Health Resources and Services Administration: Review of Internal Communication Mechanisms, Staffing, and Use of Contracts
Published: 2013-12-03T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: HRSA is charged with improving access to health care services for people who are uninsured, isolated, or medically vulnerable. HRSA carries out its mission by providing funding and support to a wide variety of programs, which have grown in number and size since the agency was established in 1982. To manage these programs, HRSA has a staff of nearly 1,900 employees, supplemented by contract staff who perform a variety of tasks to support HRSA's programs and operations. HRSA's staff are organized into seven programmatic bureaus that are responsible for overseeing HRSA's programs and nine cross-cutting operational support offices--each of which reports to the Office of the Administrator. In recent years, GAO reported on weaknesses in HRSA's oversight and monitoring of certain programs.
Given GAO's past findings and the expansion of the agency's programs, GAO was asked to review HRSA's management and operations. This report examines (1) HRSA's internal communication mechanisms and how they are used to support the agency's mission; (2) HRSA's staffing and how the agency plans for attrition; and (3) HRSA's use of contracts to support its operations. GAO reviewed and analyzed HRSA's communication methods and organizational structure; analyzed data on HRSA personnel and contracts for fiscal years 2008 through 2012; interviewed HRSA officials knowledgeable about the agency's organization, staffing, and use of contracts; and reviewed relevant documentation.
section_title: What GAO Found
paragraphs: The Department of Health and Human Services' (HHS) Health Resources and Services Administration (HRSA) has mechanisms in place to share information important for supporting the agency's mission across its various organizational components and levels of staff--a practice that is consistent with internal control standards for the federal government. These communication methods include an annual operational planning process for allocating agency resources, workgroups that involve staff from across the agency to work on issues of a cross-cutting nature, and regular meetings between the Office of the Administrator and leaders of the agency's various organizational components.
HRSA's staff grew by more than 30 percent from fiscal years 2008 to 2012. The number of HRSA employees grew from 1,418 in fiscal year 2008 to 1,857 in fiscal year 2012. According to agency officials, the most common job function within HRSA is a project officer--an employee responsible for the oversight of grantees funded by the agency's programs; and HRSA has over 400 project officers. From fiscal years 2008 through 2012, HRSA lost an average of 9 percent of its staff annually to attrition. Of those who left HRSA in fiscal year 2012, approximately 59 percent resigned and 35 percent retired. Agency-wide, over 30 percent of HRSA's permanent employees will be eligible to retire by the end of fiscal year 2017. An even larger portion of HRSA's leadership, nearly 50 percent, will be eligible to retire by 2017. If a large portion of the agency's leadership were to actually retire during this time period, HRSA runs the risk of having gaps in leadership and potential loss of important institutional knowledge. HRSA periodically tracks attrition and retirement eligibility. To respond to retirements and other attrition, HRSA has instituted succession planning efforts which generally focus on leadership development for agency staff. For example, HRSA has instituted two leadership development programs, has two other programs under development, and has established mentoring and coaching programs.
In fiscal year 2012, HRSA obligated over $240 million, or about 3 percent of its appropriations, to contracts to acquire goods and services necessary to support its operations, an amount that has generally remained steady over the past few years. Over half of the fiscal year 2012 contract obligations were for two categories of services--information technology and telecommunications services, and professional support services, which includes providing technical assistance to grantees. According to HRSA officials, the agency uses contracts to support its operations for a variety of reasons; these include supplementing HRSA staff or fulfilling short-term needs and performing functions that require specialized skills for which HRSA staff do not have the appropriate expertise, such as clinical or financial expertise.
We provided a draft of this report to HHS for its review. In its written comments, HHS noted that the report recognized the mechanisms HRSA has in place to ensure the coordinated flow of communication and plan for succession.

section_title: Letter
paragraphs: The Health Resources and Services Administration (HRSA), an agency  within the Department of Health and Human Services (HHS), is charged  with improving access to health care services for people who are  uninsured, isolated, or medically vulnerable. HRSA’s scope of work has  evolved since it was established in 1982 and its programs have grown in  number and size. According to information provided by HRSA, in the last  decade, the agency’s appropriation has also increased in nominal dollars  from approximately $7.2 billion in fiscal year 2003 to about $8.1 billion in  fiscal year 2013. Some of the agency’s recent growth is due to additional  authority, responsibilities, and funding for HRSA programs provided  through the American Recovery and Reinvestment Act of 2009 (ARRA)  and the Patient Protection and Affordable Care Act (PPACA). According  to HRSA, ARRA provided an additional $2.5 billion from fiscal years 2009  through 2011 and PPACA authorized an additional $8.2 billion for the  agency’s programs from fiscal years 2010 through 2014. While HRSA’s  programs and responsibilities have expanded, the agency is also facing  new challenges as a result of sequestration,implement a hiring freeze in January 2013.   which led the agency to  To carry out its mission “to improve health and achieve health equity  through access to quality services, a skilled health workforce, and  innovative programs,” HRSA provides leadership and financial support to  more than 3,000 grantees, including organizations in every state. These  grantees serve millions of people each year through a variety of HRSA- sponsored programs. For example, through its Health Center Program,  HRSA awards grants to nonprofit community-based or public  organizations that provide comprehensive primary care services to  millions of people regardless of their ability to pay for care. HRSA also  provides funding for poison control centers; programs for organ, bone  marrow, and cord blood donation; and scholarships to students and loan  repayment to health care providers who agree to work in underserved  areas. HRSA also has programs that award grants to organizations that  provide health care to people living with human immunodeficiency virus  and acquired immunodeficiency syndrome (HIV/AIDS); pregnant women,  mothers, and children; and people living in rural communities.
To manage its diverse array of programs, HRSA has a staff of almost  1,900 employees, supplemented by contract staff who perform a variety  of tasks to support HRSA’s programs and operations. HRSA staff are  organized into the Office of the Administrator and 16 other organizational  components—7 programmatic bureaus that are responsible for  overseeing HRSA’s programs, and 9 cross-cutting operational support  offices—each of which reports to the Office of the Administrator. Staff  must communicate across these bureaus and offices to accomplish  certain tasks such as planning for the agency’s budget, allocating staff,  implementing the HRSA-related provisions in PPACA, and overseeing  grantees.
In recent years, we reported on weaknesses in HRSA’s oversight and  monitoring of certain programs. For example, in 2011, we reported that  HRSA’s oversight of the 340B Drug Pricing Program—a program through  which drug manufacturers give certain covered entities access to  discounted prices on outpatient drugs—was inadequate to ensure that  covered entities were in compliance with program requirements. In  addition, in 2012, we reported that HRSA did not consistently follow HHS  regulations and guidance in its oversight of grantees under the Ryan  White Comprehensive AIDS Resources Emergency Act of 1990. We  also reported in 2012 that HRSA’s oversight of its Health Center Program  grantees was insufficient to ensure that the agency consistently identified  all instances of grantee noncompliance with Health Center Program  requirements.
