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. 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.) 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

Summary: 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. 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.