Hurricane Katrina: Federal Grants Have Helped Health Care Organizations Provide Primary Care, but Challenges Remain
Published: 2009-07-13T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The greater New Orleans area--Jefferson, Orleans, Plaquemines, and St. Bernard parishes--continues to face challenges in restoring health care services disrupted by Hurricane Katrina. In 2007, the Department of Health and Human Services (HHS) awarded the $100 million Primary Care Access and Stabilization Grant (PCASG) to Louisiana to help restore primary care services to the low-income population. Louisiana gave PCASG funds to 25 outpatient provider organizations in the greater New Orleans area. GAO was asked to study how the federal government can effectively leverage governmental resources to help area residents gain access to primary care services. This report examines (1) how PCASG fund recipients used the PCASG funds to support primary care services in greater New Orleans, (2) how PCASG fund recipients used and benefited from other federal hurricane relief funds that support the restoration of primary care services in the area, and (3) challenges PCASG fund recipients continued to face in providing primary care, and their plans for sustaining services after PCASG funds are no longer available.
section_title: What GAO Found
paragraphs: PCASG fund recipients reported that they used the PCASG funds to hire or retain health care providers and other staff, add primary care services, and open new sites. For example, 20 of the 23 recipients that responded to the GAO survey reported using PCASG funds to hire health care providers, and 17 reported using PCASG funds to retain health care providers. In addition, most of the recipients reported that they used PCASG funds to add primary care services and to add or renovate sites. Recipients also reported that the grant requirements and funding helped them improve service delivery and expand access to care in underserved neighborhoods. Other federal hurricane relief funds helped PCASG fund recipients pay staff, purchase equipment, and expand mental health services to help restore primary care. Eleven recipients received HHS Social Services Block Grant (SSBG) supplemental funds designated by Louisiana for primary care, and two received SSBG supplemental funds designated by Louisiana specifically for mental health care. The funds designated for primary care were used to pay staff and purchase equipment, and the funds designated for mental health care were used to provide a range of services for adults and children, including crisis intervention and substance abuse prevention and treatment. About two-thirds of the PCASG fund recipients benefited from the Professional Workforce Supply Grant incentives. These recipients hired or retained 69 health care providers who received incentives totaling over $4 million to work in the greater New Orleans area. In addition, one PCASG fund recipient expended $7.9 million it received from Louisiana to provide services through the federal Crisis Counseling Assistance and Training Program. PCASG fund recipients continue to face multiple challenges and have various plans for sustainability. Recipients face significant challenges in hiring and retaining staff, as well as in referring patients outside of their organizations, and these challenges have grown since Hurricane Katrina. For example, 20 of 23 recipients that responded to the GAO survey reported hiring was a great or moderate challenge, and among these 20 recipients over three-quarters reported that this challenge had grown since Hurricane Katrina. Six of the 7 recipients that primarily provide mental health services reported that both hiring and retention of providers were great or moderate challenges. Many PCASG fund recipients also reported challenges in referring patients outside their organization for mental health, dental, and specialty care services. Although all PCASG fund recipients have completed or planned actions to increase their ability to be sustainable, it is too early to know whether their various sustainability strategies will be successful.

section_title: Letter
paragraphs: Nearly 4 years after Hurricane Katrina, the greater New Orleans area  continues to face challenges in restoring health care services disrupted by  the storm. Before the hurricane, the low-income population in the area  had relied on hospital emergency rooms and outpatient clinics, mostly  hospital-based, as its main source of primary care. These clinics provided  care to many patients who were uninsured or covered by Medicaid.  Following the hurricane and the subsequent flooding, the hospitals and  clinics closed because of the significant damage they had sustained. As  studies have shown, disaster survivors continue to experience poor  physical and mental health for prolonged periods after the event. After  the hurricane, various health care provider organizations in the area were  able to reopen some health care clinics. However, gaps remained in the  availability of health care services in the greater New Orleans area.
To help address the continuing health care needs of low-income area  residents, the Department of Health and Human Services (HHS) awarded  the $100 million Primary Care Access and Stabilization Grant (PCASG) to  the Louisiana Department of Health and Hospitals (LDHH) in July 2007.  The grant is administered at the federal level by HHS’s Centers for  Medicare & Medicaid Services (CMS). It is intended to restore and expand  access to primary care services, including mental health care services and  dental care services, without regard to a patient’s ability to pay. The grant  is also intended to decrease costly reliance on emergency room use for  primary care services for patients who are uninsured, underinsured, or  covered by Medicaid. CMS required LDHH to use the grant to provide  short-term funding to outpatient provider organizations to help them take  such actions as increasing their staff, renovating clinics, and opening new  clinic sites. LDHH provided funds to 25 organizations—which we refer to  as PCASG fund recipients; as of March 20, 2008, the recipients were  operating 75 sites that were eligible to use PCASG funds. The Louisiana  Public Health Institute (LPHI) administers the PCASG for LDHH and  distributes grant funds as its local partner. For an organization to be  eligible for PCASG funding, it must have been a public or private nonprofit  organization serving patients in the greater New Orleans area—which CMS  defined as Jefferson, Orleans, Plaquemines, and St. Bernard parishes—at  the time that Louisiana’s grant proposal was submitted. It must also have  had the intent to be sustainable, that is, able to continue providing primary  care after PCASG funds are no longer available.
In addition to the PCASG, other federal grants were awarded following  Hurricane Katrina that could help support access to primary care services.  These include the Social Services Block Grant (SSBG) supplemental funds  from HHS’s Administration for Children and Families (ACF) and grants  from the Crisis Counseling Assistance and Training Program (CCP), which  is administered by the Federal Emergency Management Agency (FEMA)  and its federal partner, HHS’s Substance Abuse and Mental Health  Services Administration (SAMHSA). Provider organizations also could  benefit from CMS’s Professional Workforce Supply Grant, through which  incentives were paid to prospective or current employees. Grants from the  Health Center Program of HHS’s Health Resources and Services  Administration (HRSA) were also available during this time to certain  organizations providing primary care services.
