II 

111TH CONGRESS 

1ST SESSION S. 1404 

To implement demonstration projects at federally qualified community health 

centers to promote universal access to family centered, evidence-based 

behavioral health interventions that prevent child maltreatment and promote family well-being by addressing parenting practices and skills for 

families from diverse socioeconomic, cultural, racial, ethnic, and other 

backgrounds, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

JULY 7, 2009 

Mr. INOUYE introduced the following bill; which was read twice and referred 

to the Committee on Health, Education, Labor, and Pensions 

A BILL 

To implement demonstration projects at federally qualified 

community health centers to promote universal access 

to family centered, evidence-based behavioral health 

interventions that prevent child maltreatment and promote family well-being by addressing parenting practices 

and skills for families from diverse socioeconomic, cultural, racial, ethnic, and other backgrounds, and for 

other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Supporting Child Mal3 treatment Prevention Efforts in Community Health Cen4 ters Act of 2009’’. 

5 SEC. 2. FINDINGS AND PURPOSES. 

6 (a) FINDINGS.—Congress finds as follows: 

7 (1) Child abuse and neglect are serious public 

8 health problems in this country. During 2007, ap9 proximately 3,200,000 referrals, involving the al10 leged maltreatment of approximately 5,800,000 chil11 dren, were sent to child protective services agencies. 

12 (2) The most recent data show 794,000 sub13 stantiated cases of child abuse and neglect in 2007, 

14 and child maltreatment-related deaths rose 15.5 per15 cent in 2007. Approximately 1,760 children in the 

United States, nearly 3 16 ⁄4 of whom were under 4 

17 years of age, died as a result of abuse or neglect. 

18 (3) Early childhood experiences may have life19 long effects. Severe and chronic childhood stress, in20 cluding from maltreatment and exposure to violence, 

21 is associated with persistent effects and can lead to 

22 enduring health, behavior, and learning problems. 

23 (4) Child maltreatment has— 

24 (A) psychological and behavioral con25 sequences such as depression, anxiety, suicide, 


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1 aggressive behavior, delinquency, posttraumatic 

2 stress disorder, and criminal behavior; 

3 (B) health consequences, including injuries 

4 and death, chronic obstructive pulmonary dis5 ease, smoking, heart disease, liver disease, and 

6 drug use; and 

7 (C) developmental consequences that can 

8 compromise brain development and learning. 

9 (5) Child maltreatment has significant financial 

10 consequences, including the short-term costs associ11 ated with case handling by child protective services 

12 and investigations, hospitalization or emergency 

13 room visits for medical treatment of injuries, out-of14 home placement alternatives, services to address 

15 mental health and substance abuse problems, loss of 

16 productivity, and poor physical health requiring mul17 tiple treatments. 

18 (6) Child maltreatment can be prevented. Given 

19 that parents and caregivers are responsible for the 

20 majority of the abuse and neglect, caregiver-focused 

21 strategies and interventions that address parenting 

22 skills and parental risk factors such as depression, 

23 substance abuse, and intimate partner violence, as 

24 well as strategies and interventions that promote 

25 family well-being are critical. Parenting practices are 


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1 amenable to change, given reasonable efforts, and 

2 the building of safe, stable, nurturing parent-child 

3 relationships is a scientifically proven strategy for 

4 the prevention of child maltreatment. 

5 (7) Prevention of child maltreatment should 

6 have a focus on primary prevention (before any mal7 treatment), emphasizing community-centered and 

8 population-based strategies. 

9 (8) Prevention of child maltreatment should 

10 focus on promoting healthy parent-child relation11 ships and an environment that provides safe, stable, 

12 nurturing relationships for children. 

13 (9) Primary health care is an existing and wide14 ly accessed system in which a range of prevention 

15 strategies can be implemented, and there is growing 

16 evidence that primary health care settings are prom17 ising venues in which to conduct child maltreatment 

18 prevention and behavioral health promotion pro19 grams. 

