Tag Archives: FQHC

SAMHSA’s Screening, Brief Intervention and Referral to Treatment (SBRIT) and FQHCs

The Substance Abuse and Mental Health Services Administration (SAMHSA) just issued the FY ’18 Screening, Brief Intervention and Referral to Treatment (SBIRT) Funding Opportunity Announcement (FOA): it has $35 million for five-year grants up to about $1 million per year for assessment/referral to substance abuse treatment—and, most interestingly for our discussion, FQHCs are listed among the laundry list of eligible applicants.

SAMHSA is pointing the way forward for many substance abuse providers: become an FQHC. This may seem odd, because FQHCs are supposed to be primary health care providers, while substance abuse treatment is not considered primary healthcare and is usually provided by narrowly focused agencies. But the depth of the opioid epidemic, in tandem with the overall growth of healthcare funding, means that many substance abuse providers are being pushed towards becoming FQHCs—even as many FQHCs are also being encouraged to expand into substance abuse treatment. And we know that, when it comes to the Feds, “encouraged” is often a euphemism for “get ‘er done.”

Many FQHCs, of course, don’t want to be substance abuse providers—but, as programs like SBRIT show, the amount of money available may be too tempting to refuse. Right now, it’s also tough for FQHCs to stretch their Section 330 grants to provide fully integrated behavioral heath services, including substance abuse treatment. HRSA occasionally issues Notices of Funding Opportunities (NOFOs) for FQHCs to enhance behavioral health services, but the operative word is “occasionally,” and there’s not enough HRSA funding for behavioral health services.

Few, if any, of our FQHC clients, have had SAMSHA grants and most are reluctant to apply. This may be a case of grant “tunnel vision” in which FQHCs focus on HRSA in the same way that public housing authorities (PHAs) often tether themselves to HUD grants. The wider grant universe, however, provides opportunities for diversity that can help organizations weather shifts in funder priorities. And to paraphrase a salesman’s advice given to William Holden’s Joe Gillis in Billy Wilder’s Sunset Boulevard, “As long as the lady is paying for it, why not take the Vicuna?”

The Distinction Between Services Offered Now and Services Later, Illustrated by the HRSA Oral Health Service Expansion (OHSE) Program

When you’re writing a proposal for a grant intended to expand an existing program or service, it is extremely, ridiculously important to distinguish between what your organization is currently doing and what it’ll be doing with the new money. Failure to do so means that a) you raise the specter of supplantation, b) you sound like you don’t need the money because you’re already offering the services, and c) someone with a better grant story will get the money. Applying for a grant leads to a binary outcome—either you get the grant or you don’t. There are no half grants.

Let’s use HRSA’s Oral Health Service Expansion (OHSE) Program as an example. As the name of the program implies, OHSE is designed to provide additional dental services to underserved low-income patients.* A good OHSE proposal describes what, if anything, the applicant is currently doing with respect to oral health services (e.g., no services, pediatric only, pregnant women only, Medicaid only, etc.), and then describes what will be done differently. The applicant should say what additional services will be offered (e.g., sealants for children, dentures, etc.), and show how the dental patient population will be expanded. The applicant might serve additional existing FQHC medical patients, other service area residents, left-handed one-eyed cyclops, and so on.

A reasonable expansion might be as simple as saying, “The Toppenish Community Health Center currently serves 2,000 patients with 4,000 dental visits annually. The OHSE grant will allow TCHC to serve 3,000 high-risk patients, including at least ten cyclops.” What the organization can’t do, however, is claim that the CHC already serves 2,000 patients, and the grant will allow the CHC to keep serving those patients with more or less the same services. Patients have to be served in either greater number or greater services, or both.

Many  FQHCs that seek OHSE grants will also have long waiting lists, which can be used to bolster need: If the current waiting list for a new dental appointment is six months, that indicates a severe shortage of oral health service capacity. It doesn’t held your proposal to say proudly that the CHC’s wait time for a new dental patient is two days.