You asked us to study how the federal government can effectively leverage  governmental resources to help the victims of Hurricane Katrina gain  access to primary care services. In this report, we examine (1) how  PCASG fund recipients used the PCASG funds to support the provision of  primary care services in the greater New Orleans area, (2) how PCASG  fund recipients used and benefited from other federal hurricane relief  funds that support the restoration of primary care services in the greater  New Orleans area, and (3) challenges the PCASG fund recipients  continued to face in providing primary care services, and recipients’ plans  for sustaining services after PCASG funds are no longer available.
To determine how the PCASG fund recipients used PCASG funds to  support the provision of primary care services in the greater New Orleans  area, we conducted site visits at 8 of the 25 PCASG fund recipients during  April 2008. To identify the locations for our site visits, we chose a selective  sample of the recipients, including some that offered mental health care  services or dental care services and 2 that were Health Center Program  grantees. In addition, we included at least 1 recipient from each of the  area’s four parishes. During these visits we collected documents and  interviewed PCASG fund recipient, state, and local officials. Based in part  on information we gathered during the site visits, we developed a Web- based survey. Our survey focused on how recipients used PCASG funds,  the challenges they continued to face, and their plans for sustainability.
Before we disseminated the survey to the 25 recipients, the survey  questions were peer-reviewed by LPHI because of its expertise on the  grant program. We received responses from 23 of the 25 recipients, a  response rate of 92 percent. Based on activities we conducted to assess  the reliability of the survey data, such as reviewing survey data for  inconsistencies and completeness, we determined that the data were  sufficiently reliable for the purposes of this report. We also reviewed the  recipients’ applications for PCASG funding and interviewed officials at  LDHH and LPHI about how the recipients used PCASG funds.
To answer our question on how the PCASG fund recipients used and  benefited from other federal funds for hurricane relief, we identified  relevant funding sources that recipients used or benefited from, and we  examined the funding amounts and the ways the funds were used.  Specifically, we reviewed and analyzed data from LDHH on expenditures  related to the supplemental SSBG, on awards made under CMS’s  Professional Workforce Supply Grant Program, and on the CCP. Through  assessments of internal consistency and verification with state and local  officials, we determined that these data were sufficiently reliable for the  purposes of this report. We also interviewed officials at LDHH and PCASG  fund recipients about these programs.
To answer our questions on challenges PCASG fund recipients continued  to face in providing primary care services and how the recipients planned  to sustain primary care services after PCASG funding is no longer  available, we used information collected from the Web-based survey. We  also analyzed interviews we conducted with 10 recipients, including the 8  we visited, and with federal, state, and local agency officials. In addition,  we reviewed sustainability plans that the recipients included in their  applications for PCASG funding.
To provide additional information on the PCASG fund recipients, we used  data collected by LPHI on types of services that the recipients offered. We  also used patient and encounter data that LPHI summarized for us.  PCASG funds were not the only funds used to support the services these  data describe. Based on activities we conducted to assess the reliability of  these data, such as discussing with LPHI officials their processes to   establish the accuracy and reliability of the data they gave us, we  determined that the data were sufficiently reliable for the purposes of our  report.
We conducted our work from February 2008 through June 2009 in  accordance with all sections of GAO’s Quality Assurance Framework that  are relevant to our objectives. The framework requires that we plan and  perform the engagement to obtain sufficient and appropriate evidence to  meet our stated objectives and to discuss any limitations in our work. We  believe that the information and data obtained, and the analysis  conducted, provide a reasonable basis for any findings and conclusions in  this product. See appendix I for more information about our scope and  methodology.
subsections: section_title: Background
paragraphs: Since Hurricane Katrina, the population of the greater New Orleans area  has decreased, and the health care delivery system for the low-income and  uninsured population in the area has begun to change from one that was  largely hospital-based to a more community-based system of primary care.  Since the disruption to the health care system caused by the hurricane,  several federal agencies have awarded grants that facilitate access to  primary care.
subsections: section_title: Greater New Orleans Area Population
paragraphs: The estimated population of the greater New Orleans area decreased from  999,349 in July 2005 to 807,032 in July 2008, a level of about 81 percent of  the population before Hurricane Katrina. Most of the decrease in  population was in Orleans and St. Bernard parishes. (See table 1.)
section_title: Health Care Delivery in the Greater New Orleans Area
paragraphs: Before Hurricane Katrina, most health care for the low-income and  uninsured population in the greater New Orleans area was provided in  emergency rooms and outpatient clinics at Charity and University  hospitals, which together were known as the Medical Center of Louisiana  at New Orleans (MCLNO). MCLNO is part of Louisiana State University’s  (LSU) statewide system of public hospitals. About half of MCLNO’s  patients were uninsured, and about one-third were covered by Medicaid.  As a result of damage from Hurricane Katrina and the subsequent flooding,  Charity and University hospitals were closed. In November 2006, LSU  reopened University Hospital, under its new, temporary name, Interim LSU  Public Hospital. Charity Hospital remained closed as of June 2009.
In addition to the hospital outpatient clinics, other types of clinics  provided primary care, including mental health care, for the low-income  and uninsured population before Hurricane Katrina. These included health  centers participating in HRSA’s Health Center Program. Under Section 330  of the Public Health Service Act, HRSA provides grants to health centers  nationwide to increase access to primary care. HRSA uses a competitive  process to award grants, including New Access Point grants for new  grantees or for existing grantees to establish additional sites. Existing  grantees may also compete for Expanded Medical Capacity grants to  increase service capacity, such as by expanding operating hours, or  Service Expansion grants to add or expand services, such as mental  health, oral health, and pharmacy services.