Given our past findings of weaknesses in HRSA’s oversight of certain  programs, the importance of the agency’s programs to low-income and  underserved populations, and the expansion of the agency’s programs,  you asked us to review HRSA’s management and operations, including  how the agency uses contracts to support its operations. In this report, we  examine (1) HRSA’s internal communication mechanisms and how they  are used to support the agency’s mission; (2) HRSA’s staffing and how  the agency plans for attrition; and (3) how HRSA uses contracts to  support its operations.
To examine HRSA’s internal communication mechanisms and how they  are used to support the agency’s mission, we reviewed and analyzed  HRSA’s methods of communication, organizational structure, and  reporting arrangements overall and at the bureau and office level. In  addition, we interviewed the leaders of each bureau and selected  operational support offices, as well as agency-level officials about a range  of management practices related to communication among agency,  bureau, and office leaders. We reviewed relevant documents such as  organizational charts, meeting minutes, and agency reports and memos.  As part of our review, we assessed whether HRSA’s communication  mechanisms and practices were consistent with internal controls related  to communication.
To examine HRSA’s staffing and how the agency plans for attrition, we  analyzed trends in HRSA personnel data for the most recent five-year  period, fiscal years 2008 through 2012, from the Office of Personnel  Management’s Enterprise Human Resources Integration-Statistical Data  Mart (formerly the Central Personnel Data File) for civilian employees and  HHS’s Commissioned Corps Personnel and Payroll System for  employees in the U.S. Public Health Service Commissioned Corps.our analysis we combined data from both systems to create a complete  picture of HRSA’s staff. We analyzed data from these two systems to  determine  the number of staff overall and by location, organizational component,  and pay plan; attrition rates and the reasons for attrition, which include resignation,  retirement, termination, and death; retirement eligibility for HRSA staff from fiscal years 2012 through  2017, by using birth date and service computation date, as well as  retirement eligibility requirements for civilian employees and  Commissioned Corps officers.
We used the 2-year “onboard” average as the base population of “onboard” staff in a  particular year to calculate attrition. These calculations include anyone who left HRSA,  including those who left HRSA for jobs with other agencies within HHS. To identify  individuals who left HRSA to go to another HHS agency, we tracked HRSA staff over the  time period of our review and counted individuals whose agency changed from HRSA to  another HHS agency as a departure due to resignation.
Payroll System, we conducted interviews with officials knowledgeable  about the system to understand the actions taken to ensure the data’s  consistency, accuracy, and completeness. We also conducted electronic  data testing for data reliability for both systems. We determined that the  data obtained from both systems were sufficiently reliable for our  purposes. In addition to analyzing data on HRSA staffing, we interviewed  HRSA officials including the leaders of each programmatic bureau  regarding staffing allocation decisions, practices, and challenges, as well  as the agency’s tracking and planning for staff attrition and retirements.  We also reviewed relevant documentation, such as strategic plans to  identify HRSA’s approach to staff planning, including for allocation,  attrition, and retirements. Finally, we assessed HRSA’s practices against  best practices for human capital management and planning.
To examine how HRSA uses contracts to support its operations, we  analyzed data on HRSA’s contracts from the Federal Procurement Data  System-Next Generation (FPDS-NG), the primary government-wide  contracting database which provides information on government  contracting actions and procurement trends. We focused our review on  contracts with obligations in fiscal year 2012 to determine dollar amounts  of contract obligations agency-wide and by organizational component, as  well as key characteristics of contracts used to support the agency’s  operations. To assess whether HRSA’s use of contracts has changed  significantly over time, we also reviewed data on the agency’s contracts  with obligations in fiscal years 2008 through 2011. To assess the  reliability of the HRSA data we obtained from FPDS-NG, we reviewed  recent audits and certifications of HRSA’s contract data, compared the  data we obtained with data provided by HRSA, and conducted electronic  data testing to look for obvious data errors. Based on this, we determined  that the data were sufficiently reliable for our purposes. To supplement  the data from FPDS-NG, we obtained information manually compiled by  HRSA on the organizational component supported by each contract with  obligations in fiscal year 2012. We also interviewed HRSA officials  knowledgeable about the agency’s contracts, contracting data, and  approach to determining when and how to use contractors, and leaders of  HRSA’s programmatic bureaus about how the bureaus use contracts to  support their programs. In addition, we reviewed relevant documentation  about HRSA’s process for requesting and approving the need for contract  support such as procurement plan, operating plan, and decision memo  documentation.
We conducted this performance audit from January 2013 to December  2013 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: HRSA was established in 1982, and its mission is to improve health and  achieve health equity through access to quality services, a skilled health  workforce, and innovative programs. HRSA’s strategic plan contains four  main goals: (1) improve access to quality health care and services,   (2) strengthen the health workforce, (3) build healthy communities, and  (4) improve health equity. HRSA also has a human capital strategic plan  meant to ensure that the agency has the workforce it needs to carry out  its mission. That plan contains five main goals: (1) plan for and align the  workforce to ensure employees have the right experience and skills to fit  the job, (2) support continuous learning, (3) build leadership bench   (4) strengthen the performance culture, and (5) improve  strength,employee satisfaction. As of September 2013, HRSA was in the process  of updating its human capital strategic plan for the 2013 through 2015  timeframe.
subsections: section_title: Overview of HRSA Operations
paragraphs: According to information from HRSA, the agency had appropriations of  about $8.1 billion in fiscal year 2013. Since its inception in 1982, HRSA’s  appropriations have generally increased in real terms. (See fig.1.)  Increases to HRSA’s appropriations since fiscal year 2009 can partially  be attributed to ARRA and PPACA. According to HRSA, ARRA provided  an additional $2.5 billion to the agency from fiscal years 2009 through  2011. HRSA received approximately $7.8 billion through PPACA from  fiscal years 2010 through 2013, and is expecting another $400 million in  fiscal year 2014, for a total of about $8.2 billion over the 5 years.
According to HRSA, in fiscal year 2012 the agency used over 90 percent  of its budget on funding for its programs through grants, cooperative  agreements, scholarships and loan repayments, and other forms of  programmatic funding.  In addition to these funding mechanisms, HRSA  uses contracts—award mechanisms used to acquire services or property  from a non-federal party for the benefit or use of HRSA—to support its  operations and programs.
Grants constitute one form of federal assistance consisting of payments in cash or in  kind to a state or local government or a nongovernmental recipient for a specified  purpose. Cooperative agreements are another form of financial assistance similar to  grants, but where the federal agency is more involved with the recipient during the  performance of the project. HRSA also has programs that offer scholarships to students  and educational loan repayment to health care providers in exchange for a commitment to  provide care in underserved areas or for underserved populations.