In short, applicants shouldn’t ever write or imply that they won’t actually serve more patients, or a larger area, or provide additional services. This may seem obvious, but we’ve seen proposals written by others that fail to remember this rule and that are primarily boasts about how much they’re already doing. That flaw won’t always be fatal—the funder may just want to fund that particular applicant or that particular service area—but it should still be avoided.


* Fun fact: Some dentists prefer the term “oral cavity” rather than “mouth.” I’m not sure why, since to me the former term sounds vaguely pornographic, and the latter term sounds normal.

HRSA Randomizes FQHC Program Officers, Likely Trading One Set of Problems for Another Set of Problems

In days of yore, most federal grantees had a dedicated program officer who handled budget issues, contract amendments, reports, and the like; the program officer would often conduct site visits, getting to know the executive director and the nuances of the agency and target area. This system began to atrophy during the Reagan administration with cutbacks to federal travel budgets, and today grantees rarely if ever see their program officer. For example, we’ve written many funded YouthBuild proposals for a South Central LA nonprofit, which hasn’t had a site visit from their HUD program office in 20 years of implementing over ten rounds of YouthBuild funding. Still, most grantees develop a virtual relationship with a specific program officer.

We write many HRSA proposals and were surprised to learn during a scoping call with the CEO of a long-time FQHC client that HRSA has changed this system. Instead of having an assigned program officer, HRSA program officers are now randomized. This means that when an FQHC—which often juggles multiple HRSA grants—has an issue, the problem is randomly assigned to one of a pool of program officers. This is more or less the system used when one waits in line at the DMV or Katz’s Delicatessen. At the DMV, this prevents a clerk from issuing fake drivers licenses for a bribe and the counter man at Katz’s from adding a little extra corned beef to his pal’s sandwich every day at lunchtime.

I assume the same reasoning applies at HRSA: randomizing program officers presumably is aimed at preventing special treatment for favored FQHCs or, I suppose, outright graft. Avoiding special treatment has a cost, though, as it’s likely to wildly increase inefficiency and systemic friction. One sees such problems most clearly in defense contracting, but any large bureaucracy can develop them.

In a randomized oversight management system, the program officer handling a particularly issue will have no agency background or context for the problem. I’m sure that HRSA management thinks thinks will lead to “fair” treatment for all grantees, while minimizing the potential for corruption, but it will also clog the system. HRSA program officers are probably GS 11s and 12s and, like most bureaucrats, they aren’t especially motivated to quickly solve grantee problems. Relationships with the grantees can improve motivation because most of us don’t want to be considered jerks by people we know and have repeated interactions with (why this is true is beyond the scope of this post, but Joseph Henrich’s account in The Secret of Our Success is recommended; it’s also a popular book written by a scholar, not a self-help book). Program officers get paid every two weeks, whether they solve problems or create them, as long as their breath clouds a mirror (to prove they’re still alive) when the paychecks are passed out.

HRSA is changing one set of real or imagined problems for a different set of problems. An unintended consequence of this change is also likely to be more congressional interference.

Why? Let’s say you’re the CEO of the fictional Owatonna Community Health Center and need a rapid decision to amend the agency’s NAP grant budget. In the Ancien Régime, the experienced program officer could probably be sweet-talked into a quick budget revision because of the interpersonal relationship and agency knowledge. In the new system, however, the program officer might put the request under her coffee cup and leave for five days of training, followed by vacation. Why does she care about what some random FQHC in Minnesota or wherever thinks or does?

Without any other recourse, the panicked CEO is likely to call their congressperson’s district office for relief, which will result in a field deputy harassing upper level HRSA management in Washington. This will lead to more friction and bad vibes, as management puts the congressionally-induced hammer to the program officer. The program officers will become even more bureaucratic in response, and they’ll make sure every last rule gets followed. Meticulously following rules is actually a CIA-approved method for organizational sabotage. No, seriously, it is: follow the preceding link.

