Tag: HRSA

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“You Can’t Shovel Tens Pounds of Shit in a Five Pound Bag:” The New York Times Ignores CHCs, Section 330 Providers, and HRSA

In “For Many New Medicaid Enrollees, Care Is Hard to Find, Report Says,” Robert Pear discovers something that has long been obvious to our many Community Health Clinic (CHC) clients: having insurance doesn’t mean you can see a doctor. Many if not most doctors won’t see Medicaid patients. CHCs, however, are a class of primary care organization designed specifically for Medicaid patients and the uninsured. We’ve written numerous Health Resources and Services Administration (HRSA) proposals for CHCs, and everyone one of those proposals is supposed to expand access to care. This year’s New Access Point (NAP) program, for example, has $100 million available. Pear apparently does not know that CHCs exist and are funded through HRSA mostly to serve Medicaid patients.

The bigger problem regarding real-world healthcare is the number of doctors. Any discussion about the difficulty of finding care that doesn’t mention the limits on the supply of doctors is specious at best. There have been around 100,000 residency slots since the 1980s. Medical schools stopped expanding long ago. These facts are well-known to experts. Physician Assistants and Nurse Practitioners are to some extent filling in the gap, but in most states they still must practice under a doctor.

Our CHC clients’ biggest problem is rarely recruiting patients—when you subsidize goods or services, people consume more—it’s finding doctors. CHCs usually serve a high-need, difficult-to-treat population. Consequently, physicians often prefer to seek higher pay and lower stress jobs. Although there are lots of people trying to go to medical school—in Educating Physicians: A Call for Reform of Medical School and Residency, the authors note that 42,000 people applied for 18,000 medical school spots, and that at least 30,000 were likely qualified to become doctors—med school and residency act as bottlenecks to this process.

You can give every person health insurance without ensuring that they’ll actually get care, much like you can give everyone a degree without ensuring they have a brain. In the United Kingdom, care gets rationed through wait times. In the U.S., a similar dynamic is happening via provider shortages. While it is laudable that the Affordable Care Act (ACA) significantly increased the number of Americans covered by Medicaid, the landmark legislation did little to increase the number of providers to serve the newly insured. Or, as they used to say in the old days, you can’t shovel ten pounds of shit into a five pound bag. It’s a vulgar phrase but applicable to this article and the overall challenge of helping the newly insured actually access affordable, quality healthcare.

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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.

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What Happens If You Have a Party and No Girls Show Up? HRSA’s Healthy Start Initiative (HSI) FOA Tries Again

We just finished working on proposals for HRSA’s Healthy Start Initiative (HSI); we’ve written funded HSIs before, so we’re very familiar with the program. HSI, however, just reappeared as a Valentine’s Day Present, with a new deadline of March 31 and almost $40 million available. That link goes to the RFP.

What gives?

The RFP answers:

The number of applications received. . . was much less than expected. As a result, HRSA anticipates that funds will be available to support additional applicants after completing reviews and funding decisions of applications submitted for [HSI].

HRSA didn’t get enough applications—they threw a party and no girls showed up, which is strange because HRSA is trying to give away money. We can speculate on why HRSA didn’t get enough applications, or technically correct applications, starting with: The RFP was difficult. We worked on HSI over the holidays; a lot of people probably gave up and went back to the celebrations, or turned in technically incorrect proposals.

In honor of HRSA and drinking over the holidays, we’ll offer a 10% discount to anyone who wants to apply for HSI this time around. Call us at 800.540.8906 for a free quote.

We know that programs have been re-released one after another before, though we can’t think of any examples right now. Those other ones must have taken place before we started the blog, because we can’t find any posts on this particular topic. Chalk it up to the inherent weirdness of Federal grant making. As Winston Churchill is said to have said of the Russians, “It is a a riddle wrapped in a mystery inside an enigma.”

