Program Announcement and Proposed Additional Review Criteria for Cooperative Agreements for Basic/Core Area Health Education Centers Programs and Model State-Supported Area Health Education Centers Programs for Fiscal Year 1995

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

RIN: 0905-ZA82

Program Announcement and Proposed Additional Review Criteria for

Cooperative Agreements for Basic/Core Area Health Education Centers

Programs and Model State-Supported Area Health Education Centers

Programs for Fiscal Year 1995

The Health Resources and Services Administration (HRSA) announces

that applications will be accepted for fiscal year (FY) 1995

Cooperative Agreements for Basic/Core Area Health Education Centers

(AHEC) Programs authorized under section 746(a)(1) and Model State-

Supported Area Health Education Centers Programs authorized under

section 746(a)(3), title VII of the Public Health Service Act, as

amended by the Health Professions Education Extension Amendments of

1992, Pub. L. 102-408, dated October 13, 1992. Comments are invited on

the proposed additional review criteria stated below.

Purpose and Eligibility

In general, an area health education centers program shall be a

cooperative program of one or more allopathic or osteopathic medical

schools and one or more public or nonprofit private regional area

health education centers.

Section 746(a)(1) of the PHS Act authorizes Federal assistance to

schools of allopathic or osteopathic medicine which have cooperative

arrangements with one or more public or nonprofit private area health

education centers for the planning, development and operation of area

health education centers programs.

To be eligible to receive support for an area health education

centers cooperative agreement, the applicant must be a public or

nonprofit private accredited school of allopathic or osteopathic

medicine or consortium of such schools, or the parent institution on

behalf of such school(s).

Section 746(a)(3) authorizes Federal assistance to any school of

allopathic or osteopathic medicine that is operating an area health

education centers program and that is not receiving financial

assistance under section 746(a)(1), title VII of the PHS Act.

The statutory authority for the Model State-Supported AHEC Program

contains explicit language regarding activities and agreements between

the medical and osteopathic schools which develop AHEC programs and the

free-standing, community-based area health education centers which

provide training sites and resources for the activities. To accomplish

these specific tasks, a system of subcontracts is developed between the

health professions schools and the independent AHEC centers in the

communities.

Certain programmatic agreements are required for the operation of a

Model State-Supported AHEC Program. In operating this program, the

school must agree to:

a. coordinate the activities of the program with the activities of

any office of rural health established by the State or States in which

the program is operating;

b. conduct health professions education and training activities

consistent with national and State priorities in the area served by the

program in coordination with the National Health Service Corps,

entities receiving funds under section 329 or 330 and public health

departments; and

c. cooperate with any entities that are in operation in the area

served by the program and that receive Federal or State funds to carry

out activities regarding the recruitment and retention of health care

providers.

Applicants in States where more than one eligible entity exits are

encouraged to collaborate in the submission of a single Model State-

Supported AHEC Program application, which reflects a consortium of

Statewide programs to coordinate community-based health professionals

training activities.

The principal objective of the legislation for the Model State-

Supported AHEC Program is to encourage State coordination and support

for AHEC activities. The most effective approach for obtaining support

from State legislatures is to present a unified plan showing how all

the programs are working together to provide the needed services in the

State. Competitive applications from one State tend to be divisive

rather than unifying in reaching common goals.

To receive support, these programs must meet the requirements of

the regulations as set forth in 42 CFR part 57, subpart MM.

Funding

Approximately $19.9 million will be available for the Basic/Core

Area Health Education Centers Programs in FY 1995. Total continuation

support recommended is $16.5 million. It is anticipated that $3.4

million will be available to support 6 competing awards (renewals and

new starts) averaging $566.000.

Approximately $4.4 million will be available for the Model State-

Supported Area Health Education Centers Programs in FY 1995. It is

anticipated that 20 competing awards averaging $220,000 will be made.

Period of Support

Applicants for Basic/Core AHEC Programs may request up to 3 years

of support with the expectation that AHECs planned and developed in

years 1 and 2 would be fully operational no later than the 3rd year.

