HEALTH AWARENESS TITLE X GRANT FOR 2009 by harry jones

1. DATE ISSUED

DEPARTMENT OF HEALTH AND HUMAN SERVICES

12. CFDANO.

(Mo.lDaylYr.)

PUBLIC HEALTH SERVICE

93.217

12/23/2008

OPHS Office of Grants Management

3. SUPERCEDES AWARD NOTICE dated except that any additions or restrictions previously imposed remain in effect unless specifically rescinded

1101 Wootton Parkway Suite 550 Rockville, MD 20852

5. ADMINISTRATIVE CODES

4. GRANT NO.

2 FPHPA010121-38-00

FPH70

Formerly: 01HOO0121

Mo./Oay/Yr.

6. PROJECT PERIOD From

Through

12/30/2009

Through

12/30/2009

NOTICE OF GRANT AWARD AUTHORIZATION (Legislation/Regulations) P.L. 91-572 PHS Act Sec. 1001 as Amended, 42 CFR 59

Mo./Oay/Yr.

Mo./Day/Yr.

7. BUDGET PERIOD From

Mo./Day/Yr.

12/31/2008 12/31/2008

8. TITLE OF PROJECT lOR PROGRAM) 1I.Jmlt to 56 spaces)

2009 Fami y Planning Services (Region 1 - Massachusetts)

9. GRANTEE NAME AND ADDRESS

10. DIRECTOR OF PROJECT (PROGRAM DIRECTOR/PRINCIPLE INVESTIGATOR)

a. Health Awareness Services of Central Massachusetts, Inc.

(LAST NAME FIRST AND ADDRESS)

Mr. Mazloff, Michael 405 Grove St, Worcester, MA 01605

b. 405 Grove Street

c. e.MA f.01605-1270

d. Worcester

Phone: (508) 756-7123 12. AWARD COMPUTATION FOR GRANT a. Amount of PHS Financial Assistance (fromiltem 11.u)

11. APPROVED BUDGET (Excludes PHS Direct Assistance) I PHS Grant Funds Only

II Total project costs including grant funds and all other financial participation (Select one and place NUMERAL in box) a.

Salaries and Wages ..................

Fringe Benefits

..................

...........

(b) (4)

0 0

a·39

d·42

Supplies

................................................

42,895

b·40

e·43

Travel

................................................

1,407

C·41

f.44

Patient Care - Inpatient

.............. ................

Patient eare - Outpatient

..............

................

a. AMOUNT OF PHS Direct Assistance

Alterations and Renovations

b. Less Unobligated Balance From Prior Budget Periods

............................... Other ........ ........................................ Consortium/Contractual Costs ...............................

482,107

Trainee Related Expenses

................................

0 0

Consultants Costs

Equipment

f. g. h.

Trainee Stipends

. ..............................

Trainee Tuition and Fees

...............................

Trainee Travel

INDIRECT COSTS

TOTAL APPROVED BUDGET

SBIR Fee

Federal Share

Non-Federal Share

REMARKS:

(rate of)

l81

(Other Terms and Conditions Attached -

$ $

(IN LIEU OF CASH): 0

d. AMOUNT OF DIRECT ASSISTANCE THIS ACTION

15. PROGRAM INCOME SUBJECT TO 45 CFR PART 74, SUBPART F, OR 45 CFR 92.25, SHALL BE USED IN ACCORD Willi ONE OF THE FOLLOWING ALTERNATIVES: (Select one and place LETIER in box.) B. DEDUCTION b. ADDITIONAL COSTS MATCHING d. OTHER RESEARCH (Add I Deduct Option) B. OTHER (See REMARKS)

16. THIS AWARD IS BASED ON AN APPLICATION SUBMITIED TO, AND AS.APPROVED BY, THE PHS ON THE ABOVE TITlED PROJECT AND IS SUBJECT TO THE TERMS AND CONDITIONS INCORPORATED EITHER DIRECTLY OR BY REFERENCE IN THE FOLLOWING: B. The grant program legislations cited above. b. The grant program regulaUon cited above. This award noUce Including !enns and condlUons, if any. noted below under REMARKS. d. PHS Grants Policy Statement Including addenda In effect es ~f the beginning date of the budget period. 45 CFR Part 74 or45 CFR Part 92 as applicable. B. Ih the event there are conflicting or otherwise inconsistent policies applicable to the grent, the above order of precedence shall prevail. Acceptance of the grant terms and conditions IS ecknowledged by the grantee when funds are drawn or otherwise obtained from the grant payment system.

(b) (4) (b) (4) 1,138,599

379,540 759,059

Yes

TOTAL DIRECT COSTS

c. Less Cumulative Prior Award(s) This Budget Period

379,540

YEAR

TOTAL DIRECT COSTS

14. APPROVED DIRECT ASSISTANCE BUDGET

•

TOTAL DIRECT COSTS

YEAR

74,098

................................................

13. RECOMMENDED FUTURE SUPPORT (Subject to the availability of funds and saNsfactory progress of the project):

(b) (4)

................................................ ................................................

c. Less Cumulative Prior Award(s) This Budget Period d. AMOUNT OF FINANCIAL ASSISTANCE THIS ACTION

Total Personnel Costs

379,540

b. Less Unobligated Balance From Prior Budget Periods

No)

This NGA reflects that Health Awareness Services of Central Massachusetts, Inc., has been designated "High Risk", due to unstable financial management as prescribed in 45 CFR Part 74.21. Health Awareness Services of Central Massachusetts, Inc., must submit requests for the drawdown of funds to the Office of Grants Management for approval as outlined in the Special Terms and Requirements of this award. All terms and conditions remain in effect unless specificially removed.

PHS GRANTS MANAGEMENT OFFICER:

17. OBJ

CLASS

41.51

(Signature)

18. CRS

FY-CAN 20. a.

9-3014501

(Title)

Grants Management Officer, OPHS

-EIN

1042496148A2

b. b.

22.a

01HOOO121B

19.

c. c. c.

(NOTE: See reverse for payment

FPH70

d. d. d.

Information)

LIST NO.

CONGo DIST.:

AMT ACTION FIN ASST

ADMINISTRATIVE CODE

DOCUMENT NO.

21.a

PHS·5152-1 (rev. 7/92)

(Name - Typed/Print)

Karen Campbell

379,540

AMT ACTION DR ASST

e. e. e.

NOTICE OF GRANT AWARD (Continuation Sheet) ,----------r-=-c-==--==-==____-------, PAGE

2 of 6

GRANT NO.

DATE ISSUED 12/23/2008

2 FPHPA010121-38-00

SPECIAL CONDITIONS 1. By January 31, 2009, Health Awareness must submit all fiscal documentation for activites supported by the Title X grant within the last two Budget Periods (01/0112007 through 12/30/2007 and 12/3112007 through 12/30/2008). The documentation must include all invoices, receipts, purchase orders, salary and wage documention and copies of checks issued, etc. 2. Health Awareness will meet with the Regional Office at least twice during the grant period and more frequently if requested to provide updates on its fiscal and programatic operations. 3. Health Awareness will report monthly in writing to Grants Management with a courtesy copy to the Regional Office on the status of payments to retire its obligation to Montachusetts Opportunity Council and on its overall fiscal status. 4. Failure to comply with the above Special Conditions may result in a disallowance of funds, a

drawdown restriction or denial of future funding.

SPECIAL TERMS AND REQUIREMENTS 1. Health Awareness Services of Central Massachusetts, Inc., has been designated "high risk," due to the non-compliance of 45 CFR 74.21. Under the "High Risk" status, the grantee is required to submit a 270 form (see attached copy) for the Office of Grants Management (OGM) approval by the first day of each month. lIealth Awareness Services of Central Massachusetts, Inc., will use this method to request monthly advances of funds. Copies of all invoices, receipts, purchase orders, salary and wage documents, and copies of checks issued, etc., must be submited for every expense charged to this grant. These documents must be received by the 15th day of the subsequent month in order to insure timeliness of future drawdown requests. No funds will be available for drawdown from the DHHS Payment Management System (PMS) until after the OGM has received and approved the PMS-270 form. 2. $379,540 in base funding is being allocated to you at this time. This is six months funding. The total amount of expected base funding for FY 09 is $759,079 which is the amount of your funding in FY 08. The final base funding amount for FY 09 will be established in CY 09 following final authorization of the Title X Budget. At that time, you may be required to submit a revised 424, 424A and detailed budget justification if the final funding amount is different. 3. The Office of Population Affairs (OPA), Office of Family Planning (OFP) is holding a Titl~X National Grantee Meeting in Chicago, IL on August 20-21, 2009. It is expected that two to three individuals from each grantee agency will attend. Persons attending should include those individuals who have decision-making responsibility for Title X activities. Examples of attendees include executive directors, program managers, senior clinical staff, or other appropriate grantee staff. Grantees should budget accordingly for a minimal registration fee and for travel and per diem expenses. 4. It is also expected that your agency will assure attendance/participation by appropriate personnel at Regional Meetings including Directors' meetings and conference calls, Data Committee Meetings, the Regional Training Advisory Group, the Clinical Advisory Group and other relevant groups. Please budget accordingly. 5. Notwithstanding any other provision of law, no provider under Title X of the Public Health Service Act shall be exempt from any State law requiring notification or the reporting of child abuse, child molestation, sexual abuse, rape, or incest. 6. In accepting this award, the grantee certifies that it will encourage family partiCipation in the decision

PHS-5152-2

NOTICE OF GRANT AWARD (Continuation Sheet) r-=-,..---:::-::::--------.=-==-===---------, PAGE

3 of 6

I DATE ISSUED 12/23/2008

GRANT NO.

2 FPHPA010121-38-00

of minors to seek family planning services and that it provides counseling to minors on how to resist attempts to coerce minors into engaging in sexual activities. 7. This award consists of:

Program income (fees, premiums, third-party reimbursements which the project may reasonably expect to receive), as well as State, local and other operational funding, will be used to finance the non-federal share of the scope of project as defined in the approved grant application and reflected in the approved budget. Program income and the level projected in the approved budget will be used to further program objectives

379,540 Sharing Funds (10%)

(b) (4)

21,105 Funds Total Project Budget

)'Ii

1,138,599

8. The Office of Population Affairs has established the following Title X Program Priorities: a. Assuring ongoing high quality family planning and related preventive health services that will improve the overall health of individuals; b. Assuring access to a broad range of acceptable and effective family planning methods and related preventive health services that include natural family planning methods, infertility services, and services for adolescents; highly effective contraceptive methods; breast and cervical cancer screening and prevention that corresponds with nationally recognized standards of care; STD and HIV prevention education, counseling, and testing; extramarital abstinence education and counseling; .and other preventive health services. The broad range of services does not include abortion as a method of family planning;

c. Encouraging participation of families, parents, and/or other adults acting in the role of parents in the decision of minors to seek family planning services, including activities that promote positive family relationships; d. Improving the health of individuals and communities by partnering with community-based organizations (CBOs), faith-based organizations (FBOs), and other public health providers that work with vulnerable or at-risk populations; e. Promoting individual and community health by emphasizing family planning and related preventive health services for hard-to-reach populations, such as uninsured or under-insured

PHS-S\S2-3

NOTICE OF GRANT AWARD (Continuation Sheet) r-=-:-=:--------r=-:-=====----------, PAGE

4 of 6

GRANT NO.

I DATE ISSUED

1 12/23/2008

2 FPHPA010121-38-00

individuals, males, persons with limited English proficiency, adolescents, and other vulnerable or atrisk populations.

9. In addition to the Program Priorities and Legislative Mandates, the following Key Issues have implications for Title X services projects and should be acknowledged in the program plan: a. The increasing cost of providing family planning services; b. The u.s. Department of Health and Human Service priorities and initiatives, including increasing access to health care; emphasizing preventive health measures, improving health outcomes; improving the quality of health care; and eliminating disparities in health; as well as Healthy People 2010 objectives for Family Planning (Chapter 9); Health Communication (Chapter 11); HIV (Chapter 13), and Sexually Transmitted Diseases (Chapter 25). Q,Jttp:llwww.health.gov/healthypeople): c. Departmental initiatives and legislative mandates, such as the Health Insurance Portability and Accountability Act (HIPAA); Infant Adoption Awareness Training Program (IAATP); providing unmarried adolescents with information, skills and support to encourage sexual abstinence; serving persons with limited English proficiency; d. Integration of HIV/AIDS services into family planning programs; specifically,HIV/AIDS education, counseling and testing either on-site or by referral should be provided in all Title X family planning services projects. Education regarding the prevention of HIV/AIDS should incorporate the "ABC" message. That is, for adolescents and unmarried individuals, the message should include "A" for abstinence; for married individuals or those in committed relationships, the message is "B" for be faithful; and, for individuals who engage in behavior that puts them at risk for HIV, the message should include "A," "B," and "C" for correct and consistent condom use. e. Utilization of electronic technologies, such as electronic grants management systems;

f. Data collection and reporting which is responsive to the revised Family Planning Annual Report (FPAR) and other information needs for monitoring and improving family planning services; g. Service delivery improvement through utilization of research outcomes focusing on family planning and related population issues; and h. Utilizing practice guidelines and recommendations developed by recognized professional organizations and Federal agencies in the provision of evidence-based Title X clinical services.

10.The grantee shall comply with the restrictions on lobbying set out in 45 CFR Part 93. In addition, the grantee shall comply with the restrictions on grantee lobbying in section 503 of the FY 2006 Appropriations Act, as follows: a) No part of any appropriation contained in this Act shall be used, other than for normal and recognized executive-legislative relationships, for publicity or propaganda purposes, for the preparation, distribution, or use of any kit, pamphlet, booklet, publication, radio, television, or video presentation designed to support or defeat legislation pending before the Congress or any State

PHS-5152-4

NOTICE OF GRANT AWARD (Continuation Sheet) r---------,---:::----::::-===-------, PAGE

I DATE ISSUED

5 of 6

12/23/2008

GRANT NO.

2 FPHPA010121-38-00

legislature, except in presentation to the Congress or any State legislature itself. b) No part of any appropriation contained in this Act shall be used to pay the salary or expenses of any grant or contract recipient, or agent acting for such recipient, related to any activity designed to influence legislation or appropriations pending before the Congress or any State legislature. l1.The grantee is required to identify specific efforts of the Title X project to address the Title X program priorities and report on the activities in the project's annual performance report. The project's activities relative to the program priorities are to be included in addition to the project's presentation of its efforts to accomplish the project objectives established for the budget period. 12.In accepting this award, the grantee stipulates that sterilization activities are subject to all provisions of 42 CFR Part 50, Subpart B, "Sterilization of Persons in Federally Assisted Family Planning Projects".

STANDARD TERMS 1. In accepting this award, the grantee stipulates that the award and any activities thereunder are subject to all provisions of 42 CFR Part 59 currently in effect or implemented during the period of the grant. 2. Responses to reporting requirements, conditions, and requests for postaward amendments must be mailed to the attention and address of the Grants Management Specialist indicated in the "Contacts" section. All correspondence should include the Federal grant number (item 4 on page 1 of this document) and requires the signature of an authorized business official and/or the project director. Failure to follow this guidance will result in a delay in responding to your correspondence. 3. The HHS Appropriations Act requires that, when issuing statements, press releases, requests for proposals, bid solicitations, and other documents describing projects or programs funded in whole or in part with Federal money shall clearly state the percentage and dollar amount of the total costs of the program or project which will be financed with Federal money and the percentage and dollar amount of the total costs of the project or program that will be financed by nongovernmental sources. 4. Requests that require prior approval from the awarding office (See Part II, PHS Grants Policy Statement) must be submitted in writing to the GMO. Only responses signed by the GMO are to be considered valid. Grantees who take action on the basis of responses from other officials do so at their own risk. Such responses will not be considered binding by or upon any OPHS Program Office.

REPORTING REQUIREMENTS 1. Financial Status Report SF-269/long form (attached) is due within 90 days after expiration of the budget period. 2. The Single Audit Act Amendments of 1996 (31 U.S.c. 7501-7507) combined the audit requirements for all entities under one Act. An audit is required for all entities which expend $500,000 or more of Federal funds in each fiscal year. The audits are due within 30 days of receipt from the auditor or within 9 months of the end of the fiscal year, whichever occurs first. The audit report when completed should be sent to the Federal Audit Clearinghouse, Bureau of the Census, 1201 E. 10th Street, Jeffersonville, IN 47132.

CONTACTS 1. PAYMENT PROCEDURES:

PHS-5\52-5

NOTICE OF GRANT AWARD (Continuation Sheet) r::-:-=:::--------r=-:-==-==~---____, PAGE

6 of 6

DATE ISSUED 12/23/2008

GRANT NO.

2 FPHPA010121-38-00

Payments for grants awarded by OPHS Program Offices are made through the Division of Payment Management (http://www.psc.gov/). Applicant organizations are assigned a 12-digit Entity Identification Number for payment and accounting purposes. That number is an expansion of the 9digit Employer Identification Number assigned to an organization by the Internal Revenue Service. . PMS is administered by the Program Support Center (PSC), DHHS. Inquiries regarding payments should be directed to (bttp:/Iwww.dpm.psc.goy. Division of Payment Management, P.O. Box 6021, Rockville, MD 20852,1-877-614-5533. 2. Fraud. Abuse and Waste: TheDHHS Inspector General maintains a toll-free hotline for receiving information concerning fraud, waste, or abuse under grants and cooperative agreements. Such reports are kept confidential and callers may decline to give their names if they choose to remain anonymous. Office of Inspector General, Department of Health and Human Services, Attn: HOTLINE 330 Independence Ave., SW, Room 5140 Cohen Building, Washington, DC 20201 e-mail htips@os.dhhs.gov 1-800-447-8477 (1800-HHS-TIPS). 3. For assistance on programmatic issues please contact: Kathleen Desilets, Regional Program Consultant, at (617)路565-1062, FAX (617) 565-4265, email kathleen.desilets@hhs.govorOffice of Family Planning, JFK Federal Building, Room 2100, Boston, MA 02203. 4. For assistance on grants administration issues please contact: Renee Scales, Grants Management Specialist, at (240) 453-8826, FAX (240) 453-8823, e-mail renee.scales@hhs.gov or OPHS Grants Management Office, 1101 Wootton Parkway, Suite 550, Rockville, MD 20852.

PHS-5152-6

Table Of Contents Applicant:

Health Awareness Services of Central Massachusetts, Inc.

Application Number:

FPH2009003614

Project Title

2009 Family Planning Services (Region 1 - Massachusetts)

Status:

Awarded

Online Forms 1.

OPHS-1: Checklist

OPHS-1 Title X Assurances •

(Mail-In Signature Page): Required Signature Page - Please sign & mail in.

SF-424 Application for Federal Assistance (Version 2.0)

SF-424A Budget Information - Non-Construction Programs

SF-424B Assurances - Non-Construction Programs

SF-LLL Disclosure of Lobbying Activities •

(Mail-In Signature Page): Required Signature Page - Please sign & mail in.

HHS Standard Certifications

Program Narrative 1.

Budget Narrative •

(Upload #1): Budget Narrative

•

(Upload #2): Personnel Budget

Program Narrative Upload •

(Filing Detail): Abstract, Program Narrative, Progress Report and Table of Contents

•

(Upload #3): Abstract and Program Narrative

•

(Upload #4): Progress Report

•

(Upload #5): Table of Contents

Additional Information to be Submitted 1.

Miscellaneous Information •

(Filing Detail): Exhibits Band C are attached. Appendices will be sent by mail

•

(Mail-In): Appendices

•

(Upload #6): Exhibit B

•

(Upload #7): Exhibit C Page 1

•

(Upload #8): Exhibit C Page 2

•

(Upload #9): Exhibit C Page 3

•

(Upload #10): Exhibit C page 4

•

(Upload #11): Exhibit C Page 5

•

(Upload #12): List of Appendices

Note: Upload document(s) printed in order after online forms.

Page 1 of 120

OMB Approval No. 0920-0428

CHECKLIST Public Burden Statement: Public reporting burden of this collection of infonnation is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of. infonnation. An agency may not conduct or sponsor, and a person is not required to respond to a collection of infonnation unless it displays a currently valid OMB control number. Send comments regarding this budrden estimate or any other aspect of this collection of infonnation, including suggestions for reducing this burden to OS

Type of Application:

o NEW

Noncompeting D Continuation

Reports Clearance Officer, ASMB/BudgetiPIOM, Room 503H, HHH Bldg., 200 IndependenceAve., S.w. Washington, DC 20201. Do not send the completed fonn to this address. NOTE TO APPLICANT: This fonn must be completed and submitted with the original of your application. Be sure to complete both sides of this fonn. Check the appropriate boxes and provide the infonnation requested. This fonn should be attached as the last page of the signed original of the application. This page is reserved for PHS staff use only.

Competing Continuation

D Supplemental

PART A: The following checklist is provided to assure that proper signatures, assurances, and certifications have been submitted. NOT Included Applicable I. 2.

Proper Signature and Date for item 18 on SF-424 (Face Page) .................................................. .. Human Subjects Certification, when applicable (45 CFR 46) ...................................................... .

PART B: This part is provided to assure that pertinent information has been addressed and included in the application. NOT Applicable YES I.

Has a Public Health System Impact Statement for the proposed program/project been completed and distributed as required?...................................................................................... Has the appropriate box been checked for item # 16 on the SF-424 (FACE PAGE) regarding intergovernmental review under E.O. 12372? (45 CFR Part 100) .................................... Has the entire proposed project period been identified in item # I3 of the FACE PAGE? ................................................................................................................................................ Have biographical sketch(es) with job description(s) been attached, when requested?

2. 3. 4.

D IE] ~

D 5.

Has the "Budget Infonnation" page, SF-424A (Non-Construction Programs) been completed and included? ............................................ Has the 12 month detailed budget been provided? ............................................................................ Has the budget for the entire proposed project period with sufficient detail been provided? .. ... ... .... ........ ........ ............ ...... ........ ......... ........ ..... .... ... ........ ......... ..... .... ..... ...... ........ ...... ..... For a Supplemental application, does the deiailed budget address only the additional fund requested? .................................................................................................................................. For Cornpeting Continuation and Supplemental applications, has a progress report been included? ....................................................................................................................................

6. 路7. 8. 9.

PART C:

IE] IE]

D D

IE]

In the spaces provided below, please provide the requested information.

Business Official to be notified if an award is to be made.

Program DirectorlProject Direclor/Principallnvesligator designated to direct the proposed projecl or program.

Name

Title

Susan Dube . President, Board of Directors

Michael Mazloff

Tille

Organization Health Awareness Services of Central Massachusetts, 405 Grove Strcet Address Worcester, MA 01605_._12..,:7_0_ _ _ _ _ _ _ _ _ __

Organization Health Awareness Services of Central Massachusetts, In, 405 Grove Street Address Worcester, MA 01605路1270

E-mail Address

Telephone Number

mmazloff@hascm.org 508-756路7123

Fax Number

Fax Number (508) 756-8922

APPLICANT ORGANIZATlON'S 12-DIGIT DHHS EIN (If already assigned)

SOCIAL SECURITY NUMBER

HIGHEST DEGREEE EARNED

I I I I-I I I-I I I I IL-l

MP_H_ - - - - . . J

(OVER)

Page 2 of 120

PART D:

A private, nonprofit organization must include evidence of its nonprofit status with the application. Any of the following is acceptable evidence. Check the appropriate box or complete the "Previously Field" section, whichever is applicable.

D (a) A reference to the organization's listing in the Internal Revenue Service's (IRS) most recent list of

. tax-exempt organizations described in section 50 I (c)(3) of the IRS Code. A copy of a currently valid Internal Revenue Service tax exemption certificate. () A Statement from a State taxing body, State Attorney General, or other appropriate State official certifying that the appplicant ~rga,n\zation has a nonprofit status and that none of the net earnings accrue to any "nvate shareholders or Inchvlduals. D (d) A certified copy of the organization's certificate of incorporation or similar document ifit clearly establishes the nonprofit status of the organization. D (e) Any of the above proof for a State or national parent organization, and a statement signed by the parent organization that the applicant organization is a local nonprofit affiliate. ~Dx (be)

If an app'licant has evidence of current nonprofit status on file with an agency of PHS, it will not be necessary to file simIlar paper again, but the place and date of filing must be indicated. on (Date)

Previously Filed with: (Agency)

I 08/31/2000

I Region I, DHHS

INVENTIONS

If this is an a);!plication for continued support, include: (I) the report ofinventions ,conceived or reduced to practice required by the terms and conditions of the grant; or (2) a list of inventIOns already reported, or (3) a negative certification.