All health center grantees are Federally Qualified Health Centers (FQHC),  which enjoy certain federal benefits such as enhanced Medicare and  Medicaid payment rates. However, not all FQHCs receive Health Center  Program grants, and those that do not are sometimes referred to as having  an FQHC Look-Alike designation. Four health center grantees served the  greater New Orleans area at the time HHS awarded the PCASG in   July 2007.
In 2007, Louisiana enacted the Health Care Reform Act of 2007, which  directed LDHH to develop and implement a new health care delivery  system for the state’s Medicaid recipients and low-income uninsured  citizens. LDHH proposed short-term and long-term recommendations,  which included changes to the Louisiana Children’s Health Insurance  Program (LaCHIP) in 2008 to expand coverage to more children. LDHH  also submitted a demonstration waiver application to CMS for its Medicaid  program to expand coverage and create a coordinated system of care.
section_title: Federal Assistance to Restore Access to Primary Care
paragraphs: In response to Hurricane Katrina, several federal agencies provided grants  that assist with the restoration of primary care in the greater New Orleans  area. (See fig. 1.) FEMA provided CCP funds to Louisiana for certain  mental health services. ACF provided supplemental SSBG funds for  primary health care services, among other things. In addition, CMS  provided Professional Workforce Supply Grant funds to reduce health care  provider shortages and PCASG funds to restore access to primary care.
The CCP provided funds for crisis counseling services—including stress  reduction and coping education, community outreach, individual and  group crisis counseling, and referral for other services—to Louisiana. The  state subsequently distributed $29 million of these funds in the greater  New Orleans area. The CCP was designed to meet the short-term mental  health needs of people affected by disasters. State officials told us that,  generally, the CCP allows a person to have three to five counseling visits  but does not provide for a traditional mental health diagnostic assessment  and cannot be used for traditional mental health or substance abuse  services. CCP grantees may, however, provide information to families and  individuals about available mental health and substance abuse services.  Additional assistance may be available to certain families through the  Louisiana CCP’s Specialized Crisis Counseling Services.
subsections: section_title: Social Services Block Grant
paragraphs: ACF administers SSBG funding to assist states in delivering social  services, which generally do not include health care services. In 2006,  however, Congress appropriated emergency SSBG supplemental funding  that could be spent on, among other things, health care services. From  this appropriation, ACF awarded more than $220 million to Louisiana. The  Louisiana Department of Social Services (LDSS) served as the state-level  administrator and collaborated with LDHH and the Office of the Governor  to develop a spending plan that dedicated about $168 million of this  amount for resuming and restoring health care services. LDHH received  $101.7 million, which it divided into two service categories. First, LDHH  designated $80 million specifically for mental health care, including  substance abuse and developmental disability services, to meet the  emerging mental health crisis. Second, LDHH designated $21.7 million for  primary care, which could include mental health care, to restore and  resume services to meet the health care needs of people affected by the  hurricanes. The primary care funds were intended to target the  southernmost parishes and regions that had experienced a devastating  blow to their primary care infrastructure. Each local parish could develop  a proposal for restoring services its population needed and for responding  to the challenges it faced in rebuilding its basic health care system.
LDSS awarded the remaining health care services funds directly to LSU  Health Sciences Center and Tulane University Health Sciences Center.  Louisiana has until September 30, 2009, to spend these funds, which are  distributed as reimbursements after services are delivered.
LDHH distributed the mental health funds to various offices in the  department and to the state’s four regional human services districts,  which then contracted with various individuals and organizations to  provide some of the services. A state official told us that the mental health  funds were available statewide in part because many people from the  greater New Orleans area who needed mental health services following the  hurricanes were dispersed throughout the state.
section_title: Professional Workforce Supply Grant
paragraphs: The $50 million Professional Workforce Supply Grant was awarded by the  Secretary of HHS in March 2007. The purpose of the grant was to reduce  shortages in the professional health care workforce following Hurricane  Katrina, and CMS gave Louisiana flexibility to design its program within  broad federal guidelines. LDHH, which administers the grant, used the  funds to create and fund the Greater New Orleans Health Service Corps,  which recruits individual health care providers for health care  organizations by offering incentive payments to the individuals. Incentive  amounts are based on an individual’s medical specialty and range from  $10,000 to $110,000. To be eligible, a health care provider must, among  other things, agree to serve Medicare, Medicaid, and uninsured patients;  have a sliding fee scale; and provide services in a federally designated  health professional shortage area (HPSA). Health care providers are also  expected to enter into an agreement with LaCHIP to provide services to  children enrolled in that program, if appropriate. Financial incentive  payments can be given to health care providers who remain in their  qualifying job or to newly hired health care providers; individuals may  receive only one financial incentive payment.
section_title: Primary Care Access and Stabilization Grant
paragraphs: In July 2007, CMS awarded the PCASG to LDHH, which selected LPHI as  the local partner responsible for administering the grant program. The  PCASG was established by HHS under the authority of the Deficit  Reduction Act of 2005, which allowed HHS to allocate funds to restore  access to health care in communities affected by Hurricane Katrina, and to  provide funds for other services, such as those provided by Medicaid and  the State Children’s Health Insurance Program. The greater New Orleans  area was targeted to receive PCASG funds because of the unique impact  Hurricane Katrina and its resulting floods had on the area.
LDHH and LPHI determined that 25 organizations met the PCASG  requirements that CMS established, and they were all awarded funding.  The 25 organizations varied in size and other characteristics. For example,  some recipients are affiliated with an institution such as a university or  state or local government, and some are grantees of HRSA’s Health Center  Program. (For more information on the characteristics of the PCASG fund  recipients, see app. II.). In addition to primary care services—medical,  mental health, and dental care services—PCASG fund recipients could use  grant funds to provide specialty care, such as cardiology and podiatry  services, and ancillary services, including supporting services such as  translation, health education, transportation, and outreach. After being  awarded PCASG funding, outpatient provider organizations had to meet  several CMS requirements, including creating referral relationships with  local specialists and hospitals, establishing a quality assurance or  improvement program, and providing a long-term sustainability plan.