Through these mechanisms, HRSA provides funding and support for a  wide variety of programs. HRSA’s programs include a block grant to fund  services for maternal and child health across the country, compensation  for people injured by vaccines, grants to a national network of health  centers to provide primary health care, loan repayment and scholarships  for recruiting and training health care providers who practice in  underserved communities, and grants to organizations providing services  for people living with HIV/AIDS. As a result of ARRA and PPACA,  HRSA has expanded some of its programs, and started new programs in  recent years. For example, HRSA expanded its Health Center Program  and established a Home Visiting Program to improve coordination of  services and outcomes for families living in at-risk communities.
HRSA’s staff of nearly 1,900 provides oversight, technical assistance, and  operational support for the agency’s programs. Its workforce consists of  permanent civilian staff, including those within the General Schedule (GS)  employment system, the Senior Executive Service (SES), and other   HRSA also employs staff from the  government pay plans. Commissioned Corps. In addition to permanent civilian and  Commissioned Corps staff, HRSA also employs some nonpermanent  staff. For example, for its grant review panels, advisory committees, and  certain other activities, HRSA may hire individuals for discrete, time- limited activities for which a particular expertise is needed. HRSA has  headquarters staff who are assigned to the agency’s headquarters in  Rockville, Maryland, and “regional staff” who work in 1 of the agency’s 10  regional offices or 1 of 2 field locations across the United States and  Puerto Rico (see fig. 2).
The GS system is a classification and pay system for the majority of civilian federal  employees. The GS system has 15 grades—GS-1 (lowest) to GS-15 (highest). SES  positions are federal employee positions that are classified above GS-15. Other  government pay plans for which HRSA has staff include the federal wage system for  hourly, blue collar employees and a pay plan for physicians and dentists.
section_title: HRSA’s Organizational Structure
paragraphs: HRSA’s organization consists of the Office of the Administrator and 16  other organizational components—7 programmatic bureaus and 9 cross- cutting operational support offices (see fig. 3).
HRSA’s Office of the Administrator provides broad leadership and  direction to HRSA staff and plans, directs, and interprets major policies,  programs, and initiatives for the agency. The Office of the Administrator  also makes final decisions about HRSA’s organization, staff allocation,  budget, and contracts. The office includes HRSA’s Administrator, Deputy  Administrator, and Senior Advisors. HRSA’s seven programmatic bureaus  each manage a portfolio of activities dealing with a specific area of health  care services, systems, or workforce. Each of HRSA’s bureaus is led by  an Associate Administrator and Deputy Associate Administrator, who are  generally members of the SES. The bureaus are organized into smaller  components called divisions or offices that are led by a director, generally  a GS-15, who reports to the bureau’s Associate Administrator. Some of  these divisions and offices are further broken down into subcomponents  called branches which are led by chiefs who report to the division or office  directors. HRSA’s nine operational support offices provide assistance for  the agency’s programmatic work and coordination for cross-cutting or  agency-wide issues, such as human resources, acquisitions  management, and grants administration. (See table 1 for an overview of  HRSA’s bureaus and offices and app. I for a list of HRSA programs by  bureau.)
HRSA’s underlying organizational structure of bureaus and offices has  been in place for some time; however, since 2010, the agency has made  several organizational changes. These included creating new  organizational components, expanding or otherwise changing the  functions of some components, and consolidating functions in order to  eliminate a component. In addition, HRSA has made minor organizational  changes within bureaus, such as realigning branches or shifting oversight  responsibility of certain programs, and the staff responsible for them,  between or within bureaus. HRSA officials reported that organizational  changes were generally made to improve agency efficiency. For example,  in 2010, HRSA established the Office of Operations to consolidate three  previously separate offices: (1) the Office of Information Technology;      (2) the Office of Management; and (3) the Office of Financial  Management, which consisted of procurement, budget, policy, and control  functions. These offices had formerly each reported directly to the Office  of the Administrator. With this restructuring, the Chief Operating Officer— a position created in 2010—gained responsibility for oversight of these  functions. In at least one instance, HRSA made a change as a result of a  legislative requirement, namely, in October 2011 HRSA made its Office of  Women’s Health, which was previously located within its Maternal and  Child Health Bureau, a separate office in response to a requirement in  PPACA that the office be established within the Office of the  Administrator. Most recently, as a result of fiscal circumstances,  including the sequester which went into effect in March 2013, and an  ongoing hiring freeze in effect since January 2013, HRSA eliminated its  Office of Special Health Affairs and distributed most of its functions to  other existing bureaus and offices. According to HRSA, the elimination  of the Office of Special Health Affairs was made to reduce overhead costs  and better utilize staff.
section_title: HRSA Has Mechanisms in Place for Multi-Directional Communication Throughout the Agency
paragraphs: HRSA has mechanisms in place to share information important for  supporting the agency’s mission across various levels of staff in the  agency, including among agency leaders, programmatic bureau and  operational support office leaders, and staff. These communication  mechanisms include the agency’s operational planning process; cross- cutting workgroups and meetings; and regular communications among  the Office of the Administrator, leaders in the bureaus and offices, and  agency staff. The mechanisms HRSA has in place are consistent with  internal control standards for the federal government, which state that  effective communications within organizations should occur in a broad  sense with a flow of information down, across, and up the organization.
HRSA officials have established an annual operational planning process  to facilitate the exchange of information across the agency to plan its  budget and allocation of other resources. According to HRSA officials,  each bureau and office develops a proposal to request contracts, budget,  and other resources for the coming fiscal year. Next, these proposals are  shared and discussed among all bureau and office leaders to allow for  coordination and to reduce the risk of duplication or overlap of resources.  Finally, HRSA’s Administrator makes a determination about resource  allocation—such as budgets and contracts for the coming fiscal year— which is documented in a decision memo for each bureau and office.
Agency officials told us that this process improves efficiency and reduces  the chance for duplication of effort among the bureaus and offices.
In addition, HRSA has established 20 active workgroups to coordinate  across the agency’s bureaus and offices on cross-cutting topics. For  example, according to agency officials, HRSA established a workgroup in  April 2010— following the passage of PPACA—to coordinate  communications and activities related to the implementation of provisions  in the act pertaining to HRSA. The workgroup includes senior leaders  from across the agency or their designees. In November 2012, HRSA  established a Standard Operating Procedures Workgroup to monitor the  implementation of standard operating procedures related to grantee  oversight across bureaus, discuss the status of implementation, and to  share successful practices regarding their use. Members include  individuals who are tasked with leading the implementation of standard  operating procedures within each bureau. Another workgroup—the HRSA  Program Integrity Initiative Workgroup, launched in June 2010—is tasked  with identifying risks to the agency’s management of programs and  working to reduce those risks by initiating new or improved oversight  efforts. The workgroup is comprised of representatives from all bureaus  and offices. Other established workgroups focus on issues such as  providing technical assistance to potential grantees who may be new to  the application process, analyzing requests for information technology  capital projects, and monitoring performance of the agency’s ongoing  technology investments. In addition to the formal workgroups, officials in  all the bureaus told us they regularly work with colleagues from other  bureaus and offices as needed to coordinate on program areas where  topics and issues overlap.