EXECUTIVE ORDER 12372 Effective Sepetembcr 30, 1983, Executive Order 12372 (Intergovernmental Review of Federal Programs) directcd OMB to abolish OMB Circular A-95 and establish a new process for consulting with State and local elccted officials on proposed Federal financial assistance. The Department of Health and Human Services implemented the Executive Order through regulations at 45 CFR Part 100 (Inter-governmental Review of Department of Health and Human Services Programs and Activities). The Objectives of the Executive Order arc to (I) increase State flexibility to design a consultation process and select the programs it wishes to review, (2) increase the ability of State and local elected officials to influence Federal decisions and (3) compel Fedcral officials to bc responsive to State concerns, or explain the reason. The

regulations at CFR Part 100 were published in thc Federal on Junc 24, 1983, along with a notice identifying thc

Department's programs that are subject to the provisions of Executive Order 12372. Information regarding PHS programs subject to Exccutive Order 12372 is also available from the appropriatc awarding Office. States participating in this program establish State Single Points of Contact (SPOCs) to coordinate and manage the review and comment on proposed Federal financial assistance. Applicants should contact the Governor's office for information regarding the SPOC, programs selected for reviews, and the consultation (review) process designed by their State. Applicants whethcr the 12372 and, opportunity

are to certify on the face page of the SF-424 (attached) request is for a program covered under Executive Order where appropriate, whether the State has been given an to comment.

BY SIGNING THE FACE PAGE OF THIS APPLICATION. THE APPLICANT ORGANIZATION CERTIFIES THAT THE STATEMENTS IN THIS APPLICATION ARE TRUE. COMPLETE. AND ACCURATE TO THE BEST OF SIGNER'S KNOWLEDGE. AND THE ORGANIZATION ACCEPTS THE OBLIGATION TO COMPLY WITH PUBLIC HEALTH SERVICE TERMS AND CONDITIONS IF AN AWARD IS MADE AS A RESULT OF THE APPLICATION. THE SIGNER IS ALSO AWARE THAT ANY FALSE. FICTITIOUS. OR FRAUDULENT STATEMENTS OR CLAIMS MAY SUBJECT THE SIGNER TO CRIMINAL. CIVIL. OR ADMINISTRATIVE PENALTIES. THE FOLLOWING ASSURANCES/CERTIFICATIONS ARE MADE AND VERIFIED BY THE SIGNATURE OF THE OFFICIAL SIGNING FOR THE APPLICANT ORGANIZATION ON THE FACE PAGE OF THE APPLICATION: Civil Rights -- Title VI of the Civil Rights Act of 1964 (PubL 88-352), as amended, and all the requirements imposed by or pursuant to the DHHS regulation (45 CFR 80). Handicapped Individuals - Section 504 of the Rehabilitation Act of 1973 (Pub ..L. 93-112), as amended, and all requirements imposed by or pursuant to the DHHS regulation (45 CFR 84). Sex Discrimination - Title IX of the Educational Amendments of 1972 (Pub.L. 92-318), as amended and all requirements imposed by or pursuant to the DHHS regulation (45 CFR 86). Age Discrmination -- The Age Discrimination Act of 1975 (Pub.L. 94-135), as amended, and all requirements imposed by or pursuant to the DHHS regulation (45 CFR 91). Debarment and Suspension - Title 45 CFR Part 76. Certification Regarding Drug-Free Workplace Requirements - Title 45 CFR Part 76. Certification Regarding Lobbying -- Title 32, United States Code, Section 1352 and all requirements imposed by or pursuant to the DHHS regulation (45 CFR 93). Environmental Tobacco Smoke - Public Law 103-227. Program Fraud Civil Remedies Act (PFCRA)

Page 3 of 120

OPHS-1 TITLE X Assurances

Project Title:

2009 Family Planning Services (Region 1 - Massachusetts)

Project Period:

12/31/2008 to 12/30/2013

Application Organization

Health Awareness Services of Central Massachusetts, Inc.

Authorized Certifying Official:

Michael Mazloff

Title:

Executive Director

I DO NOT agree with the tenns of the Signing Agreement

121 I agree with the tenns of the signing Agreement

Page 4 of 120

OMS Number: 4040-0004 Expiration Date: 07/31/2006 Version 02

Application for Federal Assistance SF-424 • 1. Type of Submission:

• 2. Type of Application:

DPreapplication

DNew

I81ApPlication

I8IContinuation

DChanged/Corrected Application

DRevision

• 3. Date Received:

4. ApplicanUdentifier:

110/01/2008

• If Revision, select appropriate letter(s):

I • Other (Specify)

IIFPHPA010121

I • 5b. Federal Award Identifier:

5a. Federal Entity Identifier:

J State Use Onl)':

6. Date Received by State: 110101/2008

117. State Application Identifier: I

8. APPLICANT INFORMATION:

• a. Legal Name: IHealth Awareness Services of Central Massachusetts, Inc. • b. EmployerlTaxpayer Identification Number (EINITIN):

• c. Organizational DUNS:

1042496148A2

1128770765

d. Address: • Street1: Street2: • City:

1405 Grove Street

Iworcester

County:

• State:

"Massachusetts

Province: • Country:

IUNITED STATES

• Zip 1 Postal Code: 101605-1270

e. Organizational Unit: Department Name:

Division Name:

f. Name and contact information of person to be contacted on matters involving this application: Prefix:

I Middle Name: I

• First Name: IMichael

• Last Name: I Mazloff Suffix:

Title: IExecutive Director

I I

Organizational Affiliation:

• Telephone Number: 1508-756-7123 • Email:

Immazloff@hascm.or!:j

Page 5 of 120

IFax Number: 1{508l 756-8922

I 1

OMB Number: 4040-0004 Expiration Date: 07/31/2006

Version 02

Application for Federal Assistance SF-424 9. Type of Applicant 1: Select Applicant Type:

INonprofit with 501 C3 IRS Status (Other than Institution of Higher Education) Type of Applicant 2: Select Applicant Type:

I Type of Applicant 3: Select Applicant Type:

I " Other (specify):

I "10. Name of Federal Agency:

IPA-Family Planning 11. Catalog of Federal Domestic Assistance Number:

193.217

CFDA Title:

IFamily Planning Services * 12. Funding Opportunity Number:

"Title:

2009 Family Planning Services (Region 1 - Massachusetts)

13. Competition Identification Number:

I Title:

2009 Family Planning Services (Region 1 - Massachusetts)

14. Areas Affected by Project (Cities, Counties, States, etc.):

Central Massachusetts路- Worcester County and the MetroWest area (western portion of Middlesex County)

* 15. Descriptive Title of Applicant's Project:

2009 Family Planning Services (Region 1 - Massachusetts)

Attach supporting documents as specified in agency instructions.

Page 6 of 120

OMB Number: 4040-0004 Expiration Date: 07/31/2006

Application for Federal Assistance SF-424

Version 02

16. Congressional Districts Of: , a. Applicant

103

' b. pro gram/Proj ect!02,03,

Attach an additional list of Program/Project Congressional Districts if needed.

17. Proposed Project: 'a. Start Date:

112/31/2008 1

' b. End Date:

112/30/2013 1

18. Estimated Funding ($):

• a. Federal

7818511

• b. Applicant

• c. State

• d. Local

• e. Other

• f. Program Income

7590591

• g. TOTAL

15409101

* 19. Is Application Subject to Review By State Under Executive Order 12372 Process? Da. This application was made available to the State under the Executive Order 12372 Process for review on

Db. Program is subject to E.O. 12372 but has not been selected by the State for review. IEIc. Program is not covered by E.O. 12372.

, 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes", provide explanation.)

IE] No

DYes

21. 'By signing this application, I certify (1) to the statements contained in the list of certifications" and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances·· and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)

IE]"

I AGREE

•• The list of certifications and assurances. or an internet site where you may obtain this list. is contained in the announcement or agency specific instructions. Authorized Representative: Prefix:

IMr.

Middle Name: 'Last Name: Suffix: 'Title:

• First Name:

IMazloff 1

1 1

IExecutive Director

'Telephone Number: 1508-756-7123 , Email:

IMichael

IFax Number: 1508-756-8922

1mmazloff@hascm.org

, Signature of Authorized Representative: Authorized for Local Reproduction

Page 7 of 120

I ' Date Signed: I

I Standard Form 424 (Revised 10/2005) Prescribed by OMB Circular A-102

OMB Number: 4040-0004 Expiration Date: 07/31/2006

Application for Federal Assistance SF-424 â&#x20AC;˘ Applicant Federal Debt Delinquency Explanation The following field should contain an explanation if the Applicant organization is delinquent on any Federal Debt. Maximum number of characters that can be entered is 4,000. Try and avoid extra spaces and carriage returns to maximize the availability of space.

Page 8 of 120

Version 02

:,,:,.::'

'.,<" .',::.

;0':«.

.•.. : .• <

>.<

Grant Program Function or Activity (a)

Catalog of Federal Domestic Assistance Number (b)

1. Family Planning Services

93.217

2. Family Planning Services

93.217

3. Family Planning Services

93.217

4. Family Planning Services

93.217

BUDGET INFORM A TI0 N - Non-construction Programs SECTION A.:;$UDGET.$UMMA'ijY1(?';))if: ;~:;::~Tt¥;{\\~j;I~S:t;f>~-,:::-:~-:0~;;;i~-{ "

.'.

Estimated Unobligated Funds Federal (c)

Federal (e)

(d)"

;;;;/;>. ';/:;1.

........

$781,851.00

$759,059.00

$1,540,910.00

$781,851.00

$759,059.00

$1,540,910.00

Familv

a. Personnel

PIQnnin~

(2)

Familv Planninl;':

(3)

Familv PlanninQ:

;.-

.... ,,;;;:

•.... .<oJ

";;;:'~""'" Total

GRANT PROGRAM, FUNCTION OR ACTIVITY (1)

. :;.• (;.!':...•... Total (g)

Non-Federal (f)

'SECTION .B."BU£)GJ:tCAJEGO~IE$i: :</;fC:. O<',;'·;<' .' :.;";;;.i'" ~I~!;: .

6. Object Class Categories

"';-;i: 'X:

New or Revised Budget

Non-Federal

Totals .;.";"';

OMBApprova IN o. 03480044

(4) Familv Plannin"

(5)

$497,681.00

b. Fringe Benefits

(b) (4)

c. Travel

$2,814.00

$85,790.00

$664,213.00

$170,969.00

d. Equipment e. Supplies

f. Contractual g. Construction h. Other

i. Total Direct Charges (sum of6a-6h)

(b) (4)

j. Indirect Charges

(b) (4)

k. TOTALS (sum of 6iand 6j)

. ":.:"::,

::"':>.~<;.

7. Program Income

'.:.'"

$1,540,910.00

:.>/'

...... ..::.::::.:::..:....•.::.. :.

:·3;~·<·.'"

,.... ".>.·····'.:··;:··V·;/'··· .:.;:.:

$759,059.00

Authorized for Local Reproduction Previous Edition Usable

Page 9 of 120

'-,':

'!: ;.:;:. .:y.;:.:,';'; . . .

'.""'"

$759,059.00 Standard Form 424A (Rev. 7-97) Prescribed by OMB Circular A-102

(a) Grant Program' 8.

(b) Applicant

Family Planning Services

(d) Other Sources

(e) TOTALS

$759,059.00

9. Family Planning Services

10. Family Planning Scrvices 11. Family Planning Services 12. TOTAL (sum oflines 8-11)

.......•

Total for 1st Year

13. Federal 14. Non-Federal 15. TOTAL (sum oflines 13 and 14)

.>·•.. h·G '. .., '·c'··

1st Quarter

2nd Quarter

$781,851.00

$195,463.00

$195,462.00

$759,059.00

$189,765.00

$189,764.00

$1,540,910.00

$385,228.00

$385,226.00

.:S.~g1:I()N It • BUI)~~T;.M1IM."TES OF;FEI).~~F t:U~~~;:~~~D~~·.~~~;~A~~~~,qf!~~P~PJECt (a) Grant Program (b) First

16. Family Planning Services

4th Quarter

3rd Quarter

v ..· . . ; . \ . , : c. .•.

FUTURE FUNDING PERIODS (Years) (c) Second (d) Third

$781,851.00

.... . ,

(e) Fourth

17. Family Planning Serviccs 18. Family Planning Services 19. Family Planning Services

20. TOTAL (sum oflines 16-19)

21. Direct Charges: (b) (4)

12 1

(b) (4)

23. Remarks:

Authorized for Local Reproduction Page 10 of 120

Standard Form 424A (Rev. 7-97) Page 2

SF424B Assurances

Project Title.:

2009 Family Planning Services (Region 1 - Massachusetts)

Project Period:

12/31/2008 to 12/30/2013

Application Organization

Health Awareness Services of Central Massachusetts, Inc.

Authorized Certifying Official:

Michael Mazloff

Title:

Executive Director

I DO NOT agree with the terms of the Signing Agreement

lEJ I agree with the terms of the signing Agreement

Page 11 of 120

DISCLOSURE OF LOBBYING ACTIVITIES

Approved by OMS

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 See reverse for ublic burden disclosure. 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract ~a. bid/offer/application ~ a. initial filing b. grant b. initial award b. material change c. cooperative agreement c. post-award For Material Change Only: d.loan year quarter __~____ date of last report _______ e. loan guarantee f. loan insurance 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is a Subawardee, Enter Name and Address of Prime: IEl Prime 0 Subawardee Tier , if known: Health Awareness Services 405 Grove Street Worcester, MA 01605-1270 USA

Con ressional District, if known: 03 6. Federal Department/Agency:

Con ressional District, if known: 7. Federal Program Name/Description:

DHHS/OPA CFDA Number, if applicable: _9_3_.2_1_7_ __ 8. Federal Action Number, if known:

9. Award Amount, ifknown: $

10. a. Name and Address of Lobbying Registrant (if individual, last name, first name, M/):

b. Individuals Performing Services (including address if different from No. 10a) (last name, first name, M/):

Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Informalion requested through this fonm is aulhorized by tille 31 U.S.C. section â&#x20AC;˘ 1352. This disclosure of lobbying activities is a material representation of facl upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Print Name: Michael Mazloff Title: Executive Director Date:

09/30/2008

Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)

Page 12 of 120

Approved by OMS

0348-0046

DISCLOSURE OF LOBBYING ACTIVITIES CONTINUATION SHEET Reporting Entity:

Page 13 of 120

Health Awareness Services

Page

Authorized for Local Reproduction Standard Form - LLL-A

OPHS-1 Certifications

Project Title:

2009 Family Planning Services (Region 1 - Massachusetts)

Project Period:

12/31/2008 to 12/30/2013

Applic,ation Organization

Health Awareness Services of Central Massachusetts, Inc.

Authorized Certifying Official:

Michael Mazloff

Title:

Executive Director

I DO NOT agree with the terms of the Signing Agreement

I2J I agree with the terms ofthe signing Agreement

Page 14 of 120

Upload #1 Applicant:

Health Awareness Services of Central Massachusetts, Inc.

Application Number:

FPH2009003614

Project Title

2009 Family Planning Services (Region 1 - Massachusetts)

Status:

Awarded

Document Title:

Budget Narrative

Page 15 of 120

BUDGET NARRATIVE This budget reflects the total costs incurred by Health Awareness Services and its delegate agencies in providing family planning services for the period from January 1,2009 to December 31, 2009. Costs for the coming Fiscal Year have been estimated by using historical costs and estimating any changes foreseen. A. PERSONNEL: $ 497681. Program staff for HASCM Clinic, A istration and Support staff (see attached breakdown of key personnel- includes a(b) (4) increase for COLA) (b) (4) B. Taxes & Fringe: Fringe Benefit Rates are calculated at (b) (4). This is based on past costs for Family Plannin e costs. The breakdown is as follows:

(b) (4)

C. Travel $2,814 Personnel Policies authorize reimbursement for work-related travel in relation to job responsibilities. These trips may include, but are not limited to, Regional Office meetings, staff trainings by JSI and others, state association meetings, travel to other clinic sites. The reimbursement rate is $ .405/mile.

D Eguipment:

E. SUDDlies: $85,790. Supply costs are based on the actual costs incurred for family planning services in FY08 Year-to-date, and any changes projected for FY09, based on changes in utilization and/or price increases. In addition, a portion of the cost for supplies and related items that are used for Management and General functions are allocated based on the proportional size of family planning to our agency budget (48 percent). Office supplies: $4,743. Includes stationery, newsprint, writing pads, paper, etc. necessary for conducting day to day operations. Cleaning supplies: $ 319. Items, such as disinfectants, trash bags, paper towels, etc. Patient Care supplies:

Page 16 of 120

$ 76,477.

This includes the cost of medical consumables, pregnancy test kits, medications, contraceptives, exam paper, gowns, drapes, etc. This is based on last year's actual costs and projected changes for contraceptive supplies. Educational supplies: $3,526. Supplies purchased for use in counseling and educational workshops for clients and the community as approved by the CI&E Committee. Does not include development and printing of our own materials, which are also reviewed through CI&E Committee Equipment supplies: $ 725. Ink cartridges and machine supplies F. Contractual: $664,213 Funds that are allocated to our Delegates. A. Pro Health provides family planning in Northern Worcester County. Their parent agency IS Montachusett Opportunity Council. The listing of their key personnel is attached.

Personnel: Fringe: Travel: Equipment: Supplies: Contractual: Other: Total

(b) (4)

2,400 600 8,144 8,000 180,362. (b) (4)

Contractual costs include their Medical Director, consultants,(b) (4)percent of their Title X appropriation of paid to Health Awareness for administrative overhead (b) (4) ($14,448), and (b) (4) of their total budget paid to Montachusett Opportunity Council, rent organization, for indirect overhead. We intend to contract with them for (b) (4) in 2009. B. Plumley Village Health Services is a satellite clinic of UMass Memorial Health Care. It is located in a public housing development in the City of Worcester. Health Awareness subcontracts $15,000 of family planning funds from the MA Department of Public Health, to be reimbursed on a fee for service basis. There is no direct allocation of Title X dollars. c. Framingham Community Health Center is a 330 Health Center serving the City of Framingham and surrounding towns. They received $10,000 in Title X funding in 2008, and we intend to re-contract with them for $10,000 in FY09. We also will provide them with $20,000 from the MA Department of Public Health for family planning services. d. Beginning in December 2009, Health Awareness will contract with Hahnemann Family Health Center, a community-based group practice of UMass Memorial Health Care. Hahnemann Family Health Center will replace the direct care services that Health Awareness previously provided in the City Of Worcester; current clients are being

Page 17 of 120

referred to them. Health Awareness will contract with them for $80,000 in Title X funding and $20,000 in family planning funding through the MA Department of Public Health. G. Construction: H. Other:

Advertising:

$0 $ 170,969 $ 12,734

Yellow pages advertising, publicity, help wanted ads

Cleaning Service $6,637. Weekly cleaning of clinic space Dues and subscriptions $4,642. Membership in NFPRHA and local coalitions, subscriptions to medical journals Electric and Heat $6,490 .. Utilities for clinic operation Equipment rental & repair $3,075. Microscope and copier upkeep Fiscal Audit $7,847. Clinic portion of yearly agency audit $5,000 In kind Services Services of Dr. James Broadhurst MD, Medical Director. Provided by UMass Memorial Health Care in exchange for preceptorship by Nurse Practitioners of Family Practice Residency students. Lab Services $31,269. Fees for pap tests, blood pregnancy tests, urine testing and other lab exams Insurance $7,996. Includes Professional and General Liability, Directors and Officers and Property Miscellaneous $516 Bank charges and Petty Cash Occupancy $62,118 Rent is paid for all four HASCM family planning clinics and a portion of administrative space. Payroll Service $826. Clinic portion of payroll service Postage $535. Allocation cost of clinic mail Printing $10,234 Cost of brochures, letterhead and all printed materials developed for client education. Professional Fees $2,782. Cost of MD phone back up and physician consultation

Page 18 of 120

Training $498. Continuing education for current staff and training for new staff Telephone $7,770. Cost of business numbers and 800 number for centralized scheduling

TOTAL BUDGET:

$1.540.910

Projected Revenue, FY09

Massachusetts DPH Patient Fees MassHealth (Medicaid) Third Party Payers Title X * In-Kind TOT ALREVENUE

$602,242 76,817 55,000 20,000 781,851 5,000 $1,540,910

* Our FY09 allocation is $759,079. We are requesting a three percent cost-of-living allowance.

Page 19 of 120

Upload #2 Applicant:

Health Awareness Services of Central Massachusetts, Inc.

Application Number:

FPH2009003614

Project Title

2009 Family Planning Services (Region 1 - Massachusetts)

Status:

Awarded

Document Title:

Personnel Budget

Page 20 of 120

Sheet1

HEALTH AWARENESS SERVICES Jan 1, 2009 to Dec 31, 2009

SUPPLEMENTAL TO PART III, SECTION F

NAME AND POSITION TITLE Rate

ANNUAL SALARY ratew as of 8113108

(b) (4)COLA

Annwinc

#OF

%OF

MOS. TIME

hrs/wk M. MAZLOFF, EX. DIR. L. ODELL, DIR CL SERV L SMALARZ,DIR CL SERV C RIVEROS,BOOKKEEPER Y RECALDE,Bkpr/COAcoord M DONOVAN,SECRETARY D BRADY, PURCHASER

SUB TOTAL CLINIC STAFF PP HANNON, NP,CL COOR N PEARSON,NP C DIGREGARIO NP per diem M DENINE, NP M LAVOIE NP SB/MB M THOMAS NP per diem C DURAN, I&R SPEC S MCCARTHY SB COA J CARVALHO,FPC name, FPC-MB/ML A CORDERO, COAlML Vacant, COAl MB B HAYDEN,FPOR

(b) (4) (b) (4)

SUBTOTAL TOTAL FRINGE@ (b) (4) GRAND TOTAL

(b) (4)

Page 1 Page 21 of 120

Excel Title X 2009 Sheet 1

Sheet1

TOTALAMT REQUIRED 31718.23 54697.19 11313.59 5102.34 17139.20 3954.87 10712.00 134637.41 38563.20 41134.08 3711.71 72841.60 36420.80 3534.96 31064.80 11119.06 29959.32 32136.00 25708.80. 20567.04 16282.24

363043.61 497681.02 119443.44 617124.46

Page 2 Page 22 of 120

Excel Title X 2009 Sheet 1

Sheet2

(b) (4)

Page 3 Page 23 of 120

Excel Title X 2009 Sheet 2

Sheet3

(b) (4)

Page 4 Page 24 of 120

Excel Title X 2009 Sheet 3

Sheet4

For 2009 CLINIC EXPENSES PER 2007 AUDIT ADV 12734 BLDM 0 CLEANING 6637 CNT SRV 0 DUES/SUBS 4642 ELECTRIC 5061 EQR&R 3075 FISCLAUDT 7847 15694.@50%= HEAT 1429 IN KIND S&S 5000 INSURANCE 606 INSm&g 7389.5 14779.@50%= INT BANK CHG 231 LAB SERV 31269 MISC 285 OFF & CL Rnt 62118 PAYRL SERV 826 1652.@50%= POSTAGE 535 PRINTING 10234 PROF FEES 2782 PRV STPNDS 0 STF TRAINING 498 SUPPLIES 86759 TELEPHONE 7770 TRAVEL 2814 TOTAL 260541.5

Page 5 Page 25 of 120

2007 TOTAL AGENCY MINUS M&G EXP Total

2052917 279059 1773858

885567 1773858 0.499232182 50% ofM&G for audit, ins, payroll serv

CLINIC TOTAL BFR DEPREe

DIVBY For % M&G

Note 2006 2007 2008

34% 40% 50%

Excel Title X 2009 Sheet 4

Page 32 redacted for the following reason: --------------------(b) (4)

Sheet6

2009 TITLE X

for budget narrative sheets

PERSONNEL INCLUDE(b) (4)COLA

497681

(b) (4) FRINGE USE OF ALL EMPLOYEE

(b) (4)

C. D. E.

G. H.

TRAVEL RATE AT (b) (4)

2814

SUPPLIES ALL CLINIC RELATED OFFICE PTCARE ED CLEAN EO

4743 76477 3526 319 725

85790 CONTRACTUAL MOC & FRAMINGHAM PERSONNEL FRINGE TAXES SUPPLIES OTHER TOTAL PLUS FRAMINGHAM AMT

OTHER ADV BLDG CLEAN SRV DUES/SUBSC ELACT/HEAT EO RENT&REP FISCAL AUDIT INKIND SUPPLY LAB SERV SUB TOTAL TRAVEL ALL SUPPLY OTHER TOTAL

606+7389 12734 INS MISC 285+231 6637 OCCUPANCY 4642 PAYRLSERV 6490 POSTAGE 3075 PRINTING 7847 PROF FEES 5000 TRAINING 31269 TELEPHONE TOTAL

7996 516 62118 **current figures 826 new rate tbd 535 10234 2782 498 7770 170969

2814 see c above 86759 see e above

GRAND TOTAL

Page 7 Page 27 of 120

86759

876697

Excel Title X 2009 Sheet 6

Upload #3 Applicant:

Health Awareness Services of Central Massachusetts, Inc.

