Health Awareness 2009 Title X Grant

1. DATE ISSUED (Mo.lDaylYr.
)
12. CFDANO.
12/23/2008 93.217 PUBLIC HEALTH SERVICE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
3. SUPERCEDES AWARD NOTICE dated
OPHS Office of Grants Management
except that any additions or restrictions previously imposed remain
1101 Wootton Parkway
in effect unless specifically rescinded
5. ADMINISTRATIVE CODES
Suite 550
4. GRANT NO.
Rockville, MD 20852
2 FPHPA010121-38-00
FPH70
Formerly: 01HOO0121
6. PROJECT PERIOD Mo./Oay/Yr. Mo./Day/Yr.
NOTICE OF GRANT AWARD
From 12/31/2008 Through 12/30/2009
AUTHORIZATION (Legislation/Regulations)
7. BUDGET PERIOD Mo./Day/Yr. Mo./Oay/Yr. P.L. 91-572 PHS Act Sec. 1001 as Amended, 42 CFR 59
From 12/31/2008 Through 12/30/2009
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)
b. 405 Grove Street
Mr. Mazloff, Michael
405 Grove St,
c.
Worcester, MA 01605
d. Worcester e.MA f.01605-1270
Phone: (508) 756-7123
11. APPROVED BUDGET (Excludes PHS Direct Assistance) 12. AWARD COMPUTATION FOR GRANT
I PHS Grant Funds Only a. Amount of PHS Financial Assistance (fromiltem 11.u) 379,540
II Total project costs including grant funds and all other financial participation
DO
b. Less Unobligated Balance From Prior Budget Periods 0
(Select one and place NUMERAL in box) c. Less Cumulative Prior Award(s) This Budget Period 0
a. Salaries and Wages ..................
d. AMOUNT OF FINANCIAL ASSISTANCE THIS ACTION
I
379,540
b. Fringe Benefits .................. 13. RECOMMENDED FUTURE SUPPORT
c. Total Personnel Costs
(Subject to the availability of funds and saNsfactory progress of the project):
. ..........
d. Consultants Costs . ............................................... 0 YEAR TOTAL DIRECT COSTS YEAR TOTAL DIRECT COSTS
e. Equipment . ............................................... 0 a39 d42
f. Supplies ................................................ 42,895 b40 e43
g. Travel . ............................................... 1,407 C41
f.44
h. Patient Care - Inpatient .............. ................
0
14. APPROVED DIRECT ASSISTANCE BUDGET (IN LIEU OF CASH):
i. Patient eare - Outpatient .............. ................ 0
a. AMOUNT OF PHS Direct Assistance 0
j. Alterations and Renovations ............................... 0
b. Less Unobligated Balance From Prior Budget Periods
k. Other ........ ........................................ 74,098
c. Less Cumulative Prior Award(s) This Budget Period
I. Consortium/Contractual Costs ............................... 482,107
d. AMOUNT OF DIRECT ASSISTANCE THIS ACTION
I
0
m Trainee Related Expenses ................................ 0
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:
~
n. Trainee Stipends . .............................. 0
(Select one and place LETIER in box.)
B. DEDUCTION
o. Trainee Tuition and Fees . .............................. 0
b. ADDITIONAL COSTS
,. MATCHING
Trainee Travel 0
d. OTHER RESEARCH (Add I Deduct Option)
p. ................................................ B. OTHER (See REMARKS)
q. TOTAL DIRECT COSTS

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
r. INDIRECT COSTS (rate of)