We’ve written about the challenges of managing grants before. Like grant writing, grants management involves a specific set of skills and experience. Anything that makes managing grants harder is not going to help HRSA or FQHCs in the long run.

HRSA Service Area Competition (SAC) Grants: How to Defend Your Turf or Deftly Lift a HRSA Grant from an Unsuspecting Grantee

The Health Resources and Services Administration (HRSA) recently issued a Funding Opportunity Announcement (“FOA,” which is HRSA-speak for RFP) for the Service Area Competition (SAC) program. This program provides extremely valuable (for reasons we’ll explain in this post) five-year grants to operate one or more Federally Qualified Health Centers (FQHCs).

There are three ways to get become an FQHC, which will let an organization access Section 330 funds: (1) apply to have an existing health clinic certified as an FQHC (this is an incredibly complex process because the regulations are a nightmare); (2) wait for HRSA to issue a New Access Points (NAP) FOA and apply for a grant (this can be done in any community that meets Section 330 requirements, and it has a distinct advantage because a grant award is attached); or (3) wait for HRSA to publish a SAC FOA for your service area (which has the same advantage as number two).

The SAC route is probably the easiest because HRSA already knows that the area and residents qualify for Section 330 funds. Each time a FOA appears, existing Section 330 grantees at the end of their five-year grant period have to compete for new money against any other nonprofit or public agency that can (1) meet the eligibility test to become an FQHC and (2) chooses to apply.

This can make for mighty nervous Section 330 grantees, because running an FQHC or three can be a very lucrative undertaking for a nonprofit or public agency. As a result, even nominal collaborators can turn into cutthroat competitors and sack a grantee during a SAC funding cycle.*

Most federal programs require grantees to re-apply for continuation grants, including some (e.g., TRIO grants) that give bonus points to current grantees. Since operating a FQHC requires significant organizational infrastructure (e.g., specialized facilities and equipment, medical staff, HIPAA-compliant records management, and other features that go above and beyond basic nonprofit infrastructure), it is curious that HRSA requires current Section 330 grantees to compete for continuation funding. If a grantee is more or less getting the job done, why not just let them keep on doing what they’re doing? I assume the complicated re-application process is designed to keep the grantees on their toes. It also forces them to be accountable for the objectives stated in their original application (FQHC, NAP or SAC application), as well as the new SAC application.

HRSA Section 330 FOAs also require applicants to state highly specific objectives for required HRSA “Clinical and Financial Performance Measures,” as well for service delivery levels (e.g., number of patients, service encounters, etc.). Many applicants overstate their objectives beyond what is achievable in the real world. While we often differentiate between the Real World and the Proposal World in our approach to grant writing, sometimes the real world is important. HRSA Section 330 proposal writing is a case in point. Because the SAC application includes electronic data forms with highly specific input boxes and the metrics are so easily measured, a grantee can easily get too enthusiastic and wildly overstate the objectives that are likely to be achieved in the real world.

While being grandiose in stating objectives can be okay in many subjective human services proposals, it is a recipe for future unhappiness in HRSA Section 330 proposals. This is because failure to meet stated metrics will likely annoy your Program Officer, assuming you submit reasonably honest reports. An annoyed Program Officer is likely to torpedo your next SAC application or even cut back your current grant.

For example, a few years ago we wrote a number of funded HRSA, CDC, and foundation proposals for a Section 330 client in the midwest. While the client had no big problems in implementing several complex programs, she unfortunately got crosswise with her HRSA Program Officer over the stated objectives. Incredibly, the Program Officer got so annoyed that the client was forced into a SAC FOA three years ahead of schedule. With HRSA grants, don’t make this mistake and lose millions of dollars by overstating what your organization can do.

If your agency decides to try for the funding of an existing Section 330 grantee, it would be a good idea to request copies of their original application and reports. Just call up your competitor and ask them for these documents (note: this is joke, as no one in the real world would make this call). What you really want to do is call the HRSA Program Officer with the request and, if necessary, follow-up with a Freedom of Information Act (FOIA) request. Keep in mind that FOIA requests can take a long time, so it is best to plan your ambush well in advance.