Application Number:

FPH2009003614

Project Title

2009 Family Planning Services (Region 1 - Massachusetts)

Status:

Awarded

Document Title:

Abstract and Program Narrative

Page 28 of 120

PROGRAM ABSTRACT Health Awareness is applying for the continuation of funding for Family Planning Services in Central Massachusetts and the Metro West area of Middlesex County. Approximately 900,000 people live in this area. Health Awareness has been providing these services since 1976. The latest data from the Alan F. Guttmacher Institute's Women in Need of Publicly Funded Reproductive Health Care, 2004 estimates that there are 57,600 women in need of subsidized family planning services in our area. There are also significant disparities in health outcomes between racial and ethnic communities, including rates of teen pregnancy, sexually transmitted diseases, and HIV/AIDS. Health Awareness proposes to meet these needs through the provision of high quality reproductive health care, with emphasis on affordability, accessibility, cultural competency and educated client decision- making. Care will be delivered through: the three family planning clinics of Health Awareness (Marlborough, Milford, Southbridge); our delegate, . Montachusett Opportunity Council, in northern Worcester County; our delegate, Framingham Community Health Center; our contract provider, Plumley Village Health Services, located in public housing in Worcester; and our new delegate, Hahnemann Family Health Center, in the City of Worcester. Health Awareness served 5,249 users in 2007. With our new Delegate and with our expansion plans in the MetroWest area, we project serving 7,000 users by the end of2010. We expect to continue to serve individuals from low-income families, adolescents, and hard-to-reach andlor vulnerable populations, in keeping with the needs of our service area and OP A Program Priorities.

1 Page 29 of 120

A. SERVICE AREA NEEDS ASSESSMENT Introduction - This Needs Assessment is designed to provide infonnationthat will be used to direct increasingly scarce resources to the most high-risk populations in our service area. The Needs Assessment combines the following sources: Data collection on key health indicators from the MA Department of Public Health (MDPH) and municipalities; demographic data collected as part of the US Census, as well as by state and local governments; Alan Guttmacher Institute's Women in Need of Publicly Funded Reproductive Health Care, 2004; and FPAR data from Health Awareness.

1. Geographic Description of Service Area: Health Awareness provides comprehensive family planning services to the residents of Central Massachusetts. This region includes all of Worcester County, and several contiguous portions of Middlesex County. The 2000 US Census reports that Worcester County had a total population of750,963, up 5.8 percent from 1990. Fifty-one percent of the total population is female, and 21.8% are women of childbearing age. Worcester County is heavily urbanized, although there are over 1,000 fanns, the highest number of any county'in Massachusetts. The largest city is Worcester, with a population of 172,648 (up nearly 3,000 from 1990). It is the second " largest city in the state and the third largest in New England. Three-quarters of the people in the service area live in or adjacent to urban areas. There are major highways running both east-west (The Mass. Turnpike) and north-south (Rtes 190,290 and 395). Public transportation serves only the cities of Worcester, Fitchburg and Leominster. Several parts of the service area more than 40 miles from the major urban areas. The western portion of Middlesex County, to the east of Worcester County, is known as MetroWest. It's part of the Greater Boston SMSA, but is over 40 miles from the city. Its identity as a region is long established. The population of this area is estimated to be approximately 150,000 people (2000 US Census). A map of the Service Area is Attachment A. 2. Demographic Description: There are 13 communities in our service area with population greater than 15,OQO, as ofthe 2000 Census.

2 Page 30 of 120

TABLE 1: 2000 Population by Race, HASCM Service Area US Census data) Community

Worcester Auburn Fitchburg Framingham Gardner Hudson Leominster Marlborough Milford Shrewsbury Southbridge Webster W estborol!~h

Total

White, No Hispanic

Hispanic

AfricanAmerican

122,211 15,392 29,414 50,293 18,882 16,718 33,673 30,778 24,264 27,875 13,028 15,250 15,441

26,155 1,590 5,852 7,265 848 634 4,544 2,196 1,168 506 3,472 657 558

11,892 95 1,426 3,409 476 163 1,529 787 362 474 246 181 288

172,648 15,901 39,102 66,910 20,770 18,113 41,303 36,255 26,799 31,640 17,124 16,415 17,997

Asian

Native American

8,402 143 1,668 . 3,527 284 254 1,006 1,364 473 2,404 261 164 359

Biracial 5,861 95 1,198 2,263 328 362 914 1,037 475 213 453 213 395

769 16 138 116 70 18 63 72 29 36 73 49 36

Ethnically, Worcester County is predominantly white (85.6%). However, that percentage was 93.8% III 1990, showing the change in population demographics. There are large communities of Hispanics in Worcester (15.1%), Fitchburg (15.0%), Framingham (10.9%), Leominster (11.0%) and Southbridge (20.3%). There's also a significant population of Brazilians who have moved into the eastern part of our Service Area. Economic and health status differ significantly between communities in our service area: TABLE 2 -Economic Indicators By City/Town (MA DPH, 2007) Worc- Auburn Fitch- Framing Gardner Hudson Leomin- Marlbor- Milford IEconomic ~ndicator

~urg

ester

ster

!ham

Per capita 18,614 123,802 17,25{ 27,758 Income Children> 100% 17.9 15.0 8.1 3.3 poverty Total >200 % 36.2 34.5 21.1 13.3 Poverty Unemployment 6.0 9.7 4.1 4.5

18,624 26,679 121,769

ough

~hrews- ~outh~ridge ~ury

Webter

Westboro

28,723 23,742 31,570 18,514 20,410 35,063

9.6

4.5

9.5

6.9

7.2

4.8

15.4

11.0

4.7

25.9

12.5

23.7

16.4

19.1

11.7

33.9

27.9

9.8

6.5

4.8

6.3

4.1

5.0

4.2

6.7

6.3

4.0

TABLE 3 - Health Indicators By CitylTown, :MA DPH, 2000-2005) Milford Shrews- ~outh- Webster ~estWorcester iAuburn [oitchburg Fram- pardner Hudson Leomin- ~arlHealth 路ngham pury bridge ter ~orough ~oro Indicator LOW 8.1 7.6 8.1 5.0 4.2 9.6 9.2 10.7 10.1 9.7 8.4 7.2 6.7 Birthweight

Infant Mortality

6.6

9.1

8.5

3.9

1.8

In Worcester, Fitchburg, Framingham, Leominster, Marlborough and Southbridge, the level of infant mortality and low-birth weight is significantly higher among Hispanics than among Whites.

3 Page 31 of 120

TABLE 4 - Fertility Rates b'l City/Town, 1995-2000 (per 1,000 Women 15-44) - MA Dept Public Health Rates Worces ~uburn lFitch- IFram- pardner ~udson ~eomin- lMarl- Milford Shrews- South- ~eb- ~ pury borough bridge ~ter Burg ingham er !2oro ~ter Fertility Rate, 56.1 61.1 51.8 47.0 55.1 53.2 56.5 47.2 55.7 52.9 61.5 49.4 51.7

~ertility

White Fertility Rate, Hispanic Fertility Rate Black Non-Hisp.

83.8

113.3 68.1

110.3

57.1

122.2

109.2

96.2 55.5

75.5

136.0

112.5

115.1

92.7

96.6 137.3

57.8

74.1

76.2

266.7

NA 100.0

As a frame of reference, the statewide averages are as follows: TABLE 5 - Economic and Health Indicators, MA, 2007 (MA DPH) Per capita rrotal > 100% Income poverty

$25,952

9.3

Total >200 % UnemployPoverty ment rate

21.7

5.1

LBW

Infant Mortality

4.7

7.8

Fertility Rate, Fertility Rate, !Fertility Rate !Black,Non-Hisp White ~isp.

48.0

85.7

71.3

Women in Need: According to the Alan Guttmacher Institute: Women At Risk -The Need/or Family

Planning Services - State and Country Estimates - 2004, Worcester County has 40,100 women in need of subsidized contraceptive services. TABLE 6: Worcester County WIN Data, 2002 Under 20 20-44 and < 250% poverty Calendar Years TOTAL 13,120 1995-2000 38,870 25,750 2000-2002 40,100 12,980 27,120 These data do not take mto account the MetroWest area, which is part of Middlesex County; the three largest communities in Metro West have 17,500 more women in need of services. If the figures for Worcester County are combined with the three communities in Middlesex County (Framingham, Hudson and Marlborough), there are 57,600 women in need of subsidized family planning services. Adolescents:

There's been a downward trend in the state over the past eight years in the rate of teen

pregnancy. The statewide rate fell from 34.2 births per 1000 in 1990 to 25.8 in 2000 to 22.2 in 2004. This was the lowest rate recorded in 30 years! However, there are still areas of concern. In 2004, there were five communities with high rates of teen pregnancy, when compared with other communities in the state. 'Mass. TABLE 7 B"lrthRates among Teens, 15 -19 - A s Compared to CommunltIes III Community !Rank, Births, Rate per Rank, lBirths, Rate per Rank, Births, ?OOO 2006 1,000 1990 1990 1,000 ~006 ~OOO Southbridge 36 64.5 5 38 5 48 6 68.3 Fitchburg 91 58.2 146 7 10 92 60.6 6 29 NA 34 Marlborou~h NA 34.1 13 36 43.5 Worcester 242 15 290 14 399 18 34.4 41.9 44 Framingham 22 65 23 45 23.4 NA 33.3

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Rate per 1000 52.5 82.1 37.9 58.8 19.6

It's important to point out that there is a marked disparity in teen births in communities of color. In Worcester, for example, although Hispanics accounted for less than 10 percent of the city's population, they accounted for nearly 43 percent ofteen births. In Southbridge, the figures are 20.3 percent and 49.3 percent, respectively. In Fitchburg, Hispanics make up 15.1 percent of the population and account for 47.6 percent of teen births. Sexually Transmitted Diseases: There are several communities we serve with rates ofSTD's that exceed statewide averages. The data below comes from the STD Surveillance Program of MDPH and underscores the need to offer STD screenings in these communities in order to reduce morbidity associated with undetected/untreated chlamydia and gonorrhea. TABLE 8: STD Rates, 2007 (MDPH) Chlamydia, Community Rate/100,000 Fitchburg Framingham Marlborough Milford Southbridge Worcester Massachusetts

251.8 164.5 113.0 105.4 228.5 379.2 236.6

Chlamydia, 15Gonorrhea 19 Rate/l 00,000 Rate/100,000 teens 54.3 838.1 16.8 739.4 13.5 425.1 495.9 25.4 1,207.6 NA 1,348.2 46.7 1,079.6 37.7

Gonorrhea, 15-19 Rate/100,000 teens NA NA NA NA NA 90.8 110.5

This is comparable with our data from our family planning clinics: TABLE 9 -C hI amydia Positivity Rates for Health Awareness Services & MOC Family Planning Clinics 7/01-6/02 7/02-6/03 7/03-6/04 7/04-6/05 7/05-6/06 7/06-6/07 7/07-6/08 Clinic Site Worcester 2.7% 4.0% 5.2% 9.2% 8.4% 4.7% 3.5% Milford 3.0% 3.0% 4.4% 5.6% 4.3% 3.8% 3.3% Southbridge 2.9% 7.0% 5.5% 7.4% 7.2% 6.2% 6.9% Marlborough 3.0% 2.0% 3.9% 3.7% 5.6% 5.2% 7.6% 路4.0% Fitchburg & Gardner 路5.1% 4.0% 5.4% 4.6% 4.8% 3.2% Cumulative rate/yr 3.4% 5.5% 5.9% 5.3% 4.1% 4.5% 4.1% HIV/AIDS: As discussed in Section 2-L, Health Awareness has devoted significant resources to address the HIV epidemic, including prevention, education, counseling & testing, and case-management. The epidemiology has changed in the past five years. Increasingly, it is becoming more prevalent among IV drug users and their sexual partners, especially in communities of color. The percentage of women inthe

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infected population is also growing. Data is drawn from the MDPH HIV/AIDS Surveillance Program. The most common mode of exposure for those infected in Worcester was heterosexual contact (42%, presumed and reported) followed closely by Injection Drug Use (40%) and Men Having Sex with Men (16 percent). lvmg HIV/AIDS Cases as 0 f7/1/07 TABLE 10 M odeofT ransmlSSlOn, L". MSMI HTSX Pres. MSM IDU Total IDU HTSX Cases Fitchburg 15 % 0 20% 25% 40% 113 Framingham 23% 31 % 0 16% 30% 152 2% 20% Worcester 16% 40% 22% 895

The large commumtIes In our servIce have varymg rates of HIVIA IDS: TABLE 11 Cumulabve · Cases 0 fHIV/AIDS R eported,as 0 f7/1/02 and 7/1/06 Prevalence (Alive Cases, 2002 Prevalence (Alive Cases, 2006 Cases per 100,000) Cases per 100,000) Fitchburg 94 240 113 289 Framingham 181 152 227 133 Leominster NA 64 155 NA Marlborough 36 44 119 99 Worcester 741 433 895 518

Worcester has the 5tn hIghest number of new cases per 100,000 m the state; Frammgham is 19th • 1 L·IVm! . TABLE 12 Sex and Gendero fP eOPJe GENDER Female Male 55.7% 44.3 % FitchburK Framingham 40.1 % 59.9% Worcester 40.9% 59.1 %

WI·th

HIV/AIDS ,as 0 f7/1/07 RACE/ETHNICITY Hispanic White Black 27.7% 48.7% 18.5 % 39.5% 27.6% 30.9% 35.6% 24.0% 38.9%

Regardmg gender, males appear to be more at nsk. Females account for 44 percent of HIV cases in Framingham and 41 percent in Worcester. This is consistent with the experience of providers in these. communities, including ourselves, who are seeing more women becoming infected than we previously did. In regard to ethnicity, the figures in Table 14 are not news to us, but are still very disturbing. TABLE 13: HIV/AIDS Incidence and Ethnicity, as of7/1/07 Hispanic Population, Percentage of African-American 2000 Census HIV1AIDS· Cases Population, 2000 Fitchburg 15.0% 48.7% 3.6% Framingham 10.9% 30.9% 5.1 % Worcester 15.1 % 38.9% 6.8%

Percentage of HIV1AIDS Cases 18.5 % 27.6% 24.0%

. Hispanics and African Americans account for a disproportionate share of HIVIA IDS cases. There is no available data on the rates among Brazilians. As discussed in Section 2-L, Health Awareness devotes a considerable amount of its resources to HIV prevention and support· services.

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3. Priority Populations/Target Areas: The priority populations that Health Awareness has, and will continue to target, based on the Demographics and Needs of our Service Area, are:

A. Low- and moderate":income people. Six of the 13 communities in our service area, with population greater than 15,000, (as of the 2000 Census) had low-income populations in excess of the statewide average; the unemployment rates are higher and per capital income lower than the state average. Three (Worcester, Fitchburg and Southbridge) have more than 113 of their populations living in households below 200 percent of poverty. Health Awareness has been successful in serving these communities:

Below 200% of poverty

2003 91.5

2004 91.7

2005 91.3

2006 91.8

2007 91.1

Non-English-Speaking Populations: There are significant populations of people for whom language, and/or cultural attitudes toward health care are barriers to receiving services. This includes Hispanics in most parts of our service area, and Brazilians in the eastern portion (Marlborough and Milford). Their rates of fertility, teen pregnancy, low birthweight, infant mortality and HIV infection are higher than those of whites. Health Awareness and delegates have provided on-going targeted outreach to non-English speaking populations in our service areas. The growth in number of non-English speaking users at our sites is a reflection of our successful outreach and recruitment efforts towards these underserved and often uninsured individuals that are in need of family planning services.

In some of our clinics, these percentages are dramatically higher. In 2007, 61 % of clients in Marlborough spoke Portuguese and 5% spoke Spanish. In Milford, 36% spoke Portuguese and 15% spoke Spanish. Many of these people are undocumented, in terms of immigration status. Since this makes them unable to qualify for most state insurance programs, that makes our services one of their only options for health care.

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Adolescents: Five of the communities in the state with the highest rates of teen pregnancy are in our service area. This justifies making specific efforts to maintain the high percentage of teens that use our services by assuring that our settings and staff are "teen-friendly." However, the number of teens that we have been seeing has been decreasing:

Health Awareness Users Teens

2004 32.9

2005 28.6

The decline in numbers is most evident in Worcester and Fitchburg, where the Community Health Centers operate school-based clinics. Our numbers in other communities are more robust. For example, in Southbridge, which has a high teen pregnancy rate and where we operate a state-funded teen pregnancy prevention project, the percentage of teens seen last year was 45.2 percent! Males: The number of male patients seen has increased dramatically over the past ten years: TABLE 18: Gender, All Grantee Sites FY07 FY06 FY05 FY04 FY03 FY02 FYO 1 I Male Users I 22.2 20.1 I 12.0% I 11.0% I 8.0% I 6.4% I 7.5% I Health Awareness and delegates have provided on-going improvements to male services within family planning. Examples include: revamping clinic decor and outreach materials to be more sensitive to males, providing targeted outreach to males and revising male health protocols, visit forms and history forms. 4. Existing Resources: Health Awareness is the only grantee for Title X funding in Central Massachusetts and the MetroWest area, an area with over 800,000 residents. We have had this status since 1976. Health Awareness also receives funding from the MA Department of Public Health for family planning services. Our organization currently includes four Health Awareness Services family planning clinics; one delegate agency, Montachusett Opportunity Council, which operates two clinics; one delegate, Framingham Community Health Center, a federally-qualified program; and one sub-contractor, Plumley Village Health Services, which receives state funding but not federal funds. All sites are handicapped-accessible and ADA compliant. As of December 1,2008, this will change to three sites directly operated by Health Awareness, and the addition of a new Delegate in Worcester. This change is described in Section B.

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5. Community-Based Resources: There are four federally funded community health centers in our service area and one satellite health center: •

Great Brook Valley Health Center provides primary health care in the eastern part of Worcester. This is a very large health center with a dental program, on-site specialty medical programs, pharmacy, mental health division, and social services programs. They receive family planning funding from the Massachusetts Department of Public Health.

•

The Family Health Center of Worcester provides services to more than 16,000 people annually. Like Great Brook Valley, they also receive family planning funding from the Massachusetts Department of Public Health.

(We work cooperatively with both health centers in the referral of patients and the sharing of resources, both in family planning and in HIV prevention and testing activities. Memoranda of Understanding exist with both organizations.) •

In 2004, Great Brook Valley Health Center started a new 330 Project in Framingham, the Framingham Community Health Center. It is one of our delegates.

•

Community Health Connections is a large Community Health Center, opened in 2002, that serves northern Worcester County, with sites in Fitchburg, Gardner and Leominster.

•

Plumley Village Health Services in Worcester is a satellite clinic of UMass Merriorial Health Care, and is a Delegate of Health Awareness. Planned Parenthood League of Massachusetts operates a large freestanding clinic in Worcester.

They do not receive any federal funding for family planning, but they do receive family planning funding from the MA Department of Public Health. Their services are not provided on a sliding fee scale, and their state funds are used principally to subsidize the cost of services to clients under 19. 6. Unmet Family Planning Needs: There are more than 57,000 women in our service area in need of subsidized family planning services. Two-thirds live outside the City of Worcester. In past years, we have mentioned the significant number of people in our Service Area who are medically uninsured or under-insured. In the past two years, though, the state of Massachusetts has 9 Page 37 of 120

addressed this issue through the development of the Commonwealth Care Health Insurance Program (Commonwealth Care); this will be discussed in greater detail in Section 5, Financial Management. Under the new Plan, state residents ages 19.and older are required to obtain health insurance, if affordable coverage is available, or pay a tax penalty. The. state offers subsidized coverage for lowincome residents, and employers also must contribute to the cost of workers' coverage or pay into a fund. For those whose employers do not offer coverage, or cannot afford to purchase conventional plans, the state has set up mechanisms to provide subsidized plans. Those whose income is below 300 percent of poverty can apply for coverage through Commonwealth Care. Policies cover ·inpatient and outpatient care, prescriptions, mental health and substance abuse, diagnostic visits, and. preventive care. The premiums, deductibles and co-payments are adjusted based upon one's income; there are plans with higher co-payments and deductibles and lower premiums for those who wish to pay less up front. Commonwealth Care has not made subsidized Family Planning obsolete, nor even less needed. There are large groups of people who are not covered by the new Program: •

The thousands of people who are opting out of Commonwealth Care because of rising costs.

As the economy worsens, these numbers will grow. •

Undocumented immigrants are not eligible for Commonwealth Care. It's impossible to

know how many people this is. We do know, for example, that the estimates of the Brazilian population in our Service Area run in excess of 50,000 people, most of whom are undocumented. There are thousands of people from other areas, as well. •

Teens who do not want to use their parents' insurance are still coming to us, seeking

confidential care. There is no Medicaid waiver through which to serve them. Fortunately, we still have our MDPH funding for this purpose.

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Based on our Needs Assessment, Health Awareness has chosen to provide services to populations that are hard to reach, geographically isolated, and underserved. Most of our sites are in communities where there are not community health centers or other sources of subsidized care. The demographics of our service area and the declining economy indicate the need for increased, subsidized reproductive health care. This information points to the need for expansion of school-based and community-based health education as well as marketing and outreach efforts targeted at communities at risk.

B. APPLICANT AND PROJECT INFORMATION 1. Organizational and Program Management Structure a) Organizational Overview: The first Title X funding for Worcester County was awarded in 1971

to the Family Planning Foundation. When this organization dissolved in 1976, a new organization, Family Planning Services of Worcester, was formed and took over as the Title X grantee. This organization changed its name in 1978 to Family Planning Services of Central Mass. to reflect its regional mission. As the agency grew and expanded its range of services, it changed its name once more, in 1985, to Health Awareness Services of Central Mass. In addition to family planning, we provide the following: •

Comprehensive health education, AIDS education and prevention

•

HIV counseling and testing

•

Case-management and support services to people living with HIV/AIDS

•

Teen Pregnancy Prevention Services

The various programs of Health Awareness Services reach nearly 12,000 individuals yearly. Family Planning has been and remains our largest program. Funding comes from both the Office of Population Affairs and the MA Department of Public Health (MDPH). Health Awareness Services is a tax-exempt organization under IRS Code 501 (c)(3). A copy of our letter of tax -exemption is on file with the Regional Office in Boston.

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All of our departments are horizontally linked through shared education and training activities and coordination meetings. It is common for staff of two or more departments to work together oil joint efforts. Managers meet monthly to share information. The chief governing body of Health Awareness Services is our Board of Directors. The Board of Directors has the ultimate authority for the program management and fiscal oversight of the organization. The Board consists of area residents who reflect the economic and ethnic composition of our service area. A list of the members of the Board is attached. The Board reviews the agency's fmances regularly, through its Finance Committee, and on an annual basis through review of the Annual Audit. At each meeting, the Board also receives program updates so that they can provide oversight. The Board holds its Annual Meeting in June of each year. As detailed in our By-Laws, Board members are elected for an unspecified term. New members are approved by existing members, either at the Annual Meeting or by a ballot sent to Directors and approval by a majority. The Nominating Committee presents a list of nominees to the Directors at the Annual Meeting, along with a description of their backgrounds and why they are interested in serving on the Board. Any vacancy that arises during the year may be filled by the Directors at any regular meeting; the Board will act as the Nominating Committee in these instances. A member of the Board of Directors may be removed from office at the Annual Meeting or regular meeting by an affirmative vote of two-thirds of all Directors. Organizational Charts for Health Awareness (agency and family planning), Current Delegates (Montachusett Opportunity Council, Framingham Community Health Center) and Sub-recipient (Plumley Village Health Services) are in the Appendix, Attachment B.

b. Title X Program Structure - We plan to add a new Delegate in Worcester this year, Hahnemann Family Health Center (HFHC). This Delegate, along with our existing Worcester Sub-recipient site, Plumley Village Health Services (PVHS), will replace our free standing Health Awareness family planning site in

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Worcester. In November of 2008, we will cease operation of our clinic at 405 Grove Street, and on December 1, 2008, will contract with Hahnemann Family Health Center, a community-based practice of UMass Memorial Health Care and a major teaching site for the Family Practice Residency Program of UMass Medical School, as a Delegate Agency.