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The Narrative Should Use the Headers the Funder Says It Should Use: HRSA’s Health Start Initiative (HSI)

A few days ago I was describing some of the weirder sections in HRSA’s Healthy Start Initiative: Eliminating Disparities in Perinatal Health (HSI) program to my fiancée, and between the time I started and the time she fell asleep I mentioned that a proposal’s disjointedness often comes not from the writer but from the RFP. Proposals aren’t written for humans; they’re written for bureaucrats. That’s true for most federal proposals, some state proposals, fewer local proposals, and least of all for reasonably unstructured foundation proposals.

Way back in 2012 we wrote “Upward Bound means more narrative confusion,” which described how that RFP “practically hide[s] the location of the material you’re supposed to respond to.” Today I’d like to talk about an exciting, sexy, related topic: HSI (which is due tomorrow). Like Upward Bound, it has two logical places that a moderately intelligent writer could use to structure the narrative: the first is on page 22 of the RFP, which says things like: “INTRODUCTION — Corresponds to Section V’s Review Criterion 1.”

Notice the language used: “Corresponds to Section V’s Review Criterion 1.” Review Criterion 1 starts on page 43, and it has very clear section headers that could be used to structure a fairly clean and clear proposal. I was tempted to use them and I bet a lot of other people have used them in the past, since HRSA put a simple but easily missed instruction on page 22: “Use the following section headers for the Narrative.”

That instruction should be and is the end of the debate. Because of it, anyone who uses the page 43 Review Criteria is doing it wrong. As always with grant writing, it may be possible to do it wrong and then get funded anyway, but you should always err on the side of obeying the RFP.

As you might imagine, we’ve had some… discussions… around this issue with clients. I’ll leave the nature of those discussions intentionally euphemistic, but in the meantime I will note that they should not have been as long or contentious as they were.

HRSA proposals are particularly finicky with narrative starts. The Nursing Workforce Diversity (NWD) Program, for example, has the same weird, bifurcated structure, in which the narrative beings on page 10 and the review criteria on page 21. It isn’t as monstrous as HSI—the final submission package is 65 pages max, as opposed to HSI’s 100 pages, and the RFP is correspondingly shorter—but it does the same confusing thing.

From a writer’s perspective, the (imperfect) solution is to write with the mandated narrative headers and then make sure that the response hits all the review criteria. If it doesn’t, pick up some of the language from the response and then use that as a jumping off section for a paragraph. For example, HSI has a review criterion that starts, “The extent to which the proposed quality improvement plan describes an ongoing/continuous overall management approach…” and you should answer it by saying, “The proposed project will implement a quality improvement plan describes an ongoing/continuous overall management approach by creating a database that will be used by CHWs to…”

That’s a nice thing to do for the reviewers, because it allows them to check the box and ideally give you the maximum number of points possible. It would be even smarter to make the narrative instructions and review criteria identical, but HRSA evidently isn’t yet that evolved—which makes our job harder. But if we wanted an easy job, we would have become lion tamers.

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Vice President Biden Announces $100 Million for Mental Health Services — or Did He?

The White House just published this breathless news release announcing $100 Million for Mental Health Services. As soon as I spotted this, I tweeted it, even though I knew immediately that the announcement was not as it seems.

Unlike virtually every other press release you’ve ever seen, this one curiously lacks a contact phone number, email address or even name—apart from Vice President Biden, who probably won’t be returning your voicemails. Short of calling the White House and asking to speak to Uncle Joe, there’s no easy way to get more information about grant availability for new mental health services.

The announcement has two parts: $50 million for “mental health services at Community Health Centers” from DHHS and $50 million to “improve mental health facilities” in rural areas from the Department of Agriculture. But no information on actual RFPs or even program names are included.

What gives?

With respect to the “new” funding for Community Health Centers (CHCs), which are nonprofit providers largely funded by HRSA, the $50 million does not appear to be new at all. Rather, it was apparently authorized by the Affordable Care Act (ACA) three years ago. From time to time, HRSA issues RFPs for CHCs to expand services, including mental health services (think of the New Access Points program, which we wrote about at the link). The ACA, in addition to being a landmark piece of legislation, was also a vehicle for creating budget authority—including this $50 million. At some point in FY ’14, HRSA will probably issue an RFP for CHCs to propose new mental health services programs, but this is not new funding.