The period of Federal support should not exceed 12 years for an area

health education centers program and 6 years for an area health

education center.

Model State-Supported Area Health Education Centers Programs may

request up to 3 years of support.

Substantial Federal Involvement

The Bureau of Health Professions, within the Health Resources and

Services Administration, has substantial programmatic involvement in

the planning, development, and administration of the AHEC projects by:

1. Reviewing and approving plans upon which continuation of the

cooperative agreement is contingent in order to permit appropriate

direction and redirection of activities;

2. Reviewing and approving all contracts and agreements among

recipient medical or osteopathic schools, other health professions

schools and community-based centers;

3. Participating with project staff in the development of funding

projections;

4. Developing, with project staff, individual project data

collection systems and procedures; and

5. Participating with project staff in the design of project

evaluation protocols and methodologies.

National Health Objectives for the Year 2000

The Public Health Service (PHS) is committed to achieving the

health promotion and disease prevention objectives of Healthy People

2000, a PHS led national activity for setting priority areas. The

Cooperative Agreements for the Basic/Core AHEC Programs and the Model

State-Supported Area Health Education Centers Programs are related to

the priority area of Educational and Community-Based Programs.

Potential applicants may obtain a copy of Healthy People 2000 (Full

Report; Stock No. 017-001-00474-0) or Healthy People 2000 (Summary

Report; Stock No. 017-001-00473-1) through the Superintendent of

Documents, Government Printing Office, Washington, D.C. 20402-9325

(Telephone 202-783-3238).

Education and Service Linkage

As part of its long-range planning, HRSA will be targeting its

efforts to strengthening linkages between U.S. Public Health Service

education programs and programs which provide comprehensive primary

care services to the underserved.

Smoke-Free Workplace

The Public Health Service strongly encourages all grant and

cooperative agreement recipients to provide a smoke-free workplace and

promote the non-use of all tobacco products. This is consistent with

the PHS mission to protect and advance the physical and mental health

of the American people.

General Requirements

As provided in section 746(b), an allopathic or osteopathic medical

school may not receive an award for operational expenses under the

existing Basic/Core AHEC Program or under the Model State-Supported

AHEC Program unless the program:

(A) maintains preceptorship educational experiences for health

science students;

(B) maintains community-based primary care residency programs or is

affiliated with such programs;

(C) maintains continuing education programs for health

professionals or coordinates with such programs;

(D) maintains learning resource and dissemination systems for

information identification and retrieval;

(E) has agreements with community-based organizations for the

delivery of education and training in the health professions;

(F) is involved in the training of health professionals (including

nurses and allied health professionals), except to the extent

inconsistent with the law of the State in which the training is

conducted; and

(G) carries out recruitment programs for the health science

professions, or programs for health-career awareness, among minority

and other elementary or secondary students from the areas the program

has determined to be medically underserved;

Requirements for Schools

As required by section 746(c), each allopathic or osteopathic

medical school participating in an AHEC program shall:

(1) provide for the active participation in such program by

individuals who are associated with the administration of the school

and each of the departments (or specialties if the school has no such

departments) of internal medicine, pediatrics, obstetrics and

gynecology, surgery, psychiatry, and family medicine;

(2) provide that no less than 10 percent of all undergraduate

allopathic and osteopathic medical clinical education of the school

will be conducted in an area health education center and at locations

under the sponsorship of such center;

(3) be responsible for, or conduct, a program for the training of

physician assistants (as defined in section 799) or nurse practitioners

(as defined under section 822) which gives special consideration to the

enrollment of individuals from, or intending to practice in, the area

served by the area health education center of the program; and

(4) provide for the active participation of at least 2 schools or

programs of other health professions (including a school of dentistry

and a graduate program of mental health practice if there are ones

affiliated with the university with which the school of allopathic or

osteopathic medicine is affiliated) in the educational program

conducted in the area served by the area health education center.

The requirement of paragraph (3) shall not apply to an allopathic

or osteopathic medical school participating in an AHEC program if

another such school participating in the same program meets the

requirement of that paragraph.

