Tag Archives: NAP

HRSA makes it harder for NAP applicants to shoot themselves in the foot

Many of you are working on HRSA New Access Points (NAP) applications, and this year HRSA made a revealing change on page 3 of the FOA:

Form 2: Staffing Profile will no longer collect salary or federal funding data to reduce duplication with the Budget Justification Narrative. Fields have been added to collect information on use of contracted staff.

The phrase “to reduce duplication” implies that previous applicants would enter one set of positions in the Staffing Profile and another inconsistent set of positions in the Budget Justification Narrative. Those kinds of errors often lead to rejected proposals—even when the applicant does much else right. HRSA, to its credit, is trying to reduce the potential for such errors by putting salary information in one place, instead of two (or twelve: with the feds, trying to find all the places that must match is often challenging).

We’ve written before about the importance of internal consistency in grant proposals. Internal consistency is one of the most important aspects of a proposal. The other day I met with a client who is a grant-world novice and who provided a recently finished proposal she had written for a technical project concept. We were to use her previous proposal as a starting point for the new proposal we were writing. As we went over the budget, budget narrative, and program narrative of her old proposal, I pointed out several key inconsistencies, and those inconsistencies had likely caused the proposal to lose enough points to become non-fundable. I stressed that internal consistency is more important than perfect fidelity between proposal and project implementation.

Why? Most grant programs have some amount of slack in project implementation—that is, grant applications are proposals, and the actual activities may change (slightly). If you do slightly different project activities or have a slightly different staffing plan, you’ll be fine. With NAP, for example, it’s common for applicants to change sites after they’re funded. They might change a nurse practitioner to a family doc or vice-versa. As long as the funded applicant ultimately opens up a new primary health center and deliver primary health care, they’re going to be okay.

But to get that far, NAP applicants need internal proposal consistency as much as they need to demonstrate site control, even if they snag a different site later. Otherwise they’re unlikely to get funded, making the site issue moot.

Who are the HRSA peer reviewers? An anecdote from the New Access Points (NAP) Program

Federally Qualified Health Centers (FQHCs) know that the Health Resources and Services Administration (HRSA), like some other federal agencies, uses peer reviewers for proposals. That can lead to some entertaining coincidences and collisions. We were recently hired by a client who had previously served on a review panel for the last New Access Points competition. In talking with him, I mentioned that we’d written a funded NAP proposal about a year ago for a client in an unusual location. It turned out that our new client had been on the review panel for that proposal (which, fortunately, was funded).

Peer review can in effect shrink the size of the grant world. Peer reviewers also (usually) know something about the programs and processes being discussed, which isn’t necessarily the case with staff reviewers. In some funding agencies, like the Department of Labor, peer reviewers generally aren’t used; if there aren’t enough reviewers, the DOL may grab staffers from other federal agencies to review proposals. That implies grant writers should explain more about basic ideas, rather than assuming that reviewers actual understand the program they’re reviewing. So for staff-reviewed proposals, it’s a good idea to explain more than might be necessary in peer reviewed proposals, since the staffers may not be up-to-date on, say, prisoner reentry common practices, or the finer parts of the parole system.

Because of the small-world effect in peer-reviewed proposals, it can be particularly important to turn in high-quality proposals, because you never know when your proposal is going to act as an inadvertent resume. If you’re part of the Greater Seattle FQHC and someone from the Greater Nashville FQHC reads and likes your proposal as a reviewer, you may much later get a call from them offering you a job.

Don’t underestimate the power of “avoiding social embarrassment” in the list of motivations underlying human behavior.

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.

“Estimate” Means “Make It Up” In the Proposal and Grant Writing Worlds

Many RFPs ask for data that simply doesn’t exist—presumably because the people writing the RFPs don’t realize how hard it is to find phantom data. But other RFP writers realize that data can be hard to find and thus offer a way out through a magic word: “estimate.”

If you see the word “estimate” in an RFP, you can mentally substitute the term “make it up.” Chances are good that no one has the numbers being sought, and, consequently, you can shoot for a reasonable guess.

Instead of the word “estimate,” you’ll sometimes find RPPs that request very specific data and particular data sources. In the most recent YouthBuild funding round, for example, the RFP says:

Using data found at http://www.edweek.org/apps/gmap/, the applicant must compare the average graduation rate across all of the cities or towns to be served with the national graduation rate of 73.4% (based on Ed Week’s latest data from the class of 2009).

Unfortunately, that mapper, while suitably wizz-bang and high-tech appearing, didn’t work for some of the jurisdictions we tried to use it on, and, as if that weren’t enough, it doesn’t drill down to the high school level. It’s quite possible and often likely that a given high school is in a severely economically distressed area embedded in a larger, more prosperous community is going to have a substantially lower graduation rate than the community at large. This problem left us with a conundrum: we could report the data as best we could and lose a lot of points, or we could report the mapper’s data and then say, “By the way, it’s not accurate, and here’s an alternative estimate based on the following data.” That at least has the potential to get some points.

We’ve found this general problem in RFPs other than YouthBuild, but I can’t find another good example off the top of my head, although HRSA New Access Point (NAP) FOAs and Carol M. White Physical Education Program (PEP) RFPs are also notorious for requesting difficult or impossible to find data.

If you don’t have raw numbers but you need to turn a proposal in, then you should estimate as best you can. This isn’t optimal, and we don’t condone making stuff up. But realize that if other people are making stuff up and you’re not, they’re going to get the grant and you’re not. Plus, if you’re having the problem finding data, there’s a decent chance everyone else is too.

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.”

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.”