This change in plans has been submitted to and approved

by the Regional Office, through our Supplemental Grant Process; the MA Department of Public Health has also approved this plan. The reason for this change is as follows: 1. The City of Worcester, as described in Section A, has four large entities that provide subsidized primary health care, including family planning. Health Awareness should not be competing with these entities, but instead should use Title X dollars to supplement their delivery of family planning care. Our patient numbers in Worcester have dropped in recent years. 2. Of the four entities: Great Brook Valley (a 330 health center), Family Health and Social Services (a 330 health center), Hahnemann Family Health Center (HFHC) and Planned Parenthood, HFHC is the only entity hat doesn't receive state family planning funds. 3. HFHC is located in an easily accessible location, close to the major interstate (Route 290/190), with a diverse patient base. It is the most likely site to refer our current patients. 4. This relationship will add more than 1,000 new users in Worcester to our system in 2009. We are working with HFHC to insure that there is a smooth transition between the two organizations. HFHC is located in the Hahnemann Hospital Campus ofUMass Memorial Health Care, a modem, patientcentered facility, easily accessible by bus and adjacent to an exit off of Route 290, the main highway through the center of Worcester. It's in Lincoln Square, a centrally-located inner-city area on the City's east side. The surrounding neighborhood is predominantly Hispanic. Bus service to the area is excellent, and a significant percentage of HFHC clients utilize public transportation. The Hahnemann Campus has been in this location for the past eighty years (first as an independent entity and now as a campus ofUMass Memorial Health Care). HFHCprovides care in a full spectrum family medicine model, including obstetrics, serving an economically and ethnically diverse cross-section of the community. HFHC providers include family physicians, nurse practitioners, and mental health professionals, all of who are faculty

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members in the Department of Family Medicine and Corrimunity Health in the University of Massachusetts Medical School. HFHC sees approximately 20,000 patient visits each year, about half of which are covered by MassHealth, or Commonwealth Care. Interpreter services when needed are available through the hospital's Interpreter Services Office. UMass Memorial Medical Center has been a leader among Massachusetts hospitals in offering high quality interpreter services for its clients. The model that Hahnemann Family Health Center will use is very similar to that used by other Primary Care providers that are delegates in Region 1. As a Delegate, the grant will cover a portion of a clinician's time and a medical assistant that is trained in family planning. These staff-people will provide education and counseling to all clients who receive reproductive health care services. The staffwill also provide supportive referrals for related services and follow-up care, as well as data collection. HFHC already has a follow-up system in place and will incorporate family planning clients into this system. They will be able to provide FP AR quality indicators through their current data base system. Another structural change that we will make to our Title X Program Structure will be to move our Marlborough Clinic and our Administrative Office to a new site in Marlborough. This will allow us to expand our clinical services there and save money on rent. We'll locate our centralized appointment booking system and information/referral (I&R) service, currently in Worcester, at our new site in Marlborough. Health Awareness has two other Delegates and one Sub-recipient:

Montachusett Opportunity Council, (MOC) the Community Action Agency in northern Worcester County has provided health and social service programs since the early 1970's. Prior to 2008, the family planning services were in a separate department called Pro Health. In the past year, this department has

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been reorganized and combined with MOC Nutrition and HIV Services. This is shown in their Organizational Chart (Attachment B). This department provides family planning, breast and cervical cancer screening, WIC services, HIV case management, and health education in two locations - Fitchburg and Gardner. Plumley Village Health Services (PVHS) is a satellite ambulatory care center ofUMass Memorial Health Care. It was fonnerly located at a public housing project in downtown Worcester (Plumley Village), it is now on the campus of UMass Memorial Health Care, a short walk from the fonner site. Over three-quarters of the residents in Plumley Village have family incomes below $15,000 annually. There is a large population of undocumented aliens, largely from the Dominican Republic and Central America. Health Awareness has maintained a relationship with Plumley Village for nearly fifteen years. We currently subcontract $15,000 in state funds to the Plumley Village Health Service for care to uninsured, income-eligible family planning patients. We also provide technical assistance and staff training. Health Awareness Services refers clients for consult with the Plumley Village Health Service physician as needed; the physician is bilingual (English/Spanish). Framingham Community Health Center (FCHC) This health center opened in March of 2004. They remain in a temporary quarters, while a pennanent facility is being built in downtown Framingham.

addition, FCHC is working with the Framingham High School to open a school based health center; this program is anticipated to offer family planning services. This coming year, Health Awareness will provide $10,000 Title X funding and $20,000 state funding. Health Awareness Services refers clients for consult with Framingham Community Health Center physicians as needed. FCHC has trilingual (English: Spanish/Portuguese) and bilingual (English/Spanish) physicians on staff. Health Awareness Services provides technical assistance and staff training to FCHC.

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A copy of the standard contract between Health Awareness and our Delegates is in Appendix C. A new feature this year is that all contracts will have the number of users that are projected for the Delegate to serve in the Contract Year.

This will become a contract performance outcome.

c. Management and Monitoring of Delegates/Contractors - Health Awareness has maintained a relationship with Pro Health as a delegate agency since 1983. Our relationships with our new delegate, Framingham Community Health Center, and our sub-contractor, Plumley Village Health Center, follow the identical structure of that relationship. This is especially true in terms of monitoring the quality of Title X services and compliance with its regulations. Delegate/subrecipient agencies utilize Lori Odell, Director of Clinical Services, as on-going resource for clinical service issues. Ms. Odell provides delegate agencies with continuing clinical updates (updated Title X guidelines, FDA news alerts, revised Health Awareness protocols, etc.) and she serves on the Pro Health Quality Improvement Committee. Internal systems, including site and medical record reviews, are in place for assuring that delegate agencies and contractors are in compliance with Title X. Our audit tools have been approved by the Regional Office and closely resemble those used by the Office of Population Affairs to review grantees. This tool directly assesses compliance with all Title X regulations. The contract that is signed by delegates contains the following assurances: â&#x20AC;˘

â&#x20AC;˘

(The contracting agency) shall be required to comply with all relevant Title X regulations, including provisions of 42 CFR Part 59 currently in effect or implemented during the period of the grant. In accepting this award, (The contracting agency) certifies: That it will encourage family participation in the decision of minors to seek family planning services and that it provides counseling to minors on how to resist attempts to coerce minors into engaging in sexual activities. Notwithstanding any other provision oflaw, no provider under Title X of the Public Health Service Act shall be exempt from any State law requiring notification or the reporting of child abuse, child molestation, sexual abuse, rape or incest.

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One of the criteria assessments in our annual review of contractors is compliance with Section 1008, that abortion is not used as a method of family planning. None of our contractors are abortion providers. The proposed contract for 2007 includes an assurance of compliance with Section 1008. Delegates are reviewed through a formal site visit every three years; a yearly review is done using selected indicators with a randomized sample of medical records. Site Reviews cover such things as: compliance with ADA, eLlA, and OSHA standards; fire safety and protective equipment adherence; performance reviews, credentialing of staff and client confidentiality. Medical Record audits target such things as: informed consent for treatment and method specific consents; appropriate history, assessment of minors for sexual coercion, compliance with 51A State Law mandated reporter statutes, assessment and provision of care for visit; follow-up; education & counseling; preventive screening; overall documentation; and data validation review of fee policies. At the end of the review, our clinical and fiscal staff verbally summarizes their findings and process quality improvement initiatives with the appropriate management staff. A written report follows. The review outcome helps form the basis for program work plans. Health Awareness provides Title X funds to delegates and sub-recipients on a cost-reimbursement basis. Each year, the contractor must first submit an annual budget to us for approval. This budget then becomes part of the annual contract. The contractor must request reimbursement, in writing, within 20 days of the end of the previous month. An itemized invoice is filed for that month. Health Awareness staff review the request, and may ask for back-up documentation if warranted. Within 20 days, if the invoice is deemed to be correct, a payment is made. As described above, our fiscal staff goes on-site annually to verify the fiscal appropriateness of the billings and fiscal controls. This is done in conjunction with the medical audits described above.

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Health Awareness provides delegate/sub-recipient agency personnel with access to on-going continuing education, training and infonnation on Title X related topics. To assure sub-recipient needs are being represented through regional trainings Health Awareness issues JSI annual Training Needs Assessment surveys to appropriate sub-recipient staff. The most recent needs assessment survey was conducted in August 2008. Our delegates are required to submit their annual audits to Health Awareness within 120 days of the Close of their fiscal year. Audits must clearly show the use of Title X funds. Our auditors review the audit and their findings are included in our Audit report.

d. Personnel Policies - A copy is given to each employee upon hire. The most recent revision of the Personnel Policies was in May of 2008. The Board of Directors approves all revisions. Staff Recruitment and Selection - Positions are posted in-house for one week prior to being advertised externally. Postings are displayed on our agency Web site, sent to community organizations and area networks. We also advertise in newspapers and "help wanted" Web sites. Perfonnance Evaluations - Staff is evaluated annually by their immediate supervisors; all new staff receives an evaluation at three-six months of hire. Promotion - When a job is posted internally (see above), employees can apply for the position. We encourage employees to apply for higher positions when they become available. Tennination - Health Awareness Services uses a progressive discipline system in the event of unsatisfactory perfonnance. It goes from infonnal warning to fonnal disciplinary action tennination. There are prescribed actions that are taken as part of these steps. The intent is to help the employee to correct their perfonnance. If there is no improvement, the employee can be tenninated for cause.

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Compensation - This is based on the Salary Scales, which set the range for each position. Compensation for a new employee is recommended by the supervisor, and approved by the Executive Director. The Board of Directors approves the up dating of the Salary Scales. Benefits - Eligibility for benefits is based on amount of hours that employees work. This includes health insurance, dental insurance, life insurance, short-term disability, vacations, and personal days, etc. Grievance Procedures - There is a formal process for filing a formal grievance. In the event that the grievance cannot be worked out, the Personnel Committee of the Board serves as the final arbiter of the situation. Confidentiality of Personnel Records - The Personnel Policies state that no information about clients or employees be discussed with others inside or outside the agency, and client files, medical records, employee files or other agency documents cannot be taken out of the agency. All inquiries are referred to appropriate authorities. Employees, interns and volunteers are required to sign a statement of confidentiality affirming their understanding of these principles. The personnel policy statement regarding confidentiality was updated in 2007. See Attachment D. Conflicts of Interest - Employees may not have a financial interest in any of the transactions of the organization, nor may they receive personal compensation for agency work. 2. Clinical Service System and Clinical Management: a. Family Planning Service Facilities - A map of our sites for family planning and HIV counseling and testing is attached in the Appendix, Attachment A b. Service Site Information - The family planning clinic locations, hours of operation, numbers of past and projected users are contained in site specific Exhibits B. c. Family Planning Services Provided - See Appendix - Exhibit C

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d. Medical Oversight and Clinical Care Provider Information - James J. Broadhurst, MD has been the Medical Director since 1987; since 1992, HASCM has contracted with Ronald Adler, MD as our Medical Advisor. These two contracted physicians oversee the care and provide consultation to Advanced Practice . Nurses (Nurse PractitionerslNurse Midwifes) and/or Physician Assistants. The Medical Director is primarily responsible for oversight of the family planning program. In this role he conducts on-going reviews of medical literature related to family planning to ensure current practice standards are maintained, . interacts with clinicians quarterly at the Clinical Advisory Committee meetings, is responsible supervising prescriptive authority and conducting annual prescriptive reviews for advanced practice nurses and physician assistants, directly approves and co-signs all clinical protocols, reviews unusual occurrence reports when indicated and provides telephone consultation as needed. The Medical Director dedicates approximately four hours per month to family planning; he does not provide direct client services but does provide clinical inservice/practicum, as needed to clinical staff. He is the Assistant Director of the Family Practice Residency Program at the University of Massachusetts Medical School; his salary is donated by UMASS, in return for the preceptorship ofUMASS residents by Health Awareness Service provider staff within our Family Planning Program. Dr. Broadhurst contracts with Health Awareness through the Department of Family Practice and Community Medicine of the University of Massachusetts Medical Center. The Medical Advisor is primarily responsible for providing consultation to advance practice nurses or physician assistants. In this role the Medical Advisor provides on-going telephone back-up for staff as needed .during hours of operation for all clinics (e.g. complex client, client that does not fall within protocol), conducts on-going reviews of medical literature related to family planning to ensure current practice standards are maintained, interacts with clinicians quarterly at the Clinical Advisory Committee meetings and participates in annual medical record reviews. The Medical Advisor is available

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approximately 30 hours per month for telephone coverage of family planning. He does not provide direct client services but does provide clinical inservice/practicum, as needed to clinical staff. A copy of the job description s for the Medical Director and Medical Advisor, and copies of the resumes of Drs. Broadhurst and Adler are in the Appendix, Attachment E. The Board or Registration in Nursing governs the advanced practice scope of practice in accordance with 244 CMR 4.13. Registered Nurses who apply for authorization in advanced nursing practice must have either a graduate degree in advanced nursing practice or a certificate of approved educational program in advanced nursing practice of at least 1 year in length, plus certification in advanced nursing practice from a Board of Nursing approved certifying organization. All Advance Practice Nurses must have mutually agreed upon practice and treatment guidelines developed collaboratively with a supervising physician. The Board of Physician Assistants governs physician assistant scope of practice in accordance with 263 CMR 5.00. A PA must possess a baccalaureate degree, graduate from a physician assistant training program which holds a valid certificate of program approval issued by the Board and be certified by the National Commission of Certification of Physician Assistants. Physician assistants must have mutually agreed upon practice and treatment guidelines developed collaboratively with a supervising physician. Advanced Practice Nurses and Physician Assistants must apply to and be approved by the Commonwealth of Mass. Department of Public Health, Division of Food and Drugs for prescriptive authority/ Mass. controlled substance registration (schedules II-VI drugs). The supervising physician is identified and signs this application. The prescription has the name of supervising physician printed on the pad, the authorized Advance Practice Nurse or Physician Assistant must sign the prescription. e. Professional Credentials and Licensure -Health Awareness starts the credentialing process with all employees prior to hire. Reference checks are contacted to confirm curriculum vitae data and to assess past job performance (on average 3 reference checks are made). All newly hired staff must complete employee

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eligibility verification as detelIDined by the Department of Justice. As per guidelines, Health Awareness Services reviews two fOlIDs of employee ID (e.g. drivers license, social security cardlbirth certificate or U.S. passport). Upon hire, all licensed staff must present proof (source data) of current licensure/registration, Advanced Practice Nurse/Physician Assistant Prescriptive Authority by the Commonwealth of Mass. and/or Federal & State Controlled Substance Certification (DEA), certification by specialty e.g. American Nurses .Credentialing Center (ANNC), National Certification Corporation (NCC), American Board of Family Practice, etc. and CPR certification. Copies of data are placed in the employees' personnel file. Licensed staff credentialing data is confilIDed through the MA Board of Nursing, MA Physician Assistant Board or MA Board of Medicine database. All licensed staff provides Director of Clinical Services credentialing data on an on-going basis (when renewal occurs). The Director of Clinical Services at Health Awareness Services maintains credentialing records and conducts an annual credentialing review through the MA Board of Nursing/Physician Assistant/Medicine database. All physician staff must present proof of malpractice coverage upon hire and must present documentation of this annually.

In addition to the above credentialing, the Director of Clinical Services and Credentialing Consultant maintain credentialing and re-credentialing requirements for on-going and/or new contracts with third party payers. Currently this involves six third party payer contracts. f. Service Plans and Protocols - We provide comprehensive, client-centered family planning services to females and males in an infolIDative and comfortable setting. The point of entry for clients is via our clinic phone line; here clients interact with our bilingual Clinic Appointment System Coordinator and are given infolIDation, an appointment or referral infolIDation. The clinic . reception area is the clients' second point of entry. The reception areas are well stocked with diverse health and social service infolIDation for both genders, all ages and in several languages. We have

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posters that target health concerns in a subtle yet clear manner (e.g. abstinence, condom use, HIV risks & prevention, folic acid, pregnancy can happen to you, smoking, domestic violence, etc.). Condoms (male and female) are free and accessible in waiting areas, bathrooms and in counseling sessions. Informed voluntary consent is required for all clients receiving services; consents are written in English, Spanish and Portuguese. All initial clients review and sign or decline a Notice of Privacy Practices form in accordance with The Health Insurance Portability & Accountability Act of 1996 (HIPAA). These forms are in English, Spanish and Portuguese.

Initial and/or Annual Comprehensive Visits include the following: Education/Counseling is interactive and based on a client's individual need and knowledge. Staff utilizes active listening skills and open-ended question to assess client concerns, risk factors and knowledge. This is provided in an age appropriate, culturally competent, non-judgmental manner. Things such as, preventive health screenings, such as breast self-exam, pap smears and other health screenings (i.e. fecal occult blood, mammography, testicular self exam etc.) are reviewed and discussed. Breast/testicular self-exam information is provided; instruction is done by the provider during the exam. Abstinence as an option for pregnancy prevention and harm reduction is reviewed with all teens. Sexual coercion is assessed with teen clients and counseling regarding resisting coercion is provided. In addition, family involvement is explored, discussed and encouraged with adolescent clients. All clients are assessed for domestic/relationship violence and are provided with information related to this; direct referrals are provided as needed.

Disclosure of

domestic/relationship violence is difficult; often a trust needs to be formed between staff and a client before disclosure can occur. In addition to discussing this issue with clients and providing information re: referral sources, we have wallet cards and posters in the bathrooms that identify this issue and list resources. Through utilizing this visual and confidential medium in bathrooms both clients and guests have access to this information. What we have found is that many cards are taken at each clinical session and

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occasionally a client discloses. This underscores the need to offer an anonymous means for individuals to access information, as well as, an opportunity to interface with staff to discuss risks, disclose and be provided with direct referrals.

Awareness of sexually transmitted diseases (STD) and HIV/AIDS is assessed and explored with clients through an individual risk assessment. Risk assessments are done in the client's primary language. Clients are assessed for their individual lifestyle (e.g. significant other relationships) risk factors, patterns of behavior, socio-economic issues, and individual concerns. Family Planning staff processes information and concerns with clients in a manner that promotes identification of individual risks and reduction of risk behavior(s). Lifestyle & risk factors are reviewed with clients during each clinic encounter (e.g. comprehensive visit, Depo-Provera visit, etc). Clinic counselors and clinicians process harm reduction and behavior change strategies with clients. All clients who are identified as high risk are offered additional counseling, information and referral for further education, HIV testing or other indicated medical services. Health Awareness has adopted the CDC's "Revised Recommendations for HIV Testing Adults, Adolescents and Pregnant Women In Health Care Settings"; HIV testing is offered on site at all Health

Awareness Family Planning sites. FDA approved contraceptive methods are available through Health Awareness Services, delegate and sub-recipient sites. Individual life styles are discussed and an all method comparison is reviewed with clients, this affords clients sound knowledge for decision- making. In-depth counseling and education is provided regarding their method of choice: how it works, benefits and risks, details about safety, effectiveness, potential side effects, complications and contraindications. Information is presented to clients verbally and in writing. Method specific consents are obtained prior to initiating a new method of birth control. All consent forms are in English, Spanish and Portuguese. Appropriate birth control is dispensed to clients at the time of their visit. All clients are counseled about Emergency contraception (EC) and

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offered a provision of EC or prescription to utilize if needed. Other counseling/education provided to clients include nutrition (calcium & folic acid), domestic violence awareness (how to get help if needed), and other topics as per client history (e.g. smoking cessation, substance use, etc.).

History: Family planning counselors review family history, individual medical, surgical, social, sexual and reproductive health history at initial visits and this is updated annually. A review of systems, history of sexually transmitted infections (including HBV, HCV and HIV), and date, result oflast past Pap smear or past abnormal Pap smear data is elicited in the history. An authorization for disclosure of protected health information to obtain release of past medical records is requested if indicated by history. Allergies, prescriptions, medications, primary care provider, drug use (tobacco, alcohol or other drugs), condom use, sexual coercion, relationship violence and immunization status is included in the history taken.

Comprehensive exam: pelvic eXam which includes vulvar evaluation and bimanual exam & pap smear (females), chlamydia screening for individuals 25 years or younger or with risk factors for chlamydia, breast exam/testicular exam, review of systems, hypertension screening and digital rectal exams are done on individuals over the age of 40 years and fecal occult blood screening is done on individuals age 50 or older. Initial visits for female clients also include anemia screening through afinger stick hemoglobin determination. Deferred exams are offered to female clients seeking contraceptive services when indicated (guidelines are in place re: duration and circumstances for deferment). We have adopted ACOG's cervical cancer screening guidelines. Initial screening begins three years after first sexual intercourse or by age 21, whichever comes first. Cytology screening may be done sooner at provider's discretion. Other laboratory services are offered as indicated (i.e. urine dipstick, urine culture and sensitivity, GC screening, CBC, etc.). Referrals are provided as needed.

Other Visits or Revisits Include: Clients return to the clinic for a variety of reasons: contraceptive method follow-up, cytology follow-up, treatment of vaginal / urinary tract / sexually transmitted infections,

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contraceptive method concerns, pregnancy testing and counseling and other problems related to reproductive health. The client's presenting issue/problem is assessed and appropriate diagnostics, care and education/counseling is provided. At these visits histories are updated related to allergy, any changes in medications, medical/surgical history or partner since last visit? If indicated, contraception or other medications are dispensed or administered. Referrals are provided as needed. When indicated, medical services are provided with collaboration from the client's primary care provider. If clients do not have a primary care provider they are offered referral information. Health Awareness, delegates/sub-recipients DO NOT perform sterilization procedures. We have a request for a waiver from the sterilization-reporting requirements on file at the Regional Office. Health Awareness and its delegates provide counseling and referral for sterilization.

Protocols: We provide comprehensive care in compliance with accepted family planning practices and professional standards. The Quality Improvement Committee (Clinical Advisory Committee at Health Awareness) assesses protocols on an on-going basis and reviews/approves all protocols related to medical services. The need for revision or new protocols is determined several ways: priorities set by the QI committee, new guidelines issued (i.e. ACOG guidelines for abnormal cytology follow-up of adolescents), new contraceptive methods, treatments or screenings, current literature on treatment modalities or assessments and/or results of internal medical record reviews. Appropriate protocol/procedure development is done by subcommittees or individuals and brought back to this Committee for final approval. Policy, procedure, protocol manuals are reviewed annually by members of the Quality Improvement Committee. This review is documented on a "sign off' sheet in the policy/procedure/protocol manual. The Board of Directors is updated on protocol development by the Board liaison and Director of Clinical Services. A copy of the Table of Contents for the Health Awareness Family Planning Policy, Procedure and Protocol Manual is in the Appendix, Attachment F.

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g. Adherence to State Laws Regarding Reporting of Child Abuse, Child Molestation Sexual Abuse, Rape, or Incest: Health Awareness Services, d~legates and sub-recipient agencies adhere to MA. State Laws regarding reporting child abuse, child molestation, sexual abuse, rape and incest. Clinic staff are mandated reporters and comply with the Massachusetts General Law, Chapter 119: Section 51 A Injured Children. Counseling summary forms have been revised to ensure careful assessment of sexual coercion of minor clients. Copies of the "Child AbuselNeglect Reporting Policy and Procedure (51A)" and "Sexual Coercion Assessment and Counseling with Minors" Policy are in Attachment G. In addition, all clinical sites have a copy of the manual for Title X Providers "Confidential Services and Reporting of Child Abuse and Neglect" developed by the John Snow Institute (JSI) for Region I Title X Providers. This manual is kept on site as a provider resource. h. Bilingual Services - Over the past years Health Awareness Services has seen an increase in the number of non-English speaking clients in our Milford, Marlborough and Worcester sites. The primary languages of non-English speaking clients in our service area are Spanish and Portuguese. In response to the growing number of non-English speaking clients we have increased the number of bilingual/trilingual staff. All family planning and HIV counseling and testing services have one or more bilingual staff. Staff that book appointments for family planning are bilingual and outgoing messages, when clinics are closed, are in English, Spanish and Portuguese. In order to assist clients with medical and social histories we translated our initial and annual history forms into Spanish and Portuguese. Educational materials are in these languages as well. To enhance clinical services we cross-train bilingual Clinic Office Assistant staff (receptionist !bookkeeping) and the bilingual Clinic Appointment System Coordinator as family planning medical interpreters. As a requirement, any staff utilized for medical interpreting must complete a 54-hour medical interpreter training offered

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by AHEC.