HRSA also has mechanisms in place to ensure the flow of information up  and down the organizational hierarchy, such as from the Office of the  Administrator down to individual bureaus and offices. The Office of the  Administrator uses a variety of standing meetings and reporting tools to  communicate and exchange information with bureau and office leadership  on a broad range of policy, program, and management matters. For  example, HRSA’s Administrator holds a weekly senior staff meeting with  the leaders of all of HRSA’s bureaus and offices. Topics for discussion  include HRSA’s budget, operations, and implementation of PPACA.  During these meetings, bureau and office leaders have the opportunity to  share their concerns and discuss issues that they think may be of interest  to the other organizational components of the agency. In addition, officials  told us that HRSA’s Administrator, Deputy Administrator, and a Senior  Advisor hold a meeting every other week with each of the bureaus’  Associate Administrators to discuss any problems that arise concerning  grantees, plans for upcoming grant awards, program integrity issues, and  any other bureau news or updates. Officials indicated that HRSA’s  Administrator meets monthly with the directors from all nine operational  support offices; officials from the Office of the Administrator also meet  weekly for one-on-one discussions with the directors from most of these  offices. In addition, the leaders of each of the bureaus told us they hold  regular meetings with their staff such as one-on-one meetings with  division directors, weekly senior staff meetings within the bureau where  participants can raise issues of concern or topics for discussion, and “all- hands” meetings used to inform all bureau staff.
In addition to participating in these standing meetings, bureau leaders  make use of routine reports and other written communication to convey  key programmatic information from the bureau to the Office of the  Administrator. For example, bureau leaders provide monthly written  updates on their programs and activities for inclusion in an agency-level  report for the Secretary of HHS. These reports include information about  HRSA collaboration with other agencies, programmatic updates, status of  efforts related to PPACA, areas of concern, and completed congressional  testimonies. HRSA officials also prepare decision papers to outline policy  options for the Administrator’s consideration. For example, officials sent  decision papers to the Administrator to outline proposals for  organizational changes, such as the disbanding of the Office of Special  Health Affairs. These papers outlined the rationale for the change, budget  and staffing implications, and specific recommendations for the  Administrator.
section_title: HRSA’s Staff Has Grown in Recent Years; About Half of Its Leadership Will Be Eligible to Retire by 2017
paragraphs: HRSA’s staff has grown approximately 30 percent over the last 5 years.  While the number of staff has grown, HRSA experienced attrition  averaging 9 percent per year over the past five years. Looking forward,  almost half of HRSA’s leadership will be eligible to retire by fiscal year  2017. HRSA periodically tracks attrition and retirement eligibility and has  focused its succession planning efforts on leadership development.
subsections: section_title: HRSA’s Staff Has Grown in Recent Years with the Largest Segment of Staff Concentrated at the GS-13 Level
paragraphs: HRSA’s staff grew by more than 30 percent from fiscal years 2008 to  2012; the number of HRSA employees at the end of each fiscal year grew  from 1,418 in fiscal year 2008 to 1,857 in fiscal year 2012. (See fig. 4.)  HRSA officials indicated that the staffing increases correspond in part  with HRSA’s increased responsibilities and funding due to ARRA and  PPACA. The majority of HRSA’s staff, about 86 percent in fiscal year  2012, were stationed in HRSA’s Rockville, Maryland headquarters. The  remaining employees were regional staff who were located in one of  HRSA’s 10 regional offices or 2 field locations in the United States and  Puerto Rico. While the overall number of staff grew, the total number of  regional staff declined by about 14 percent—from 311 in fiscal year 2008  to 269 in fiscal year 2012.
HRSA’s organizational components vary in size and how staff are  distributed across headquarters and regions. As of the end of fiscal year  2012, the organizational component with the greatest number of staff was  the Bureau of Primary Health Care (308 employees) and the one with the  fewest staff, with 4 employees, was the Office of Women’s Health. Eight  of HRSA’s organizational components—five programmatic bureaus and  three operational support offices—had regional staff. The Office of  Regional Operations had the largest number and proportion of regional  staff–70 of 84 staff (83 percent), followed by the Healthcare Systems  Bureau (40 percent) and the Bureau of Clinician Recruitment and Service  (25 percent). (See fig. 5.)
As of the end of fiscal year 2012, HRSA’s staff were employed in one of  76 job occupations. The 5 most common occupations were: Public  Health Program Specialist (635 employees), Management and Program  Analysis (336 employees), General Health Science (165 employees),  Grant Management (92 employees), and Miscellaneous Administration  and Program (70 employees). Officials indicated that within HRSA, the  most common job function is a project officer. HRSA has over 400 project  officers who are responsible for the ongoing oversight of an assigned  portion of program funding recipients, such as grantees. Individuals from  different occupations may serve as project officers, as the project officer  function is not a distinct occupation.
The majority of HRSA’s staff, 1601 individuals or 86 percent of the staff in  fiscal year 2012, were civilians within the GS pay plan, with GS-13s  representing the largest number of employees—651 staff members   (35 percent of HRSA employees). The remaining HRSA staff were SES,  Commissioned Corps officers, or employees paid under one of several  additional civilian pay plans. (See fig. 6 for the distribution of HRSA staff  by pay plan.) Within HRSA, 510 staff members (27 percent) were GS-14s  or above (including individuals in the SES)—individuals who are generally  supervisors, according to HRSA officials.
From fiscal years 2008 through 2012, HRSA lost an average of about   9 percent of its staff per year to attrition. HRSA’s annual attrition rates  from fiscal years 2008 through 2012 ranged from a low of 7.6 percent in  fiscal year 2009 to a high of 9.9 percent in fiscal year 2008. In fiscal   year 2012, HRSA had an attrition rate of 8.8 percent. Of those who left  HRSA in that year, approximately 59 percent resigned, 35 percent retired,  and 4 percent were terminated or removed.
Attrition rates varied by pay plan and organizational component. In fiscal  year 2012, attrition ranged from a high of 16.1 percent among GS-1s  through GS-8s to a low of 3.9 percent for SES employees. While three  organizational components, including the Office of the Administrator, had  no attrition in fiscal year 2012, the Office of Planning, Analysis, and  Evaluation had an attrition rate over 21 percent. Across HRSA’s  programmatic bureaus, attrition rates ranged from 6.1 percent in the  Office of Rural Health Policy to 13.4 percent in the Bureau of Health  Professions. (See fig. 7.)