FOLLOWING:
$
B. The grant program legislations cited above.
s. TOTAL APPROVED BUDGET
1,138,599
b. The grant program regulaUon cited above.
,. This award noUce Including !enns and condlUons, if any. noted below under REMARKS.
t. SBIR Fee d. PHS Grants Policy Statement Including addenda In effect es ~ f the beginning date of the budget period.
B. 45 CFR Part 74 or45 CFR Part 92 as applicable.
u. Federal Share $ 379,540
Ih the event there are conflicting or otherwise inconsistent policies applicable to the grent, the above order of precedence shall
Non-Federal Share $ 759,059
prevail. Acceptance of the grant terms and conditions IS ecknowledged by the grantee when funds are drawn or otherwise
v. obtained from the grant payment system.
REMARKS: (Other Terms and Conditions Attached - l81 Yes 0 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
FY-CAN
20. a.
9-3014501
21.a
22.a
PHS5152-1 (rev. 7/92)
(Signature) (Name - Typed/Print)
Karen Campbell
18. CRS -EIN 1042496148A2
(Title)
Grants Management Officer, OPHS
19. LIST NO.
DOCUMENT NO. ADMINISTRATIVE CODE AMT ACTION FIN ASST
b. 01HOOO121B c. FPH70 d. 379,540
b. c. d.
b. c. d.
(NOTE: See reverse for payment Information)
CONGo DIST.: 03
AMT ACTION DR ASST
e.
e.
e.
0
(b) (4)
(b) (4)
(b) (4)
(b) (4)
NOTICE OF GRANT AWARD (Continuation Sheet) ,----------r-=-c-==--==-== ____ -------,
PAGE 2 of 6 I DATE ISSUED
12/23/2008
GRANT NO. 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 T i t l ~ 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-=-,..---:::-::::--------.=-==-===---------,
12/23/2008
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%)
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
(b) (4)
NOTICE OF GRANT AWARD (Continuation Sheet) r-=-:-=:--------r=-:-=====----------,
1 12/23/2008
individuals, males, persons with limited English proficiency, adolescents, and other vulnerable or at-
risk 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---------,---:::----::::-===-------,
12/23/2008
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 = - : - = = - = = ~ - - - _ _ _ _ ,
12/23/2008
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 9-
digit 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 (1-
800-HHS-TIPS).
3. For assistance on programmatic issues please contact: Kathleen Desilets, Regional Program
Consultant, at (617)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:
Application Number:
Health Awareness Services of Central Massachusetts, Inc.
FPH2009003614
Project Title
Status:
2009 Family Planning Services (Region 1 - Massachusetts)
Awarded
Online Forms
1. OPHS-1: Checklist
2. OPHS-1 Title X Assurances
(Mail-In Signature Page): Required Signature Page - Please sign & mail in.
3. SF-424 Application for Federal Assistance (Version 2.0)
4. SF-424A Budget Information - Non-Construction Programs
5. SF-424B Assurances - Non-Construction Programs
&. SF-LLL Disclosure of Lobbying Activities
(Mail-In Signature Page): Required Signature Page - Please sign & mail in.
7. HHS Standard Certifications
Program Narrative
1. Budget Narrative
(Upload #1): Budget Narrative
(Upload #2): Personnel Budget
2. 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 #10): Exhibit C page 4
(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
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.
Type of Application: o NEW
Noncompeting
D Continuation
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. Proper Signature and Date for item 18 on SF-424 (Face Page) .................................................. ..
2. 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
YES Applicable
I. Has a Public Health System Impact Statement for the proposed program/project
been completed and distributed as required?...................................................................................... D
2. 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) .................................... IE]
3. Has the entire proposed project period been identified in item # I3 of the FACE
PAGE? ................................................................................................................................................ ~
4. Have biographical sketch(es) with job description(s) been attached, when requested?
5. Has the "Budget Infonnation" page, SF-424A (Non-Construction Programs) been
completed and included? ............................................ IE]
6. Has the 12 month detailed budget been provided? ............................................................................ IE]
7. Has the budget for the entire proposed project period with sufficient detail been
provided? .. ... ... .... ........ ........ ............ ...... ........ ......... ........ ..... .... ... ........ ......... ..... .... ..... ...... ........ ...... ..... ~
8. For a Supplemental application, does the deiailed budget address only the additional
fund requested? .................................................................................................................................. D
9. For Cornpeting Continuation and Supplemental applications, has a progress report
been included? .................................................................................................................................... IE]
PART C: In the spaces provided below, please provide the requested information.
D
D
D
D
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 Susan Dube Name Michael Mazloff
Title . President, Board of Directors Tille
Organization Health Awareness Services of Central Massachusetts, Organization Health Awareness Services of Central Massachusetts, In,
405 Grove Strcet 405 Grove Street
Address Worcester, MA 01605_._12..,:7_0 __________ _ Address Worcester, MA 016051270
E-mail Address E-mail Address mmazloff@hascm.org
Telephone Number Telephone Number 508-7567123
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.
(be) 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 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.
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.
Previously Filed with: (Agency) on (Date)
I Region I, DHHS I 08/31/2000
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
Register 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 are to certify on the face page of the SF-424 (attached)
whethcr the request is for a program covered under Executive Order
12372 and, where appropriate, whether the State has been given an
opportunity 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
o 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
Application for Federal Assistance SF-424
1. Type of Submission: 2. Type of Application: If Revision, select appropriate letter(s):
DPreapplication DNew
I I
I81ApPlication I8IContinuation
Other (Specify)
DChanged/Corrected Application DRevision
1
3. Date Received: 4. ApplicanUdentifier:
110/01/2008 IIFPHPA010121
I
5a. Federal Entity Identifier: 5b. Federal Award Identifier:
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:
1405 Grove Street
Street2:
I
City:
Iworcester
I
County:
I I
State:
"Massachusetts
Province:
I I
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 I
First Name:
IMichael
Middle Name: I
I
Last Name:
I Mazloff
Suffix:
I I
Title: IExecutive Director
,
Organizational Affiliation:
I
Telephone Number: 1508-756-7123 IFax Number:
1{508l 756-8922
Email:
Immazloff@hascm.or!:j
Page 5 of 120
1
OMS Number: 4040-0004
Expiration Date: 07/31/2006
Version 02
J
I
I
I
,
I
I
I
I
I
1
,
I
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 I
"10. Name of Federal Agency:
IPA-Family Planning
11. Catalog of Federal Domestic Assistance Number:
193.217
I
CFDA Title:
IFamily Planning Services
* 12. Funding Opportunity Number:
I I
"Title:
13. Competition Identification Number:
I I
Title:
14. Areas Affected by Project (Cities, Counties, States, etc.):
OMB Number: 4040-0004
Version 02
I
I
I
I
I
Central Massachusetts- Worcester County and the MetroWest area (western portion of Middlesex County)
* 15. Descriptive Title of Applicant's Project:
Attach supporting documents as specified in agency instructions.
Page 6 of 120
Application for Federal Assistance SF-424 Version 02
16. Congressional Districts Of:
, a. Applicant
103
1
' b. program/Proj ect!02,03,
1
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
I
7818511
b. Applicant
01
c. State
01
d. Local
01
e. Other
01
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
1 1
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.)
DYes IE] No
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 com-
ply 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.
1
First Name:
IMichael
1
Middle Name:
1 1
'Last Name:
IMazloff
1
Suffix:
1 1
'Title:
IExecutive Director
1
'Telephone Number: 1508-756-7123 IFax Number: 1508-756-8922
1
, Email:
1 mmazloff@hascm.org
1
, Signature of Authorized Representative: I
I
' Date Signed:
I I
Authorized for Local Reproduction Standard Form 424 (Revised 10/2005)
Prescribed by OMB Circular A-102
Page 7 of 120
Applicant Federal Debt Delinquency Explanation
Version 02
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
A I BUDGET INFORM T 0 N - Non-c onstruction Programs
OMBA pprova IN 03480044 o.
. :,,:,.::'
;0':. '.,<" .',::.
... : . < >.<
.'. SECTION A.:;$UDGET.$UMMA'ijY1(?';))if:
" "';-;i: 'X: .. :; .(;.!': ......
Grant Program Catalog of Federal
Estimated Unobligated Funds New or Revised Budget
Function Domestic Assistance
or Activity Number Federal Non-Federal Federal Non-Federal Total
(a) (b) (c) (d)" (e) (f) (g)
1. Family Planning Services 93.217 $781,851.00 $759,059.00 $1,540,910.00
2. Family Planning Services 93.217
5. Totals $781,851.00 $759,059.00 $1,540,910.00
;;;;/;>. ';/:;1.
.;.";"';
." ........ 'SECTION :</;fC: .. O<',;';<' .' :.;";;;.i'" ..
;.-....
,,;;;:

.... . <oJ
6. Object Class Categories
GRANT PROGRAM, FUNCTION OR ACTIVITY Total
(1) Familv (2) Familv Planninl;': (3) Familv PlanninQ: (4) Familv Plannin" (5)
a. Personnel $497,681.00 $497,681.00
b. Fringe Benefits
c. Travel $2,814.00 $2,814.00
d. Equipment
e. Supplies $85,790.00 $85,790.00
f. Contractual $664,213.00 $664,213.00
g. Construction
h. Other $170,969.00 $170,969.00
i. Total Direct Charges (sum of6a-6h)
j. Indirect Charges
k. TOTALS (sum of 6iand 6j) $1,540,910.00 $1,540,910.00
. ":.:"::, , '.:.'" :.>/'
" ...... ..::.::::.::: .. : .....:: .. :. , ....
".>.'.:;:V;/' .:.;:.:
'-,':
".
'!:
;.:;:. .:y.;:.:,';'; .....
'.""'"
7. Program Income
Previous Edition Usable
Page 9 of 120
$759,059.00
Authorized for Local Reproduction
$759,059.00
Standard Form 424A (Rev. 7-97)
Prescribed by OMB Circular A-102
(b) (4)
(b) (4)
(b) (4)
(a) Grant Program' (b) Applicant (c) State (d) Other Sources (e) TOTALS
8. Family Planning Services
$ $759,059.00 $759,059.00
10. Family Planning Scrvices
12. TOTAL (sum oflines 8-11) $759,059.00 $759,059.00
.......
Total for 1st Year 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
13. Federal
$781,851.00 $195,463.00 $195,463.00 $195,463.00 $195,462.00
14. Non-Federal $759,059.00 $189,765.00 $189,765.00 $189,765.00 $189,764.00
15. TOTAL (sum oflines 13 and 14) $1,540,910.00 $385,228.00 $385,228.00 $385,228.00 $385,226.00
.> ... hG '. .., 'c' It v ....;.\.,: c. .. .... .,
(a) Grant Program FUTURE FUNDING PERIODS (Years)
(b) First (c) Second (d) Third (e) Fourth
16. Family Planning Services $781,851.00 $781,851.00 $781,851.00
17. Family Planning Serviccs
20. TOTAL (sum oflines 16-19) $781,851.00 $781,851.00 $781,851.00
21. Direct Charges: 12
1
23. Remarks:
Standard Form 424A (Rev. 7-97) Page 2
Page 10 of 120
(b) (4) (b) (4)
SF424B Assurances
Project Title.: 2009 Family Planning Services (Region 1 - Massachusetts)
Application Organization Health Awareness Services of Central Massachusetts, Inc.
o 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
0348-0046 Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
See reverse for ublic burden disclosure.
1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:
EJ a. contract
b. grant
~ a . bid/offer/application ~ a. initial filing
b. initial award b. material change
c. cooperative agreement
d.loan
c. post-award For Material Change Only:
e. loan guarantee
f. loan insurance
4. Name and Address of Reporting Entity:
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:
DHHS/OPA
8. Federal Action Number, if known:
10. a. Name and Address of Lobbying Registrant
(if individual, last name, first name, M/):
11 Informalion requested through this fonm is aulhorized by tille 31 U.S.C. section
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.
Page 12 of 120
year quarter __ ~ __ __
date of last report ______ _
5. If Reporting Entity in No.4 is a Subawardee, Enter Name
and Address of Prime:
Con ressional District, if known:
7. Federal Program Name/Description:
CFDA Number, if applicable: _9_3_.2_1_7 __ _
9. Award Amount, ifknown:
$
b. Individuals Performing Services (including address if
different from No. 10a)
(last name, first name, M/):
Signature: ___________________ _
Print Name: Michael Mazloff
Date: 09/30/2008
Standard Form LLL (Rev. 7-97)
Reporting Entity:
Page 13 of 120
DISCLOSURE OF LOBBYING ACTIVITIES
CONTINUATION SHEET
Page
2
of
Approved by OMS
0348-0046
2
Standard Form - LLL-A
OPHS-1 Certifications
Project Title: 2009 Family Planning Services (Region 1 - Massachusetts)
Applic,ation Organization Health Awareness Services of Central Massachusetts, Inc.
o I DO NOT agree with the terms of the Signing Agreement
I2J I agree with the terms ofthe signing Agreement
Page 14 of 120
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 15 of 120
Upload #1
FPH2009003614
Awarded
Budget Narrative
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 increase for COLA)
B. Taxes & Fringe:
Fringe Benefit Rates are calculated at . This is based on past costs for Family
Plannin e costs. The breakdown is as follows:

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: $0
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: $ 76,477.
Page 16 of 120
(b) (4)
(b) (4)
(b) (4)
(b) (4)
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

2,400
600
8,144
8,000
180,362.

Contractual costs include their Medical Director, consultants, percent of their Title X
appropriation of paid to Health Awareness for administrative overhead
($14,448), and of their total budget paid to Montachusett Opportunity
Council, rent organization, for indirect overhead. We intend to contract with
them for 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
(b) (4)
(b) (4)
(b) (4)
(b) (4)
(b) (4)
(b) (4)
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: $0
H. Other: $ 170,969
Advertising: $ 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
In kind Services $5,000
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
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 20 of 120
Upload #2
FPH2009003614
Awarded
Personnel Budget
Jan 1, 2009 to Dec 31, 2009
NAME AND POSITION TITLE Rate
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
SUBTOTAL
TOTAL
FRINGE@
GRAND TOTAL
Page 21 of 120
Sheet1
HEALTH AWARENESS SERVICES
SUPPLEMENTAL TO PART III, SECTION F
ANNUAL SALARY ratew Annwinc #OF
as of 8113108 COLA MOS.
hrs/wk

Page 1
%OF
TIME

Excel
Title X 2009
Sheet 1
(b) (4)
(b) (4)
(b) (4)
(b) (4)
(b) (4)
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 22 of 120
Sheet1
Page 2
Excel
Title X 2009
Sheet 1
Sheet2