20 (10) Community health centers (referred to in 

21 this Act as ‘‘CHCs’’) serve more than 18,000,000 

22 individuals in the United States annually, including 

23 individuals who are poor, uninsured, hard-to-reach, 

24 and at-risk for child maltreatment. 


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1 (11) One in 5 low-income children in the United 

2 States receives health care at a CHC. 

3 (12) CHCs are an existing network of neighbor4 hood health clinics widely and regularly accessed by 

5 families in need that can serve as a fitting venue for 

6 child maltreatment prevention initiatives. 

7 (13) In the last decade, behavioral issues have 

8 had an expanding presence in the portfolio of serv9 ices of CHCs. Seventy percent of CHCs have some, 

10 if minimal, on-site mental health and substance 

11 abuse services. When demand exceeds capacity or 

12 on-site services do not exist, CHCs refer individuals 

13 to off-site options. 

14 (14) The integration of behavioral health serv15 ices in primary care settings is a promising frame16 work. Evaluation results of integrated care have 

17 shown— 

18 (A) improvement in service utilization, 

19 such as shorter waiting time and fewer sessions 

20 to complete treatment; 

21 (B) reduction in the stigma related to 

22 mental health services; and 

23 (C) improvement in access to services. 

24 (b) PURPOSES.—The purposes of this Act are as fol25 lows: 


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1 (1) To fund the implementation of a minimum 

2 of 10 demonstration projects of evidence-based and 

3 promising parenting programs at federally qualified 

4 health centers. 

5 (2) To provide universal access to a family cen6 tered integrated and voluntary services model that 

7 prevents child maltreatment and promotes family 

8 well-being and which may include: 

9 (A) implementation of evidence-based pre10 ventive parenting skills training programs at 

11 health centers or permanent or temporary resi12 dences of caregivers to strengthen the capacity 

13 of parents to care for their children’s health 

14 and well-being and promote their own ability to 

15 create safe, stable, nurturing family environ16 ments that protect children and youth from 

17 abuse and neglect and its consequences and 

18 support children’s optimal social, emotional, 

19 physical, and academic development; 

20 (B) screening to identify parental risk fac21 tors such as depression, substance abuse, and 

22 intimate partner violence that are associated 

23 with the likelihood that parents will abuse or 

24 neglect their children, and to further develop 

25 screening methods and instruments; and 


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1 (C) linkage with, and referral to, on-site 

2 individualized quality mental health services 

3 provided by trained mental health professionals 

4 for parents and caregivers screening positive for 

5 child maltreatment risk factors to help them 

6 overcome the impediments to effective parenting 

7 and change their behaviors toward child rearing 

8 and parenting. 

9 (3) To coordinate the design and implementa10 tion of an evaluation plan to assess the impact and 

11 feasibility of integrated services model implementa12 tion at each federally qualified health center partici13 pating in the demonstration project for health out14 comes, cost effectiveness, patient satisfaction, pro15 gram local adaptation, reduction of child maltreat16 ment and injuries, and improvement of parenting be17 haviors and family functioning. 

18 (4) To implement critical system factors for 

19 successful implementation of the integrated services 

20 model to prevent child maltreatment. Such factors 

21 include training of a culturally and linguistically 

22 competent workforce, use of best available tech23 nology, establishment of cooperation among FQHCs 

24 participating in the demonstration project, and 


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1 building internal and external buy-in and support for 

2 the project. 

3 (5) To coordinate the design and implementa4 tion of the cross-site system-wide evaluation plan to 

5 assess the impact and feasibility of an integrated 

6 services model on the reduction of child maltreat7 ment and injuries, to increase a family’s access to 

8 services, to evaluate the effectiveness of the response 

9 of FQHCs organizational systems to the model im10 plemented, and to identify lessons learned and out11 line recommendations for system-wide areas for im12 provement and changes. 