Agency-wide, 31.3 percent of HRSA’s permanent employees will be  eligible to retire by the end of fiscal year 2017; a rate similar to that for the  entire federal government. However, a larger portion of HRSA’s  leadership, nearly 50 percent, is eligible to retire in the next few years.  Specifically, over 55 percent of HRSA’s SES employees, who serve as  the leaders of HRSA’s bureaus and offices, and almost 50 percent of   GS-15s, which include Division Directors, will be eligible to retire by the  end of fiscal year 2017. Although eligibility to retire does not necessarily  mean that employees will do so at the time they become eligible, if there  were a large number of retirements among the agency’s leadership  during this time period, HRSA runs the risk of having gaps in leadership  and potential loss of important institutional knowledge.
Within HRSA, retirement eligibility rates also vary by organizational  component. By fiscal year 2017, over 40 percent of the employees in  HRSA’s Office of the Administrator, the Healthcare Systems Bureau, the  Maternal and Child Health Bureau, and several of HRSA’s operational  support offices, will be eligible to retire. (See fig. 8.)
HRSA periodically tracks attrition and retirement eligibility data. Collecting  and analyzing data on attrition rates and retirement eligibility are  considered a fundamental element for measuring the effectiveness of  human capital approaches in support of an agency’s mission and goals.  HRSA receives a quarterly report from HHS that provides agency-wide  attrition data by reason for departure. Additionally, HRSA officials stated  that staff in the Office of Operations track employee attrition data as  needed for making agency-wide hiring and budget decisions. According  to these officials, staff attrition data is shared with leaders of the  programmatic bureaus and operational support offices as requested, or  when high rates of attrition occur.
In addition to reviewing attrition data, officials from several bureaus  reported that they use information from exit interviews to help them  understand the reasons for attrition. According to officials, a common  reason why staff leave the agency is limited promotion potential,  particularly from the GS-12 or GS-13 levels into more senior positions.  Another reason officials reported for attrition is that some employees have  expertise or skill sets that are easily transferrable and in demand  elsewhere, including within other HHS and federal agencies. In particular,  officials noted that the skill sets of project officers and those with  information technology backgrounds are highly sought elsewhere in the  government. While exit interviews provide insight into why staff are  leaving the agency, officials also reported that they use information from  the Federal Employee Viewpoint Survey to get a sense of the number of  staff considering leaving the agency in the next year.
HRSA also tracks retirement eligibility at the agency, bureau, and office  levels. Quarterly, HRSA receives agency-wide data from HHS on the  proportion of staff, including supervisory staff, eligible to retire in the next  5 years. Additionally, in early 2013, HRSA officials began providing  leaders in each bureau and office with the names and retirement eligibility  dates of their staff who are eligible to retire within the next 5 years. HRSA  officials indicated they plan to provide these data on an annual basis  going forward; however, officials indicated that the retirement eligibility  reports are of limited use to them because eligibility to retire does not  mean that an employee actually plans to retire.
To respond to retirements and other types of attrition, HRSA has  instituted succession planning efforts which generally focus on providing  leadership development to agency staff. In 2011, HRSA launched two  agency-wide leadership development programs to help prepare staff to  take on leadership roles when such opportunities arise. One of these  programs, the Mid-Level Leadership Development Program, is for staff at  the GS-12 and GS-13 levels and focuses on leadership skills  development, interdepartmental project experience, exposure to HRSA  leaders, and an understanding of HRSA’s mission, challenges, and  opportunities. The other program, the Administrative Management  Development Program, focuses on individuals who are interested in  careers handling the administrative management functions of the agency.  HRSA officials indicated that, as of September 2013, 59 staff had  completed one of these two programs. According to HRSA officials, as of  July 2013, the agency was in the process of developing two additional  leadership development programs—one targeted to staff at the GS-11  level and below and another for staff at the GS-14 and GS-15 levels.  Officials estimated these additional programs would become operational  in fiscal year 2014.
In addition to leadership development programs, HRSA officials said that  there are several other opportunities for staff to gain leadership  experience and professional development. For example, HRSA has  established a mentoring program, which focuses on leadership  development for both the participating mentor and mentee, and a  coaching program, which provides participating supervisors and  managers with opportunities to focus on specific areas for further  development. Officials across the agency also promote opportunities for  employees to be assigned to acting roles in more senior positions when  there is a vacant position or when a supervisor is on leave. For example,  if a branch chief were to retire or be out of the office for an extended  period, a senior level employee in the branch may be asked to act as the  branch chief until the position can officially be filled or the branch chief  returns. HRSA officials indicated that they work to train individuals to  enhance their capabilities, which may better position staff to be  successful candidates when leadership positions open up in the agency.  In addition, opportunities to serve in an acting capacity in a role more  senior to their own allows employees to smoothly transition into a position  should they be selected for it on a permanent basis. For example, HRSA  officials we spoke with told us that when the Associate Administrator of  one of the bureaus was recently promoted—leaving a key vacancy—the  Deputy Associate Administrator served as Acting Associate Administrator  until promoted into the position permanently. Leaders from some bureaus  also noted additional bureau-specific succession planning efforts. For  example, the HIV/AIDS Bureau created its Organizational Development  Unit in fiscal year 2012 to help deal with staff attrition issues within the  bureau by providing training, helping staff create individual development  plans, and providing mentoring opportunities to encourage staff to stay  and continue to grow professionally.
HRSA officials told us they also promote cross-training opportunities  among staff, where employees work on multiple programs to assure a  broader range of knowledge so that they are able to take over for each  other should someone leave the bureau or agency. For example, Office of  Rural Health Policy leaders said that they have their staff work on multiple  programs to ensure they obtain a broader range of skills than they would  acquire by working on just one program. Similarly, they assign their policy  staff to a lead and backup role on key regulations so that if one person  leaves the organization or is out of the office for an extended period of  time, another is also familiar with the topic and able to complete the  review. HRSA officials noted that some of these succession planning  efforts, such as leadership training, also help with staff retention. In  addition, officials noted that they have other efforts in place to promote  staff retention, such as employee recognition and morale boosting  opportunities.
section_title: HRSA Obligated Over $240 Million for Contracts in Fiscal Year 2012, the Majority of Which Were for Information Technology and Program Support
paragraphs: In fiscal year 2012, HRSA obligated over $240 million, or about 3 percent  of its appropriations, to contracts to acquire goods or services necessary  to support its operations. With the exception of fiscal year 2008, when  HRSA had approximately $167 million in contract obligations, the amount  of HRSA’s contract obligations generally remained steady over the past   5 years. (See fig. 9.)