LPHI is responsible for distributing funds to PCASG fund recipients,  including an initial disbursement and five supplemental disbursements.  These are lump sum payments and are not reimbursement for individual  services provided. The 25 recipients received initial disbursements totaling  $17 million. The supplemental disbursements are to be made over the  grant period. CMS requires that more of the funds be disbursed during  the early part of the grant period and that funding decline over the 3 years  to ensure that recipients do not rely primarily on PCASG funds for their  continued operation and sustainability.
LDHH and CMS provide oversight of the PCASG program. LDHH oversees  the work performed by LPHI, conducts site visits at PCASG fund  recipients, reviews budgets for LPHI and recipients, reviews and approves  payments to recipients, and determines whether to approve recipients’  requests to renovate sites. CMS visits recipients to observe their  operations and reviews reports from LDHH and LPHI in collaboration with  officials from other HHS agencies. Although the PCASG does not include a  requirement for a program evaluation, a private foundation is scheduled to  evaluate the PCASG program, and CMS officials plan to review and  approve this evaluation before it is published.
section_title: PCASG Fund Recipients Used PCASG Funds to Support Primary Care Services by Hiring Health Care Providers and Other Staff and Adding Services and Sites
paragraphs: PCASG fund recipients reported that they used PCASG funds to hire or  retain health care providers and other staff, add primary care services, and  open new sites. Recipients also said that the PCASG funds have helped  them improve service delivery and access to care.
subsections: section_title: Almost All PCASG Fund Recipients That Responded to Our Survey Used PCASG Funds to Hire or Retain Health Care Providers and Other Staff
paragraphs: Most of the PCASG fund recipients that responded to our survey reported  they used PCASG funds to hire health care providers or other staff.  Twenty of the 23 responding recipients reported using PCASG funds to  hire health care providers. (See fig. 2.)
Sixteen recipients hired mental health care providers, including mental  health counselors and psychiatrists. One recipient reported that by hiring  one psychiatrist, it could significantly increase clients’ access to services  by cutting down a clinic’s waiting list and by providing clients with a  “same-day” psychiatric consultation or evaluation. Fourteen of the  recipients responded they used PCASG funds to hire medical care  providers. One recipient reported that it hired 23 medical care providers,  some of whom were staffed at its new sites. Eighteen of the 23 PCASG  fund recipients that responded to our survey reported they used PCASG  funds to hire other staff, such as a medical director and a medical office  assistant, in addition to hiring health care providers. Some recipients  reported that the ability to hire providers enabled them to expand the  hours some of their sites were open.
PCASG fund recipients responded that in addition to hiring health care  providers and other staff, they also used PCASG funds to retain health  care providers and other staff. Of the 23 recipients that responded to our  survey, 17 reported they used PCASG funds to retain health care  providers, and 15 of these reported that they also used grant funds to  retain other staff. For example, one recipient reported that PCASG funds  were used to stabilize positions that were previously supported by disaster  relief funds and donated services.
section_title: A Large Proportion of PCASG Fund Recipients Used PCASG Funds to Add Services and to Add or Renovate Sites
paragraphs: Nineteen of the 23 PCASG fund recipients that responded to our survey  reported using PCASG funds to add or expand medical, mental health, or  dental care services, and more than half of these added or expanded more  than one type of service. (See table 2.)
PCASG fund recipients also reported using grant funds to add or expand  specialty care services or to add ancillary services. Eight recipients added  or expanded specialty care services. For example, one of these recipients  reported that it added podiatry services. The ancillary services that  recipients used grant funds to add included health education,  transportation, and outreach activities. One recipient reported that it used  PCASG funds to create a television commercial announcing that a clinic  was open and that psychiatric services were available there, including free  care for those who qualified financially.
Almost all of the PCASG fund recipients that responded to our survey  reported they used PCASG funds for their physical space. Fifteen  recipients used the funds to open new sites or relocate sites. One of these  recipients reported that it relocated to a larger site, which allowed  providers to have additional examination rooms. Ten recipients reported  using grant funds to renovate existing sites. Some of these recipients  made renovations—such as expanding a waiting room, adding a  registration window, and adding patient restrooms—to accommodate  more patients.
section_title: PCASG Fund Recipients Reported That Program Requirements and Funding Have Improved Service Delivery and Access
paragraphs: PCASG fund recipients that responded to our survey reported that certain  program requirements have had a positive effect on their delivery of  primary care services. Almost three-quarters of responding recipients  reported a requirement that they develop a network of local specialists  and hospitals for patient referrals has had a positive effect. Similarly, over  two-thirds of the responding recipients reported that the requirement to  establish a quality assurance and improvement program, which must  include developing clinical guidelines or evidence-based standards of care,  has had a positive effect on the provision of primary care within their  organization.
Various PCASG fund recipients have stated that PCASG funds helped them  improve access to health care services for residents of the greater New  Orleans area. One recipient reported to LPHI that PCASG funds allowed it  to expand its services beyond residents in its shelter and housing  programs to include community residents who were not homeless but  previously lacked access to health care services. Representatives of other  recipients have publicly stated that their organization improved access to  health care by expanding services in medically underserved  neighborhoods or to people who were uninsured or underinsured. In  addition, representatives of local organizations told us that the PCASG  provided an opportunity to rebuild the health care system and shift the  provision of primary care from hospitals to community-based primary care  clinics.
section_title: Other Federal Hurricane Relief Funds Helped PCASG Fund Recipients to Pay Staff, Purchase Equipment, and Expand Mental Health Services to Help Restore Primary Care
paragraphs: PCASG fund recipients also used other federal hurricane relief funds to  provide services. They used SSBG supplemental funds designated by  Louisiana for primary care to pay for staff salaries and equipment, and  they used SSBG supplemental funds designated for mental health care to  provide a range of mental health services. PCASG fund recipients also  benefited from the Professional Workforce Supply Grant, which provided  incentives for health care providers, and one used funds from the CCP to  provide counseling services.