13 SEC. 3. DEFINITIONS. 

14 In this Act: 

15 (1) FEDERALLY QUALIFIED HEALTH CENTER

16 OR FQHC.—The term ‘‘federally qualified health cen17 ter’’ or ‘‘FQHC’’ means an entity receiving a grant 

18 under section 330 of the Public Health Service Act 

19 (42 U.S.C. 254b). 

20 (2) CAREGIVERS.—The term ‘‘caregiver’’ means 

21 an adult who is the primary caregiver, including bio22 logical, adoptive, or foster parents, grandparents or 

23 other relatives, and non-custodial parents who have 

24 an ongoing relationship, and provides physical care 

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1 givers may be individuals who were born in, or out2 side of, the United States and individuals whose 

3 main language is not English, including American 

4 Indians and Alaska Natives. Caregivers may be het5 erosexual or homosexual, and may have learning, 

6 physical, and other disabilities. 

7 (3) CENTER-BASED EVIDENCE-BASED PREVEN8 TIVE PARENTING SKILLS PROGRAM.—The term 

9 ‘‘center-based evidence-based preventative parenting 

10 skills program’’ means research-based and proven, 

11 promising interventions provided and located at a 

12 health center that— 

13 (A) have the potential for broad impact 

14 across multiple types of maltreatment, including 

15 physical and psychological abuse and neglect; 

16 (B) are associated with effective parent be17 haviors and parenting practices and with reduc18 ing child behavior problems; 

19 (C) may be expected to reduce child mal20 treatment rates; and 

21 (D) may be implemented at the FQHCs. 

22 (4) HOME VISITATION PROGRAM.—The term 

23 ‘‘home visitation program’’ means an evidence-based 

24 program in which trained professionals visit a care25 giver in the permanent or temporary residence of the 


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1 caregiver, and provide a combination of information, 

2 support, or training regarding child development, 

3 parenting skills, and health-related issues. 

4 (5) MENTAL HEALTH SERVICES.—The term 

5 ‘‘mental health services’’ means psychotherapeutic 

6 interventions offered at health centers, or off-site lo7 cations in partnership with health centers, by mental 

8 health professionals to caregivers that screen for or 

9 are referred for child maltreatment. 

10 (6) SCREENING.—The term ‘‘screening’’ means 

11 a form of triage, using valid, culturally sensitive 

12 tools such as scales or questionnaires applied univer13 sally by trained professionals to identify caregivers 

14 who are at-risk for maltreating or neglecting chil15 dren. Screening assesses parental risks for child 

16 maltreatment such as depression, substance abuse, 

17 and intimate partner violence. 

18 SEC. 4. GRANTS FOR DEMONSTRATION PROJECTS ON INTE19 GRATED FAMILY CENTERED PREVENTIVE 

20 SERVICES. 

21 (a) DEMONSTRATION PROJECT GRANTS.—The Sec22 retary of Health and Human Services, acting through the 

23 Director of the National Center for Injury Prevention and 

24 Control of the Centers for Disease Control and Preven25 tion, shall award competitive grants to eligible federally 


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1 qualified health centers to fund a minimum of 10 dem2 onstration projects to promote— 

3 (1) universal access to family centered, evi4 dence-based interventions in the FQHCs that pre5 vent child maltreatment by addressing parenting 

6 practices and skills; and 

7 (2) behavioral health and family well-being for 

8 families from diverse socioeconomic, cultural, racial, 

9 and ethnic backgrounds, including addressing issues 

10 related to sexual orientation and individuals with 

11 disabilities. 

12 (b) ELIGIBILITY.—To be eligible to receive a grant 

13 under subsection (a), an entity shall— 

14 (1) be a federally qualified community health 

15 center; and 

16 (2) submit to the Secretary an application at 

17 such time, in such manner, and containing such in18 formation as the Secretary may require. 