Page 3
Page 23 of 120

Excel
Title X 2009
Sheet 2
(b) (4)

Page 24 of 120
Sheet3

Page 4

Excel
Title X 2009
Sheet 3
(b) (4)
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 2052917
MINUS M&G EXP 279059
Total 1773858
CLINIC TOTAL BFR DEPREe 885567
DIVBY 1773858
For % M&G 0.499232182
50% ofM&G
for audit, ins, payroll serv
Note
2006
2007
2008
34%
40%
50%
Excel
Title X 2009
Sheet 4
Page 32 redacted for the following reason:
- - - - - - - - - - - - - - - - - - - - -
(b) (4)
2009
A.
B.
C.
D.
E.
F.
G.
H.
Page 27 of 120
Sheet6
TITLE X for budget narrative sheets
PERSONNEL INCLUDE COLA 497681
FRINGE USE OF ALL EMPLOYEE
TRAVEL RATE AT 2814
SUPPLIES ALL CLINIC RELATED
OFFICE 4743
PTCARE 76477
ED 3526
CLEAN 319
EO 725
85790
CONTRACTUAL MOC & FRAMINGHAM
PERSONNEL
FRINGE
TAXES
SUPPLIES
OTHER
TOTAL PLUS FRAMINGHAM AMT
OTHER
ADV 12734 INS 606+7389 7996
BLDG MISC 285+231 516
CLEAN SRV 6637 OCCUPANCY 62118
DUES/SUBSC 4642 PAYRLSERV 826
ELACT/HEAT 6490 POSTAGE 535
EO RENT&REP 3075 PRINTING 10234
FISCAL AUDIT 7847 PROF FEES 2782
INKIND SUPPLY 5000 TRAINING 498
LAB SERV 31269 TELEPHONE 7770
SUB TOTAL TOTAL 170969
TRAVEL 2814 see c above
ALL SUPPLY 86759 see e above
OTHER
TOTAL
GRAND TOTAL 876697
Page 7
86759
**current figures
new rate tbd
Excel
Title X 2009
Sheet 6
(b) (4)
(b) (4)
(b) (4)
(b) (4)
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 28 of 120
Upload #3
FPH2009003614
Awarded
Abstract and Program Narrative
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
T ABLE 1: 2000 Population by Race, HASCM Service Area US Census data)
Community Total White, No Hispanic African- Asian Native Biracial
Hispanic American American
Worcester 172,648 122,211 26,155 11,892 8,402 769 5,861
Auburn 15,901 15,392 1,590 95 143 16 95
Fitchburg 39,102 29,414 5,852 1,426 1,668 . 138 1,198
Framingham 66,910 50,293 7,265 3,409 3,527 116 2,263
Gardner 20,770 18,882 848 476 284 70 328
Hudson 18,113 16,718 634 163 254 18 362
Leominster 41,303 33,673 4,544 1,529 1,006 63 914
Marlborough 36,255 30,778 2,196 787 1,364 72 1,037
Milford 26,799 24,264 1,168 362 473 29 475
Shrewsbury 31,640 27,875 506 474 2,404 36 213
Southbridge 17,124 13,028 3,472 246 261 73 453
Webster 16,415 15,250 657 181 164 49 213
W 17,997 15,441 558 288 359 36 395
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)
IEconomic
Worc- Auburn Fitch- Framing Gardner Hudson Leomin- Marlbor- Milford Web- West-

ester !ham ster ough ter boro
Per capita 18,614 123,802 17,25{ 27,758 18,624 26,679 121,769 28,723 23,742 31,570 18,514 20,410 35,063
Income
Children> 1 00% 17.9 3.3 15.0 8.1 9.6 4.5 9.5 6.9 7.2 4.8 15.4 11.0 4.7
poverty
Total >200 % 36.2 13.3 34.5 21.1 25.9 12.5 23.7 16.4 19.1 11.7 33.9 27.9 9.8
Poverty
Unemployment 6.0 4.5 9.7 4.1 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)
Health Worcester iAuburn [oitchburg Fram- pardner Hudson Leomin- Milford Shrews- Webster
Indicator
ngham ter pury bridge
LOW 7.6 10.1 9.7 8.4 7.2 8.1 6.7 5.0 4.2 9.6 9.2 10.7 8.1
Birthweight
Infant 6.6 NA 9.1 8.5 0 NA 3.9 1.8 0 NA NA NA NA
Mortality
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.
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TABLE 4 - Fertility Rates b'l City/Town, 1995-2000 (per 1,000 Women 15-44) - MA Dept Public Health
Rates Worces lFitch- IFram- pardner lMarl- Milford Shrews- South-