subsections: section_title: PCASG Fund Recipients That Received SSBG Supplemental Funds Designated for Primary Care Used Them to Pay Salaries and Purchase Equipment
paragraphs: Nearly half of PCASG fund recipients received SSBG supplemental funds  designated for primary care and used them to pay staff salaries, purchase  medical equipment, and support operations. According to LDHH data, 11  PCASG fund recipients expended $12.9 million of the $21.7 million in  SSBG supplemental funds awarded to Louisiana and designated by the  state for primary care, as of August 2008. After a competitive process in  2006, LDHH distributed SSBG supplemental funds ranging from $209,000  to over $2.6 million each to individual recipients. (See table 3.) Officials  from PCASG fund recipient organizations that received these funds told us  they had used SSBG supplemental funds to pay salaries, purchase supplies  and medical equipment, and support their operations. For example, one  recipient used SSBG supplemental funds to hire new medical and support  staff and, as a result, expanded its services for mammography, cardiology,  and mental health. It also used SSBG supplemental funds to remodel the  associated examination rooms and lobby and to purchase operating  services, such as accounting services and insurance.
In addition to distributing SSBG supplemental funds to LDHH for primary  care, LDSS distributed SSBG supplemental funds directly to one PCASG  recipient to support, in part, primary health care services. Specifically,  LSU Health Sciences Center New Orleans—which also received SSBG  supplemental funds for primary care from LDHH—used $173,000 of the  $33.5 million it received directly from LDSS to pay for staff salaries and  benefits at its PCASG sites.
section_title: Two PCASG Fund Recipients Used SSBG Supplemental Funds Designated for Mental Health Care to Provide a Range of Services, Including Crisis Intervention and Substance Abuse Prevention and Treatment
paragraphs: The two PCASG fund recipients that received SSBG supplemental funds  designated for mental health care used them to provide crisis intervention,  substance abuse, and other mental health services. LDHH distributed  almost $12 million of the $80 million in SSBG supplemental funds  designated for mental health care to the two PCASG fund recipients that  are state regional human services districts—$4.3 million to Metropolitan  Human Services District (MHSD) and $7.6 million to Jefferson Parish  Human Services Authority (JPHSA). MHSD and JPHSA in turn  distributed most of these funds through contracts to other organizations  and providers. They also retained a portion of these funds to spend on  the direct provision of mental health care services or other expenses that  were necessary for the restoration of these services, such as minor repairs  or replacement of equipment and supplies. MHSD obligated $3.3 million  under 30 contracts and retained $1 million for direct expenses; JPHSA  obligated $4.3 million under 80 contracts and retained nearly $3.4 million.  Except for just over $88,000 of JPHSA’s funds, all $12 million had been  expended as of March 3, 2009.
LDHH identified five mental health care service categories for the use of  the SSBG supplemental funds. (See table 4.) Through March 3, 2009, the  largest portion of funds that MHSD expended was for the category  “substance abuse treatment and prevention.” The largest portion of funds  that JPHSA expended was for the category “immediate intervention— crisis response,” with the second largest portion expended for the  category “behavioral health services for children and adolescents.”
MHSD officials told us they used the SSBG supplemental funds to help  maintain staff and relocate them to community-based mental health  centers, where clients could be assessed and treated for mental health and  addiction problems. In addition, MHSD placed an addiction counselor in a  school-based health center to provide early intervention and treatment for  substance abuse. MHSD officials also reported that they used funds to  support crisis and addiction counseling for adults and children in  churches, grief counseling for children in elementary schools, a summer  camp that included mental health counseling, and community outreach  services.
JPHSA officials told us they used SSBG supplemental funds to provide  services such as assertive community treatment, crisis intervention  teams, mobile crisis services, suicide prevention services, group and  individual therapy, and psychiatric evaluation. For example, JPHSA  expanded its assertive community treatment program, in which services  are provided at home or in community-based locations and include help  with medication administration and monitoring. JPHSA officials reported  that this program focused on patients who had a history of noncompliance  with mental health treatment and were generally considered to be the  persons most in need of mental health services. JPHSA also used the funds  to support a program of community-based services for patients who were  no longer in need of inpatient services or who were in crisis but not in  need of an inpatient psychiatric hospital stay. Patients were given 24-hour  care and supervision and attended group and individual counseling  designed to provide crisis resolution skills and coping strategies; they  were also linked to community-based resources such as community  mental health clinics and supportive or independent housing. This  program also served to alleviate the burden on inpatient psychiatric  hospitals.
section_title: About Two-Thirds of the PCASG Fund Recipients Employed a Health Care Provider Who Received a Professional Workforce Supply Grant Incentive Payment, and More Incentives Were Used for Retention Than for Hiring
paragraphs: As of August 2008, 17 of the 25 PCASG fund recipients had retained or  hired a health care provider who had received a Professional Workforce  Supply Grant incentive payment to continue or begin working in the  greater New Orleans area. Among the health care providers working for  PCASG fund recipients, 69 received incentives that totaled $4.5 million.  (See table 5.) The number of those health care providers who were  employed by individual PCASG fund recipients ranged from 1 or 2 at   7 recipient organizations to 10 at 2 recipient organizations. These one-time,  lump sum incentive payments, which could be used for purposes such as  student loan repayment or relocation expenses, ranged from $10,000 to  $110,000 each; the largest percentages of incentive payments and of funds  went to primary care providers. In a 2008 survey conducted by LDHH,   88 percent of all incentive recipients reported that the availability of an  incentive payment affected their decision to remain or practice in the  greater New Orleans area.