Regarding the second pot of money, it may seem odd that the Department of Agriculture has $50 million for mental health facilities—but not to me. The Department of Agriculture has had the Rural Development (RD) office for decades, which, among other things, provides grants and loans for all kinds of rural community facilities—including mental health facilities.

Although not stated in the news release, I assume this $50 million is just part of RD’s existing funding appropriation, not new funding. The challenge RD faces, however, is finding projects to fund. This is because the real problem in rural areas is not building the facility—it’s operating the facility. So Steele County in Minnesota could apply for an RD grant and/or loan (most RD projects are offered a combination of both) to build a mental health center in Owatonna, but how would they staff it over time? By definition, rural areas are sparsely populated, the tax base is thin, and most counties and cities have trouble keeping open the facilities they have.

I’m sorry to have given readers the above bad news about phantom funding. While I’m glad that Vice President Biden decided to issue a press release saying that the sun rises in the east, in the world of grant writing, what really matters are RFPs.

If there is no link to a RFP or information about when one will be released, there really is no news. In this case no news is not good news.

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HRSA’s Healthy Start Initiative Inadvertently Illuminates* How Grant Funding Decisions are Actually Made

Our old pals at HRSA just issued the FY ’14 Healthy Start Initiative (HSI) Funding Opportunity Announcement (“FOA,” which is HRSA-speak for RFP). HSI has over $81 million up for grabs for a wide array of project concepts that will

reduce disparities in infant mortality and adverse perinatal outcomes by: 1) improving women’s health, 2) promoting quality services, 3) strengthening family resilience, 4) achieving collective impact, and 5) increasing accountability through quality improvement, performance monitoring, and evaluation.

There’s an interesting twist to the funding distribution of HSI, however. Most RFPs contain some version of the following, which we’re taking from the recently issued Department of Labor Youth CareerConnect SGA (Solicitation for Grant Applications, which is DOL-speak for RFP):

The Grant Officer may also consider other factors such as geographic balance; the availability of funds; and representation among various H-1B industries/occupations.

This more or less means that DOL can fund any technically correct proposal that reaches the point funding threshold, without justifying its reasoning to anyone. This inherent uncertainty about which good proposals will be funded makes applicants nervous and can discourage some applicants from even applying. Let’s say you run a rural nonprofit that does youth job training. You might feel you can’t compete against big city applicants and give up Youth CareerConnect before you start. If one were cynical, one could say that’s exactly why this weasel language is almost always found in RFPs. Still, it’s usually worthwhile for that rural nonprofit to apply anyway, since it might be a token rural nonprofit that gets funded to provide rural/urban balance.

The HSI FOA is different. HSI will award grants up to $2 million/year for five years. But the $82 million in available HSI funds and the large size of the grants are not what makes this FOA particularly interesting. Instead, it’s the way HSI funds will be parceled out, which the FOA clearly states—instead of hiding behind the kind of typical RFP language cited above for Youth CareerConnect. Three award levels will be made:

  • Level 1, Community-Based (basically a local program): $51.75 million with 69 grants to $750K/year for five years)
  • Level 2, Enhanced Service (local plus building a community collaborative): $12 million with 10 grants to $1,200,000/year for five years
  • Level 3, Leadership and Mentoring (local plus collaborative plus establishing a center for regional/statewide support): $18 million with 9 grants to $2,000,000/year for five years

Even better, 35 Level-1 grants are reserved for rural projects, while five level 1 grants are reserved for US/Mexico border projects (which is another way of saying these five are reserved for projects targeting Hispanics).

With this information, it’s much easier for potential applicants to try to divine their relative chances of being funded. Different applicant types have guaranteed funding streams, instead of the usual implicit assurances.