er Burg ingham borough pury bridge !2oro
Fertility Rate, 49.4 51.7 47.0 55.1 53.2 56.5 47.2 55.7 52.9 61.5 56.1 61.1 51.8
White
Fertility Rate, 83.8 NA 113.3 68.1 110.3 57.1 122.2 136.0 112.5 115.1 92.7 96.6 137.3
Hispanic
Fertility Rate 109.2 NA 96.2 55.5 NA NA 75.5 57.8 74.1 76.2 266.7 NA 100.0
Black Non-Hisp.
As a frame of reference, the statewide averages are as follows:
TABLE 5 - Economic and Health Indicators, MA, 2007 (MA DPH)
Total >200 % Unemploy- LBW Infant Fertility Rate, Fertility Rate, !Fertility Rate Per capita rrotal > 100%
Income poverty Poverty ment rate Mortality White !Black,Non-Hisp
$25,952 9.3 21.7 5.1 7.8 4.7 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
Calendar Years TOTAL Under 20 20-44 and < 250% poverty
1995-2000 38,870 13,120 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.
TABLE 7 B" hR lrt T ates among eens, -
-
s 15 19 A C d C ompare to 'M ommunltIes III ass.
Community !Rank, Births, Rate per Rank, lBirths, Rate per Rank, Births, Rate per
2006 1,000 ?OOO 1,000 1990 1990 1000
Southbridge 6 36 64.5 5 38 68.3 5 48 52.5
Fitchburg 7 91 58.2 10 92 60.6 6 146 82.1
NA 29 34.1 13 36 43.5 NA 34 37.9
Worcester 18 242 34.4 15 290 41.9 14 399 58.8
Framingham 22 65 33.3 23 45 23.4 NA 44 19.6
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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, Chlamydia, 15- Gonorrhea Gonorrhea, 15-19
Community
Rate/100,000 19 Rate/l 00,000 Rate/100,000 teens
Rate/100,000 teens
Fitchburg 251.8 838.1 54.3 NA
Framingham 164.5 739.4 16.8 NA
Marlborough 113.0 425.1 13.5 NA
Milford 105.4 495.9 25.4 NA
Southbridge 228.5 1,207.6 NA NA
Worcester 379.2 1,348.2 46.7 90.8
Massachusetts 236.6 1,079.6 37.7 110.5
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
Clinic Site 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
Worcester 2.7% 4.7% 4.0% 3.5% 9.2% 8.4% 5.2%
Milford 3.0% 3.8% 3.0% 3.3% 4.4% 5.6% 4.3%
Southbridge 6.2% 2.9% 7.0% 6.9% 5.5% 7.4% 7.2%
Marlborough 3.0% 5.2% 2.0% 7.6% 3.9% 3.7% 5.6%
Fitchburg & Gardner 4.0% 4.0% 5.4% 3.2% 4.6% 4.8% 5.1%
Cumulative rate/yr 3.4% 4.1% 4.5% 4.1% 5.5% 5.9% 5.3%
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).
TABLE 10 M d fT o eo ransmlSSlOn, L". HIV/AIDS C lvmg ases as 0 f7/1/07
MSM IDU MSMI HTSX Pres. Total
IDU HTSX Cases
Fitchburg 15 % 40% 0 20% 25% 113
Framingham 23% 31 % 0 16% 30% 152
Worcester 16% 40% 2% 20% 22% 895
..
The large commumtIes In our servIce have varymg rates of HI VIA IDS:
TABLE 11 C l C fHIV/AIDS R rt d f7/1/02 d 7/1/06 umu abve ases 0 epo e ,as 0 an
Cases, 2002 Prevalence (Alive Cases, 2006 Prevalence (Alive
Cases per 100,000) Cases per 100,000)
Fitchburg 94 240 113 289
Framingham 133 181 152 227
Leominster NA NA 64 155
Marlborough 36 99 44 119
Worcester 741 433 895 518
tn . .
Worcester has the 5 hIghest number of new cases per 100,000 m the state; Frammgham is 19
th

