Tag Archives: CHCs

Grant Writing Confidential Goes to the Movies Part 3: Ghostbusters (Who Ya Gonna Call? Program Officers!)

Ghostbusters was Jake’s favorite movie when he was a child. He watched the video at least a hundred times and it remains a classic of its type.* As Ray Parker put it in his incredibly catchy, eponymous Ghostbusters theme song, “When there’s something strange in the neighborhood, who ya gonna call? Ghostbusters!” There’s a Koanic simplicity in this advice: when you have a problem, call the expert, not someone pretending to be the expert.

I was reminded of this over the summer, because we wrote proposals for clients applying to several federal grant programs with incredibly complex RFPs and underlying guidelines, including the HRSA New Access Point (NAP) and the Early Head Start (EHS) programs. Our clients for these assignments all had unusual or complex project concepts that required closely reading and carefully interpreting the RFPs and regs. The RFPs and regs raised issues for both our clients, though we can’t specify what those issues are; trust us when we say that they were real.

Our standard advice to clients in this situation—and as we’ve we’ve written about many times—is to immediately contact the Program Officer listed in the RFP and pop any questions about vague descriptions or apparent conflicts. At Seliger + Associates, we almost never contact Program Officers directly, since they rarely pay attention to consultants. Instead, we coach our clients on how to pose the question and get as clear a written interpretation as possible.

But our NAP and EHS clients didn’t want to contact the Program Officers; instead, they sought guidance from their state association, which are effectively trade groups for grantees. For large programs, like HRSA Section 330 and Head Start, networks of state and national organizations have grown up, which provide technical assistance and the ever-popular grantee conferences. An example is the Community Health Care Association of New York State, which is composed of Section 330 providers in New York and assorted hangers-on (note that we did not write a NAP proposal in New york this year—and I found CHSNYS through a Google search). When a big RFP for NAP, Head Start and similar federal programs comes along, these associations put on a full-court press to “help” applicants in their states prepare proposals. This help does not mean writing the proposal, although sometimes the association will provide data and research citations. The technical assistance usually involves meetings, Powerpoint presentations, webinars and so on.

Applicants rarely realize, however, that their association provides the same help to all agencies in their state. Rather than being truly interested in their particular agency submitting a technically correct proposal, the association is more like a mom passing out orange slices at a middle school swim meet—they want all agencies to come in first. Like a swim meet, however, and human nature being what it is, some applicants are favored by the “moms” and get extra orange slices, while others get orange-dyed onion slices.

We had a NAP client a few years ago in a western state that ran into active opposition from the state association because the association staff hated our client. I know this for a fact, because the association Executive Director told me so! Despite the association’s animus and refusal to provide a support letter, we wrote a compelling proposal, which was funded, much to the annoyance of the association, which then had to include our client.

The basic problem in asking associations or consultants for RRP interpretation is simple: they don’t work for the federal agency. Their opinions regarding a particular RFP don’t mean anything. The only way to get an interpretation of an RFP is by asking the Program Officer in writing and getting a written reply. Even then, the response is likely to say something like “this is subject to the guidelines, as published in the Federal Register.” Over the years, we’ve helped our clients thread their way through this process many times, including instances in which the federal agency published a correction to the RFP (as Jake writes at the link). A published RFP amendment is the gold standard for RFP interpretation.

Be careful in taking the advice of your state association, no matter how much fun their conferences are. When there’s something strange in a RFP neighborhood, who ya gonna call? Program Officers!


* I recently saw the grandaddy of ghost/comic films, 1940’s The Ghost Breakers, with the hilarious Bob Hope, exquisitely beautiful Paulette Goddard and a very young Anthony Quinn. If you like Ghostbusters, you’ll love The Ghost Breakers. It’s little non-PC, but the movie was made in 1940.

Many Proposals Are Swimming Against the Tide: An Example From HRSA’s New Access Point (NAP) FOA

Take a look at the laundry list of stuff that HRSA wants New Access Point (NAP) applicants to somehow improve (the quote comes from page 38 of the 101-page FOA):

Diabetes, Cardiovascular Disease, Cancer, Prenatal Health, Perinatal Health, Child Health, Weight Assessment and Counseling for Children and Adolescents, Adult Weight Screening and Follow-Up, Tobacco Use Screening and Cessation, Asthma – Pharmacological Therapy, Coronary Artery Disease (CAD) – Lipid Therapy, Ischemic Vascular Disease (IVD) – Aspirin Therapy, Colorectal Cancer Screening, New HIV Cases With Timely Follow Up, Depression Screening and Follow Up, and Oral Health.

Improving almost all of those metrics really starts with behavior, not with care. The real way to better health can be reduced to a couple things: 1. Eat better. 2. Get some exercise.* 3. Avoid the obvious drugs. 4. Brush and floss.