If we are unable to translate for a client on site we use the Interpreter services through

UMASS Memorial Health Care. Cultural competency doesn't involve simply speaking the language, or hiring bicultural staff. It requires an agency-wide commitment to understanding and appreciating the belief systems and attitudes that people use as consumers of health care, and the issues that their communities are facing. Health Awareness provides opportunities for all staff to receive training and orientation in these matters. Health Awareness is planning a training for March 2009 in conjunction with several community-based organizations. This training will focus on cultural responsiveness in the provision of health care to emerging immigrant populations. The training is part of our Technical Assistance support from JSI. All client satisfaction services are written in English, Spanish and Portuguese. Feedback from clients helpsus gauge their perception of the cultural competency of our services. Our Delegate agencies also see a large Spanish-speaking population. All ofMOC's family planning counselors are bilingual and bicultural. The physician at Plumley Village Health Service is bilingual in Spanish. The Framingham Community Health Center has a physician who is bilingual (Spanish) and another who is trilingual (Spanish and Portuguese). i. Laboratory Services - Health Awareness holds current CLIA certifications for provider-performed

microscopy procedures and holds a Special Project Waiver for Waived/Rapid HIV Testing. Routine laboratory tests performed on-site include: urine pregnancy testing, finger-stick hemoglobin, urine chemstrips, vaginal pH, and microscopic wet smears. In 2007 Worcester Family Planning staff offered OraQuick rapid HIV testing; this changed to UniGold rapid testing in September 2008. Confirmatory serum testing is done on all reactive rapid tests. The HIV Counseling and Testing Program offers HIV testing on site for our other family planning clinics; testing methods include UniGold (Rapid testing), OraSure (oral swab) and serum sampling. Other labs are collected on-site and sent out for testing .. These

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include liquid based cytology, chlamydia screening, gonorrhea screening, venous blood testing for cholesterol, glucose, lipid profiles, hepatitis Band C screening, RPR, Rubella titers, and others as indicated. Eligible clients have cervical and/or urine specimens for chlamydia Igonorrhea screening mailed to MDPH STD Lab for processing and data collection as part of the Region 1 Infertility Prevention Project. Health Awareness Services has extensive laboratory quality assurance monitoring systems: •

Daily lab and follow-up log book: All labs

~ent

out are recorded in this log. When lab results are

returned they are checked off as received and the results are noted. All abnormal labs are commented on regarding action taken. Any pending labs are clearly identified by the fact that results have not been received. Clients with labs that require a prolonged follow-up plan (e.g. Pap repeated in 3 or 6 months) are entered into the lab follow-up tickler system as well. This is a manual monthly tracking system for following-up clients. All attempts to reach clients regarding lab follow-up is documented in the client record. •

Monthly lab and follow~up log book reviews are done by the clinic coordinator. Any outstanding

labs are followed-up on (e.g. calling a lab to assure receipt of lab and to request results). Any clients who have incomplete lab follow-up will be contacted to close follow-up. •

All hard copy lab reports are signed off and dated by a licensed staff member, then they are secured

in the chart. All abnormal labs are signed offby an advance practice nurse or physician assistant. •

Our Central Office in Worcester maintains pregnancy test control logs. As per manufacturer

recommendations each lot of pregnancy tests are tested with a positive and negative control; these are recorded on the log. The Worcester Clinic receives and dispenses all pregnancy tests to other sites. Each lot number is tested by a staff member before it is used in Worcester or released to other sites. When the Worcester office closes this responsibility will be transferred to our Marlborough site.

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•

We use a hemocue photometer for hemoglobin determinations (finger stick hemoglobin). Controls

are done daily to assess proper functioning of the photometer and are recorded on a daily log. We have a hemoglobin determination hemocue procedure in place; cleaning, maintenance and trouble shooting is included. Autoclaves have chemical indlcator testing with each run to assess proper sterilization. On a monthly basis, they are cleaned and spore testing is done. Testing and cleaning is documented.

•

Refrigerator temperature is recorded each clinic session and maintained at 36 -46 degrees F. No food

or beverage is stored in medically designated refrigerators. •

A monthly QA check list determines that routine procedures are up to date (e.g. autoclave cleaning &

spore testing, fire safety check, lab book checked for returned labs, tickler file review) •

All lab/specimen collection activities have appropriate protocol (PH test, Pap smear, Chlamydia)

•

An exposure control plan in place; personal protective equipment is on hand for staffuse. Annual

OSHA training is provided on bloodbome pathogens to all clinical staff. Health Awareness assesses lab related criteria when performing delegate site reviews (sharps disposal, autoclave spore testing, personal protective equipment, OSHA trainjng, biohazard waste removal, etc). We require contracted labs to present CLlA and/or pathology certification; these are kept on file and are reviewed annually. When selecting an outside lab the Director of Clinical Services, Medical Director and Coordinator of Clinical Services review the information obtained from a potential lab. Labs are asked to provide a reference check and copies of certification. Pricing and services are reviewed (i.e. are all labs done on site or ani certain labs subcontracted, do pick-up schedules coincide with clinic session schedules, how does the fee charged measure against state reimbursement for labs, will the lab provide sharps containers, vacutainers, what type ofintemal QA systems do they have in place (verification of results) and what type of QA data can they provide us, etc. Preliminary data is reviewed the Director of Clinical Services and presented to the Executive Director and Clinical Advisory Committee for final decision.

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Several laboratory testing methods and or contracts were assessed in 2007 and eventually changed in 2008. These included HIV in-house rapid testing (OraQuick-UniGold), in-house urine pregnancy testing (PHATECH Quick Card HCG-Stanbio HCG test kit), and contracted laboratory services. All of these changes entailed research and staff training. In 2007 the Director of Clinical Services worked with the Clinical Advisory Committee to consolidate labs used, which meant changing current labs. In February of 2008 a new lab contract was entered with Quest Laboratories and lab services were discontinued with Cyto Lab and BioLab. This improved overall lab processing and turnaround time for results. In addition, we utilize the Massachusetts Department of Public Health (MDPH) STD Division State Lab for Chlamydia screening of eligible clients under tbe Region I Infertility Project and/or gonorrhea screening for MDPH Family Planning eligible clients. j. Pharmacy Services: Massachusetts permits nurses under the supervision of a physician to

dispense controlled substances in quantities necessary for treatment. These practitioners can dispense multiple doses, as they are exempt from the requirement that drugs dispensed be in a single dose or as necessary for immediate treatment. Health Awareness has protocols in place for storing, .. labeling & dispensing medications on-site, drug recall and prescription privileges for nurse practitioners. All Nurse Practitioners and Physician Assistants have prescriptive authority for schedule VI drugs from the MA DPH Division of Food and Drugs; this provides clients with access to written prescriptions for medications that are not dispensed on site. We provide contraceptives and some antibiotics on-site. Several vaginal gels/creams are available for treatment of vaginitis and a limited supply of oral antibiotics are stocked (including one dose treatment of Azithromycin for chlamydia). Medications, syringes arid prescription pads are secured in locked areas. Health Awareness Services does not stock narcotic or tranquilizing drugs.

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All medications are labeled with client's name, date medication dispensed, medication dispensed, lot number, expiration date, instruction for use, Medical Directors name and initials of the person dispensing the medication. All medications are logged on a log specific for that drug. The log contains the name and dose of the drug, amount dispensed, route of administration, date dispensed, name of client, client medical record number, drug lot number, drug expiration date and initials of the staff person dispensing the drug. The medication dispensed is recorded in the client record along with documentation of client education. All clinical sites have protocols for emergency medical treatment, emergency medical boxes for emergency treatment (epinephrine, Benadryl, rescue breathing tubes, cold packs, ammonia inhalants) and ambu bags with mask attachments. The location of this equipment is known and readily accessible to all staff. Emergency response drills are held bi-annually at all sites. This equipment is routinely checked for proper functioning and expiration dates.

All licensed staff is certified in CPR and are

recertified at intervals as per current recommendations for recertification. k. Client Education & Counseling - On their first visit all clients are provided with a copy of the "client

bill of rights" that highlights their right to be informed about all aspects of their care and their right to confidentiality.

In addition, they are provided with a confidentiality letter that outlines the client

confidentiality policy of Health Awareness services, have the "Notice of Privacy Practices" reviewed and have a "Consent to Treatment" form reviewed with them. Prior to services, if in agreement, the client signs the "Notice of Privacy Prac.tices" and "Consent to Treatment" forms. Any client seeking contraception has a method specific consent form reviewed with them; prior to dispensing or administering the method the client signs the appropriate consent. Any time the client changes a method of contraception a method specific consent form is reviewed and signed. All of these materials are written in English, Spanish and Portuguese (the primary languages of our client population). The Notice of Privacy Practices and all consent forms are kept on file in the client medical record. These are stored in a

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secured locked file cabinet.

A detailed summary of client education and counseling services for initial

and annual visits provided in Section 2f. Client education and counseling services is interactive and based on a client's individual need and knowledge. Staff utilizes active listening skills and open-ended question to assess client concerns, risk factors and knowledge .. This is provided in an age appropriate, culturally competent, non-judgmental manner. Family involvement is explored, discussed and encouraged with adolescent clients (see "Family Involvement Policy in Attachment H). Health Awareness Services, delegates and sub-recipients recognize the positive role that families can bring to adolescent sexual decision- making and on-going reproductive health care. Clinic staff inquires whether the client has spoken with a parent or other adult family member (e.g. aunt, sibling) about their reproductive health decision-making, issues, concerns and/or needs. If they have, they are asked how this went and are given positive feedback for their family involvement. If not, the option of family involvement is explored with the teen. If indicated, role-playing on how to involve a family member in their reproductive health decision-making is utilized. When appropriate, clients are encouraged to involve their families in decisions regarding their reproductive health. Abstinence as an option for pregnancy prevention and harm reduction is reviewed and discussed with all teens. Sexual coercion is assessed with teen clients and counseling regarding resisting coercion is provided. All clients are assessed for domestic/relationship violence, provided with information and given referrals as needed. Sterilization Compliance: Neither Health Awareness, Delegates or sub-recipients perform sterilizations. Our request for a waiver from sterilization-reporting requirements is on file at the Regional Office. Pregnancy Counseling Compliance: We are in compliance with Program Guidelines assuring that clients requesting information on options for the management of an unintended pregnancy are given non-directive counseling on the following: prenatal care & delivery; infant care, foster care/adoption, pregnancy termination; clients are given referrals to these services upon request.

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We provide comprehensive options counseling and referral services for all clients who present for pregnancy testing services. Options for clients with negative results include continued care at our family planp.ing sites, other medical referrals, and infertility service referrals, as indicated. In accordance with our policy regarding family involvement, clients are encouraged to consult with their parents, when appropriate, regarding pregnancy decisions, regardless of the result of the pregnancy test. I. HIVIAIDS Services - HIV/ AIDS is one of the leading causes of death in Massachusetts among young

people ages 20-J5; parts of our service area have very high rates of HIV infection, and many of our clients are specifically at risk from their reported behaviors. We have devoted a significant portion of resources to HIV/AIDS prevention and education. Health Awareness Services Family Planning Program has adopted the CDC's "Revised Recommendations for HIV Testing Adults, Adolescents and Pregnant Women In Health Care Settings"; testing is offered on site at all Health Awareness Family Planning sites. In addition, a self administered HIV/STD individual risk assessment is done with all clients; this form is translated into English, Spanish and Portuguese. This allows the client the opportunity to identify their individual risks and provides a venue in which to review their risks during their family planning counseling session. As indicated, harm reduction and behavior change strategies are explored with the client. Clients seeking HIV screening and enhanced counseling receive these services in-house. Individuals seeking support groups related to risk factors are referred in-house or to other community-based agencies providing support or counseling services. Since the beginning of the AIDS Epidemic, Health Awareness has been directly involved in prevention and education efforts to popUlations at risk. Our current services include: Prevention & Education: Health Awareness is funded through the MA Department of Public Health to conduct HIV Prevention and Education in the City of Worcester. Our target populations are men who have sex with men, Injection Drug Users (lDU's), and female partners ofIDU's. Activities include street

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outreach, internet outreach and bar outreach with risk assessment, referral, harm reduction information with distribution of condoms, bleach kits, and other harm reduction items; one-to-one and group education sessions at shelters, recovery programs, detoxification programs, drop-in centers and halfway houses, including risk assessment and referral. Referrals are made to our HIV Counseling and Testing services, Family Planning Program and HIV Case-management program. HIV Counseling &Testing: The HIV Counseling and Testing Program of Health Awareness Services is the only non-clinical program funded by the MA Department of Public Health to do counseling, testing and referral in both Central MA and the MetroWest. Anonymous & Confidential Testing is done at multiple sites including shelters, substance abuse programs, hospital-based clinics, Family Planning clinics and community-based agencies. All services are provided by the HIV Counseling and Testing Program of Health Awareness Services are free to the client; blood and oral mucosa testing and Rapid Testing (UniGold) are the methods used. We use the Massachusetts State Laboratory for analysis and confirmation. Multilingual staff provides supported referrals as well as counseling and testing. Our HIV Counseling and Testing Program provides on-site testing at our family planning clinic sites in Southbridge, Marlborough, and Milford and for Framingham Community Health Center. We also provide counseling and testing at our Case management Program in Framingham, area shelters and substance abuse recovery programs. Last year, we provided counseling and testing to more than 1300 people at 21 different sites. We incorporate the ABC guidelines for counseling on risk reduction in our HIV Counseling and Testing efforts. The Worcester Family Planning Clinic was granted approval by the Massachusetts Department of Public Health Family Planning and HIV/AIDs Bureau to integrate HIV counseling and rapid testing services within family planning. In preparation for this, protocols were developed and family planning staff received extensive training in HIV services. The Health Awareness HIV Counseling and Testing Program collaboratively worked with the Family Planning Program in protocol development and precepted family

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planning staff in implementing this service. This was fully integrated in December 2007 and has continued to date. Initially OraQuick HIV rapid testing was utilized, in September 2008 rapid testing was changed to UniGold. What we found was that by integrating HIV services within family planning more family planning clients opted for testing. Health Awareness would like to extend this model of testing to our other family planning sites. We are in the process of assessing this with the Massachusetts Department of Public Health Family Planning Program. All clients who disclose having HIV or who have a positive test result are given the option of referring their partner(s) for HIV testing or utilizing the State PCRS/Partner Notification program. Olir HIV Counseling and Testing program staff engag;e all HIV positive clients in a discussion of partner notification. We also provide short-term support services for individuals testing HIV positive. All of our providers, nurses and family planning counselors attended several trainings and workshops on HIV counseling and testing in 2007 and continue to attend related trainings in 2008. Health Awareness has adopted the 2006 "Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care-Settings" issued by the CDC. In September 2007 we integrated HIV OraQuick rapid testing within family planning at our Worcester site and changed over to UniGold in September 2008. HIV counseling and testing is provided at our other family planning sites through our HIV Counseling and Testing Program. We are currently working with the Massachusetts Department of Public Health Family Planning Program and HIVI AIDS Bureau to expand integrated HIV counseling and testing services by family planning staff at our Milford, Marlborough and Southbridge sites. HIV service delivery will remain a focus of family planning quality improvement activities in the upcoming years. Case-Management: Health Awareness is the AIDS Service Organization for Metro West. On March 1, 2005, the contract for Client Services for all of MetroWest was awarded to Health Awareness through the Boston Public Health Commission (through Title I of the Ryan White Act). We are the only provider of

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this program in the service area. Our case-managers provide services in Spanish, Portuguese and English. We currently have a caseload of202 clients; when we took over the program in 2005, there were 88 clients at that time! We also provide support groups and food vouchers for clients. Our Case-Management Program is located in Framingham; HIV Counseling and Testing is offered at the same site.

m. STD Prevention: Health Awareness and delegates serve individuals at risk for STDs and related morbidity. We are diligent in our efforts to promote prevention and offer early detection and treatment to females and males. We do this through outreach and direct clinical services. STD prevention, testing and treatment services are offered in accordance with Title X Program Guidelines. As an integral component of family planning visits, family planning counselors and clinicians provide all clients with an STD/HIV risk assessment and incorporate prevention and harm reduction strategies into services delivered. STD screening services offered on site include: chlamydia, gonorrhea, pelvic inflammatory disease, herpes, human papillomavirus, hepatitis (B and C), trichomonas, molluscum, pediculosis/scabies, syphilis, HIV and other infections such as bacterial vaginosis and vulvovaginal candidiasis. History, physical exam and laboratory testing are key elements in assessing and diagnosing STDs. In-house microscopy (wet mounts) is done to assist in the differential diagnosis of trichomonas, bacterial vaginosis and/or vulvovaginal candidiasis. Rapid HIV testing is done in-house to screen for HIV; same day confirmatory serum testing is . done with any reactive result. Contracted laboratory services are utilized to process specimens for the diagnosis of other STDs. Health Awareness has adopted American College of Obstetricians and Gynecologists (ACOG) standards for cervical cytology screening. We utilize liquid based cytology screening and reflexive high risk HPV screening to any client with a Pap smear that indicates atypical cells of undetermined significance (ASCUS); which means there are mild cellular changes and the cause is unknown. By performing this HPV screening the lab is able to identify clients who have high risk HPV, associated

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with an increased risk of cervical cancer, and those that do not. This data is essential in detennining which clients are in need of colposcopy to further assess cervical dysplasia related to high risk HPV infection; it also eliminates unnecessary colposcopy for individuals. Health Awareness provides liquid based cytology and HPV typing despite the fact that neither is fully reimbursed under our Massachusetts Department of Public Health Family Planning contract, which reimburses care and labs for the majority of our clients. As a preventive service, Health Awareness is in the process of adding Gardasil HPV vaocination to our family planning services. We have developed protocols and vaccination visit fonns and plan on offering this in the Fall of2008. Health Awareness has participated in the Region I Infertility Prevention Project (IPP) since 1994. The Director of Clinical Services is an active member of this project. Initially the Worcester Family Planning Clinic participated in this project; now all Health Awareness clinical sites and MOC Delegate sites participate in the project. Through the Region I Infertility Prevention Project (IPP) all eligible clients are offered chlamydia screening, free of charge, through the Massachusetts Department of Public Health (MDPH) STD Division of the State Lab. Clients who do not meet IPP criteria for chlamydia screening (i.e. insured clients) have screening done through our contracted lab. In 2008 the MDPH Family Planning Program and MDPH STD Division ofthe State Lab worked collaboratively to offer chlamydia and gonorrhea testing at the State Lab to eligible clients. Chlamydia screening will be done under the Region I IPP and gonorrhea screening will be paid for through earmarked Health Awareness MDPH Family Planning Program dollars. This combined testing through the MDPH STD Division began in July 2008 and will improve laboratory services for family planning clients eligible under the MDPH Family Planning Program.

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n. Social Services and Other Related Services - Health Awareness operates an HIV Prevention and Education Program in Worcester that both refers clients to our clinics and gets referrals from them. These referrals are for people who need substance abuse services, more HIV or STD prevention counseling, referrals for mental health care, housing, etc, and related support services. Health Awareness and Montachusett Opportunity Council operate state-funded Teen Pregnancy Prevention Programs in Southbridge and Fitchburg, respectively. These programs work with at-risk teens and their families, providing support services, health education, advocacy and case-management. At our Milford Clinic, we host a Patient Navigator, employed through another agency, who works with immigrants in obtaining health care.

o. Medical Records - Health Awareness has written policies/protocols regarding medical records that delineate maintenance, retention, confidentiality and release of records. Health Awareness, delegates and sub-recipients are compliant with the Health Information Portability and Accountability Act (HIP AA) regulations regarding privacy and security. We have authorization for disclosure of protected health . information and privacy forms in place. Medical record information is secured in file folders and stored in locked cabinets.

Agency computers and the Region 1 FPER database that contains client information are

secure. Framingham Community Health Center has an electronic medical record that is on a secured site. All staff is instructed on HIP AA guidelines upon hire and sign an agency confidentiality agreement.

3. Community Education/Outreach The Health Awareness Services' Mission Statement is: "Health Awareness Services builds healthy communities through prevention, education, and the delivery of quality health services." As discussed earlier in this proposal, one way that we accomplish this is by hiring people, at all levels, from the communities that we serve. Another is to network with other community agencies and to elicit active feedback and participation from the community at large. Examples ofsome of the

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community coalitions/ groups that Health AWareness regularly interfaced with during 2007 include: Worcester: The Central Mass Center for Healthy Communities, MA Community Health Worker Network, Worcester Women's HIV Initiative Steering Committee and the Worcester Regional Council meeting, Milford: Community Health Network Agency (CHNA) #6, Milford Adolescent Breakfast meetings and the Causana Project; Southbridge: The Southbridge Partnership for Teen Health quarterly meetings, Southbridge Community Connections, CHNA #5, and Southbridge Pregnant and Parenting Teens Program; Marlborough/Framingham: the Assabett Valley Practical Nurse Advisory Committee, MetroWest Community Health Coalition and TeenConnection Coalition. Some of our regional based outreach activities in 2007 included: targeted mailings explaining our services and how to access care to Middle School, High School, Vocational School and Colleges directed to health, guidance and sports departments (100 mailings). Targeted mailing to all free care clinics in our service areas. Worcester: Advertising our services on the "Woo Bus" that is a transport system between area colleges, provided educational programs for the UMass Graduate School of Nursing, Anna Maria College and Becker College, participated in area community events such as: the "Latin American Festival", "Pride Day", "Sober in the Sun", "Teen Fair", "YWCA Women's Health Forum" and health fairs at "North High School", Plumley Village Health Services", "Anna Maria College" and "Quinsigamond Community College"; Milford: participation in area health fairs/ community events such as: the "Milford Provider Fair", "Family Fair", "Dean College Fair", Marlborough/Framingham: Presentations to Assabet Valley Vocational School in Marlborough, participation in area health fairs at Hudson High School and Algonquin High School (Northborough) and held pro~ams for the Mass. Association of Portuguese Speakers (MAPS), WIC and the Pentecostal Church in Framingham: Southbridge: Conducted a training for Program for teens at

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Pregnant & Parenting Teens, Voices for Choices, two programs for Partnership for Teen Health, four educational sessions at the Wells Junior High School in Southbridge that reached 146 students, six educational sessions for Southbridge High School that reached 100 students and participated in the Nichols College Health Fair. Our outreach activities are both formal and informal. They are conducted in English, Portuguese and Spanish. Outreach materials are in these languages as well. This year we had ten group outreach programs conducted in Portuguese/Spanish; some of these were in private homes or area businesses. Health Awareness is recognized as a teaching site for many regional health programs. In 2007, our family planning program precepted University of Massachusetts Family Medicine Residents and Medical Students, Nurse Practitioner students and Sexual Assault Nurse Examiner (SANE) students. In addition, we participated in health and social service panels that provided educational programs in our service areas. Examples include: the "Women's Sexual Health Question and Answer Session" sponsored by the Worcester City Manger's Advisory Committee on the Status of Women and the roundtable discussion with the Webster community in a workshop entitled "Working to Strengthen Families and Individuals by Ending Domestic Violence and Sexual Assault" sponsored by New Hope. In 2005-2007 Health Awareness made revisions to the agency web site to reflect new health information and program changes. Family planning is listed on our web site; information related to services, health information and locations are included. Over the past few years we have recruited an increased number of new clients from this site. Health Awareness Services utilizes the I&E Advisory Committee to review all educational materials. In 2006-2007 the Health Awareness I&E Advisory Committee had a subcommittee of teens from the

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Worcester Youth Center assist us in evaluating our teen outreach materials and teen appeal or our Web site, as well as, review our educational materials. Through feedback from these teens we revamped some of our outreach materials and added several teen focused brochures that address issues such as sexual coercion and abstinence. The Health Awareness Information and Education (I&E) Advisory Committee works in conjunction with the Clinical Advisory Committee (provider group) and the Interdisciplinary Clinical Improvement Committee. An overview of the Health Awareness Information and Education (I&E) Advisory Committee is in Attachment I

4. QUALITY ASSURANCE - Continuous quality improvement is an integral part of our Family Planning Program. Health Awareness ensures on-going availability of effective and high quality family planning clinical services through an infrastructure of committees and activities that provide continuous evaluation of quality assurance. Family planning staff of all levels actively participates in these committees. Through systematic evaluation, assessment and planning, we formulate and implement quality improvement steps. Health Awareness provides delegate oversight of evaluation and quality assessment and assurance in accordance with Title X guidelines. The relationship between family planning quality improvement committees and the improvement process is outlined in the Health Awareness Family Planning Quality Improvement Process Chart and in the Continuous Quality Improvement (QI) Plan for Health Awareness (both are in Attachment J). In addition, projected activities and time lines for Health Awareness QI activities are outlined in the Work Plan. Our clinical tracking system for follow-up regarding client lab work and quality assurance monitoring systems was described in detail in section "2-i. Laboratory services". In addition to lab follow-up, these systems are used to follow-up on referrals made (i.e. colposcopy). All lab and referral follow-up is done and documented on a monthly basis by Nurse Practitioner staff.