TABLE 12 S ex an d G d fP 1 L .
en ero eOPJe IVm! th HIV/AIDS WI ,as 0 f7/1/07
GENDER RACE/ETHNICITY
Male Female White Black Hispanic
FitchburK 55.7% 44.3 % 27.7% 18.5 % 48.7%
Framingham 59.9% 40.1 % 39.5% 27.6% 30.9%
Worcester 59.1 % 40.9% 35.6% 24.0% 38.9%
Regardmg gender, males appear to be more at nsk. Females account for 44 percent of HI V 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 Percentage of
2000 Census HIV 1 AIDS Cases Population, 2000 HIV 1 AIDS Cases
Fitchburg 15.0% 48.7% 3.6% 18.5 %
Framingham 10.9% 30.9% 5.1 % 27.6%
Worcester 15.1 % 38.9% 6.8% 24.0%
. Hispanics and African Americans account for a disproportionate share of HI VIA 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:
2003 2004 2005 2006 2007
Below 200% of poverty 91.5 91.7 91.3 91.8 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 2004 2005
Teens 32.9 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
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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 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 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, patient-
centered 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 sub-
contract $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. In
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/sub-
recipient 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:
(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, 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 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 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. HIV I AIDS 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 HI V 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 HIV I 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 of some 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 p r o ~ a m s 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
HIV I AIDS 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; 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.
2. 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-paymentsare 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 low-
income 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 Metro West 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 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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(b) (4)
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 $ 1 million 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.
G II Ob f 1 cr oa , '.Iec Ive
- mica
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 sub-
recipient Plumley Village Health Services (PVHS).
Timeline Activitiesl Action Steps Responsibility Evaluation
December 1, 1. Implement contract with !Executive Director, HFHC and PVHS will complete
2008 Hahnemann Family Health !Director of Clinical FPER's on all Title X clients
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
Awareness clients to care Nurse Manager and database will be utilized for data
within HFHC or PVHS. Office Manager of analysis.
HFHC and PVHS
December 1. Continue focused voordinator of 2009FPAR
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%
assurance improvement Executive Director,
standards Clinical Director of
3. Maintain delegate and sub- !Delegates
recipient contracts.
2010 & 2011 1. Continue focused marketing of 2010 FPAR
efforts in our service areas. putreach and Total Users = 6,500
2. Maintain strong quality 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 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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G II Ob 2 cr . I
oa , IJectIve - IDlca
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
for services to individuals from low-income families.
Ob.iective 2.1: Increase the number of users seen at our clinical sites in MetroWest.
Timeline Activities/Action Steps Responsibility Evaluation
January 1, I.Move our Marlborough IExecutive Director, We will move into a new site
2009 clinical site to allow for fiscal Director, . n Marlborough in December
expansion of services. of 2008. This site should be in
adding services and Outreach and pperation by 111109.
providing space to health & Marketing, Director Monitor utilization of services
social service providers at of Clinical Services, hrough analysis of clinic
Milford and Marlborough Clinical staff flPpointment schedules and
sites to promote access for of users served. Expand
populations in need. services as indicated by
analysis.
December 31 1. Continue focused Director of Clinical Users, 2007 FPAR
2009 marketing efforts in our Services, Executive Marlborough Clinic = 502
service areas. Director, Milford Clinic = 600
2. Retain/recruit staff that Coordinator of Framingham CHC = 346
meets linguistic needs of Outreach and
populations in service area. Marketing, Clinic Projected Users, 2009
3. Maintain delegate contract Delegate Marlborough Clinic = 575
with Framingham Community Director Milford Clinic = 675
Health Center. Framingham CHC = 450
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
adding or collaborating with putreach and
2011
other health/social service Clinic
Marlborough Clinic = 700
programs that will promote Clinical
Milford Clinic = 750
access to care/services for pirector of
Framingham CHC = 550
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
2009 - 2011 1. On-going training to staff to Director of Annual medical record reviews
support family participation in Clinical are conducted to assess
the decision of minors to Services, documentation of discussions
access family planning Clinic staff, with teens regarding family
services Clinical involvement, sexual coercion and
2. On-going training will be Director of abstinence counseling.
provided on strategies to Delegates
Health Awareness maintains staff
prevent coercive sexual
relationships and dating
education logs; these are
violence.
reviewed on a semi-annual basis.
3. Sexual coercion and
Health Awareness and
relationship violence will be
delegate/sub-recipient sites
assessed and discussed with all
clients ..
participate in the annual JSI needs
4. Augment counseling session
assessment survey to identify
what staff identifies as areas of
with brochures and/ or other
needed training. Trainings are
related information that
addresses abstinence and sexua
formulated based on survey
coercion.
results.
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
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. In 2008
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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.
2009-2011 1. Continue to offer options for Director of Monitor screening compliance
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
member of the Region I Director of client screening for chlamydia,
Infertility Project and be Delegates gonorrhea, syphilis, HIV and
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 I III Ob' ti 2 cr . lIAd ..
oa , 'lee ve : mIca mimstrative
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.
2009-2011 1. On-going assessment of family Director of The Clinical Advisory
planning offerings, service delivery Clinical Committee will meet
and areas of quality Improvement Services, quarterly. Annual peer
2. On-going staff training to Medical medical record reviews will
enhance knowledge and skills in the Director, be conducted by Clinical
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 and these reviews.
to quantify standards are met Delegate/Sub-
recipient
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 Metro West Clinics have experienced the largest increase in immigrant non-
English 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 in- Marketing 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 t a r ~
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.
1. Maintain integrated male health Director of In 2007,22 percent of total
services within family planning. Clinical Services users were male. This should
2009-2011 2. The Community Education Clinical Director increase each year:
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.
2009-2011 1. Provide marketing and Director of Clinical 25 percent of new users in 2007
outreach to teens in both out-of- Services, Coordinator were under 20 years of age. In
school and school settings. of Outreach and 2006 teens were 28 percent of
2. Participate in community- Marketing, C o m m u n i ~ overall users. We need to strive
based efforts to lower teen Education Staff, Clinic for 30 percent utilization by
pregnancy rates. Weare already Director/Outreach staf teens:
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 under-
insured 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
2009-2011 Massachusetts to ensure that family Services, had incomes below 200 percent
planning services are fully covered Director of of poverty. This percentage
under any state plan. Clinical should be maintained or
2. Work with state agencies to make Services, surpassed in the upcoming
our services accessible to newly-
Clinical Project Years.
insured people.
Service and
3. Approach provider and gate-keeper
Fiscal
organizations to pursue affiliation and
Directors of
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.
Timelill Activities/Action Steps Responsibility Evaluation
1. Health Awareness Internal peer provider Director of Grantee evaluation of quality
eview and site reviews. Clinical Services assurance, quality
2009 12. Conduct review of Hahne mann Family Director and improvement needs and
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.
2010 1. Health Awareness Internal peer provider Chi Director of Grantee evaluation of quality
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/
nternal client satisfaction surveys conducted. Sub-recipients
2. Conduct review of selected indicators for
pelegates andlor Sub-recipients.
2011 1. Health Awareness Internal peer provider ch Director of Grantee evaluation of quality
eview and site reviews Clinical Services assurance, quality
Conduct review of Framingham Communit) Director and improvement needs and
Center, including clinical site and chart Clinical Director achievements.
eviews, clinical indicator reviews and review of Delegates
nternal client satisfaction surveys, site and ch,
eviews conducted.
Conduct review of selected indicators for
!Delegates andlor Sub-recipients
2009 - 1. Review FPER submission compliance of all Director of Grantee evaluation of quality
Clinical Services assurance, quality
2011 12. Review of FP AR data for Grantee and Delegate improvement needs and
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.
65
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Applicant:
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Progress Report
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 Outcome Data Progress Narrative
Increase the - In 2007, we saw 5249 The decline in users is directly attributable to
number of users users. This is a drop of Montachusett Opportunity Council, which saw 453 less
seen. By the clos( 345 users from 2006. It is users in 2007.
of FY2009, see still a 4 percent increase
6,400 users. At over 2005, which we are Metro West continues to be an area of growth. We
least 88 percent using as our baseline. expanded hours of operation in our Milford and
should have Marlborough sites.
. incomes below 20 - 91.3 percent of users had
percent of the incomes below 200
We ran a separate Worcester Male Health Service
federal poverty percent of poverty.
2007. We saw a significant number of new male users
level.
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.
Page 95 of 120
Maintain the In 2007 the Clinical Health Awareness revised male health protocols, exam
substantive role Advisory Committee forms and history forms.