19 (c) USE OF GRANT FUNDS.—A federally qualified 

20 health center receiving a grant under subsection (a) may 

21 use such funds to— 

22 (1) conduct a needs assessment for the dem23 onstration project, including the need for proposed 

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1 volved, an organizational assessment, workforce ca2 pacity and needs, and technological needs; 

3 (2) use available technologies to collect, orga4 nize, and provide access to health and mental health 

5 information of patients, and to provide referrals, 

6 train staff, monitor service delivery and outcomes, 

7 and create networking opportunities for on-site pro8 viders and others in the community; 

9 (3) adapt and implement evidence-based par10 enting skills training programs for caregivers from 

11 all backgrounds who use the health center for health 

12 care and child well-visits, through on-site programs 

13 or programs operated at permanent or temporary 

14 residences and administered, supervised, and mon15 itored by trained professionals employed by the 

16 FQHC; 

17 (4) adapt instruments and screen caregivers for 

18 child maltreatment risk factors such as depression, 

19 substance abuse, and intimate partner violence, pro20 vided that such screening is conducted by trained 

21 professionals employed by the FQHC; 

22 (5) provide access to mental health services to 

23 caregivers screened positive for child maltreatment 

24 risk factors, which may include services offered at 

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1 ship with the health centers, and which shall be con2 ducted by mental health professionals; 

3 (6) promote models of integrated care that in4 volve behavioral health specialists and primary care 

5 providers working collaboratively in integrated teams 

6 to deliver services that prevent child maltreatment 

7 and promote family well-being; 

8 (7) develop public education campaigns to in9 crease community awareness of the integrated serv10 ices offered by the health centers; and 

11 (8) evaluate patient satisfaction, project cost ef12 fectiveness, results of the integrated services model, 

13 and effectiveness of evidence-based parenting pro14 grams in improving parenting practices and reducing 

15 child abuse and neglect. 

16 (d) DURATION OF GRANT.—A grant under sub17 section (a) shall be awarded for a period not to exceed 

18 5 years. 

19 (e) TECHNICAL ASSISTANCE AND PROJECT COORDI20 NATION.— 

21 (1) IN GENERAL.—The Secretary shall award a 

22 contract to 1 or more eligible entities to provide— 

23 (A) technical assistance and project coordi24 nation for the recipients of grants under sub25 section (a); 


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1 (B) training for health care professionals, 

2 including mental health care professionals, at 

3 FQHCs that receive grants under subsection 

4 (a); and 

5 (C) cross-site evaluation of the demonstra6 tion projects under subsection (a). 

7 (2) ELIGIBLE ENTITIES.—To be eligible to re8 ceive a contract under this section, an entity shall— 

9 (A) be— 

10 (i) an institution of higher education 

11 (as defined in section 101 of the Higher 

12 Education Act of 1965 (20 U.S.C. 1001)); 

13 (ii) a nonprofit organization that 

14 qualifies for tax exempt status under sec15 tion 501(c)(3) of the Internal Revenue 

16 Code of 1986; or 

17 (iii) such national and professional or18 ganizations and community-based organi19 zations as the Secretary determines appro20 priate; 

21 (B) have expertise in parent-child relation22 ships, parenting programs, prevention of child 

23 maltreatment, the integration of behavioral 

24 health in primary and community health center 

25 settings, and coordinating multi-site projects; 


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1 (C) demonstrate a defined or proposed col2 laboration with purveyors of evidence-based 

3 child maltreatment prevention interventions; 

4 and 

5 (D) submit to the Secretary an application 

6 that includes— 

7 (i) an outline of a technical assistance 

8 and coordination plan and timeline; 

9 (ii) a description of activities, services, 

10 and strategies to be used to reach out and 

11 work with the FQHCs and others involved 

12 in the demonstration projects under sub13 section (a); and 

14 (iii) a description of the evaluation 

15 methods and strategies the entity plans to 

16 use, and an outline of the progress and 

17 final reports required under subsection 

18 (f)(2). 