The vast majority of HRSA’s fiscal year 2012 contract obligations  (approximately 97 percent) were used to obtain services, while the  remaining 3 percent of obligations went toward goods, such as computer  software. Nearly 60 percent of HRSA’s fiscal year 2012 contract   (1) information  obligations were for two categories of services:technology and telecommunications services, which includes HRSA’s  contract to support the operation and management of the agency’s online  system for documenting its grantee oversight activities, called the  Electronic Handbook; and (2) professional support services, which  includes HRSA’s contracts for the provision of technical assistance, such  as site visits, to grantees. (See table 2.)
In fiscal year 2012, nearly 40 percent, or $95,697,751, of HRSA’s contract  obligations provided cross-cutting support, meaning that they were  utilized by more than one HRSA organizational component. The  remaining 60 percent of HRSA’s obligations were for programs and  activities specific to a single programmatic bureau, though the amount of  obligations varied by bureau. (See table 3 for a summary of the amount of  contract obligations by organizational component and app. II for  information on the contract with the highest obligation for each  component.)
HRSA’s bureaus utilized contracts for different purposes. For example,  nearly 78 percent of the Bureau of Health Profession’s fiscal year 2012  obligations were for information technology and telecommunications  services, primarily for the National Practitioner Data Bank, while the  Maternal and Child Health Bureau did not have any obligations for that  purpose.Bureau’s obligations in fiscal year 2012 were for professional services  such as for a newborn hearing, screening, and intervention programs  study, while about 12 percent of the Bureau of Health Professions’  obligations were for professional services. See appendix III for  information on the top categories of contracted services or goods by  organizational component.
Conversely, 69 percent of the Maternal and Child Health  According to HRSA officials, the agency uses contracts to support its  operations for a variety of reasons, including to supplement HRSA staff  because of time constraints, or to fulfill short-term needs. In addition,  HRSA uses contracts to perform functions that require specialized skills  for which HRSA staff do not have the appropriate expertise, such as  clinical or financial expertise. For example, the Office of Rural Health  Policy uses contract staff with special expertise in areas such as oral and  primary health care to provide technical assistance to its broad range of  grantees, while the Bureau of Primary Health Care uses contract staff  with financial expertise to conduct site-visits to health center grantees,  assist HRSA staff with understanding grantees’ financial audits, and help  grantees develop plans to improve their financial stability. Furthermore,  according to HRSA officials, the agency uses contracts to support its  operations when contract staff can perform the functions more efficiently  and at a lower cost than HRSA staff. For instance, the Maternal and Child  Health Bureau obtains logistical support services, such as supporting  large advisory committee meetings, from a contractor because it is more  efficient and cost effective than having bureau staff manage these  functions. Finally, HRSA uses contracts for other reasons including when  the agency is legislatively required to do so. For example, HRSA is  required by law to contract with one or more entities to carry out certain  aspects of its C.W. Bill Young Cell Transplantation Program, a program  overseen by the Healthcare Systems Bureau related to cord blood, bone  marrow, and transplantation.
section_title: Agency Comments
paragraphs: We provided a draft of this report to HHS for its review. In its written  comments, HHS noted that the report recognized the mechanisms HRSA  has in place to ensure the coordinated flow of communication and plan for  succession. (HHS comments are reprinted in app. IV.)
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 the Administrator of HRSA.  In addition, the report will be available on the GAO website at  http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or draperd@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 V.
section_title: Appendix I: Health Resources and Services Administration’s (HRSA) Programs by Programmatic Bureau, Fiscal Year 2013
subsections: section_title: Programs Bureau of Clinician Recruitment and Service Faculty Loan Repayment Program
paragraphs: Provides individuals from disadvantaged backgrounds with an eligible health professions  degree (e.g., dentistry, physician assistant) opportunities to serve as faculty members in  an accredited and eligible health professions school for a minimum of two years. For each  year of service, participants are awarded up to $30,000 for their educational loans.
Designates federal HPSAs (areas in which there may be a shortage of primary medical  care, dental, or mental health providers), Medically Underserved Areas (areas in which  residents have a shortage of personal health services), and Medically Underserved  Populations (which may include groups of persons who face economic, cultural, or  linguistic barriers to health care). Shortage designations are used to prioritize HRSA’s  health professional scholarship and loan repayment programs and other federal and state  programs.
Offers assistance to HPSAs in every U.S. state and territory to recruit and retain qualified  primary care providers by providing scholarships or loan repayments to individuals who  agree to provide services in shortage areas.
Supports the demand for more health care professionals to deliver primary health  services to Native Hawaiians in the State of Hawaii by providing scholarships in return for  a commitment to serve in designated areas for a specified time period.
Alleviates the shortage of nurses and economic barriers that may be associated with  pursuing a career in nursing or teaching as nurse faculty by offering loan repayment  assistance to registered nurses in return for a commitment to serve as a nurse in a critical  shortage facility (in designated HPSAs) or as nurse faculty at an accredited eligible school  of nursing, and offering scholarships to nursing students in return for service in a critical  shortage facility.
In partnership with HRSA’s Bureau of Primary Health Care, this program supports  cooperative agreements with 54 State Primary Care Offices and territorial agencies to  facilitate the coordination of activities such as needs assessments and technical  assistance within a state that relate to the delivery of primary care services, and the  recruitment and retention of critical health providers.
Provides infrastructure grants to schools to build and enhance advanced nursing  education programs, and two traineeships—the Advanced Education in Nursing  Traineeship and the Nurse Anesthetist Traineeship. In addition, the Advanced Nursing  Education Expansion Program provides grants to schools of nursing to accelerate the  production of primary care advanced practice nurses.
Promotes a national role in addressing health care workforce shortages, particularly in the  areas of health career awareness and interdisciplinary and interprofessional community- based primary care training.
Supports activities to enhance the academic performance of underrepresented minority  students, support underrepresented minority faculty development, and facilitate research  on minority health issues.
Supports graduate medical education and training of residents and fellows in freestanding  children’s teaching hospitals and enhances the supply of primary care and pediatric  medical and surgical subspecialties.
Description  Provides support to train and educate individuals who provide geriatric care for the  elderly.
Improves access to quality health care to the elderly through a range of programs that  focus on increasing the number of geriatric specialists and increasing geriatrics  competencies in the generalist workforce through education and training to improve care.
Collects and analyzes health workforce data and information through the National Center  for Health Workforce Analysis (National Center) in order to provide national and state  policy makers and the private sector with information on health workforce supply,  demand, and needs. The National Center also evaluates workforce policies and programs  as to their effectiveness in addressing workforce issues.
Supports activities for kindergarten through 12th grade, baccalaureate, post- baccalaureate, and graduate students to improve the recruitment and enhance the  academic preparation of students from disadvantaged backgrounds into the health  professions.