Three-quarters of recipients of incentive payments were existing  employees who were retained, while one-quarter were newly hired. This  pattern is consistent with the incentive payments that were made overall,  regardless of employing organization. In addition, no PCASG fund  recipient hired more than two new staff who had received an incentive  payment. In discussing these payments, a state official commented that  retaining an existing employee is generally easier than hiring a new one.
section_title: One PCASG Fund Recipient Provided Counseling Services through the CCP
paragraphs: One PCASG fund recipient provided counseling services with CCP funds.  In 2005, immediately following Hurricane Katrina, the Louisiana Office of  Mental Health contracted with Catholic Charities Archdiocese of New  Orleans to be the sole CCP service provider in the four area parishes. This  recipient expended $7.9 million of the $29 million in CCP funds awarded to  Louisiana. In addition to providing counseling services, Catholic Charities’  counselors provided information about available services such as primary  care; mental health services; substance abuse treatment; and food,   clothing, and housing assistance. Catholic Charities terminated its CCP  role in May 2007, and the Louisiana Office of Mental Health took over its  role.
section_title: PCASG Fund Recipients Face Multiple Challenges and Have Various Plans for Sustainability
paragraphs: PCASG fund recipients face significant challenges in hiring and retaining  staff, as well as in referring patients outside of their organizations, and  these challenges have grown since Hurricane Katrina. Recipients are  taking actions to address the challenge of sustainability, but it is too early  to know whether they will be successful.
subsections: section_title: PCASG Fund Recipients Face Significant Staffing and Referral Challenges, and These Challenges Have Grown Since Hurricane Katrina
paragraphs: Although most of the 23 PCASG fund recipients that responded to our  survey hired or retained staff with grant funds, most have continued to  face significant challenges in hiring and retaining staff. Hiring has been  especially challenging. For example, 11 of the 23 recipients reported the  hiring of health care providers to be a great challenge, and 9 reported it  was a moderate challenge. (For detailed information on recipients’  responses to the questions in our Web-based survey regarding challenges,  see fig. 3.) Among those that reported hiring providers was a great or  moderate challenge, over three-quarters responded that this challenge had  grown since Hurricane Katrina. In discussing challenges, officials from  one recipient organization told us that after Hurricane Katrina they had  greater difficulty hiring licensed nurses than before the hurricane. They  also told us that most of the nurses who were available to be hired were  recruited by hospitals, where the pay was higher. Moreover, officials we  interviewed from several recipient organizations said that the problems  with housing, schools, and overall community infrastructure that  developed after Hurricane Katrina made it difficult to attract health care  providers and other staff. An additional indication of limited availability of  primary care providers in the area is HRSA’s designation of all of Orleans,  Plaquemines, and St. Bernard parishes and much of Jefferson Parish as  HPSAs for primary care. While some portions of the greater New Orleans  area had this HPSA designation before Hurricane Katrina, additional  portions of the area received that designation after the hurricane.
Retention of staff has also been a challenge for the PCASG fund recipients.  (See fig. 3.) For example, 16 of the 23 recipients reported that retaining  health care providers was a great or moderate challenge. Among those that  reported retaining health care providers was a great or moderate  challenge, about three-quarters also reported that this challenge had  grown since Hurricane Katrina. Retaining other staff has also been a  challenge, with 14 of the 23 recipients reporting it to be a great or  moderate challenge. About two-thirds of those reporting that retaining  other staff was a moderate or great challenge also said this challenge had  grown since Hurricane Katrina.
The PCASG fund recipients that primarily provide mental health services  in particular faced challenges both in hiring providers and in retaining  providers. Six of the seven that responded to our survey reported that  both hiring and retaining providers were either a great or moderate  challenge. Six recipients reported that hiring was a great challenge, and  five of these reported that the challenge was greater than before Hurricane  Katrina. Three recipients reported that retention was a great challenge,  and two of these also reported that the challenge had grown since  Hurricane Katrina. An indication of more limited availability of mental  health care providers is HRSA’s designation of the four parishes of the  greater New Orleans area as HPSAs for mental health in late 2005 and  early 2006; before Hurricane Katrina, none of the parishes had this  designation for mental health. Officials we interviewed from one  recipient with multiple sites told us that while the Greater New Orleans  Health Service Corps, which was funded through the Professional  Workforce Supply Grant, had been helpful for recruiting and retaining  physicians, it had not helped fill the need for social workers. Furthermore,  officials we interviewed from two recipients with multiple sites told us  that some staff had experienced depression and trauma themselves and  found it difficult to work in mental health settings.
Beyond challenges in hiring and retaining their own providers and other  staff, PCASG fund recipients that responded to our survey reported  significant challenges in referring their patients to other organizations for  mental health, dental, and specialty care services. (See fig. 3.) Specifically,  14 of the 23 recipients reported that the availability of mental health  providers willing to accept referrals was a great or moderate challenge,  and over two-thirds of those reporting that level of challenge responded  that this challenge had grown since Hurricane Katrina. In addition, 10 of  the 16 recipients that indicated that the question on dental service  referrals was applicable to them reported that the availability of dentists  willing to accept referrals was a great or moderate challenge, and about  two-thirds of those reporting that level of challenge also reported that this  challenge was greater than before Hurricane Katrina. An additional  indication of limited availability of dental care is that HRSA has designated  all of Orleans, St. Bernard, and Plaquemines parishes and part of Jefferson  Parish as HPSAs for dental care; before Katrina, only part of Orleans  Parish and part of Jefferson Parish had this designation. Finally, 13 of the  20 recipients that indicated that the question on specialty care referrals  was applicable to them reported that the availability of providers willing to  accept referrals for specialty care was a great or moderate challenge, and  two-thirds of those reported that this challenge had grown since Hurricane  Katrina.
section_title: PCASG Fund Recipients Are Taking Actions to Address the Challenge of Sustainability, but It Is Too Early to Know Whether They Will Be Successful
paragraphs: An additional challenge that the PCASG fund recipients face is to be  sustainable after PCASG funds are no longer available. All 23 recipients  that responded to our survey reported that they had taken or planned to  take at least one type of action to increase their ability to be sustainable— that is, to be able to serve patients regardless of their ability to pay after  PCASG funds are no longer available. For example, all responding  recipients reported that they had taken action—such as screening patients  for eligibility—to facilitate their ability to receive reimbursement for  services they provided to Medicaid or LaCHIP beneficiaries. Furthermore,  16 recipients reported that they were billing private insurance, with an  additional 5 recipients reporting they planned to do so. However,  obtaining reimbursement for all patients who are insured may not be  sufficient to ensure a recipient’s sustainability, because at about half of the  PCASG fund recipients, over 50 percent of the patients are uninsured.