As a hoary (“hoary,” not whorey; there is a difference, usually) grant writer, however, I don’t think it’s all that useful to try to handicap your chances of success. Despite the FOA’s slicing and dicing on awards to be made, you can’t know how many applicants will compete at the various levels. You also can’t know in advance how many technically correct proposals will actually be submitted. Remember: if the proposal is not deemed technically correct, it never gets scored.**

Getting that technically correct proposal completed and out the door won’t be easy for many organizations. HRSA only allowed 43 days between the FOA publication on December 5 and the deadline of January 17, the Holidays are coming up and, at 73 single-spaced pages, the FOA is incredibly complicated. It’s so complicated that mistakes were made and HRSA has already published a major modification, in the form of a revised FOA and application kit file.

The short deadline, holiday season and mind-numbing FOA will probably combine to reduce the number of technically correct proposals that are submitted. All you have to do is be the exception: set aside your holiday plans, study the revised FOA, write a compelling proposal and submit a technically correct grants.gov kit file at least 48 hours ahead of the January deadline. The money, however, will go to those who forego vacations (or hire consultants like us) and get the job done.

* It is generally not a good idea to use alliteration in proposals, but I couldn’t resist in this headline.

** We should note, however, that we’ve written and turned in numerous proposals for applicants that were technically ineligible, only to have the applicant be funded. We’ve also turned in proposals with missing elements, like mandatory letters of support that the applicant couldn’t secure, and seen them funded. When we think an organization is ineligible for a grant, we tell them—but they sometimes tell us in turn that they want to apply anyway. Occasionally that attitude works out.

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Don’t Trust Grants.Gov, Which Makes a $200,000,000 Mistake: An Example from the Teaching Health Center Graduate Medical Education (THCGME) Program

I’m preparing our weekly e-mail grant newsletter and see the Affordable Care Act – Teaching Health Center Graduate Medical Education (THCGME) Program, which, according to Grants.gov, has $20,250,000 available. Twenty million: that’s not bad but isn’t spectacular either. Good enough to include in the newsletter, especially since it appears that community health centers (CHCs) and organizations that partner with CHCs are good applicants.

Then I hunt down the RFP, which is located at an inconvenient, non-obvious spot.* The second page of the RFP says there is $230,000,000 available—about ten times as much as the Grants.gov listing. That’s a huge difference. So huge that I’m using bold, which we normally eschew because it’s primarily hacks who have to resort to typographical tricks to create impact. But in this case, the magnitude of the difference necessitates extreme measures.

If you see an RFP that looks interesting, always track down the source, even if the amount of money available or number of grants available doesn’t entice you. Don’t trust grants.gov. As with chatting up strangers in a bar, you never know what you’ll find when you look deeper.

* This is why subscribing to our newsletter is a good idea: I do this kind of tedious crap so you don’t have to.

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HRSA’s Service Area Competition (SAC) Soaks Up Some Sun in Miami, While Brownfields Grants Are Available in California

This week’s Grant Alert e-mail newsletter has a curious RFP: a single HRSA Service Area Competition (SAC) grant is available to Miami-area nonprofits. You might remember SAC because we wrote “HRSA Service Area Competition (SAC) Grants: How to Defend Your Turf or Deftly Lift a HRSA Grant from an Unsuspecting Grantee” back in June, when the general competition was underway.

The fact that a second competition is being held exclusively for Miami could mean a couple of things:

1. Whoever got the Miami grant screwed it up and had their funding pulled. If so, the local Miami paper should be on this story but probably isn’t.

2. None of the Miami applications were fundable, but for whatever reason HRSA wants to fund Miami.

3. HRSA somehow came up with extra money, perhaps through a Congressional appropriation or earmark, for Miami money.

4. Something even more devious is going on behind the scenes that we’re not aware of.

Of those, number 1 is the most plausible. This also means that Miami-area nonprofits who want to get on the SAC Section 330 bandwagon have an unusual opportunity to do so, because no one is defending that turf at the moment.