19 (3) PRIORITY.—In awarding contracts under 

20 this subsection, the Secretary shall give priority to 

21 eligible entities whose applications under paragraph 

22 (2)(D) demonstrate that the evaluation design of 

23 such eligible entity uses strong experimental designs 

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1 grated health-behavioral health services model. Such 

2 evaluation designs should provide evaluation results 

3 that identify lessons learned and generate rec4 ommendations for improvements and changes. 

5 (4) AUTHORIZED ACTIVITIES.—Each recipient 

6 of a contract under this subsection shall use such 

7 award to provide technical assistance to the FQHCs 

8 receiving a grant under subsection (a) and to pro9 vide coordination and cross-site evaluation of such 

10 demonstration projects to the Secretary. Such tech11 nical assistance and coordination and cross-site eval12 uation may include— 

13 (A) establishing and implementing uniform 

14 tracking and monitoring systems across FQHCs 

15 participating in the demonstration project, 

16 using the best available, highest level of techno17 logical tools; 

18 (B) developing and implementing a cross19 site, multi-level evaluation plan using rigorous 

20 research and evaluation designs to evaluate the 

21 demonstration projects across FQHCs; 

22 (C) ensuring that, in implementing the evi23 dence-based parenting training programs, each 

24 such FQHC follows standardized manuals and 

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1 grated services of each FQHC in promoting 

2 positive stable, nurturing parent-child relation3 ships and preventing child maltreatment and in4 juries; 

5 (D) ensuring an effective and feasible eval6 uation of the outcomes of the demonstration 

7 projects, including an assessment of— 

8 (i) improvement of parent knowledge 

9 of child social, emotional, cognitive devel10 opment; 

11 (ii) improvement of parent-child rela12 tionships; 

13 (iii) parental use of positive discipline 

14 methods and effective communication 

15 skills; 

16 (iv) health outcomes for children; 

17 (v) reduction of incidence of child 

18 maltreatment; 

19 (vi) cost-effectiveness of the dem20 onstration projects; 

21 (vii) implementation that follows 

22 standardized manuals and protocols; 

23 (viii) the interdisciplinary collaborative 

24 model; 


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1 (ix) cultural sensitivity and local ad2 aptation of the projects; 

3 (x) any increase in access to services; 

4 and 

5 (xi) further improvements and 

6 changes needed at the FQHCs; 

7 (E) establishing and coordinating the im8 plementation of a workforce development and 

9 training plan to ensure that professionals work10 ing at the health centers, including physicians, 

11 nurses, nurse practitioners, psychologists, social 

12 workers, physician’s assistants, clinical phar13 macists, and others, are trained to participate 

14 in interdisciplinary teams and work collabo15 ratively to provide culturally competent and lin16 guistically sensitive integrated services to all 

17 caregivers coming to such center, with a focus 

18 on the development and strengthening of— 

19 (i) knowledge of the public health 

20 model, child development, family func21 tioning, the problem of child maltreatment, 

22 and methods of prevention; 

23 (ii) core attitudes, including the belief 

24 that child maltreatment is preventable, 

25 professionals have a role in prevention, 


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1 families are partners in preventing mal2 treatment, and evaluation is a critical ele3 ment of interventions; 

4 (iii) ability to conduct screenings, im5 plement evidence-based parenting pro6 grams, provide mental health services, and 

7 collaborate with evaluation efforts; 

8 (iv) ability to manage the site project, 

9 participate in interdisciplinary teams, work 

10 on integrated efforts, and master tech11 nology for best results; 

12 (v) the knowledge, skills, and attitude 

13 to work with individuals from diverse cul14 tural, racial, ethnic, and other back15 grounds; and 

16 (vi) an understanding of cross-field 

17 culture and language to effectively partici18 pate in interdisciplinary teams and collabo19 rate in integrated activities; 