* For more on the “collaborative” aspects of HRSA FOAs, see “Is it Collaboration or Competition that HRSA Wants in the Service Area Competition (SAC) and New Access Points (NAP) FOAs?.”

** See also The Real World and the Proposal World.

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)

The Health Resources and Services Administration (HRSA) just issued a Funding Opportunity Announcement (FOA, which is HRSA-speak for RFP) for the New Access Points (NAP) program. There is $250,000,000 available and 350 grants up to $650/000/year for five years! The deadline is November 17. This the first NAP FOA in over three years, and the NAP program is the best way to fund primary health care and prevention for medically indigent folks. In other words, this is a great opportunity. The real question is, where has the NAP program been for the last three years?

I have no idea why HRSA has not issued any NAP FOAs lately, but it may have something to do with the change in administrations and the extended health care reform debate. The NAP program was greatly expanded during the Bush administration, and HRSA issued NAP FOAs frequently during the early and mid years of the decade. We wrote many funded NAP grants and became very familiar with the program in the process. Then funding for NAP was either not included in HRSA appropriations or HRSA slowed down the grant making process, causing NAP to disappear beneath the waves a year or so before President Obama assumed office. But NAP funding was included in the recently passed Health Reform Act of 2010. This Act authorizes dozens of new competitive federal grant programs, as well as some old friends like NAP, and voila, HRSA issues this enormous FOA, so it seems that the NAP program is once again in favor.

For those not in the know, to be eligible for a NAP grant, the applicant has to be, or agree to set-up, a nonprofit “Health Center” under Section 330 of the Public Health Service Act (42 USCS § 254b), or, as they are termed in the trade, a Section 330 provider. Older terms that are sometimes used, like Federal Qualified Health Centers (FQHC) or FQHC Look-Alikes. Without getting too far inside baseball, the intent of such health centers is to provide access to patients who are eligible for public insurance programs, such as Medicaid, Medicare and SCHIP, or have no insurance. Although services are nominally provided on a sliding scale and no one is supposed to be turned away, Section 330 providers have to keep the doors open and, like all health care providers, they prefer patients with third party payers.

The entire Section 330/FQHC/FQHC Look-Alike system grew up to replace the chaotic but never dull “free clinic” model of the late 1960s and 1970s, which was pioneered to serve assorted hippies, druggies, runaways and other youth by the Haight Ashbury Free Clinic and LA Free Clinic. When I moved to LA in 1974, I almost went to work for the LA Free Clinic’s founding Executive Director, Lenny Somberg, who was a very interesting guy but was unfortunately killed by an intruder a few months after I met him.

While I didn’t get the job, I eventually volunteered and served on the board of the Harbor Free Clinic in San Pedro*, another one of the original free clinics. The basic idea of free clinics was to use volunteer docs and allied health professionals to provide free health care while not accepting Medicaid or any other insurance. Although some organizations retain “Free Clinic” in their name, I don’t think any still use this model, having shifted long ago to some version of the Section 330/FQHC paradigm—in other words, they are primarily Medicaid/Medicare providers and use paid medical staff.

These days, if an organization wants to provide primary health care for the uninsured, publicly insured or underinsured, they become a Section 330 provider, and a NAP grant is the organization’s ticket into the Medicaid reimbursement world. This is the first opportunity to compete for a NAP grant in three years, so start writing f you’re eligible. Who knows when the next NAP FOA will pop up in the federal trough?


*Pronounced “Peedro” by residents, not “Paydro,” and often affectionately termed, “The city where the sewer meets the sea.” I lived in Pedro for a few years and can attest to its many charms. Among other things, Pedro often turns up as a locale in movies and TV, including the most recent episode of my favorite TV show, Mad Men, “The Good News.”