of the Quality focused on five main
Improvement activities:
STD protocols were reviewed and revised, as indicated, to
Committee(s) to - Enhancing
comply with 2006 CDC Guidelines.
assure the male health
We have adopted the CDC revised guidelines for HIV
provision of . services
testing in health care settings and in December 2007 we
high quality care - Revising STD
integrated HIV C&T within family planning at our
that meets Protocols to
current practice comply with
Worcester site. As of 6/30/08 the Worcester Family
Planning Clinic tested 239 clients for HIV. Other family
standards. CDC 2006
planning sites have HIV C&T provided on site by the Health
Guidelines
- Adoption of the
Awareness HIV C& T Program.
2006 CDC
In order to improve overall lab service to clients, a change
"Revised
Recommendation for
of laboratory services occurred in 2/08
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 Progress Narrative
Assure that 100 Health Awareness and Clinical sites comply with the CDC re-screening
percent of ProHealth assess screening guidelines for 3-4 months after a positive chlamydia test;
patients:::: 25 of clients..::: age 25 follow-up mechanism in place to remind clients when.
years of age are annually as a performance re-screening is overdue.
offered measure. Data reflects
Chlamydia screening has met guideline
Health Awareness clients continue to have a high
screening criteria.
positivity rate for Chlamydia.
annually and
Early detection and treatment decreases morbidity.
that all
Targeted medical record 7/07-6/08 = 5.5%
individuals with
reviews reflect compliance 7/06-6/07 = 6.5%
risk factors for
with treatment 7/05-6/06 = 6.3%
chlamydia are
7/06-6/07 = 6.7%
offered
7/07-6/08 = 5.3%
screening.
11
Page 96 of 120
GOAL I, OBJECTIVE #4
Assure that In 2007 three mandatory In preparation for offering HIV C&T within family
family planning trainings for all direct care planning at our Worcester site, provider and nursing staff
staff attends at staff included: HIV attended a series HIV C&T meetings and trainings
least one clinical Counseling and Testing offered by MDPH.
training per year (JRI), OraQuick HIV Rapid
The family planning program and HIV C&T program
in FY06-FY09. HIV Testing Training
(MDPH HIV/AIDS
worked collaboratively to revise HIV C&T guidelines,
Bureau) and Domestic
protocols and visit forms.
Violence (MDPH).
All provider staff participated in the Female and Male
All bilingual family
Genital Dermatology Web Cast offered by JSI.
planning staff utilized for
All family planning direct care staff have attended "Infant
interpreting have completed
the Language Link 54-hour
Adoption" training.
comprehensive Medical
Two providers attendee the "Women's Health Care of
Interpreter Training
Program offered by AHEC.
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 100 100 percent of teens seen Our counseling summary form was revised in 2006 to
percent of teens in our clinics received include a counseling section to assess, discuss and document
seen in family information and support to teen sexual decision making, family involvement and sexual
planning clinics encourage the delay of coercion.
with information sexual activity, as
and support to determined through
Health Awareness has posters in waiting areas that
encourage the randomized chart audits.
encourage family involvement "talking to parents" about
delay of sexual
sexual decision making, as well as posters empowering
activity.
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
Page 97 of 120
GOAL III: Emphasize clinical services for hard-to-reach populations (uninsured or under-
insured women, males in need of clinical services, adolescents).
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!
users each year
services in the counseling and care that we offer.
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 28 percent in 2005.
through the 54-hour Language Link Program of AHEC.
~ e a k e r s .
+
GOAL III, OBJECTIVE #2:
Provide 22.2 percent of Users in We ran a separate Worcester Male Health Service 2007.
reproductive 2007 were inale This is an We saw a significant number of new male users but our
health services increase from 2006 (20.1 %) overall male users remained about the same as 2006. Males
to males. By
A Men's Health Service was
accessed services equally at our three clinic sessions and
the close of did not prefer the male health clinic. Due to low utilization
2009,25
established at our Worcester
of a separate male health service, this was discontinued in
percent of total
Clinic in November of 2006.
12/07.
users should
A male, bilingual Physician
be male.
Assistant was hired and We offered Hepatitis A immunization to male clients at our
trained. 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.
GOAL III Ob f 3 , 1.lec lVe
At least 30 25 percent of new users in Southbridge ranks 6
th
highest for MA teen pregnancies. In
percent of new 2007 were under 20 years 2007 our Southbridge NP did educational programs for
users should be of age. both the Southbridge High School and Middle School that
under 20 years focused on prevention of pregnancy & STI's.
of age. In 2006 teens made up 28
Health Awareness began a satellite health clinic at the
percent of overall users.
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.
IV
Page 98 of 120
GOAL IV: Eliminate financial barriers to access to reproductive health services. Enable clients to
k f bl' I f d d h Ith' rna e use 0 pu ICIY un e ea IDsurance pr02rams.
Ob.iective #1 Outcome Data 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
least 88 percent 200 percent of the federal 2007. Family Planning is a covered service under the new
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 m. r02ra
Maintain the In 2007 Health Awareness Health Awareness and Delegate/Sub-recipients assess the
quality of care conducted the following 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 2007- counseling, 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
Assure that 100 Our focus in 2007 was to Maintaining an active I&E Committee has remained a
percent of make continuous quality challenge for Health Awareness and Montachusett
information and improvements to the Opportunity Council. Both agencies have had difficulty
education agency Web site that was retaining andlor recruiting members to serve on this
materials launched in 2006. We have committee.
utilized by the updated the Web site to
grantee and reflect service changes and We will continue to focus our recruiting efforts on
delegate are relevant health information membership that is reflective of the communities and
reviewed and for populations served. populations we serve.
approved by the
Information and
Education (I&E)
Advisory
Committee.
Ensure that all Health Awareness and Policies and procedures are in place that meets HIP AA
information Delegate/Sub-recipient sites standards.
systems are in are HIP AA compliant.
compliance with All newly hired staff are trained in HIP AA standards and
HIPAA for sign agreement to maintain these standards.
privacy and
security
In 2007, Health Awareness deferred In February 2007, Health Awareness developed an RFP. A
conduct a anRFP for Northern draft was sent to the Regional Office prior to issuance.
competitive Worcester County Family The RFP was sent to all hospitals, health centers, and non-
application Plarining in 2006; it was profit health organizations in northern Worcester County
process to done in February 2007. on March 5, 2007. Montachusett Opportunity Council
allocate funds (MOC) was the only respondent. Their application was
to delegates in submitted in April. It was reviewed by staff of Health
northern Awareness and was judged to be acceptable for funding.
Worcester A letter of award was sent to MOC on May 22,2007.
County.
In three years, we will initiate another proposal process.
This time, it will include our Metro West region, as well as
northern Worcester County.
VI
Page 100 of 120
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Upload #5
FPH2009003614
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Table of Contents
HEALTH AWARENESS SERVICES OF CENTRAL MASSACHUSETTS, Inc.
Project Abstract
PROJECT NARRATIVE
TITLE X APPLICATION
September 29, 2008
TABLE OF CONTENTS
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
C. Family Planning Service Delivery Plan
1. Program Work Plan and Evaluation Plan
2. Efforts to Address OPA Priorities
Budgets:
Form 424A
Personnel Budget
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
PAGE
1
2
11
19
39
42
48
54
65
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
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FPH2009003614
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Exhibit B
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
S ervIce So I ~ ~ h F 1 PI P d db I
b I ~ de n ormatIOn or t e amlly annm2 r02ram IS proVI e e ow m ta u ar orm
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 W lO:OOam- 1247/1200
Awareness 405 Grove Worcester 9:00am- 4:30pm
Services Street area 5:00pm F 9:30am-
Note: this clinic phone 3:30pm
will close coverage
11112/0S.
Worcester
clients will be
covered by sup-
recepient sites.
Health Milford Blackstone M-F T 1:45pm- 600/700
Awareness Valley 1-S00# 7:00pm
Services 25S Main Street phone Th. 11 :45pm-
coverage 5:45pm
Fri lOam-
3:30pm
Health Southbridge Southern M-F Th. 12:30pm- 294/300
Awareness Worcester 1-S00# 6:00pm
Services 50 Elm Street County phone
coverage
Health Marlborough Western M-F M 2:00pm- 502/650
Awareness 155 Union St Middlesex 1-S00# 5:45pm
Services Note: this site County phone W 1:00pm-
will move to 200 coverage 5:45pm
East Main: Street F lOam-
12/0S 3:30pm
Page 105 of 120
EXHIBIT B - Service Site Information
Delegate Agenc': MOe, Inc.
Sub- Location Service Area Office FPCLINIC #OF
Recipient Hours HOURS USERS
Agency LAST
Service Site FPARI
NUMBER
PROJECT
ED
NEXT
FPAR
lMontachusett Fitchburg No. Central
~
M 9am-12pm 1399/1200
Iopportunity . MA 8:30am- &
!council 326 Nichols 17:30 pm 1pm-6pm
Rd. rrU 8:30am- Male clinic
Professional ~ : 3 0 p m 6pm-8pm (3
Building@ ~ 12pm- weeks/mo)
Fitchburg p:30pm l\1D clinic
Campus of rrH 8:30am- 5pm-7pm
Health ~ : 3 0 p m ; 6pm once/month
Alliance t--8:30pm
IF 12pm- T 9-1pm
~ : 3 0 p m
W 4-8pm
Th 9-1pm
F 2-5pm
(Teen
Clinic-walk
ins)
Montachusett Gardner Greater phone linked Th.2:30pm- 1531140
Opportunity Gardner area with 5:30pm
Council 57 City Hall Fitchburg
Ave.
Page 106 of 120
Delegate Agency: Plumle, Village Health Service
Sub- Location Service Area Office CLINIC #OFUSERS
Recipient Hours HOURS LAST
Agency FPARlNumber
PROJECTED
Next FPAR
Plumley 116 Belmont St. Downtown Mon- M& Th 8:30- 298/350
Village Worcester, Ma Worcester Friday 6:30p
Health T, W, F 8:30-5p
Services *( 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
Deleeate Aeenq: Framineham Community Health Center
Sub-Recipient. . Location Service Area Office CLINIC # OF USERS
Agency Hours HOURS LAST FPARI
PROJECTED
Framingham Framingham Framingham Mon-Fri M 9:00am- 346/400 .
Community and 5:30pm
Health Center 19 Concord surrounding T 9:00am-
Street communities 7:30pm
W9:00am
- 5:30pm
Th
1O:00am-
5:30pm
F 9:00am-
5:00pm
Monday- M 9:00am-
72 Union Ave Friday 5:45pm
Framingham T . 8:30am-
and 5:45pm
surrounding W9:00am
communities -7:00pm
Th
1 O:OOam-
5:00pm
F 8:00am-
5:00pm
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 1 O. 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
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Awarded
Exhibit C Page-1
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
HAS =
PVHS =
FCHC =
MOC =
Plumley Village Health Services
Framingham Community Health Center
Montachusett Opportunity Council
Applicant:
Application Number:
Project Title
Status:
Document Title:
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Exhibit C Page 2
,
Identification of Level 1