But those things have been public health goals for the last 50 years, and in the meantime Americans have gotten fatter and by most metrics less healthy—except, curiously, for longevity. We’ve built cities and suburbs that are actively unhealthy because they force everyone to drive everywhere all the time. Smoking rates have fallen, but they’re still stubbornly high and have been hovering between 20 and 25% for years. Cancer and heart disease look like eternal public enemies who can no more defeated than drug traffickers or superheroes.

Changes can’t and thus aren’t going to come from a bunch of doctors and nurses telling their patients—yet again—to lay off the McDonald’s and the soda and instead hit the gym for squats. HRSA knows this to some extent, and whoever sees the evaluations for NAPs in a couple years is going to know that opening one new primary care health clinics is equivalent to chucking a pebble in the river of behavior and culture. It is true that the federal government also subsidizes big agriculture in various ways that make eating well relatively harder and more expensive than it should otherwise be, but a lot more people could swim against that tide than actually do.

People who get and stay in shape do so because they realize it makes them feel better and because it dramatically increases their mating market value. Until they get sick and tired of being sick and tired—or, rather, until they get sick and tired of being the butt of jokes—no one is going to make them change. Pressure from external sources, like doctors, rarely does it. Treatment will never be as effective as prevention, but prevention can’t be mandated from above. It has to emerge from below. It would be interesting to see a study of the health behaviors of HRSA bureaucrats compared to the general population and a population of their peers.

The other night I was hanging out with a bunch of doctors and almost all of them were smoking cigarettes outside a bar. These are doctors. No one knows more about how dangerous smoking is. But they wanted drinks to take the edge off and for the usual reasons having a cigarette or three helped the relaxation process. I’m not even going to start into the unprotected sex stories—commonly referred to as “raw dogging” among today’s urban 20- and 30-somethings. As usual the stories may be exaggerated, but some episodes may also not bubble up into even impolite conversation.

(By the way, these same doctors like to note how infrequently patients take their standard advice: stop smoking, drink less, lose 20 pounds. To them medicine often feels like a futile endeavor.)

We’ve noticed one other thing, which isn’t related to the main point of this post but is likely to be hilarious to the right audience. CHCs—sometimes called Section 330 providers—must have community-based Board of Directors. At least 51% of these Boards must be composed of “consumers,” and the board is supposed to “Approve the selection/dismissal and conducts the performance evaluation of the organization’s Executive Director/CEO.” HRSA requires that NAP applicants say as much, and say that the Board has control over the Executive Director. This is saying the applicant will certify that the sun rises in the East.

The bylaws of every nonprofit typically state that the executive director/CEO serves at the pleasure of the board. Who else would hire, evaluate and, if necessary, fire the CEO? While some CHC CEOs can come from the clinical side, like a physician, they are often a health administrator type or general purpose nonprofit manager. More importantly, they are often the founder and/or prime mover in the organization.

Let me repeat that: they are the driving force behind the organization. That isn’t true in the largest organizations, but in small ones the Executive Director usually controls the board, no matter what the bylaws nominally say, because taking away the key person who built the organization usually kills the organization. It’s like “firing” the donor keeping the organization alive. It rarely happens in small- or medium-sized organizations. Nonetheless, in the proposal world the patients represented on the board have all the power. Among most actual NAP applicants, the real power isn’t likely to reside in the non-experts who can be rounded up to sit on the Board.


* I’ve become a much more regular lifter since reading “Everything You Know About Fitness Is a Lie,” and to a lesser extent Starting Strength and Arnold: The Education of a Bodybuilder. The last one is admittedly not very good yet I like it anyway.

January Links: Health Care, the Affordable Care Act Teaching Health Center, the Maternal and Child Health Pipeline Training Program, and more

* Isaac was interviewed on Nonprofit Spark Radio.

* As Ranks of Insured Expand, Nation Faces Shortage of 150,000 Doctors in 15 Years: “A shortage of primary-care and other physicians could mean more-limited access to health care and longer wait times for patients.” Limited access to care health care is already here—not because of insurance, per se, but because many people on Medicare/Medicaid simply can’t find providers who take either.

* As Grant Writing Confidential readers already know from reading “Be Nice to Your Program Officer: Reprogrammed / Unobligated Federal Funds Mean Christmas May Come Early and Often This Year,” unspent grant dollars tend to get spent. Politicians evidently don’t know that or don’t want to admit this, as evidenced in “Unspent Stimulus Tough to Retrieve” from the Wall Street Journal.

* The New York Times: “Consumer advocates fear that the health care law could worsen some of the very problems it was meant to solve — by reducing competition, driving up costs and creating incentives for doctors and hospitals to stint on care, in order to retain their cost-saving bonuses.”

* Strapped Cities Hit Nonprofits With Fees.

* The [Unjust] war against cameras:

Police across the country are using decades-old wiretapping statutes that did not anticipate iPhones or Droids, combined with broadly written laws against obstructing or interfering with law enforcement, to arrest people who point microphones or video cameras at them. Even in the wake of gross injustices, state legislatures have largely neglected the issue.

* Modern Parenting: If we try to engineer perfect children, will they grow up to be unbearable? Fortunately, I do not believe this was a problem for me growing up.