Works to close the gap in access to mental and behavioral health care services by  increasing the number of adequately prepared mental and behavioral health and  substance abuse providers.
Serves as a flagging system intended to prompt a comprehensive review of health care  practitioners’ licensure activity, medical malpractice payment history and record of clinical  privileges. Used in conjunction with information from other sources, the National  Practitioner Data Bank assists in promoting quality health care, and deterring fraud and  abuse in the health care delivery system.
Supports initiatives to expand the nursing pipeline, promote career mobility, enhance  nursing practice, provide continuing education, and support retention.
Supports the establishment and operation of a loan fund within participating schools of  nursing to assist nurses in completing their graduate education to become qualified nurse  faculty.
Increases nursing education opportunities for individuals from disadvantaged  backgrounds, including racial and ethnic minorities underrepresented among registered  nurses, by providing student stipends and scholarships.
Includes a range of programs designed to increase access to culturally competent, high  quality dental health services to rural and other underserved communities by increasing  the number of oral health care providers and improving the training programs for oral  health care providers.
Primary Care Training and Enhancement  Supports and develops primary care physician and physician assistant training programs.
Supports activities that train public health and preventive medicine students, residents,  and professionals to enhance the supply and expertise of the public health workforce.
Increases diversity in the health professions and nursing workforce by providing grants to  eligible professions and nursing schools for use in awarding scholarships to students from  disadvantaged backgrounds with financial need, many of whom are underrepresented  minorities.
Provides Graduate Medical Education payments to support community-based training by  covering the costs of resident training in community-based ambulatory primary care  settings, such as health centers, and bolstering the primary care workforce.
section_title: Programs Bureau of Primary Health Care Free Clinics Medical Malpractice
paragraphs: Provides medical malpractice protection at sponsoring health clinics to encourage health  care providers to volunteer their time at free clinics, thus expanding the capacity of the  health care safety net.
Supports the construction and renovation of health centers.
The Health Center Program administers the Federal Tort Claims Act program, under  which employees of eligible health centers may be deemed to be federal employees  qualified for malpractice coverage under the Federal Tort Claims Act.
Provides grants to eligible health centers to deliver comprehensive, high-quality, cost- effective primary health care to patients regardless of their ability to pay.
Provides grants for the establishment of school-based health centers; grant funds can be  used for expenditures for facilities, equipment, or similar expenditures.
Requires drug manufacturers to provide discounts or rebates to a specified set of HHS- assisted programs and hospitals that meet the criteria in the Public Health Service Act  and the Social Security Act for serving a disproportionate share of low-income patients.
Provides compensation to individuals for serious physical injuries or deaths from  pandemic, epidemic, or security countermeasures.
Attempts to increase the number of transplants for recipients suitably matched to  biologically unrelated donors of bone marrow and cord blood.
Provides care and treatment for Hansen’s Disease (leprosy) and related conditions to any  patient living in the United States or Puerto Rico through direct patient care at its facilities  in Louisiana, through grants to an inpatient program in Hawaii, by contracting with 11  regional outpatient clinics, and providing payments to the State of Hawaii for hospital and  clinic facilities at Kalaupapa, Molokai, and Honolulu. Also provides for the renovation and  modernization of the Louisiana facilities to eliminate structural deficiencies and keep with  accepted standards of safety, comfort, human dignity, efficiency, and effectiveness.
Works on building a genetically and ethnically diverse inventory of high-quality umbilical  cord blood for transplantation.
Provides compensation to people found to be injured by certain vaccines given routinely  to children and adults, such as seasonal flu vaccine, measles, mumps, rubella, or polio.
Attempts to extend and enhance the lives of individuals with end-stage organ failure for  whom an organ transplant is the most appropriate therapeutic treatment by providing a  national system to allocate and distribute donor organs to individuals waiting for an organ  transplant.
Funds poison centers; maintains a single, national toll-free number to ensure universal  access to poison center services and connect callers to the poison center serving their  area; and implements a nationwide media campaign to educate the public and health  care providers about poison prevention, poison center services, and the toll-free number.
Provides grants to metropolitan areas experiencing the greatest burdens of the country’s  human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS)  epidemic, and provide those communities with resources they need to confront the highly  concentrated epidemic within the jurisdiction.
Description  Provides grants to all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin  Islands, Guam and 5 U.S. Pacific Territories or Associated Jurisdictions to provide  services for people living with HIV/AIDS. The AIDS Drug Assistance Program supports  the provision of HIV medications and related services.
Provides grants to 344 community and faith-based primary health clinics and public health  providers in 49 states, Puerto Rico, the District of Columbia, and the U.S. Virgin Islands  for targeting HIV medical services to underserved and uninsured people living with  HIV/AIDS in specific geographic communities, including rural and frontier communities.
Provides grants to public or private nonprofit entities that provide or arrange for primary  care and support services for HIV-positive women, infants, children, and youth.
Funds the AIDS Education and Training Centers—a network of 11 regional centers with  more than 130 local performance sites and five national centers—that offers specialized  clinical education and consultation on HIV/AIDS transmission, treatment, and prevention  to front-line health care providers.
Provides access to oral health care for people living with HIV/AIDS by reimbursing dental  education programs for the unreimbursed costs associated with providing care to people  with HIV and by working with partners to provide education and clinical training for dental  care providers, especially those in community-based settings.
Although overseen by multiple federal agencies, the HIV/AIDS Bureau manages HRSA’s  contributions to this program whose mission is to deliver HIV/AIDS care and treatment  and helps build sustainable health systems so that host countries can confront their  epidemics in the future.
Supports the development of innovative models of HIV care to quickly respond to the  emerging needs of clients served by the Ryan White HIV/AIDS CARE Act Program by  evaluating the effectiveness of the models’ design, implementation, utilization, cost, and  health-related outcomes, and promoting the dissemination and replication of successful  models.
Under the auspices of the Combating Autism Act of 2006, this program supports activities  to provide information and education to increase public awareness, promote research into  the development and validation of screening tools and interventions, promote early  learning of individuals at higher risk, increase the number of individuals who are able to  confirm or rule out a diagnosis, and increase the number of individuals able to provide  evidence-based interventions for autism spectrum disorders or other developmental  disabilities.
Emergency Medical Services for Children  Focuses on generating evidence on best practices regarding pediatric emergency care as  well as direct outreach to the states, territories, and the District of Columbia to implement  these best practices.
Provides grants funded by the Patient Protection and Affordable Care Act to family- staffed, family-run organizations to ensure families have access to adequate information  about health care, community resources, and support in order to make informed decisions  around their children’s health care.
Provides grants to communities with exceptionally high rates of infant mortality to reduce  disparities in access to and utilization of health services, improve the quality of the local  health care system, empower women and their families, and increase consumer and  community voices and participation in health care decisions.
