FY 2024 Annual Performance Plan and Report - Strategic Goal 1: Objective 1.3

Fiscal Year 2024
Released March, 2023

Topics on this page: Objective 1.3: Expand equitable access to comprehensive, community-based, innovative, and culturally-competent healthcare services, while addressing social determinants of health | Objective 1.3 Table of Related Performance Measures

Objective 1.3: Expand equitable access to comprehensive, community-based, innovative, and culturally-competent healthcare services, while addressing social determinants of health

HHS invests in strategies to expand equitable access to comprehensive, community-based, innovative, and culturally- and linguistically-appropriate healthcare services while addressing social determinants of health.  HHS supports community-based healthcare services to meet the diverse healthcare needs of underserved populations while removing barriers to access to advance health equity and reduce disparities.  The Department also works to understand how to best address social determinants of health in its programs. 

The Office of the Secretary leads this objective.  The following divisions are responsible for implementing programs under this strategic objective: ACL, AHRQ, ASPE, CDC, CMS, HRSA, IHS, NIH, SAMHSA, OASH, and OCR.  In consultation with OMB, HHS has determined that performance toward this objective is progressing.  The narrative below provides a brief summary of progress made and achievements or challenges, as well as plans to improve or maintain performance.

Objective 1.3 Table of Related Performance Measures

The Indian Health Service (IHS) Public Health Nursing (PHN) Program provides critical support for health care services in the tribal communities served.  PHNs are licensed, professional nursing staff that support population-focused services to promote healthier communities through community based direct nursing services, community development, and health promotion and disease prevention activities.  The PHN Program expands access to comprehensive, community-based, innovative, and culturally-competent healthcare services.  One way the PHN Program measures this intervention is through monitoring the total number of individual public health encounters documented in the electronic health record and reported by the PHN data mart system with an emphasis on primary, secondary, and tertiary prevention activities to individuals, families, and community groups.  The FY 2022 target for the PHN Program measure was 411,325 encounters.  The final FY 2022 result of 385,356 patient encounters did not meet the target by 25,969 enounters, a 6 percent decrease.  During the IHS COVID-19 pandemic response, PHNs reported critical patient encounters for communicable disease, surveillance, contact tracing, testing, patient monitoring, and vaccination activities.  These efforts resulted in an overall increase in the number of PHN activities reported for community nursing services to address the COVID-19 crisis in FY 2020 and 2021.  PHNs worked tirelessly with local community partners and public health officials in AI/AN communities to address the pandemic crisis, but in FY 2022 expanded their focus on the growing concern in the public health and health promotion arena which resulted from delays or avoidance of medical care because of COVID-19 including urgent, routine, and preventive health care services. To support prevention and control of comorbid conditions, PHNs joined agency activities such as the pediatric immunization improvement project, ongoing childhood obesity prevention and breastfeeding promotion, and sexual transmitted infection treatment and prevention.  This shift in service away from hosting massive immunization, vaccination clinics and the overall pandemic activity resulted in a decrease in FY 2022 PHN patient encounters. As new COVID-19 variants emerged, triggering local outbreaks, and with unpredictable implications for prevention and treatment strategies, PHN staff shortages challenged efforts to administer vaccines, support case investigation, and monitor individuals for adverse events.  Prior to FY 2020, the PHN program did not meet the established targets due to anticipated Tribal programs migrating away from reporting to the IHS Resource and Patient Management System.  The PHN Program shares data, such as provider productivity and the number of health care delivery services provided, to inform I/T/U decision-making and promote data reporting.  In 2022, the IHS enhanced  the PHN data mart to include updated health promotion and disease prevention reports to support staff to access critical program performance data.

The PHN program uses key evidence-based strategies in delivering services.  PHNs improve care transitions by providing patients with tools and support that promote self-management of their condition as they transition from the hospital/clinical setting to home.  The PHN expertise in communicable disease assessment, outreach, investigation, and surveillance, aids in the management and prevention of the spread of communicable diseases.  PHNs contribute to several primary prevention efforts such as providing community immunization clinics, administering immunizations to homebound AI/AN individuals, and through public health education, encouraging AI/AN people to engage in healthy lifestyles and ultimately live longer lives.  PHNs provide nurse home visiting services via referral for such activities as follows: maternal and pediatric populations, including childhood obesity prevention through breastfeeding promotion, screening for early identification of developmental problems, and parenting education; elder care services including safety assessment and health maintenance care; chronic disease care management; and communicable disease investigation and follow up.  The PHN program works to improve the overall wellness of AI/AN people by using a variety of methods to educate the AI/AN population such as, individual and group patient education sessions, screening activities and referring high-risk patients, and immunizing individuals to prevent illnesses.  PHNs provide valuable preventative health care service to the AI/AN population by promoting healthy lifestyles and providing early treatment for illnesses.