Many PCASG fund recipients reported that they intended to use Health  Center Program funding or FQHC Look-Alike designation—which allows  for enhanced Medicare and Medicaid payment rates—as one of their  sustainability strategies. Four recipients were participating in the Health  Center Program at the time they received the initial disbursement of  PCASG funds. One of these recipients had received a Health Center New  Access Point grant to open an additional site after Hurricane Katrina and  had also received an Expanded Medical Capacity grant to increase service  capacity, which it used in part to hire additional staff and buy equipment.  Another of these recipients received a New Access Point grant to open an  additional site after receiving PCASG funds. Beyond these four recipients,  one additional recipient received an FQHC Look-Alike designation in July  2008 and a New Access Point grant in March 2009. Of the remaining 18  recipients that responded to our survey, 6 said they planned to apply for  both a Health Center Program grant and an FQHC Look-Alike designation.  In addition, 1 planned to apply for a grant only and another planned to  apply for an FQHC Look-Alike designation only. Although many recipients  indicated that they intended to use Health Center Program funding as a  sustainability strategy, they may not all be successful in obtaining a grant.  For example, in fiscal year 2008 only about 16 percent of all applications  for New Access Point grants resulted in grant awards.
About three-quarters of PCASG fund recipients reported that as one of  their sustainability strategies they had applied or planned to apply for  additional federal funding, such as Ryan White HIV/AIDS Program grants,  or for state funding. In addition, a few reported that they had applied or  planned to apply for private grants, such as from foundations.
Although PCASG fund recipients have completed or planned actions to  increase their ability to be sustainable, it is too early to know whether  their various sustainability strategies will be successful. One factor that  may affect the degree of challenge in achieving sustainability is whether a  recipient is part of a larger institution, such as a university or government  body, that could potentially provide additional funds after PCASG funds  are no longer available. Similarly, sustainability may be a less difficult  challenge for organizations that are already grantees of HRSA’s Health  Center Program.
section_title: Agency Comments
paragraphs: HHS reviewed a draft of this report and provided technical comments,  which we incorporated as appropriate.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the Secretary  of Health and Human Services and other interested parties. In addition, the  report will be available at no charge on the GAO Web site at  http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-7114 or bascettac@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made major contributions to this report  are listed in appendix III.
section_title: Appendix I: Scope and Methodology
paragraphs: We focused our review on the 25 outpatient provider organizations that in  September 2007 received funding through the Primary Care Access and  Stabilization Grant (PCASG), which the Department of Health and Human  Services (HHS) awarded to the Louisiana Department of Health and  Hospitals (LDHH). The PCASG funds were targeted to the greater New  Orleans area—specifically, Jefferson, Orleans, Plaquemines, and St.  Bernard parishes—because of the impact Hurricane Katrina had on this  area. In this report we examine (1) how PCASG fund recipients used the  PCASG funds to support the provision of primary care services in the  greater New Orleans area, (2) how PCASG fund recipients used and  benefited from other federal hurricane relief funds that support the  restoration of primary care services in the greater New Orleans area, and  (3) challenges the PCASG fund recipients continued to face in providing  primary care services, and recipients’ plans for sustaining services after  PCASG funds are no longer available.
In conducting our work, we reviewed relevant literature. We also  interviewed officials at various agencies within HHS, including the  Administration for Children and Families, Centers for Medicare &  Medicaid Services (CMS), Health Resources and Services Administration  (HRSA), and Substance Abuse and Mental Health Services Administration.
To determine how the PCASG fund recipients used PCASG funds to  support the provision of primary care services in the greater New Orleans  area, we conducted site visits and developed and implemented a Web- based survey. We also reviewed the recipients’ grant applications and  interviewed officials at the LDHH and Louisiana Public Health Institute  (LPHI) about how the recipients used PCASG funds. LPHI administers the  PCASG program and distributes the grant funds as the local partner of  LDHH.
We conducted site visits at 8 of the 25 PCASG fund recipients during   April 2008. During these visits we collected documents and interviewed  PCASG fund recipient, state, and local officials. To identify the locations  for our site visits, we chose a selective sample of the recipients to include  at least 1 from each of the area’s four parishes. We also selected recipients  so that our sample would include some that offered mental health care  services and some that offered dental care services, and we included 2  recipients that were grant recipients of HRSA’s Health Center Program.
We developed a Web-based survey that focused on how PCASG fund  recipients used PCASG funds, the challenges they continued to face, and  their plans for sustainability. To develop our survey questions, we  analyzed our interviews with officials from PCASG fund recipients, CMS,  and state and local agencies; reviewed the recipients’ applications for  funding; and reviewed the PCASG Notice of Award. In addition, before we  disseminated the survey to the 25 recipients, the content of the survey  questions was peer-reviewed by LPHI because of its expertise on the grant  program. We received responses from 23 of the 25 recipients, a response  rate of 92 percent. To assess the reliability of the survey data, we  performed quality checks, such as reviewing survey data for  inconsistencies and completeness and, when necessary, followed up with  survey respondents via the telephone to resolve any inconsistencies and  obtain missing information. Based on these efforts, we determined that the  survey data were sufficiently reliable for the purposes of this report.