Health
Grantee & Male HIV Estrongen-Exposed Infertility Promotion/Disease Special GYN Emergency
Ut:llt:lgcHt:I Services' Sb,v, ..... ., IVTlspnng Services 'vu, .. ",., Prevention
D., -orlo 'res
I Cor",
HAS 1 1 1 1 1 1 *4 1
PVHS

3 1
1
1 1 1 1
FCHC 1 1 1 1 1 1 1 1
MOe 1 1 1 1 1 1 1 1
11' lon-site at all sites I'" ""'''' 1<" outside delegate but paid for by Title' X
1"-- ,vv,u"J within delegate system, but not at all sites 14=Not provided
not provided, referral made
Page 112 of 120
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Exhibit C Page 3
3 Month Hormonal!
Female Hormonal Hormonal Oral Contraceptive Vaginal Cervical Contraceptive
Delegate Sterilization IUDIIUS Implant Injection Contraceptives Patch Ring Cap/Diaphragm Sponge
HAS 4 1 **4 1 1 1 1 1 4
PVHS 4 1 **4 1 1 1 1 1 4
FCHC 4 1 **4 1 1 1 1 1 4
MOC 4 1 **4 1 1 1 1 1 4
11-Provided on-site at all delegate sites 13-Referral outside delegate system, but paid for by Title X
2-Provided within delegate system, but not at all sites 14=Not provided
** not provided: referrals made (onsite offering pending) .
Page 114 of 120
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Exhibit C page 4
Spermicidal FE
Grantee & Female Methods of
I A _".
Other
" Condom Products Male Condom Methods IV.,:>"lilUII
j 1

1 *4 1 4
IPVHS 1 1 1 1 *4 1 4
IFCHC 1 1 1 1 *4 1 4
IMOC 1 1 1 1 *4 1 4
1-Provided on-site at all delegate sites 3=Referral outside dele ate s stem, but paid for by Title X
2-Provided within delegate system, but not at all sites 4=Not provided
* not provided; referral made
Page 1160f120
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Exhibit C Page 5
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.
(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.
(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
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List of Appendices
Appendix
Attachment A: Map of Service Area and Map of Program Sites
Attachment B: Organizational Charts
Grantee: Health Awareness Services
Delegate: Montachusett Opportunity Council
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

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