through parts of central and east New Orleans – one of the saddest tours I can ever remember taking. As we moved further east in our tour, miles and miles of empty, wrecked homes and businesses gradually gave way to huge areas where homes had been totally demolished by the storm or by the wrecking crews that followed. The vegetation had grown tall, and the area looked more like rural fields than the vibrant urban neighborhoods that once were there.

I want to thank Mike Andry, CEO of the EXCELth health center in New Orleans for guiding us through that melancholy and unforgettable trip. We are keeping our attention focused on New Orleans and we will continue to do whatever we can to see that the health care safety net there is increasingly capable of meeting demand for its services as the city rebuild and repopulates.

And I should tell you that five of the new High Poverty Counties grants, totaling about $3 million, go to help poor counties in Louisiana.

I know health centers represent about a third of all Ryan White Part C grantees, so let me interrupt my remarks about health centers for a few minutes to tell you about the intense year my staff at HRSA has had.

When President Bush signed the new Ryan White legislation last December, it gave HRSA staff an incredibly short amount of time to meet the first of several deadlines they faced.

Just 71 days after the new law was signed, HRSA on March 1 released $376 million to Ryan White grantees in metropolitan areas across the country. That feat involved making the new eligibility determinations and running new funding formulas.

Almost all other Ryan White funds during the course of the year have gone out on time, with some distributions slowed only by the demands of new legislative requirements and the need to write application guidances for new programs.

One change in the legislation, for example, codified the Minority AIDS Awards under Ryan White for the first time and made it a competitive grant program. New guidances had to be developed and sent to potential grantees.

To tackle these and other issues associated with the new law, we have a HRSA-wide implementation team, which I lead. It meets weekly to assure coordination and linkages to Departmental partners.

Throughout this process, we have been aided by our Office of General Counsel, whose opinions were required before moving forward in implementing several parts of the new legislation. They have been fabulous partners in this challenging adventure.

This has been a very busy year, and I am very grateful to Deborah Parham Hopson, the grant staff under Nancy McGinness, and our legislation and communications staffs, just to mention a few elements of our HRSA-wide team.

Let me conclude by telling you about some internal changes we’ve made at HRSA since we last met.

In April, we announced the creation of a new Bureau of Clinician Recruitment and Service. The new bureau assumes administration of the National Health Service Corps, the Nursing Scholarship and Nursing Education Loan Repayment Programs, as well as the Faculty Loan Repayment and Native Hawaiian Scholarship Programs.

By consolidating administration of these programs, we hope to make our service to loan repayors and scholars more efficient and improve the support we offer to them. We fully expect that the result of that improved service will be better retention rates once clinicians complete their obligated term of service.

Rick Smith is the associate administrator of the new bureau; he also will continue to direct the National Health Service Corps. Incidentally, we now have more than 4,000 NHSC clinicians in the field – the highest total ever!

Rick has led in the Corps in doing a great job to sign up more NHSC “Ambassadors.” Ambassadors are academicians, primary care professionals and former clinicians who volunteer their time and expertise to spread the good news about the NHSC on campuses and in community-based organizations across the nation. The program today is the strongest it’s ever been with more than 900 Ambassadors, compared to just 100 six years ago! Rick, I thank you and your staff for those impressive gains.

Additionally, I’ve appointed Marcia Brand, associate administrator of the Office of Rural Health Policy, to be associate administrator in our Bureau of Health Professions. Marcia will remain in her position at the Office of Rural Health Policy as she takes on her new role. Jennifer Riggle will leave ORHP to join Marcia at BHPr, and Tom Morris -- the current deputy in the rural health office -- will take on greater day-to-day responsibilities there.

I’m excited that Marcia has accepted her new role. I’ve asked her to look for innovative ways to train health professionals that meet real-world needs. For instance, she’s looking into more and better ways to use distance learning to train nurses. And I saw first-hand the result of a good partnership in developing links among health centers, academe and blossoming young health professionals during my recent trip to Montana. Lil Anderson’s health center in Billings brings medical students and residents in on rotations to intern in primary care medicine. Giving them a taste of the primary care field seems like a great way to persuade them to make it a career.

Regarding internal realignment of duties and responsibilities at the Bureau of Primary Health Care, Jim Macrae will tell you more about those in his remarks tomorrow, so I won’t steal his thunder today.

Let me end by saying how happy I am to be able to speak with all of you on a twice-yearly basis as I have during my term as HRSA Administrator. It’s a wonderful opportunity for me to hear from all of you as well.

I’m also glad that I’ve been able to meet in a regular fashion by phone with the members of the NACHC board. I think it’s a valuable way to keep in touch between these meetings.

It’s just another part of our strategy to work together, to talk and listen and learn, do our best, and show up for work everyday. We might have stubbed our toes once or twice along the way, but we pushed steadily forward until the President’s goal came into view.

Look at us now: we’re almost there!

We’ve done it together, and together we’ll surpass that goal in the very near future. Thank you for working together with us, and thank you for being our partners in this heroic achievement. Millions more people across America have access to health care because of your commitment and dedication.

Thank you for all that you’ve done.

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