To answer our question on how the PCASG fund recipients used and  benefited from other federal funds for hurricane relief, we reviewed and  analyzed data collected by LDHH on expenditures related to the  supplemental Social Services Block Grant (SSBG). Where possible, we  used documents from and interviews with state and PCASG fund recipient  officials to identify SSBG supplemental funds expended at PCASG sites. In  addition, we reviewed and analyzed data gathered by LDHH related to the  incentive payments made under the Professional Workforce Supply Grant  and expenditures under the Crisis Counseling Assistance and Training  Program (CCP). For the incentive payments made using the Professional  Workforce Supply Grant, LDHH provided us with information about health  care providers working at PCASG sites. They used the employment  address, rather than recipient name, to identify which providers to include.  They provided data about the amount of payment, payment type (retention  or hiring), and provider type (for example, internist or nurse). For the  CCP, we obtained data from LDHH on program expenditures at PCASG  sites. We also interviewed officials from LDHH and PCASG fund recipients  about the implementation of these programs in the greater New Orleans  area. To assess the reliability of the data we received from LDHH related  to the SSBG, Professional Workforce Supply Grant, and CCP, we  performed checks of internal consistency and verified information with  state and local officials where possible. Based on these efforts, we  determined that the data were sufficiently reliable for the purposes of this  report.
To answer our questions on challenges PCASG fund recipients continued  to face in providing primary care services and how PCASG fund recipients  plan to sustain primary care services after funds are no longer available,  we used information collected from our Web-based survey. We also  analyzed interviews we conducted with 10 recipients, including the 8 we  visited, and from federal, state, and local agencies. In addition, to  determine how recipients planned to sustain primary care services, we  reviewed sustainability plans that the recipients included in their  applications for PCASG funding. We also analyzed information provided  by HRSA on Health Center Program grants awarded to PCASG fund  recipients and on overall program grants awarded in fiscal years 2007 and  2008.
To provide additional information on the PCASG fund recipients, we used  data collected by LPHI about the recipients. We analyzed data that LPHI  provided to us on each PCASG fund recipient for the period September 21,  2007, through March 20, 2008, regarding (1) patients and encounters, and  (2) types of services that recipients offered. We obtained these data for  this period because at the time of our request, this was the only period for  which LPHI had completed its data accuracy and reliability checks on the  patient and encounter data. We requested that LPHI summarize for us at  the recipient level both the number of patients and the number of  encounters, by age and insurance status.
To assess the reliability of data we received from LPHI on patient and  encounter data and on types of services offered, we did the following:   (1) reviewed relevant documentation, (2) discussed with knowledgeable  agency officials the data and the processes they used to establish the  accuracy and reliability of the data provided, and (3) where possible,  compared data to published sources. Based on these activities, we  determined that these data were sufficiently reliable for the purposes of  our report.
We conducted our work from February 2008 through June 2009 in  accordance with all sections of GAO’s Quality Assurance Framework that  are relevant to our objectives. The framework requires that we plan and  perform the engagement to obtain sufficient and appropriate evidence to  meet our stated objectives and to discuss any limitations in our work. We  believe that the information and data obtained, and the analysis  conducted, provide a reasonable basis for any findings and conclusions in  this product.
section_title: Appendix II: Primary Care Access and Stabilization Grant Fund Recipients: Characteristics, Patients, and Services
paragraphs: In July 2007, HHS awarded the $100 million PCASG to LDHH, which in  turn provided funds to 25 outpatient provider organizations in the greater  New Orleans area in September 2007. CMS is responsible for  administering the program at the federal level. LPHI is LDHH’s local  partner for administering the grant program.
The 25 organizations that are PCASG fund recipients vary in size and in the  geographical area they serve. (See table 6.) Furthermore, some recipients  are affiliated with an institution such as a university or state or local  government, and some receive funding from the Health Center Program of  HHS’s HRSA.
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the person named above, Helene F. Toiv, Assistant Director;  Martha R. W. Kelly; Carolyn Feis Korman; Deitra Lee; Roseanne Price;   Dan Ries; Jennifer Whitworth; Rasanjali Wickrema; and Malissa Winograd  made key contributions to this report.
section_title: Related GAO Products
paragraphs: Hurricane Katrina: Barriers to Mental Health Services for Children  Persist in Greater New Orleans, Although Federal Grants Are Helping to  Address Them. GAO-09-563. Washington, D.C.: July 13, 2009.
Disaster Assistance: Greater Coordination and an Evaluation of  Programs’ Outcomes Could Improve Disaster Case Management.   GAO-09-561. Washington, D.C.: July 8, 2009.
Catastrophic Disasters: Federal Efforts Help States Prepare for   and Respond to Psychological Consequences, but FEMA’s Crisis  Counseling Program Needs Improvements. GAO-08-22. Washington, D.C.:  February 29, 2008.
Hurricane Katrina: Allocation and Use of $2 Billion for Medicaid and  Other Health Care Needs. GAO-07-67. Washington D.C.: February 28, 2007.
Hurricane Katrina: Status of Hospital Inpatient and Emergency  Departments in the Greater New Orleans Area. GAO-06-1003.  Washington, D.C.: September 29, 2006.
Hurricane Katrina: Status of the Health Care System in New Orleans  and Difficult Decisions Related to Efforts to Rebuild It Approximately   6 Months after Hurricane Katrina. GAO-06-576R. Washington, D.C.:  March 28, 2006.
Hurricane Katrina: GAO’s Preliminary Observations Regarding  Preparedness, Response, and Recovery. GAO-06-442T. Washington, D.C.:  March 8, 2006.
Mental Health Services: Effectiveness of Insurance Coverage and Federal  Programs for Children Who Have Experienced Trauma Largely  Unknown. GAO-02-813. Washington, D.C.: August 22, 2002.