* You should blog even if you have no readers.

* Eminent domain now effectively has no limits, and that’s definitely a bad thing.

* A study confirms every suspicion you ever had about high-school dating.

* The last time the Maternal and Child Health Pipeline Training Program appeared in the Seliger Funding Report was 2005. Unless we managed to miss a year, it’s been a while since we’ve seen this program.

* The challenge to German liberalism, which may have its lessons for the United States as well.

* The Problem of Measurement in evaluating teachers, with these problems still being better than no measurement at all, which currently exists.

* A hacker’s guide to tea. This is really worth reading—who knew that “Tea contains L-theanine, an amino acid that promotes mental acuity. The combination of L-theanine and caffeine creates a sense of ‘mindful awareness.’ ”

* Apparently, the Nissan Leaf is pretty good.

* Touching Your Junk: An Ontological Complaint.

* To mildly alleviate the doctor shortage mentioned above, HRSA released the Affordable Care Act Teaching Health Center Graduate Medical Education Payment Program. But there’s something unusual about this RFP: HRSA says $230,000,000 is available for 10 awards of up to $900,000 each. We sent out this caveat in the Seliger Funding Report:

Note that the bizarre numbers in the amount ($230M), number available, and max grant size are HRSA’s (10 x $900,000 = $9M; where are the other $221M?).

* This is not good but, regardless of whether it’s good, may simply be the new state of things: “In essence, we have seen the rise of a large class of “zero marginal product workers,” to coin a term. Their productivity may not be literally zero, but it is lower than the cost of training, employing, and insuring them.

* Not Really ‘Made in China’: The iPhone’s Complex Supply Chain Highlights Problems With Trade Statistics. The short version: beware trade statistics, especially those related to manufacturing.

* The Future of China? Look at Mexico.

* Department Of Education Study Finds Teaching These Little Shits No Longer Worth It.

* Close the Washington Monument.

* Shortage of Engineers or a Glut: No Simple Answer.

Is it Collaboration or Competition that HRSA Wants in the Service Area Competition (SAC) and New Access Points (NAP) FOAs?

HRSA just issued a Funding Opportunity Announcement (FOA, which is HRSA-speak for RFP) for the Service Area Competition (SAC). SAC FOAs are issued each year for different cities and rural areas in which HRSA has existing section 330 grantees, including Community Health Centers (CHCs), Migrant Health Center (MHCs), Health Care for the Homeless (HCHs), and Public Housing Primary Cares (PHPCs). Without going too far inside baseball, as section 330 grantee contracts expire, HRSA groups them together and forces them to reapply while encouraging other organizations to complete for the contracts. Hence the word “competition” in SAC.

SAC applicants are required to respond to a section of the FOA called “Collaboration” by describing “both formal and informal collaboration and coordination of services with other health care providers, specifically existing section 330 grantees, FQHC Look-Alikes, rural health clinics, critical access hospitals and other federally-supported grantees.” I’m guessing that if your organization is applying to take the contract away from the current Section 330 grantee, that grantee is probably not going to be in much of a mood to collaborate with your application and give you a letter of support.

To put a requirement for “collaboration” in a FOA that uses the term “competition” in its title demonstrates HRSA’s cluelessness. A particularly fun aspect of the SAC FOA is that HRSA pats itself on the back by stating in the Executive Summary that “For FY 2011, the HRSA has revised the SAC application in order to streamline and clarify [emphasis added] the application instructions.” The instructions are 112 single-spaced pages and the response is limited to 150 pages! And there a two-step application process involving an initial application submitted through our old friend Grants.gov, as well as a second application with a second deadline through a HRSA portal called Electronic Handbooks (EHBs). That’s what I call streamlining and clarifying. I would hate to see the results if HRSA tried to complicate and obscure the application process.

HRSA has another FOA process underway for the New Access Points (NAP) program, which I recently wrote about in “The Health Resources and Services Administration (HRSA) Finally Issues a New Access Points (NAP) FOA: $250,000,000 and 350 Grants! (Plus Some Important History).” A quick search of the FOAs reveal that the term “collaboration” is used at least 32 times in the NAP FOA, compared to 8 times in the SAC FOA. I suppose collaboration is four times as important in writing a NAP proposal that in writing a SAC proposal. For those with inquiring minds, the word “competition” is not used at all in the NAP FOA. As far as I can tell, HRSA does not let NAP applicants know that, if they are successful, they will eventually have to compete to keep their contract, while simultaneously committing to collaborating with their competitors. Since I have written many NAP and SAC proposals, I know how to thread this word needle by writing out of both sides of my Mac. But novice grant writers and new HRSA applicants will find this a challenge.

For more of my reasoning on the essential pointlessness of requiring grant applicants to profess their undying commitment to collaboration, see “What Exactly Is the Point of Collaboration in Grant Proposals? The Department of Labor Community-Based Job Training (CBJT) Program is a Case in Point.”