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Health Awareness identifies improvement issues and initiates on-going quality improvement through a variety of ways. Examples include: medical record reviews, site reviews, client satisfaction surveys, unusual occurrence reports and literature reviews. Once improvement goals are identified improvement steps are formulated, initiated and quantified through follow-up assessments. For example, in 2004 the targeted provider review identified CV A tenderness was not routinely being documen,ted as assessed in client visits for urinary tract infections (UTI). This finding was reviewed at a subsequent 2004 Clinical Advisory Committee. The medical director and medical advisor reviewed & discussed UTI assessment and related documentation with all Health Awareness provider staff at this meeting. In 2005 a follow-up collective peer medical record review was done to assess improvements made in this area of assessment. The Clinical Advisory Committee met to review outcomes of the review and identified that CV A tenderness assessment documentation was still below an acceptable percentage for our standards. To assist in improving this outcome measure a problem visit sheet specific for urinary tract assessment was developed and implemented. In 2006 and 2007 peer medical record reviews were conducted and as part of this review urinary tract infection visits were reviewed. The implementation of the UTI Visit form increased documentation ofCVA tenderness from approximately 50% in 2004 and 2005 to nearly 100% in 2006 and 2007. The Clinical Advisory Committee of Health Awareness monitors services and has systematic mechanisms to evaluate and initiate quality improvements related to all aspects of clinical care and operations.

In 2007, the Clinical Advisory Committee established five quality improvement goals: 1. Enhance male health services. 2. Revise STD Protocols to comply with CDC 2006 Guidelines. 3. Implement the 2006 CDC "Revised Recommendation for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings".

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4. Integrate HIV counseling and testing services within family planning at our Worcester site. 5. Review and consolidate contracted laboratory services. ~

Improvement Steps taken in order to achieve improvement goal

1. In September 2006 Health Awareness collaboratively planned our Regional Training with the John Snow Institute (JSI) entitled "Clinical Services: Caring for Men's Reproductive and Sexual Health Needs". This was a mandatory training attended by all staff. In 2006,2007 and recently in 2008 the Clinical Advisory Committee has reviewed and revised male health protocols. We included the 2006 CDC STD screening recommendations for men who have sex with men (MSM). Health Awareness obtained provider status with the Immunization Program to offer Hepatitis A vaccination to MSM clients at our Worcester Clinic. All provider staff participated in the "Female and Male Genital Dermatology" Web Cast offered by JSI in December 2007. 2. In October 2006 Health Awareness sent all providers and nurses to the eight hour "Clinical Institute: Contraceptive STI Update" sponsored by the JSI. The 2006 revised CDC guidelines were reviewed at this update. The Director of Clinical Services issued copies of the revised 2006 CDC STD Guidelines to providers on staff, as well as our physician Medical Director and Medical Advisor; all of which comprise our Clinical Advisory Committee. 3. Over the course of 2007 Health Awareness has provided staff with several trainings related to providing HIV counseling and testing services and adopting the new CDC guidelines for testing in health care settings, such as family planning. In January 2007 several staff attended two HIV meetings sponsored by the Massachusetts Department of Public Health Family Planning Program and HIVIAIDS Bureau to review the "Revised Recommendation for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings" and to discuss implementation of Rapid HIV testing within family planning; 路We had a mandatory seven-hour in-house training on "HIV Rapid Testing" that all family planning clinic staff attended; this was done by the Justice Resources Institute (JRI), which is a contracted MDPH HIV/AIDS Bureau trainer. 4.

All staff designated to provide HIV Rapid testing at our Worcester site attended other mandatory HIV counseling and testing trainings, including proficiency testing in both OraQuick and UniGold.

5. Over 2007 the RN Director of Clinical Services and the NP Coordinator of Clinical Services had several meetings with three laboratories to assess the feasibility of contracts with Health Awareness Services. In addition, the Clinical Advisory Committee was apprised of meetings and was consulted on selecting laboratory service. Areas assessed included such things as, quality of services,

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credentials of laboratory, access of services to diverse populations re: uninsured and insured, cost of services, ability to service multiple sites and provide courier service, lab turn around time, etc. ~

Improvement Outcomes:

1. Health Awareness ran a separate male health service in Worcester in 2007 that was staffed With a male provider. We of(ered Hepatitis A vaccination to MSM clients at this clinic. 2. The Clinical Advisory Committee reviewed STD protocols in place and made revisions, as needed, to comply with the 2006 CDC STD Guidelines. These were implemented in 2007. The state of Massachusetts has a significant number of quinolone-resistant Neisseria gonorrhoeae cases. Due to this, the Massachusetts Department of Public Health recommends Ceftriaxone 250 mg 1M to treat gonorrhea, while the CDC recommends Ceftriaxone 125 mg. The Clinical Advisory Committee reviewed literature and assessed regional data to determine practice guidelines, in this case, we treat gonorrhea with Ceftriaxone 250 mg 1M. 3. Health Awareness has adopted the 2006 CDC "Revised Recommendation for HIV Testing Of Adults, Adolescents, and Pregnant Women in Health-Care Settings" in our delivery of family planning services. All sites have HIV counseling and testing available. The HIV Counseling and Testing Program of Health Awareness Services offers this testing in Milford, Marlborough and Southbridge. In our Worcester Family Planning Clinic it is fully integrated into our services; family planning staff offer this service directly. 4. In December 2007 HIV counseling and testing services were integrated into family planning at our Worcester site. As of 6/30108 the Worcester Family Planning staff provided HIV counseling and testing services to 239 clients. We have found that clients are more likely to have testing done if it is with the same staff that provides direct family planning services. Our Worcester site has successfully implemented offering and providing all clients the opportunity to "know their status" as part of routine health care. We're working with the MDPH Family Planning Program to assess integrated HIV testing to our other family planning sites. 5. Health Awareness Services consolidated two contracted labs to one contracted lab. This has streamlined laboratory services and improved offerings of labs to clients.

In addition to the five quality improvement goals set by the Clinical Advisory Committee internally Health Awareness set two additional improvement goals: 1.

Employ multicultural staff and continue to offer cultural and linguistically competent services.

Maintain a balance of uninsured and insured clients. Contract with Commonwealth Care

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Plans to offer ready access to family planning services at Health Awareness Services to this growing population. ~

Improvement Steps taken in order to achieve improvement goal

1. Health Awareness continues to maintain staff reflective of populations served. All staff used for medical interpretation must attend and successfully complete the Area Health Education Center (AHEC) 54-hour medical interpreter program. In May 2008 two Milford staff members attended the UMass/AHEC eight hour training "Paving the Way To Health Care Access: Exploring Alternative Medicine." At our Milford site we serve a significant number of indigenous Indians from Ecuador; this conference addressed the alternative medicine used by this population. 2. The Director of Clinical Services and our credentialing consultant industriously worked to both credential and re-credential with various third party insurers 2006-2007. Unfortunately, the Commonwealth Care Plan offered through Fallon will not contract with family planning providers. Fallon has a significant stronghold in Worcester, Milford and Southbridge. ~

Improvement Outcomes:

1. All of our Family Planning Counselors and Clinic Office Assistants are bicultural and bilingual. In 2006 six Health Awareness Staff completed the AHEC Medical Interpreter Training and in 2007 an additional two staff members completed the program. 2. Currently Health Awareness holds provider contracts with MassHealth, Network Health Forward, Boston Medical Center HealthNet, Neighborhood Health Plan, Tufts and Blue Cross/Blue Shield. In addition, we have registered all of our providers with the Coalition of Affordable Quality Health Care (CAQH). By registering providers with CAQH a centralized credentialing database will be maintained on providers to assist with future credentialing and/or re-credentialing with third party insurers. Documentation of quality assurance activities is maintained in meeting minutes, training logs, surveys and audits conducted. Unusual Occurrence Reporting is another means of identifying quality improvement areas. The Director of Clinical Services and Executive Director of Health Awareness Services review all clinical unusual occurrence reports. Each unusual occurrence report has a corrective action plan written to address improvement steps. When indicated, unusual occurrence reports are reviewed by the Medical

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Director and if appropriate, brought to the Clinical Advisory Committee for review. An example of this was in February 2008 staff at different sites reported weak positive urine pregnancy test results through on-site testing done that were negative when confinnatory serum testing was done. Collectively, there were four false positive tests. Unusual Occurrence reports were filed with the Director of Clinical Services that identified this trend. In tum, the Director of Clinical Services and a staff nurse practitioner participated in a conference call with the company's Quality Assurance Manager and President to report the false positives and assess the quality of the product. The outcome of the conference call and the unusual occurrence reports concerning the false positive urine pregnancy tests were discussed with the Medical Director and at the Health Awareness Clinical Advisory Committee Meeting. Based the company's response and overall product perfonnance, the Clinical Advisory Committee recommended selecting an alternative urine pregnancy testing device. The Director of Clinical Services researched other devices and the Clinical Advisory Committee approved a new urine pregnancy test device. Annual client satisfaction surveys are perfonned at Health Awareness Services and Pro Health. Surveys are conducted in English & Spanish at both agencies and in Portuguese at Health Awareness. Client satisfaction surveys provide feedback on how clients perceive care, convenience, cost, etc. and offers opportunity for insight and improvements. The last Health Awareness Services client satisfaction survey was conducted in November 2007. In this survey 19% of respondents spoke Portuguese, 7% spoke Spanish and 11 % were male. Overall, clients reported being very satisfied with the care and education they received. The next survey is planned in the Fall of 2008. The Interdisciplinary Clinical Improvement Committee and Board of Directors review client satisfaction survey results. The Director of Clinical Services of Health Awareness participates in Q.1. Committee meetings held by Pro Health. This has enhanced quality of services at both agencies through sharing infonnation and

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ideas with each other. All internal client satisfaction and chart reviews are forwarded to and reviewed by the Director of Clinical Services. Delegate site and medical record reviews are done annually. 5. FINANCIAL MANAGEMENT: Health Awareness maintains its financial records on an accrual basis in accordance with generally accepted accounting principles, Government Auditing Standards issued by the Comptroller General of the United States, and the provisions of Office of Management and Budge"t Circular A-133, and Government Auditing Standards. We comply with all other federal and state regulations in force in regard to employment, personnel, and financial disclosure. The accounting system is structured to prepare cost reports for internal & external purposes (cost review and analysis), develop expenditure reports for budget review purposes, account for all funding sources and the application of expenditures to revenue, maintain records in an auditable manner, and maintain budget controls over expenditures a. Billing and Collections: 1) In developing our charges for visits, laboratory procedures, contraceptives and supplies, we use the reimbursement structure under MassHealth (Medicaid) as a baseline. This rate of reimbursement is considered full payment for patients on MassHealth, any patient whose income is below 100 percent of poverty, and minors for whom it's not feasible to determine family income. There is no additional billing. For those who are not in any of the above mentioned groups, we use a sliding scale (see (b), below). The fees for laboratory tests, contraceptive supplies and antibiotics are based on an analysis of what it costs us to purchase and administer each item or procedure. No one is ever refused services for inability to pay. This policy is stated in the orientation and instruction manuals for clinic staff and is prominently stated in our promotional literature and Patient Bill of Rights, which is given to every client. A second tenet of our practice is that confidentiality is never compromised.

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2) Health Awareness conducts fonnal cost analyses of our visit costs in order to accurately detennine the full cost for medical services. We also survey local providers, to insure that our costs are among the most affordable in the area. The full charge is never more than what it costs us to deliver services. We have recently conducted two cost analyses to detennine what our fees should be: The Mass. Family Planning Providers, of which Health Awareness is a member, conducted a cost analysis with the MA Division of Health Care Finance and Policy, which was submitted in July of 2007. Each agency calculated their costs, using 2006 data, for their total family planning program. We included health education and promotion efforts that were directly related to family planning, in accordance with Title X guidelines. The State detennined that there was justification for a rate increase for family planning providers through MassHealth (Medicaid). The rates were increased as of January 1,2008. These new rates became the basis for our current sliding fee schedule. In 2007, we used Federal Technical Assistance funds for: 1) a cost analysis of the impact of lowering contraceptive charges to paying clients and 2) a cost and utilization analysis of our male health service and Worcester Family Planning Clinic. We hypothesized that lowering the cost of contraceptives could improve client recruitment and retention. Our cost analysis provided needed data on the number of new clients that would need to be seen to off set the reduced cost of contraceptives. We did lower charges, and the results were mixed - increases in new users at some locations, little or no change in new users at other sites. We are currently conducting a client satisfaction survey; we assess these results to see the impact of cost reductions on client fiscal satisfaction with services. A copy of our latest Sliding Fee Schedule, which includes full charges, is in Attachment K. The assessment of our male health service clearly indicated a separate male health service was not clinically indicated, not preferred by male clients and not cost effective. December 2007 we discontinued a separate male health service. The Worcester Clinic utilization and cost data analysis, along with our administrative assessment of the urban health care structUre WIthin Worcester, pointed to subcontracting family planning services to a primary care provider rather than continuing to provide family planning services at a free standing site. This prompted Health Awareness Services to contact Hahnemann Family Health Center to explore the feasibility of subcontracting family planning services within their health care system.

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3) The sliding fee scale is updated at least once every year, in accordance with changes in the Federal Poverty level. It is updated more often, as prices rise on certain products and procedures, or to keep pace with financial situations. Typically, at least one month's notice is given to staff and clients about changes in the fee schedule. We try to keep the top charges on the fee scale less than the prevailing ones in our area. Our fee scale currently has seven categories: Category 1: Medicaid. There is no charge to clients for the visit. Category 2A: Under 100% of poverty based on family size and income, and minors who for confidentiality we cannot determine family resources. There is no charge for the visit, medications/contraceptives or labs. Category 2B: 101-150 percent of poverty - Clients pay a small co-pay, and the bulk of their visit is billed to the MA Department of Public Health, which reimburses us at Medicaid rates. Category 2C: 150-200 percent of poverty. The co-pay is slightly higher than 2B; the balance is billed to MA Department of Public Health. Category 3: 201-225 percent of poverty Category 4: 226-250 percent of poverty Category 5: Above 250 percent of poverty; full-charge. The decision on fee schedules is made by the Executive Director, Director of Clinical Services and the Director of Fiscal Services, with input from staff. This latter input is essential, especially given the remote sites that we operate. We try to keep our services affordable to the people we serve. We require our delegate and contract agencies to submit their fee schedules as part of the contracting process. The advent of Health Care Reform in Massachusetts (see below, #5) may have dramatic effects on our fee scale. Providers are working with the Regional Office to assess the impact on the fee scale. 4) When a client enters a family planning clinic, they meet with a Clinic Office Assistant (COA), and fill out medical history forms and our client intake forms. The COA then meets with the client in an area where conversations cannot be overheard. They are asked information on family size and income. If clients are not willing to give this information, the matter is not pressed; they still receive care. If a minor requests that we not ask for information about parents' resources, then we base charges on the resources of that minor. We do not require proof of income. Clients' financial information is reviewed every time they come in for an annual or routine visit. Clients are not asked for donations in lieu of payment.

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5) The MA Division of Medical Assistance certifies all sites of Health Awareness and its Delegates as MassHealth (Medicaid) providers in good standing.

In 2005, Massachusetts applied for a

Medicaid Waiver, to expand family planning funds to 250 percent of poverty. Before the Federal authorities could rule on this, however, the Massachusetts Legislature passed landmark legislation on April 12, 2006 to subsidize health insurance. As a result, the Waiver application was not processed. Under the new Health Care Reform Plan, the Commonwealth Care Health Insurance Program (Commonwealth Care), residents ages 19 and older are required to obtain health insurance, ifaffordable coverage is available, or pay a tax penalty. The state offers subsidized coverage for low-income residents, and employers also must contribute to the cost of workers' coverage or pay into a fund. For those whose employers do not offer coverage, or cannot afford to purchase conventional plans, the state has set up mechanisms to provide subsidized plans. Those whose income is below 300 percent of poverty can apply for coverage through Commonwealth Care. Policies cover inpatient and outpatient care, prescriptions, mental health and substance abuse, diagnostic visits, and preventive care. The premiums, deductibles and co-payments路are adjusted based upon one's income; there are plans with higher co-payments and deductibles and lower premiums for those who wish to pay less up front. As of January 1, 2008, all Massachusetts residents must demonstrate on their state income tax forms that they have health insurance. If not, they will lose the personal exemption on their taxes. Everyone who had been on Medicaid was moved into the first tier of Commonwealth Care. There are no premiums or co-payments for those under 150 percent of poverty. The premiums and co-payments increase with one's income level. There are four insurance carriers who write these policies and compete for enrollments (Network Health; BMC HealthNet; Neighborhood Health Plan; and Fallon Health Plan). Health Awareness is contracted provider with three of them. One carrier, Fallon Health Plan, will not

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contract with family planning agencies. Unfortunately, Fallon is the largest health plan in Central Massachusetts. There are many successes to show, to date, for Health Care Reform in Massachusetts. It's estimated that 340,000 of the estimated 600,000 people in Massachusetts who were uninsured before the law was passed are now covered by it. Of these, 50,000 have been added to MassHealth, 175,000 to Commonwealth Care (subsidized plans for those below 300% of poverty) and the rest to the Commonwealth Choice plans. There are problems still being worked out. The state's share of the cost has far exceeded original estimates; premiums and deductibles have been raised as a result. This has created hardships for many policy holders and thousands of individuals have received exemptions from tax penalties. It's estimated that 40,000 people in the state are in the "middle" - they can't afford Commonwealth Care premiums, which would cost them much more than the tax penalties. These people are remaining uninsured. Another problem is that the strain on the state budget from Commonwealth Care is already affecting other health care subsidies and related program through Legislative cost-cutting. The Free Care Pool that was formerly used to subsidize hospitals and health centers is being drastically restricted. The Women's Health Network, which subsidized services such as pap smears, colposcopies, and mammograms for lowincome women, went through drastic changes and cuts in July 2008. They now focus primarily on women over 40 (only 10% of their resources can be used for younger women). Mammograms will not be available for those under 40. Our MetroWest service area was hit hardest by these cuts; there is only one, very limited service provider contracted for this entire region, at Metro West Medical Center.

6) Health Awareness has contracts with Blue Cross/Blue Shield, Tufts Health Care, Network Health Plan, BMC HealthNet, and Neighborhood Health Plan. When a client comes to one of our sites, s/he is asked if they are covered by one of these plans. If so, we make a copy of their insurance card and

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keep it in their file. If a co-pay is required by the plan, we then charge the co-pay. The payment from the third-party payer and the co-pay are considered full payment. There is no balance billing. 7) We do not bill patients unless there's a large outstanding balance, efforts have been made to develop a payment schedule, and the patient has indicated that we can send mail to their home. Any balances due are updated at the next visit. Outstanding accounts are aged and bills are sent out if there is no progress being made in reducing the bill. Clinic Office Assistants may make adjustments to bills based on conversations with clients experiencing financial problems. Individual eligibility for discounts and adjustments are documented in the clients' records. Bills to clients show total charges less any allowable discounts. A copy of our Agency policies on Fee Determination and Collection is in Attachment L.

2. Financial Audit: a) Health Awareness Services is audited annually by

(b) (4)

Our fiscal

year runs from January 1 to December 31. Our audit is prepared in the following three months. As part of the audit, our staff performs quarterly internal audits at each of our clinic sites. These audits consist of checking at least 3 patient records per month, following the audit trail from intake to payment from the client or third-party source, and assuring that transactions are recorded on patient accounts. When the draft audit is completed, a principal of the firm meets with the Executive Director and the Director of Fiscal Services to review the draft. The Finance Committee of the Board of Directors then meets and reviews the draft of the audit and Management Letter. Their comments and questions are incorporated into the final audit, which the auditor presents to the Board. The approved audit is shared with our funders. b) The FY07 Audit did not have any exceptions noted. The Audit was presented to the Board of Directors at their meeting on May 13,2008 and formally approved. We ended up with a surplus of$9,389 before depreciation and $1,919 after depreciation. This was our third consecutive year of surpluses. c) Delegates are required to send a copy of their Annual Audit to Health Awareness 120 days after the close of their fiscal year. We ask that the Audit segregate activities related to family planning, and that

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Title X funds are itemized as a source of revenue. The Finance Committee of the Board of Directors and our Auditors review the audits

3. Insurance Program: a) Health Awareness carries malpractice insurance on all clinical employees, except for physician-consultants. The coverage is $1,000,000 each event and $3,000,000 aggregate on an occurrence basis: The carrier is Crum and Forster. The only exclusion is for abortions, which we do not provide. We have never had a claim filed against this policy. Crum and Forster also provide coverage for general liability, fire and theft at the same level as our professional liability. All sites are identified under this coverage. The Board of Directors and officers are covered under a Directors and Operators Policy through Protector's Group Insurance. Coverage is for $1,000,000 aggregate. In addition, our Blue Cross/Blue Shield provider contract mandates that each nurse practitioner'have an individual liability insurance policy; Health Awareness covers the cost of this policy for our staff nurse practitioners. , Physician residents, nurse practitioner students, physician assistant students and medical assistant students whom we precept must have professional liability coverage through their institutions. b) Montachusett Opportunity Council has professional and general liability insurance with coverage of at least $1,000,000 each event and $3,000.000 aggregate, through ProMutual Insurance Company for Professional Liability and Traveler's Insurance Company for General Liability. Plumley Village Health Services is covered through UMass Memorial Health Care; coverage is $3 million for each medical incident and $12 million aggregate. Framingham Community Health Center is covered under the Federal Tort Act, with coverage of $ 1million each incident and $3 million aggregate.

C. FAMILY PLANNING SERVICE DELIVERY PLAN 1. Program Work Plan and Evaluation Plan This Work Plan covers the period from January 1, 2009 to December 31, 2011. The Work Plan will increase the level of family planning services; address the needs of communities at risk; strengthen our

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organizational and financial operation; improve quality of care; and maintain compliance with Title X and related federal regulations.

cr路

G oaII, Ob路 mica '.Iec f Ive 1 Need: As stated in Section A, there are nearly 57,000 low-income women.in our service area in need of subsidized contraceptive services. Goal 1: Assure continued high quality family planning and reproductive health services that will improve the overall health of people. Assure access to comprehensive, high quality, family planning and reproductive health services including provision of highly effective contraceptive methods, breast and cervical cancer screening/prevention and STD/HIV prevention education, counseling and testing that will improve the overall health of people. Objective 1.1: Increase the number of users seen. By the close ofFY2011, see more than 7,000 users At least 90 percent should have incomes below 200 percent ofthe federal poverty level. Objective 1.2: Increase the number of low-income family planning users in Worcester from 574 in 2007 to 1,800 by the end of 2010 through a new Health Awareness Services (HAS) Delegate relationship with Hahnemann Family Health Center (HFHC) and on-going relationship with subrecipient Plumley Village Health Services (PVHS). Responsibility Evaluation Timeline ActivitieslAction Steps December 1, 1. Implement contract with !Executive Director, HFHC and PVHS will complete Hahnemann Family Health !Director of Clinical FPER's on all Title X clients 2008 Center (HFHC) to become Services and Fiscal seen for family planning services Delegate Agency Director through the sub-contract with 2. Transition current Health Health Awareness. The Region I Nurse Manager and database will be utilized for data Awareness clients to care within HFHC or PVHS. Office Manager of analysis. HFHC and PVHS 1. Continue focused voordinator of 2009FPAR December 31,2009 marketing efforts in our Outreach and Total Users = 6,200 service areas. Marketing, Director HFHC Users =, 1,600 2. Maintain strong quality of Clinical Services, Less than 200% poverty = 89% Executive Director, assurance improvement standards Clinical Director of 3. Maintain delegate and sub- !Delegates recipient contracts. 2010 FPAR 2010 & 2011 1. Continue focused marketing ~oordinator of Total Users = 6,500 efforts in our service areas. putreach and 2. Maintain strong quality ~arketing, Director Less Than 200% poverty = 89% assurance & improvement pf Clinical Services, 2011 FPAR standards !Executive Director, Total Users = 7,000 3. Monitor and maintain delega ~linical Director of Less than 200% poverty = 90% and sub-recipient contracts !Delegates OPA Priority: Assurin2 hi2h quality, subsidized services to low-income individuals.