20 (F) educating and involving the governing 

21 boards of FQHCs participating in the dem22 onstration projects in the integrated service ef23 forts; 

24 (G) promoting partnerships with State and 

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1 nity networks, and professional associations for 

2 staff training and recruitment; 

3 (H) promoting collaboration and net4 working among FQHCs participating in the 

5 demonstration projects; and 

6 (I) establishing and coordinating child mal7 treatment prevention collaboratives across 

8 FQHCs participating in the demonstration 

9 projects and helping such FQHCs partner with 

10 local departments of child welfare and commu11 nity mental health centers. 

12 (5) ADVISORY GROUPS.— 

13 (A) IN GENERAL.—Each recipient of a 

14 contract under this subsection shall establish an 

15 advisory group. Each such advisory group shall 

16 provide feedback and input to the contract re17 cipient to ensure such recipient’s effectiveness 

18 in providing quality services. 

19 (B) MEMBERSHIP.—Each such advisory 

20 group shall be composed of representatives of— 

21 (i) national organizations representing 

22 community health centers; 

23 (ii) national professional organizations 

24 representing professionals from various 


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1 fields, including pediatrics, nursing, psy2 chology, and social work; and 

3 (iii) government agencies with rel4 evant expertise, as determined by the Di5 rector of the National Center for Injury 

6 Prevention and Control of the Centers for 

7 Disease Control and Prevention. 

8 (f) EVALUATION AND REPORTING.— 

9 (1) DEMONSTRATION PROJECT REPORTING.— 

10 (A) ANNUAL PROGRESS EVALUATION AND

11 FINANCIAL REPORTING.—For the duration of 

12 the grant under subsection (a), each FQHC 

13 shall submit to the Secretary an annual 

14 progress evaluation and financial reporting indi15 cating activities conducted and the progress of 

16 the health center toward achievement of estab17 lished outcomes, including cost effectiveness, 

18 patient satisfaction, program local adaptation, 

19 reduction of child maltreatment and injuries, 

20 and improvement of parenting behaviors and 

21 family functioning. 

22 (B) FINAL REPORT.—At the end of the 

23 grant period, each FQHC shall submit a final 

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1 sions related to the outcomes of the demonstra2 tion project. 

3 (2) TECHNICAL ASSISTANCE REPORTING.— 

4 (A) ANNUAL PROGRESS AND FINANCIAL

5 REPORT.—For the duration of the contract 

6 under subsection (e), each technical assistance 

7 provider shall submit to the Secretary an an8 nual progress and financial report indicating 

9 activities conducted under such contract. 

10 (B) FINAL REPORT.—At the end of the 

11 contract period, each recipient of a technical as12 sistance contract under subsection (e) shall sub13 mit to the Secretary a final report that in14 cludes— 

15 (i) an analysis of comparative data re16 lated to effectiveness and feasibility of 

17 projects implemented at the FQHCs, work18 force training, and achievement of out19 comes at the FQHCs; 

20 (ii) overall recommendations for sys21 tem improvement and changes that would 

22 allow the demonstration projects to be ex23 panded; 

24 (iii) an outline of the project results; 

25 and 


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1 (iv) a plan that outlines opportunities 

2 and vehicles for the dissemination of cross3 site evalution results, findings, and rec4 ommendations. 

5 (g) AUTHORIZATION OF APPROPRIATIONS.— 

6 (1) IN GENERAL.—To carry out the demonstra7 tion project grant program described in subsection 

8 (a), there are authorized to be appropriated 

9 $10,000,000 for fiscal year 2010, and such sums as 

10 may be necessary for each of fiscal years 2011 

11 through 2014. 

12 (2) TECHNICAL ASSISTANCE.—The Secretary 

13 shall reserve not less than 10 percent of the 

14 amounts appropriated under paragraph (1) to carry 

15 out the technical assistance program described in 

16 subsection (e). 

Æ 


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