The PATH program serves individuals with serious mental illness (SMI), or with SMI and a co-occurring substance use disorder, who are homeless or at risk of homelessness.  The PATH program offers an array of essential services and supports, including community mental health services.  A significant aspect of the PATH program that may not be supported by traditional mental health programs or funding is extensive outreach activity to build relationships with hard-to-reach homeless populations and link them to needed services.  PATH providers ensure that the PATH-eligible clients receive treatment and recovery services either through the PATH program, Medicaid, or other funding sources.  SAMHSA encourages PATH providers at the local level to work with HUD continuums of care to ensure PATH eligible clients will be prioritized for HUD housing vouchers.  SAMHSA will encourage grantees (states) to provide supportive services for those who are at risk of housing instability.  The combination of linkage to essential services, such as community mental health, and housing supportive services is important for the attainment and maintenance of housing stability for the people served by this program.

Targets were set for FY 2023 based on the FY 2020 target.  The number of people experiencing homelessness has remained steady over the years.

The FY 2021 result for ACL Measure ID - 2.10 is calculated using data from the State Program Report and the 2021 National Survey of Older Americans Act Participants¹⁵.  ACL collaborates with the Aging Network to target services to those at high risk of losing their independence.  ACL has consistently strived to exceed this goal by ensuring the most vulnerable participants receive home- and community-based services and caregiver support by collaborating with the Aging Network, promoting community living, and providing person centered services.  These successes reflect ACL’s collaboration with the Aging Network and efforts to target services to those at high risk of losing their independence and thereby promote and enhance community living.  Since FY 2012, ACL had been successful in exceeding this goal.  Unfortunately, with annual rises in expenditures per unit of service, the target for Fiscal Year 2021 was not met.  While many of our targets are being met or exceeded, ACL’s most recent performance measure results are demonstrating that our current methodology does not have the ability to account for outlier years such as 2021 for measures that are sensitive to fluctuations in the per unit cost increase or decrease due to unforeseen events like the COVID-19 pandemic.  Programs are finding new and innovative ways to demonstrate their adaptability, and ACL is monitoring these trends through performance, monitoring, and assessment to understand the impact of changing norms on our programs as well as how our performance measures stand up to severe outliers.

Timely entry into prenatal care is an indicator of both access to and quality of care.  Identifying maternal disease and risks for complications of pregnancy or birth during the first trimester can also help improve birth outcomes.  At HRSA funded health centers, results over the past few years demonstrate improved performance as the percentage of pregnant health center patients that began prenatal care in the first trimester grew from 57.8 percent in 2011 to 74.0 percent in 2021, meeting the program target.  HRSA set the FY 2024 target based on data trends.

In light of the disproportionate impact of COVID-19 on communities of color, OCR launched an initiative to partner with the Department of Homeland Security’s Office of Civil Rights and Civil Liberties and FEMA to conduct compliance reviews to evaluate their compliance with Title VI of the Civil Rights Act of 1964, focusing on whether states’ COVID-19 response efforts provide meaningful access to persons with limited English proficiency (LEP) to health care programs and services.  The scope of states’ COVID-19 related programs included in this initiative is testing, treatment, and vaccination.  By conducting compliance reviews in a nationwide sample of states, OCR identifiedgaps in states’ efforts and best practices.  These observations informed discussions with HHS, DHS and FEMA on themes for possible technical assistance.  Under Title VI of the Civil Rights Act of 1964 and the HHS implementing regulation, states receiving federal financial assistance were required to provide services free of discrimination on the basis of national origin, among other bases.  Nondiscrimination on the basis of national origin includes the provision of language assistance services to LEP persons.  These compliance reviews created baseline results to be used in strengthening this measure going forward to provide guidance to providers about non-discriminatory practices and information to consumers about their rights.  These compliance reviews and the guidance stemming from them will build upon HHS efforts to expand equitable access to comprehensive, community-based, innovative, and culturally-competent healthcare services, while addressing social determinants of health, and will supplement non-discrimination guidance documents that OCR has issued since the beginning of the COVID-19 pandemic.

Endnotes

¹⁵ This is a composite measure that utilizes data from multiple sources.  One source is the State Program Report.  Another source is the National Survey.  The State Program Report data is submitted annually by grantees (states and territories).  The web-based submissions include multiple data checks for consistency.  The National Survey draws a sample of Area Agencies on Aging to obtain a random sample of clients receiving selected Older Americans Act (OAA) services.  Since the National Survey draws a sample of Area Agencies on Aging to obtain a random sample of clients it is not possible to measure the actual number of vulnerable people who continue to live in their homes after receiving these services.