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. I G oa II, Ob路 IJectIve 2 - crIDlca Need: Two-thirds of the 57,000 low-income women in our service area who are in need of subsidized contraceptive services live outside Worcester. The demand for our services has been growing in the Metro West area, which includes Marlborough, Framingham and Milford Goal 1: Assure the delivery of quality family planning and related preventive health services, where evidence exists that those services should lead to improvement in the overall health of individuals, wi ~riority for services to individuals from low-income families. Ob.iective 2.1: Increase the number of users seen at our clinical sites in MetroWest. Activities/Action Steps Responsibility Evaluation Timeline IExecutive Director, We will move into a new site January 1, I.Move our Marlborough .n Marlborough in December clinical site to allow for fiscal Director, 2009 ~oordinator of 2008. This site should be in expansion of services. pperation by 111109. ~.Explore adding services and Outreach and providing space to health & Marketing, Director Monitor utilization of services of Clinical Services, hrough analysis of clinic social service providers at Milford and Marlborough Clinical staff flPpointment schedules and ~umber of users served. Expand sites to promote access for populations in need. ~xisting services as indicated by ~ata analysis. Director of Clinical Users, 2007 FPAR December 31 1. Continue focused marketing efforts in our Services, Executive Marlborough Clinic = 502 2009 service areas. Director, Milford Clinic = 600 2. Retain/recruit staff that Coordinator of Framingham CHC = 346 Outreach and meets linguistic needs of populations in service area. Marketing, Clinic Projected Users, 2009 3. Maintain delegate contract ~taff, Delegate Marlborough Clinic = 575 with Framingham Community Director Milford Clinic = 675 Framingham CHC = 450 Health Center. 2010 & 2011 1. Continue focused marketing Director of Clinical 2010 FPAR efforts in our service areas Services, Executive Marlborough Clinic = 650 2. Monitor and maintain deleg2 Director, Director 0 Milford Clinic = 725 and sub-recipient contracts Fiscal Services, Framingham CHC = 500 3. Continued assessment of Coordinator of 2011 adding or collaborating with putreach and Marlborough Clinic = 700 other health/social service ~arketing, Clinic = 750 Milford Clinic programs that will promote ~taff, Clinical Framingham CHC = 550 access to care/services for pirector of populations in need. pelegate OPA Priority: Assuring high quality, subsidized services to low-income individuals. COMMENT: Our non-English speakmg client population has continued to grow in Milford and Marlborough. We are recruiting a second bilingual counselor to work in both sites; this will allow us to provide improved access for clients. In 2008 we renovated our Milford Clinic to allow for expansion of services. We added an exam room and additional counseling rooms. The expansion has allowed us to increase the number of clients per clinical session and to sublet space to the AHEC Patient Navigator. This person assists Ecuadorian non-English speaking individuals to access health and social services. This linkage allows for a cross referral of clients between our services.

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GOAL II: Goal II, Objective 1: Community Education and Outreach Need: Health Awareness encourages family participation in the decision of minors to seek family planning services. This can be promoted through on-going training and support of staff that deal directly with teens and their families. Training is essential to increase clinical skills and improve patient care, incorporate new technologies into our services, and ensure cultural appropriateness of care. In addition, on-going staff development through education and skill building, adds to professional growth, job satisfaction and staff retention. GOAL II: Encourage participation offamilies, parents, and/or legal guardians in the decision of minors to seek family planning services; provide counseling to minors on how to resist attempts to coerce minors into engaging in sexual activities. Objective 1.1 Provide 100 percent ofteens seen in family planning clinics with information and support to encourage the delay of sexual activity. Objective 1.2 Assure that family planning staff attends at least one clinical training per year Responsibility Evaluation Timeline Activities/Action Steps 1. On-going training to staff to Director of Annual medical record reviews 2009 - 2011 are conducted to assess support family participation in Clinical the decision of minors to Services, documentation of discussions access family planning Clinic staff, with teens regarding family services involvement, sexual coercion and Clinical 2. On-going training will be Director of abstinence counseling. provided on strategies to Delegates Health Awareness maintains staff prevent coercive sexual education logs; these are relationships and dating reviewed on a semi-annual basis. violence. 3. Sexual coercion and Health Awareness and relationship violence will be delegate/sub-recipient sites assessed and discussed with all participate in the annual JSI needs clients .. assessment survey to identify 4. Augment counseling session what staff identifies as areas of with brochures and/ or other needed training. Trainings are related information that formulated based on survey addresses abstinence and sexua results. coercion. OPA Priority: Encouraging family involvement, educating minors to resist attempts to coerce them into sexual activity. COMMENT: In September 2008 Health Awareness staff and staff from delegate/subcontract agencies attended "Family Planning and Family Violence: Making the Connection" training sponsored by MA 路Department of Public Health.. This training assisted staff in looking at behaviors/visits that may correlate with undisclosed patterns of domestic violence and aided staff in asking the right questions to prompt discussion with clients about this issue. The Director of Clinical Services actively participates in the Region I Regional Technical Advisory Committee (RTAC) and the Region I Clinical Advisory Committee (CAC). Both committees are responsible for collaboratively working with the John Snow Institute (lSI) to formulate trainings and training materials for Region I Title X agencies.

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In 2008

Health Awareness utilized this resource tool to provide an on-site training to staff. This video and resource will be added to our orientation of all new staff. GOAL III Goal III, Objective 1: Clinical Need: Health Awareness encourages chlamydia screening for all females :::..age 25 years or any client with risk factors for chlamydia. Our overall positivity rate continues to be relatively high (5.5%). We comply with the CDC recommendation to retest any individual who has a positive chlamydia or gonorrhea test 3-4 months post-positive testresult to assess possible re-exposure. We offer gonorrhea testing to "at risk" individuals. We offer both urine and swab testing for chlamydia and gonorrhea. Chlamydia and Gonorrhea rates for Worcester, Fitchburg and Leominster are much higher than the statewide rate, especially for teens. Our outreach efforts will continue to encompass educating teens and other high-risk populations about risk factors for sexually transmitted infections (including age) and how to get screened. Goal III: Provide preventive health ca,re services in accordance with nationally recogniied standards of care, including breast and cervical cancer screening and prevention, STD and HIV education, testing and referral, and other preventive services. Objective 1.1: Assure that 100 percent of patients :s 25 years of age are offered Chlamydia screening annually and that all individuals with risk factors for Chlamydia are offered screening. Timeline Activities/Action Steps Responsibility Evaluation 1. Continue to offer options for Director of Monitor screening compliance 2009-2011 chlamydia screening (urine or Clinical through Region I database and swab specimen collection). Services, chart reviews. 2. Continue to be an active Clinical Annual review of outcome data of Director of member of the Region I client screening for chlamydia, Delegates gonorrhea, syphilis, HIV and Infertility Project and be proactive in participating in cervical cytology. special initiatives for screening, Monthly review of lab logs and treatment, etc. through this follow-up tickler system to assess project. treatment and/or referral of any 3. Utilize clinical indicators of abnormal labs. positive sexually transmitted Assessment of State surveillance infections and treatments to data to determine disease quantify treatment outcomes morbidity and prevalence. (done through periodic review). OPA Priority: Provide preventive health care in accordance with nationally recognized standards .

COMMENT: The maJonty of chents wIth posItlve chlamydIa results are asymptomatlc females under the age of 25 who are seeking contraceptive services or pregnancy tests. This underscores the necessity of routine screening for females under the age of25. Periodic reviews demonstrate we are in compliance with recommended screening criteria. The Director of Clinical Services maintains active participation in the Region I Infertility Project.

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G oaI III, Ob''leetive 2 : crmIca . lIAdmimstrative .. Need: Family planning programs must keep current with on-going changes in contraceptive technology and changes in treatment modalities. This requires an organized, disciplined system of oversight and monitoring. Goal III: Provide preventive health care services in accordance with nationally recognized standards of care, including breast and cervical cancer screening and prevention, STD and HIV education, testing and referral, and other preventive services. Objective 1.1: Maintain the substantive role of the Quality Improvement Committee(s) to assure the provision of high quality care that meets current practice standards. Responsibility Evaluation Timeline Activities/Action Steps Director of The Clinical Advisory 2009-2011 1. On-going assessment of family planning offerings, service delivery Clinical Committee will meet Services, quarterly. Annual peer and areas of quality Improvement 2. On-going staff training to medical record reviews will Medical be conducted by Clinical enhance knowledge and skills in the Director, delivery of family planning services Medical Advisory Committee 3. Quarterly Clinical Advisory Advisor, members; quality indicators Committee meetings Provider staff will be evaluated through 4. Annual medical record reviews these reviews. and to quantify standards are met Delegate/Subrecipient Medical and Clinical Directors OPA Priority:OPA has identified efficiency and effectiveness as Key Issues in the delivery of family planning health care .. COMMENT: All chmcal servIce protocols are estabhshed and approved by the Chmcal Advisory Committee. Service delivery is determined by several factors: current standards of care, regional health trends and client populations. The Clinical Advisory Committee of Health Awareness monitors services and has systematic mechanisms to evaluate and initiate quality improvements related to all aspects of clinical care and operations. For example: Over the past few years we have seen increase in client requests for intrauterine devices (IUD) as a contraceptive method. This in part, is due to the growing number of immigrants from countries where the IUD is a common method of birth control. This prompted our Clinical Advisory Committee to work with providers to increase skill sets related to IUD insertion and management of problems. Trainings were provided to clinicians and protocols were revised.

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GOAL IV Goal IV, Objective 1: Clinical Need: Health Awareness has been steadily increasing the number of Hispanics and non-English speakers who use our clinical services. In 2007, 32 % of all users spoke either Spanish or Portuguese as their primary language compared with 27 % in 2006 and 25 % in 2005. In 2007,32 % of users were Hispanic, compared with 33 % in 2006 and 28 % percent in 2005. There are several established and emerging non-English speaking immigrant populations in the communities we serve. Our MetroWest Clinics have experienced the largest increase in immigrant nonEnglish speaking clients. Nearly half of our patients in Marlborough and one quarter of our patients in Milford are Brazilian. In Worcester and Framingham there is a strong influx of Africans, especially from Liberia and Ghana and in Fitchburg immigrants from Uruguay. Linguistic, cultural and economic issues present barriers to care for these populations. Goal IV: Address the comprehensive family planning and other health needs of individuals, families, and communities through outreach to hard-to-reach and/or vulnerable populations, and partnering with other community-based health and social service providers. Objective 1.1 Increase services to linguistic and ethnic minorities in our area. At least 30 % of total users each year should be non-English speakers. Timeline Activities/Action Steps Responsibilin Evaluation 2009 - 2011 1. Employ people representative Director of Monitor the percentage of non-English of populations we serve. Clinical speaking and Hispanic 2. Conduct targeted outreach to Services, users through the Region I database. hard to reach populations. Coordinator of Maintain a minimum baseline of 3. Conduct programs and inMarketing and 30% non-English speaking service presentations for staff on Outreach, and 30 % Hispanic clients. he health care orientations of Clinical Direct Outreach logs will be maintained he populations they serve, and of Delegates and evaluated semi-annually to assure tar~ how to deliver care in a populations have been reached. vulturally sensitive manner. Educational and outreach materials will bf 4. Collaborate with other translated into primary languages of clients organizations to do outreach to All clinics will employ bilingual staff arget populations. representative of linguistic and cultural needs of populations served. OPA Priority: Emphasize clinical services for hard-to-reach populations COMMENT: Health Awareness has been the convenmg agency for the Causana Project, a community-based coalition that works with the Ecuadorian community in Milford to address health . care needs.

In March 2009 we'll sponsor a conference, funded through JSI Technical Assistance

Funds, on the provision of culturally responsive services to emerging immigrant populations. Health Awareness has a growing number of non-English speaking clients in both our Milford and Marlborough sites. Spanish speaking clients are primarily from Ecuador, Guatemala, Mexico, Honduras and EI Salvador. Portuguese speaking clients are primarily from Brazil, Portugal and CapeVerde.

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Goal IV, Objective 2: Clinical Need: Health Awareness is committed to the provision of reproductive health care to males. Through our community education programs and HIV prevention efforts, we have reached large numbers of males who do not have a source of reproductive health care. Goal IV: Address the comprehensive family planning and other health needs of individuals, families, and communities through outreach to hard-to-reach and/or vulnerable populations, and partnering with other community-based health and social service providers. Objective 2.1: Provide reproductive health services to males.- By the close of 2009, 23.5% of total users should be male.

Timeline

Activities/Action Steps

Responsibility

Evaluation

In 2007,22 percent of total 1. Maintain integrated male health Director of services within family planning. Clinical Services users were male. This should Clinical Director increase each year: 2009-2011 2. The Community Education Program and Family Planning of Delegates 2008: 23% Program will collaborate outreach 2009: 23.5% efforts to males; a special 2010: 24% emphasis will be placed on reaching "at-risk" males. 3. Continue to make clinic service areas "male friendly" and incorporate information related to male concerns in counseling sessio (i.e. testicular self exam, HIV and STI prevention, etc.). 4. Assess male satisfaCtion with services through annual surveys. OPA Priority: Emphasize clinical services for hard-to-reach populations (uninsured or under-insur women, males in need of clinical services; adolescents).

.. COMMENT: All our family plannmg clImcs have mtegrated male servIces. The majorIty of males

that are seen within family planning are seeking sexually transmitted infection screening and/or HIV testing. In general, males tend to seek care after a risk exposure. As with females, a focus in -counseling males is on preventive health education and harm reduction. We attribute our success in serving males to the fact that providers and staff have received on-going training in delivering services to males and we are viewed as a male friendly service.

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Goal IV, Objective 3: Community Education and Outreach/Clinical Need: There are six communities in our service area where the teenage pregnancy rates are higher than the statewide average. In Worcester, Leominster and Fitchburg, chlamydia rates among teens are also much higher than the statewide average. We need to ensure that teens continue to use our services, even as we expand our outreach efforts to other populations. Goal N: Address the comprehensive family planning and other health needs of individuals, families, and communities through outreach to hard-to-reach and/or vulnerable populations, and partnering with other community-based health and social service providers. Objective 3.1 At least 30 percent of new users should be under 20 years of age by 2011. Timeline Activities/Action Steps Evaluation Responsibility 2009-2011 1. Provide marketing and Director of Clinical 25 percent of new users in 2007 outreach to teens in both out-ofServices, Coordinator were under 20 years of age. In school and school settings. 2006 teens were 28 percent of of Outreach and 2. Participate in communityMarketing, Communi~ overall users. We need to strive based efforts to lower teen Education Staff, Clinic for 30 percent utilization by Director/Outreach staf teens: pregnancy rates. Weare already involved with efforts in of Delegates 2008: 26 percent Southbridge and Framingham; 2009: 27 percent we'll expand this to 2010: 28 percent Marlborough and Milford. 2011: 30 percent 3. Encourage teen-friendly services through staff training and orientation. 4. Maintain relationships with youth centers and youth-serving organizations. OPA Priority: Emphasize clinical services for hard-to-reach populations (uninsured or underinsured women, males in need of clinical services, adolescents). Health Awareness operates a state-funded Teen Pregnancy Prevention Project, and Montachusett Opportunity Council operates one in Fitchburg. Framingham Community Health Center plans on starting a School-based health center in the coming year, and Hahnemann Family Health Center is considering starting a Teen Clinic on-site.

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GOAL V: Goal V, Objective 1: Financial Need:. As described in Section A, there are significant numbers of people living in cities and towns that we serve whose income levels fall below 200 percent of the federal poverty level. Evenwith the advent of Health Care Reform in Massachusetts, there are still many people for whom reproductive health care is unaffordable. Goal V: Eliminate financial barriers to access to reproductive health services. Enable clients to make use of publicly funded health insurance programs. Objective 1.1: Advocate for full inclusion offamily planning in the state's health care reform package of subsidized health insurance plans. Objective 1.2: Advocate for continued state funding for family planning services for those who are not covered by the state's Health care reforms plans (Commonwealth Care). Timeline Activities/Action Steps Responsibility_ Evaluation 1. Continue to work with other Title X Director of Using FPAR data, we know and family planning providers in Fiscal that 88 percent of users in 2007 Services, had incomes below 200 percent 2009-2011 Massachusetts to ensure that family planning services are fully covered Director of of poverty. This percentage under any state plan. Clinical should be maintained or surpassed in the upcoming 2. Work with state agencies to make Services, Clinical Project Years. our services accessible to newlyService and insured people. Fiscal 3. Approach provider and gate-keeper Directors of organizations to pursue affiliation and provider contracts; to date, three of the Delegate four plans are open to Family Planning Providers. 4. Work with the MA Legislature to ensure that Family Planning funding through MDPH remains as a safety net. OPA Priority: OPA puts a priority on "services to individuals from low-income families." COMMENT: FamIly Planmng IS fully covered under Commonwealth Care, the state's new health plan. Although we've seen a slight increase in insured clients, a significant number of our clients continue to be uninsured. This is due, in part, to the large number of undocumented immigrant clients we serve. Other clients who fall outside the insurance parameter include teens who want confidential care and don't want to use their parents' insurance and others who chose not to enroll or cannot afford Commonwealth Care premiums. The threshold for Commonwealth Care is 300 percent of poverty. In July 2008, MDPH raised the eligibility for the funds they give us to 300 percent of poverty. Since our funding is a capped amount, this may result in us billing out our contracts well before the end of the Fiscal Year.

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GOAL VI Goal VI, Objective 1: Administrative Need: Quality Assurance and Improvement activities are essential to the provision of high quality, effecti and client-centered reproductive health care. Goal V: Maintain an organizational structure that ensures effective management of the Title X Program. Objective 1.1 Maintain a system of continuous quality improvement within the Health Awareness Family Planning Program that complies with Title X guidelines and priorities. Objective 1.2: Monitor and assure the quality of care of Delegate and Sub-recipient Agencies through technical assistance, oversight and reviews. Responsibility Evaluation Timelill Activities/Action Steps Grantee evaluation of quality 1. Health Awareness Internal peer provider ch~ Director of eview and site reviews. Clinical Services assurance, quality improvement needs and Director and 2009 12. Conduct review of Hahnemann Family Health Center, including clinical site and chart Clinical Director achievements. eviews, clinical indicator reviews, and review of Delegates of internal client satisfaction surveys conducted. 3. Conduct review of selected indicators for Delegates andlor Sub-recipients. Grantee evaluation of quality 2010 1. Health Awareness Internal peer provider Chi Director of eview and site reviews. Clinical Services assurance, quality 2. Conduct review ofMontachusett Opportuni Director and improvement needs and Council, including clinical site and chart Clinical Director achievements. eviews, clinical indicator reviews and review of Delegates/ 路nternal client satisfaction surveys conducted. Sub-recipients 2. Conduct review of selected indicators for pelegates andlor Sub-recipients. Grantee evaluation of quality 2011 1. Health Awareness Internal peer provider ch Director of eview and site reviews Clinical Services assurance, quality ~. Conduct review of Framingham Communit) Director and improvement needs and ~ealth Center, including clinical site and chart Clinical Director achievements. eviews, clinical indicator reviews and review of Delegates 路nternal client satisfaction surveys, site and ch, eviews conducted. ~. Conduct review of selected indicators for !Delegates andlor Sub-recipients Grantee evaluation of quality 2009 - 1. Review FPER submission compliance of all Director of Clinical Services assurance, quality ~ites. improvement needs and and Delegate 2011 12. Review of FPAR data for Grantee 3. Review annual audited financial statements /Sub-recipient achievements. for all sites. Administrators OPA Priority: Effective and efficient operation of Title X agencies. COMMENT: As a Grantee we perform an annual retrospective reVIew of dIstnbutlOn of users by

age, race, ethnicity, language and poverty level; data on client contraceptive methods, data analysis related to number of Pap smears done correlated with number of abnormal results and data analysis related to number ofSTD screenings (syphilis, gonorrhea and Chlamydia) and HIV tests done

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correlated with number of positive results. This review assists us in ascertaining whether or not we are serving target populations, identifies contraceptive trends and provides STD rates for clients served. This data gives us a window in which we can assess our client population and compare it with demographic and health trends in the communities we provide services. It is an essential component in formulating a needs assessment and service delivery plan. Efforts to Address OPA Priorities: The OPA {Priorities for 2009 have been incorporated into our Work Plan. All of our Goals are drawn directly from the OP A Priorities or the Key Issues for Title X Projects, as stated in the Announcement of Anticipated Availability of Funds for Family Planning Services Grant. There are two OPA Priorities that are not addressed directly in the Work Plan, because they are intrinsic to our clinical operation: - Assuring access to a wide range of acceptable and effective family planning methods. As we discussed in Section B, Applicant and Project Infornlation, Health Awareness and its Delegates are committed to the provision of a wide range of family planning and related health sources, including natural family planning methods, infertility counseling, and services for adolescents, including abstinence counseling. This range of services does not include abortion as a method of family planning. - Assuring compliance with State laws requiring notification or the reporting of child abuse, child molestation, sexual abuse, rape or incest. As described in SectionB-2-g and B-2-k, we are in full compliance with State regulations to protect children. Copies of the "Child AbuselNeglect Reporting Policy and Procedure (5 I A)" and "Sexual Coercion Assessment and Counseling with Minors" policy are in the Appendix. Our yearly Technical Assistance trainings in 2007 and 2008 addressed these issues. Our Delegates must comply with this OP A Priority as a condition of contracting with Health Awareness.

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Upload #4 Applicant:

Health Awareness Services of Central Massachusetts, Inc.

Application Number:

FPH2009003614

Project Title

2009 Family Planning Services (Region 1 - Massachusetts)

Status:

Awarded

Document Title:

Progress Report

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PROGRESS REPORT The Progress Report covers Project Year 2007, from January 1, 2007 to December 31,2007, except in situations where the Objectives were time-limited to the first half of 2008. Otherwise, the events of the first half of 2008 are described in Section B, the Program Work Plan. GOAL I: Assure continued high quality family planning and reproductive health services that will improve the overall health of people. Assure access to comprehensive, high quality, family planning and reproductive health services including provision of highly effective contraceptive methods, breast and cervical cancer screening/prevention and STD/HIV prevention education, counseling and testing that will improve the overall health

of people. Objective #1 Increase the number of users seen. By the clos( of FY2009, see 6,400 users. At least 88 percent should have . incomes below 20 percent of the federal poverty level.

Outcome Data

Progress Narrative

- In 2007, we saw 5249 users. This is a drop of 345 users from 2006. It is still a 4 percent increase over 2005, which we are using as our baseline.

The decline in users is directly attributable to Montachusett Opportunity Council, which saw 453 less users in 2007. MetroWest continues to be an area of growth. We expanded hours of operation in our Milford and Marlborough sites.

- 91.3 percent of users had We ran a separate Worcester Male Health Service incomes below 200 2007. We saw a significant number of new male users percent of poverty. but our overall male users remained about the same as 2006. Males accessed services equally at our three clinic sessions and did not prefer the male health clinic. Due to low utilization of a separate male health service, this was discontinued in 12/07. We ran a satellite teen health service at the Worcester Youth Center in 2007 that offered modified family planning services, health education & HIV testing. Utilization of services was low; the clinical services were discontinued in 12/07. We have maintained health education services at this site.

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Objective #2 Maintain the substantive role of the Quality Improvement Committee(s) to assure the provision of high quality care that meets current practice standards.