The other set of RFPs in this week’s newsletter are three Brownfields programs that should be of special interest to California public agencies and nonprofit affordable housing developers that are interested in developing Brownfields sites. The grants should generate more interest than usual because the California legislature recently eliminated redevelopment agencies, along with tax-increment financing and the 20% set-aside of tax increment funds for affordable housing that was previously required. In this face of this sea change, Brownfields grants have become a much more attractive way of defraying development costs than they were previously.

If you’re part of a city in California, you should be thinking about this RFP.

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Is It Really a Partnership, Or Is It a Convenient Arrangement To Get the Money?

Is it really love if she only comes back for $300 an hour?

Is it really a partnership if one person holds a gun to the other’s head?

Does Microsoft really care about your business when they’ve kept you on hold for an hour, listening to aggravating muzak, only to tell you that they won’t give you the product key you need?

In grant writing, when you can’t get other local agencies to partner with you for a grant application, it’s often time to offer them a subcontract or some other piece of the action that can be measured in dollars. The piece you want or need can vary with the grant or the importance of the agency to the project and the nature of the project, but if you need the partnership badly enough you’ll pay for it.

In some circumstances this isn’t optimal, and if you’re paying for partnerships you might also be moving other local agencies from an economy based on gifts, favors, and reciprocity to one based on straightforward money—which might make accomplishing your actual goals harder. (Lewis Hyde describes gift versus exchange economies in The Gift, and there’s a rich economics literature on the subject too.) Many organizations, like many interpersonal relationships, don’t exist in a solely gift or solely mercantile space; they operate somewhere in between, and whether a relationship primarily involves gifts or fee-for-service depends a myriad of factors that are beyond the scope of this blog post.

But if an organization doesn’t want to help you out of the goodness of their hearts, or out of the promise that you’ll be their nominal partner on some future project, then money might be your only route forward. School districts are notoriously difficult in this regard, largely because they know that they’ll get ADA money regardless of whether they provide Joe’s Nonprofit with a letter.

Sometimes, however, Joe’s Nonprofit can strike back by getting the local newspaper to write an article about how the district’s intransigence might cost the community a $500,000 grant. A couple of years ago, we were writing a HUD Lead-Based Paint Hazard Control (LBPHC) proposal for a city in California. The LBPHC requires specific health metrics and interventions that are the domain of counties in California. The cognizant agency at first refused to cooperate with our client. We suggested that our client call the county rep and tell her that the next call would be to the newsperson, so that a story about why the county wants young low-income children to be poisoned could run. The county immediately agreed to cooperate and provided a strong letter and data. The proposal was funded. And our client didn’t have to offer any money to get it funded.

Given the realities of “partnerships,” why are funding agencies so interested in partnerships? We’ve addressed this question before, in posts like “Is it Collaboration or Competition that HRSA Wants in the Service Area Competition (SAC) and New Access Points (NAP) FOAs?” and “There Will Be No Fighting in the War Room: An Example of Nonprofit Non-Collaboration in Susan G. Komen for the Cure,” and “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.” As we’ve said, genuine partnerships might be appropriate and useful in some circumstances, but much of the time they just look cosmetic, as we’ve discovered from talking to clients who are attempting to wrangle partnerships out of recalcitrant agencies.

When partnerships are primarily cosmetic, I suspect the larger issue is, like so much of grant writing, one of signaling.* In grant writing, partnerships are a kind of social proof—if you can get other people to agree to associate with you, their association is a form of implicit approval of your actions. If you’ve ever seen bars where one guy seems to be talking to all the women in the place, you’re in part seeing social proof at work; if you’ve been reluctant to eat an empty restaurant or happy to wait for a table at a full one, you’ve also seen it.

Among grant applicants, partnerships are being used to prove that the applicant and jump through a large number of somewhat arbitrary hoops, in the hopes that those applicants with the fortitude, tenacity, and skill necessary to do so are also the ones most likely to operate programs well.

* Robin Hanson has written extensively about signaling and its pervasiveness in human social life; his recent post “How Social Are Signals?” is a good place to start if you’re curious. Unfortunately, he hasn’t written a book about signaling and other aspects of his blogging life, so there’s no large-scale guide to his thinking on the subject. Yet.

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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.