Description  Works to improve the ability of states to provide newborn and child screening for heritable  (genetic) disorders.
Provides grants to support the physiologic testing of newborn infants prior to their hospital  discharge; audiologic evaluation by three months of age; and entry into a program of early  intervention by six months of age with linkages to a medical home and family-to-family  support.
Aims to improve the health of all mothers, children, and their families to reduce health  disparities, improve access to health care, and improve the quality of health care. The  program has three components: (1) block grant funds to states distributed by formula;   (2) Special Projects of Regional and National Significance which supports a variety of  projects in research, training, screening, and other services; and (3) Community  Integrated Service Systems which supports projects that seek to increase the capacity for  service delivery at the local level and to foster formation of comprehensive, integrated,  community level service systems for mothers and children.
Collaborates with the Administration for Children and Families to improve coordination of  services for at-risk communities, to identify and provide comprehensive services to  improve outcomes for families who reside in at-risk communities, and to strengthen and  improve the programs and activities carried out under the Maternal and Child Health  Block Grant program.
Develops systemic mechanisms for the treatment of sickle cell disease and the  prevention of morbidity and mortality associated with the condition.
Provides grants to (1) fund the development and implementation of statewide systems  that ensure access to comprehensive and coordinated traumatic brain injury services  including: transitional service, rehabilitation, education and employment, and long-term  community support; and (2) provide services such as referrals, advice, and legal  representation to individuals with traumatic brain injury.
section_title: Office of Rural Health Policy Black Lung
paragraphs: Provides grants to public and private entities, including faith-based and community-based  organizations, to establish and operate clinics that provide for the outreach and  education, diagnosis, treatment, rehabilitation, and benefits counseling of active and  retired coal miners and others with occupation-related respiratory and pulmonary  impairments.
Provides grants to states, local governments, and appropriate health care organizations  to support programs for cancer screening for individuals adversely affected by the mining,  transport, and processing of uranium, and the testing of nuclear weapons for the nation’s  weapons arsenal.
Provides funds to community partnerships, which then purchase and distribute automatic  external defibrillators to be placed in rural communities and train emergency first  responders to use the devices.
Provides grants to improve access to care, coordination of care, integration of services,  and focus on quality improvement in rural communities.
Supports a range of policy analysis, research, and information dissemination for the  Office of Rural Health Policy.
Supports a range of activities focusing primarily on Critical Access Hospitals through  three grant programs: (1) the Medicare Rural Hospital Flexibility (Flex) Grant Program;   (2) Small Hospital Improvement Program; and (3) the Flex Rural Veterans Health Access  Program.
Provides grants to states to establish and maintain State Offices of Rural Health.
Description  Provides grants that support telehealth technologies through the following three  programs: (1) Telehealth Network Grant Program, which provides funding for pilot  projects to examine the cost impact and value-added from telehome care and tele- monitoring services and activities such as chronic disease management and distance  learning; (2) Telehealth Resource Center Grant Program, which provides technical  assistance to communities wishing to establish telehealth services; and (3) Licensure  Portability Grant Program, which assists states to improve clinical licensure coordination  across state lines.
As of April 2013, the Healthcare Systems Bureau managed two programs that no longer receive  funding: (1) the Health Care and Other Facilities Program, which provided grants for new  construction, renovation, design development and equipment to hospitals, community health centers,  universities, and research centers; and (2) the Hill-Burton Loan Guarantee and Project Grant  Program which provided loan guarantees and grants to facilities for construction. Although these  programs were not funded in fiscal year 2012, HRSA officials told us that they continue to monitor  recipients of prior years funding under these programs.  A block grant is a type of grant where funding recipients have substantial discretion over the type of  activities to support, with minimal federal administrative requirements or restrictions.  At-risk communities are communities with concentrations of (1) premature birth, low-birth weight  infants, and infant mortality, or other indicators of at-risk prenatal, maternal, newborn or child health;  (2) poverty; (3) crime; (4) domestic violence; (5) high-school drop outs; (6) substance abuse;   (7) unemployment; or (8) child maltreatment.  Critical Access Hospitals are small, rural hospitals. To be certified as a Critical Access Hospital a  facility must meet certain criteria, including being located in a rural area, having no more than 25  inpatient beds, and furnishing 24-hour emergency care services 7 days a week.  Telehealth is the use of electronic information and telecommunications technologies to support long  distance health care, patient and professional health related education, public health, and health  administration.
section_title: Appendix II: HRSA Contracts with the Highest Total Amount of Obligations by Organizational Component, Fiscal Year 2012
paragraphs: Provides services to maintain, update, and enhance the  National Practitioner Data Bank  Provides supplemental expert assistance and support to  health center grantees and federal staff by providing  technical and consultative assistance through site visits,  documentation reviews, and consultations to new and  existing grantees  Establishes and maintains the National Bone Marrow  Coordinating Center  Provides technical assistance for the Ryan White  HIV/AIDS CARE Act Program  Operates the Maternal, Infant, and Early Childhood  Home Visiting Program Technical Assistance  Coordinating Center  Provides technical assistance for grantee programs to  expand access to, coordinate, restrain the cost of, and  improve the quality of health care through the  development of health care networks in rural areas and  regions  Supports development, maintenance, and enhancement  efforts for HRSA’s Electronic Handbook, the agency’s  online system for documenting its grantee oversight  activities, by integrating new business processes into the  Electronic Handbook or integrating the Electronic  Handbook with other existing systems  We have included contract data for the National Hansen’s Disease Program with the data for the  Healthcare Systems Bureau, as this bureau took oversight responsibility for this program in August  2012. Prior to that, the program was under the auspices of the Bureau of Primary Health Care.
Cross-cutting refers to contracts that were utilized by more than one HRSA organizational  component.
section_title: Appendix III: Top Three Products or Services Obtained through Contracts by Organizational Component, Fiscal Year 2012
paragraphs: Percent of component’s  contract obligations  48.9%  2.  Education and Training  1.  3.  Special Studies and Analysis  2.  Special Studies and Analysis  3.  1.  Medical, Dental, and Surgical Services  2.  3.  Administrative Support Services  3.  Administrative Support Services  1.
We have included contract data for the National Hansen’s Disease Program with the data for the  Healthcare Systems Bureau, as this bureau took oversight responsibility for this program in August  2012. Prior to that, the program was under the auspices of the Bureau of Primary Health Care.
Cross-cutting refers to contracts that were utilized by more than one HRSA organizational  component.
section_title: Appendix IV: Comments from the Department of Health and Human Services
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Michelle B. Rosenberg, Assistant  Director; Jill K. Center; Kathleen Diamond; Cathleen J. Hamann;   Julia Kennon; Emily Loriso; Rebecca Shea; and Jennifer M. Whitworth  made key contributions to this report.