Outcome Data In 2007 the Clinical Advisory Committee focused on five main activities: - Enhancing male health . services - Revising STD Protocols to comply with CDC 2006 Guidelines - Adoption of the 2006 CDC "Revised Recommendation for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings" - Integrating HIV C&T services within Family Planning, Worcester site. - Review of laboratory services

GOAL I, OBJECTIVE #3 Ob.iective #3 Outcome Data Assure that 100 percent of patients:::: 25 years of age are offered Chlamydia screening annually and that all individuals with risk factors for chlamydia are offered screening.

Health Awareness and ProHealth assess screening of clients..::: age 25 annually as a performance measure. Data reflects screening has met guideline criteria. Targeted medical record reviews reflect compliance with treatment

Progress Narrative Health Awareness revised male health protocols, exam forms and history forms. STD protocols were reviewed and revised, as indicated, to comply with 2006 CDC Guidelines. We have adopted the CDC revised guidelines for HIV testing in health care settings and in December 2007 we integrated HIV C&T within family planning at our Worcester site. As of 6/30/08 the Worcester Family Planning Clinic tested 239 clients for HIV. Other family planning sites have HIV C&T provided on site by the Health Awareness HIV C&T Program. In order to improve overall lab service to clients, a change of laboratory services occurred in 2/08

Progress Narrative Clinical sites comply with the CDC re-screening guidelines for 3-4 months after a positive chlamydia test; follow-up mechanism in place to remind clients when. re-screening is overdue. Health Awareness clients continue to have a high positivity rate for Chlamydia. Early detection and treatment decreases morbidity. 7/07-6/08 = 5.5% 7/06-6/07 = 6.5% 7/05-6/06 = 6.3% 7/06-6/07 = 6.7% 7/07-6/08 = 5.3%

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GOAL I, OBJECTIVE #4 Objective #4 Outcome Data Assure that family planning staff attends at least one clinical training per year in FY06-FY09.

In 2007 three mandatory trainings for all direct care staff included: HIV Counseling and Testing (JRI), OraQuick HIV Rapid HIV Testing Training (MDPH HIV/AIDS Bureau) and Domestic Violence (MDPH). All bilingual family planning staff utilized for interpreting have completed the Language Link 54-hour comprehensive Medical Interpreter Training Program offered by AHEC.

Progress Narrative In preparation for offering HIV C&T within family planning at our Worcester site, provider and nursing staff attended a series HIV C&T meetings and trainings offered by MDPH. The family planning program and HIV C&T program worked collaboratively to revise HIV C&T guidelines, protocols and visit forms. All provider staff participated in the Female and Male Genital Dermatology Web Cast offered by JSI. All family planning direct care staff have attended "Infant Adoption" training. Two providers attendee the "Women's Health Care of Older Women" conference in June 2007.

GOAL II: Encourage family participation in the decision of minors to seek family planning services, including activities that promote positive family relationships. GOAL II, OBJECTIVE #1 Objective #1 Outcome Data Pro2ress Narrative Provide 100 percent of teens seen in family planning clinics with information and support to encourage the delay of sexual activity.

100 percent of teens seen in our clinics received information and support to encourage the delay of sexual activity, as determined through randomized chart audits.

Our counseling summary form was revised in 2006 to include a counseling section to assess, discuss and document teen sexual decision making, family involvement and sexual coercion. Health Awareness has posters in waiting areas that encourage family involvement "talking to parents" about sexual decision making, as well as posters empowering teens delay sexual activity through abstinence. These posters serve as a subliminal tool to reach teens and are in English and Spanish. In addition to posters, Health Awareness utilizes brochures/handouts that encourage family involvement, empower the choice of abstinence and alert teens to sexual coercion. These materials are used in counseling sessions as well as in outreach. Health Awareness held an in-house training on sexual coercion for all family planning staff on 9/12/08. We utilized the Region I video "Counseling Teen Clients Experiencing Sexual Coercion" and Video Discussion Guide and Resources Handbook to facilitate this training.

III

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GOAL III: Emphasize clinical services for hard-to-reach populations (uninsured or underinsured women, males in need of clinical services, adolescents). Outcome Data Progress Narrative Ob.iective #1 Increase services In 2007,32 percent of total We have continued outreach to targeted communities, to linguistic and users spoke either Spanish or maintained multilingual services in our clinics, and ethnic minorities Portuguese as their primary continue to hire people from the communities that we in our area. At language compared with 25 serve. least thirty percent in 2005. This is a We are cognizant to provide culturally responsive percent of total significant increase! services in the counseling and care that we offer. users each year should be people In 2007,32 percent of total users Health Awareness continues to require that bilingual of color and/or were Hispanic, compared with direct care staff be trained in medical interpreting non-English 路28 percent in 2005. through the 54-hour Language Link Program of AHEC. ~eakers.

+ GOAL III, OBJECTIVE #2: Objective #2 Outcome Data Provide 22.2 percent of Users in reproductive 2007 were inale This is an health services increase from 2006 (20.1 %) to males. By A Men's Health Service was the close of established at our Worcester 2009,25 Clinic in November of 2006. percent of total Physician A male, bilingual users should Assistant was hired and be male. trained.

GOAL III, Ob路 1.lecf lVe 3 Ob.iective #3 Outcome Data 25 percent of new users in At least 30 2007 were under 20 years percent of new users should be of age. under 20 years In 2006 teens made up 28 of age. percent of overall users.

Progress Narrative We ran a separate Worcester Male Health Service 2007. We saw a significant number of new male users but our overall male users remained about the same as 2006. Males accessed services equally at our three clinic sessions and did not prefer the male health clinic. Due to low utilization of a separate male health service, this was discontinued in 12/07. We offered Hepatitis A immunization to male clients at our Worcester site who report same-sex activity. We attribute our success in reaching males to our targeted outreach and "word of mouth" that we are a "male friendly" service.

Progress Narrative th Southbridge ranks 6 highest for MA teen pregnancies. In 2007 our Southbridge NP did educational programs for both the Southbridge High School and Middle School that focused on prevention of pregnancy & STI's. Health Awareness began a satellite health clinic at the Worcester Youth Center in October, 2006, with a peer education component. The clinical component was ended in 2007, due to lack of use. Young people reported that they did not feel that the Youth Center was a sufficiently comfortable or confidential place to receive family planning services. Both Health Awareness and Montachusett Opportunity Council operate state-funded teen pregnancy prevention projects, in Southbridge and Fitchburg, respectively.

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GOAL IV: Eliminate financial barriers to access to reproductive health services. Enable clients to rna k e use 0f pu bl'ICIY I f unded heaIth'IDsurance pr02rams. Outcome Data Ob.iective #1 Pr02ress Narrative Maintain the 88.9 percent of users in In 2006 Massachusetts enacted a law to mandate all legal standard that at 2007 had incomes below residents secure health insurance; it went into effect July 200 percent of the federal 2007. Family Planning is a covered service under the new least 88 percent of users have poverty level. Massachusetts Commonwealth Care program. There are incomes below four Health Plans that are available to low-income people 200 percent of through Commonwealth Care. Currently, three of the four the Federal contract with family planning organizations. Poverty Level. Although we have seen a slight increase in insured clients due to health care reform, a significant number of our clients continue to be uninsured. This is due, in part, to the large number of undocumented immigrant clients we serve. Other clients who fall outside the insurance parameter include teens that want confidential care and do not want to use their parents' insurance.

GOAL V: Maintain an organizational structure that ensures effective management ofthe Title XP r02ra m. Ob.iective #1 Outcome Data Progress Narrative Maintain the In 2007 Health Awareness Health Awareness and Delegate/Sub-recipients assess the conducted the following quality of care below performance measures annually: by ensuring reVIews: - chlamydia screening for females age::: 25 women annual reviews. - Site medical record - females at risk for unintended pregnancy receiving The following reviews to assess contraception. will be done documentation of yearly in 2007counseling, education and Health Awareness conducts semi-annual internal reviews to 2009: Clinical delivery of care assess user data by visit type, age, race, ethnicity and site and chart - Clinic site reviews to language. This measure quantifies whether or not target reviews, clinical assess quality assurance populations are being served. indicator criteria such as storage of reviews, client medications, running of Health Awareness conducts annual review of user satisfaction coptrols, abnormal lab contraceptive methods, number of Pap smears done surveys, site and follow-up systems, etc. correlated with number of abnormal results (including chart reviews of - Targeted chart review to presence of high risk HPV), number of STI (syphilis, all delegate assess male health services gonorrhea and chlamydia) and HN tests done correlated agencies. - Targeted reviews of pap with number of positives. This measure assists us in smear follow-up and evaluating user contraceptive trends and prevalence of referral logs STI'sIHN in populations served. In 2007 we conducted a medical record review of .Framingham Community Health Center. In 2007 a Client Satisfaction Survey was conducted in English, Spanish and Portuguese.

v Page 99 of 120

GOAL V, OBJECTIVE #2 Objective #2 Outcome Data Assure that 100 percent of information and education materials utilized by the grantee and delegate are reviewed and approved by the Information and Education (I&E) Advisory Committee.

Our focus in 2007 was to make continuous quality improvements to the agency Web site that was launched in 2006. We have updated the Web site to reflect service changes and relevant health information for populations served.

GOAL V, OBJECTIVE #3 Objective #3 Outcome Data Ensure that all information systems are in compliance with HIPAA for privacy and security

Health Awareness and Delegate/Sub-recipient sites are HIPAA compliant.

Maintaining an active I&E Committee has remained a challenge for Health Awareness and Montachusett Opportunity Council. Both agencies have had difficulty retaining andlor recruiting members to serve on this committee. We will continue to focus our recruiting efforts on membership that is reflective of the communities and populations we serve.

Progress Narrative Policies and procedures are in place that meets HIPAA standards. All newly hired staff are trained in HIP AA standards and sign agreement to maintain these standards.

GOAL V, OBJECTIVE #4 Objective #4 Outcome Data In 2007, conduct a competitive application process to allocate funds to delegates in northern Worcester County.

Progress Narrative

Health Awareness deferred anRFP for Northern Worcester County Family Plarining in 2006; it was done in February 2007.

Progress Narrative In February 2007, Health Awareness developed an RFP. A draft was sent to the Regional Office prior to issuance. The RFP was sent to all hospitals, health centers, and nonprofit health organizations in northern Worcester County on March 5, 2007. Montachusett Opportunity Council (MOC) was the only respondent. Their application was submitted in April. It was reviewed by staff of Health Awareness and was judged to be acceptable for funding. A letter of award was sent to MOC on May 22,2007. In three years, we will initiate another proposal process. This time, it will include our MetroWest region, as well as northern Worcester County.

Page 100 of 120

Upload #5 Applicant:

Health Awareness Services of Central Massachusetts, Inc.

Application Number:

FPH2009003614

Project Title

2009 Family Planning Services (Region 1 - Massachusetts)

Status:

Awarded

Document Title:

Table of Contents

Page 101 of 120

HEALTH AWARENESS SERVICES OF CENTRAL MASSACHUSETTS, Inc. TITLE X APPLICATION September 29, 2008

TABLE OF CONTENTS PAGE

Project Abstract

PROJECT NARRATIVE A. Service Area Needs Assessment

B. Applicant and Project Information 1. Organization and Project Management Structure 2. Clinical Service System and Clinical Management 3. Community Education/Outreach 4. Quality Assurance and Assessment 5. Financial Management

39 42 48

C. Family Planning Service Delivery Plan 1. Program Work Plan and Evaluation Plan 2. Efforts to Address OPA Priorities

Budgets: Form 424A Personnel Budget路 Budget Narrative Progress Report Exhibits A. Title X Assurance of Compliance B. Family Planning Program Service Site Information C. Grantee and Delegate Services Provided Appendix Attachment A: Map of Service Area and Map of Program Sites Attachment B: OrganiZational Charts Grantee: Health Awareness Services Delegate: Montachusett Opportunity Council Delegate: Framingham Community Health Center Sub-Recipient: Plumley Village Health Services Attachment C: Sample Delegate Contract . Attachment D: Personnel Confidentiality Policy Attachment E: Staff Job Descriptions and curriculum vitae of key staff Attachment F: Health Awareness Policy, Procedure and Protocol Table of Contents

Page 102 of 120

Appendix (continued) Attachment G: "Sexual Coercion Assessment and Counseling with Minors" Policy "Child Abuse/Neglect Reporting (5IA)" Policy and Procedure Attachment H: "Family Involvement" Policy Attachment I: Overview, I&E Advisory Committee, Health Awareness Attachment J: Health Awareness Services Quality Improvement Process Chart Health Awareness Continuous Quality Improvement Plan Attachment K: Health Awareness Sliding Fee Scale Attachment L: Health Awareness policy on fee determination and collection

Page 103 of 120

Upload #6 Applicant:

Health Awareness Services of Central Massachusetts, Inc.

Application Number:

FPH2009003614

Project Title

2009 Family Planning Services (Region 1 - Massachusetts)

Status:

Awarded

Document Title:

Exhibit B

Page 104 of 120

EXHIBIT B - Family Planning Program Service Site Information 2008 Grantee: Health Awareness Services Projects: Worcester, Milford, . Southbridge and Marlborough Grantee Subcontract site: Plumley Village Health Services: Worcester Delegate: Pro Health: Fitchburg and Gardner Delegate: Framingham Community Health Center 째1 PIannm2 P r02ram IS proVI째d edb eIow m ta b u Iar ~orm ServIce Sode I n ~ormatIOn ~or t h e F amlly AGENCY LOCATION SERVICE OFFICE FPCLINIC # OF USERS AREA HOURS HOURS LAST FPARI NUMBER OF PROJECTED NEXT FPAR Grantee: Worcester, Central 5294/5500 Health Milford, MA Awareness Southbridge, MetroWest Services Marlborough, Northern Framingham, Worcester Fitchburg, County Gardner Health Worcester Greater M-F 1247/1200 W lO:OOamAwareness 405 Grove Worcester 9:00am4:30pm Services Street area 5:00pm 9:30amF Note: this clinic phone 3:30pm will close coverage 11112/0S. Worcester clients will be covered by suprecepient sites. Health Milford Blackstone M-F T 1:45pm600/700 Awareness Valley 1-S00# 7:00pm Services 25S Main Street phone Th. 11 :45pmcoverage 5:45pm Fri lOam3:30pm Health Southbridge Southern M-F Th. 12:30pm294/300 Awareness Worcester 1-S00# 6:00pm Services 50 Elm Street County phone coverage Health Marlborough Western M-F M 2:00pm502/650 Awareness 155 Union St Middlesex 1-S00# 5:45pm Services Note: this site County phone W 1:00pmwill move to 200 coverage 5:45pm East Main: Street F lOam12/0S 3:30pm

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SubRecipient Agency Service Site

lMontachusett Iopportunity . !council

EXHIBIT B - Service Site Information Delegate Agenc': MOe, Inc. Location Service Area Office FPCLINIC HOURS Hours

Fitchburg

No. Central MA

326 Nichols Rd. Professional Building@ Fitchburg Campus of Health Alliance

8:30am17:30 pm rrU 8:30am~:30pm

~ 12pmp:30pm rrH 8:30am~:30pm; 6pm t--8:30pm IF 12pm-

M 9am-12pm & 1pm-6pm Male clinic 6pm-8pm (3 weeks/mo) l\1D clinic 5pm-7pm once/month

#OF USERS LAST FPARI NUMBER PROJECT ED NEXT FPAR 1399/1200

T 9-1pm

~:30pm

W 4-8pm

Th 9-1pm F 2-5pm (Teen Clinic-walk ins)

Montachusett Opportunity Council

Page 106 of 120

Gardner 57 City Hall Ave.

Greater Gardner area

phone linked with Fitchburg

Th.2:30pm5:30pm

1531140

EXHIBIT B - Service Site Information SubRecipient Agency

Plumley Village Health Services

Delegate Agency: Plumle, Village Health Service Location Service Area Office CLINIC Hours HOURS

116 Belmont St. Worcester, Ma

Downtown Worcester

MonFriday

#OFUSERS LAST FPARlNumber PROJECTED Next FPAR

M& Th 8:306:30p T, W, F 8:30-5p

*(old location until 07125/08: 34 Laurel St. Worcester, Ma)

Plumley Village Health Services offers family planning as part of a full range of family medicine clinical services and does not have a separate clinical session for family planning.

Page 107 of 120

298/350

EXHIBIT B - Service Site Information Deleeate Aeenq: Framineham Community Health Center Sub-Recipient. . Location Service Area Office CLINIC Agency Hours HOURS Framingham Community Health Center

Framingham 19 Concord Street

Framingham and surrounding communities

Mon-Fri

MondayFriday

72 Union Ave Framingham and surrounding communities

M 9:00am5:30pm T 9:00am7:30pm W9:00am - 5:30pm Th 1O:00am5:30pm F 9:00am5:00pm M 9:00am5:45pm T . 8:30am5:45pm W9:00am -7:00pm Th 1O:OOam5:00pm F 8:00am5:00pm

# OF USERS LAST FPARI PROJECTED 346/400 .

Framingham Community Health Center offers family planning as part of a full range of family medicine clinical services and does not have a separate clinical session for family planning. ** The Framingham Community Health Center has continued to seek a permit to open a larger site in downtown Framingham. These were granted by the Planning Board on March 1,2008. The current Framingham sites located at 72 Union Avenue and 19 Concord Street are not large enough to accommodate the increased volume of clients seeking care at the Framingham Community Health Center. Construction is scheduled to begin spring of 2009 with completing summer of 20 1O. The plan is to phase out the other sites once the new building is occupied. . ***FCHC has continued to discuss the opening of a school based health center within the Framingham High School. This would function during normal school hours and is anticipated to offer family planning services. Renovations have been completed and DPH inspection is anticipated at the end of September. * 1 Times of day/days of month that medical provider clinics are held * 2 Number of users should be reported/projected at the sub-recipient/delegate agency level for umbrella agencies

Page 108 of 120

Upload #7 Applicant:

Health Awareness Services of Central Massachusetts, Inc.

Application Number:

FPH2009003614

Project Title

2009 Family Planning Services (Region 1 - Massachusetts)

Status:

Awarded

Document Title:

Exhibit C Page-1

Page 109 of 120

KEY:

Grantee: Delegates:

---

EXHIBIT C: SERVICES PROVIDED

1-Provided on-site at all dele ate sites 2-Provided within delegate system, but not at all sites

Page 110 of 120

= Health Awareness Services = Plumley Village Health Services

HAS PVHS FCHC MOC

= Framingham Community Health Center

Montachusett Opportunity Council

Upload #8 Applicant:

Health Awareness Services of Central Massachusetts, Inc.

Application Number:

FPH2009003614

Project Title

2009 Family Planning Services (Region 1 - Massachusetts)

Status:

Awarded

Document Title:

Exhibit C Page 2

Page 111 of 120

EXHIBIT C: SERVICES PROVIDED

Grantee & Ut:llt:lgcHt:I

Male HIV Services' Sb,v, ..... .,

, Level 1 Identification of Estrongen-Exposed Infertility Services IVTlspnng

HAS PVHS

1 3

1 1

FCHC MOe

1 1

11' 1"--

lon-site at all ~gilte sites ,vv,u"J within delegate system, but not at all sites

â&#x20AC;˘ not provided, referral made

Page 112 of 120

I~~~r

Health Promotion/Disease Special GYN Emergency D., -orlo 'res 'vu, ..",., Prevention I Cor",

1 1

*4 1

1 1

I'" ""'''' 1<" outside delegate sys~, but paid for by Title' X 14=Not provided

Upload #9 Applicant:

Health Awareness Services of Central Massachusetts, Inc.

Application Number:

FPH2009003614

Project Title

2009 Family Planning Services (Region 1 - Massachusetts)

Status:

Awarded

Document Title:

Exhibit C Page 3

Page 113 of 120

EXHIBIT C: SERVICES PROVIDED

Delegate HAS PVHS FCHC MOC

3 Month Female Hormonal Hormonal Oral Injection Contraceptives Sterilization IUDIIUS Implant

4 4 4 4

1 1 1 1

**4 **4 **4 **4

11-Provided on-site at all delegate sites 2-Provided within delegate system, but not at all sites

1 1

13-Referral outside delegate system, but paid for by Title X 14=Not provided

** not provided: referrals made (onsite offering pending) .

Page 114 of 120

Hormonal! Contraceptive Contraceptive Vaginal Cervical Ring Cap/Diaphragm Sponge Patch

4 4 4 4

Upload #10 Applicant:

Health Awareness Services of Central Massachusetts, Inc.

Application Number:

FPH2009003614

Project Title

2009 Family Planning Services (Region 1 - Massachusetts)

Status:

Awarded

Document Title:

Exhibit C page 4

Page 115 of 120

EXHIBIT C: SERVICES PROVIDED

Grantee &

" IHA~ IPVHS IFCHC IMOC

Female Condom j

1 1 1

Spermicidal Methods of Products

1 1 1 1

FE IA

1 1 1

1-Provided on-site at all delegate sites 2-Provided within delegate system, but not at all sites

* not provided; referral made

Page 1160f120

_".

~:;~~~(~~M) I~~:~~~~~" 1 1 1 1

IV.,:>"lilUII

*4 *4 *4 *4

Other Male Condom Methods 1 4 4 1 1 4 1 4

3=Referral outside dele ate s stem, but paid for by Title X 4=Not provided

Upload #11 Applicant:

Health Awareness Services of Central Massachusetts, Inc.

Application Number:

FPH2009003614

Project Title

2009 Family Planning Services (Region 1 - Massachusetts)

Status:

Awarded

Document Title:

Exhibit C Page 5

Page 117 of 120

Exhibit C Services Provided page 5 Grantee and Delegate standards for the provision of emergency and after-hours coverage: Health Awareness Services (HAS): 1) After hours, all calls entering the system are relayed to the family planning clinic answering system. Clients receive a telephone message informing them that we do not provide offhours or emergency services during non-clinic hours. In case of an emergency during non-clinic hours, clients are directed to seek care at a local emergency room. 2) Protocols are in place to direct staff re: emergency medical or other emergency situations (fire, disaster, etc.) that occur on site. All licensed staff maintains current CPR certification. Plumley Village Health Services (PVHS) 1) Patients may call Plumley Village Health Services 24 hours. An answering machine gives patients the after hours phone number. A resident supervised by faculty physicians from Hahnemann Family Health center will return the patients phone call. Care is provided at Memorial Hospital Emergency Room if deemed necessary. 2) Protocols are in place to direct staff re: emergency medical or other emergency situations (fire, etc.) that occur on site. All licensed staff maintains current CPR certification. Framingham Health Center (FCHC) 1) Patients may call Framingham Health Center 24 hours. An answering service handles incoming calls. A provider is on-call for emergencies. Care is provided at the Metro West Hospital Emergency Room if deemed necessary. 2) Protocols are in place to direct staff re: emergency medical or other emergency situations (fire, etc.) that occur on site. All licensed staff maintains current CPR certification. Montachusset Opportunity Council (MOC) 1) After hours, all calls entering the system are relayed to an answering system. If the caller has an emergency, the recording on the answering machine directs clients to their local emergency room or primary care physician, if they have one. All new clients are given an informational pamphlet on the services provided to them within the clinic. This pamphlet also explains what to do in the case of emergency. 2) Protocols are in place to direct staffre: emergency medical or other emergency situations (fire, etc.) that occur on site. All licensed staff maintains current CPR certification.

Page 118 of 120

Upload #12 Applicant:

Health Awareness Services of Central Massachusetts, Inc.

Application Number:

FPH2009003614

Project Title

2009 Family Planning Services (Region 1 - Massachusetts)

Status:

Awarded

Document Title:

List of Appendices

Page 119 of 120

Appendix Attachment A: Map of Service Area and Map of Program Sites Attachment B: Organizational Charts Grantee: Health Awareness Services Delegate: Montachusett Opportunity Council Delegate: Framingham Community Health Center Sub-Recipient: Plumley Village Health Services Attachment C: Sample Delegate Contract Attachment D: Personnel Confidentiality Policy Attachment E: Staff Job Descriptions and curriculum vitae of key staff Attachment F: Health Awareness Policy, Procedure and Protocol Table of Contents AttachmentG: "Sexual Coercion Assessment and Counseling with Minors" Policy "Child Abuse/Neglect Reporting (SIA)" Policy and Procedure Attachment H: "Family Involvement" Policy Attachment I: Overview, I&E Advisory Committee, Health Awareness Attachment J: Health Awareness Services Quality Improvement Process Chart Health Awareness Continuous Quality Improvement Plan

Attachment K: Health Awareness Sliding Fee Scale

Attachment L: Health Awareness policy on fee determination and collection

Page 120 of 120