Requirements for Centers

As required by section 746(d), each AHEC shall specifically

designate a geographic area or a medically undeserved population it

will serve, which is in a location remote from the main site of the

teaching facilities of the school or schools which participate in the

program with such center.

In addition, each AHEC shall:

(A) provide for or conduct training in health education services,

including education in nutrition evaluation and counseling, in the area

served by the center;

(B) assess the health personnel needs of the area served by the

center and assist in the planning and development of training programs

to meet such needs;

(C) provide for or conduct a rotating osteopathic internship or a

medical residency training program in family medicine, general internal

medicine, or general pediatrics in which no fewer than four individuals

are enrolled in first-year positions in such program;

(D) provide opportunities for continuing medical education

(including education in disease prevention) to all physicians and other

health professionals (including allied health personnel) practicing

within the area served by the center;

(E) provide continuing medical education and other educational

support services to the National Health Service Corps members serving

within the area served by the center;

(F) conduct interdisciplinary training and practice involving

physicians and other health personnel including, where practicable,

physician assistants, nurse practitioners, and nurse midwives;

(G) arrange and support educational opportunities for medical and

other students at health facilities, ambulatory care centers, and

health agencies throughout the area served by the center; and

(H) have an advisory board of which at least 75 percent of the

members shall be individuals, including both health service providers

and consumers, from the area served by the center.

Any AHEC which is participating in an AHEC program in which another

center has a medical residency training program (described in (C)

above) need not provide for or conduct such a medical residency

training program.

Funding Provisions

At least 75 percent of the total funds provided to a school under

any AHEC program authority (Basic/Core AHEC program or Model State-

Supported AHEC programs) must be expended by the AHEC program in AHEC

centers and the school is required to enter into an agreement with each

of such centers for purposes of specifying the allocation of the 75

percent of funds.

Section 746(e)(1)(B) of the Act requires that not more than 75

percent of total operating funds of a Basic/Core AHEC Program in any

year shall be provided by the Federal Government. However, as provided

in section 746(e)(2), for an AHEC center developed as part of an AHEC

program first funded under the basic AHEC authority on or after October

13, 1992, a ceiling of 55 percent of the costs of any fifth or sixth

year of the development or operation of a center is established.

With respect to the costs of operating the Model State-Supported

AHEC program, the school will make available (directly or through

donations from public or private entities) non-Federal contributions in

cash toward such costs in an amount that is not less than 50 percent of

such costs. These funds must be for the express use of the AHEC Program

and Centers, and not funds designated for other categorical or specific

purposes. Amounts provided by the Federal Government may not be

included in determining the amount of non-Federal contributions in

cash.

Section 746(a)(3)(D) states that schools must maintain expenditures

on non-Federal amounts at a level that is not less than the level of

such expenditures for the fiscal year preceding the first fiscal year

for which the school receives an award.

The following criteria for allocation of funds for Model State-

Supported AHEC programs were established in the Federal Register on

September 14, 1993, (at 58 FR 48068) after public comment and are being

continued in FY 1995.

As a condition of receiving funding:

(1) applicants must meet the eligibility conditions of programs as

set forth in section 746(b), and the AHEC centers they wish to have

included must meet eligibility requirements in accordance with section

746(d);

(2) the non-Federal cash contribution to the AHEC program(s) in the

current year is at least equal to the amount to be received from the

Federal program as required by section 746(a)(3)(B); and

(3) the program activities for which support is requested are

determined by peer reviewers to be qualitatively acceptable.

Programs that submit acceptable applications, in accordance with

the above criteria, will receive funding based on the following

allocation of funds:

1. Annually, the total amount available for funding under section

746(a)(3) will be divided by the total number of qualifying AHEC

centers in approved applications. This will yield the per center

allocation. The coordinating AHEC applicant for each State will receive

an amount equal to the number of qualifying centers in the approved

application times the per center allocation subject to the amount of

non-Federal cash contributions and approved program activities.

2. In accordance with the provisions of section 746(e)(1)(A), the

award will clearly indicate that 75 percent of the awarded funds are to

be spent in approved centers. The remaining 25 percent may be allocated

to the AHEC program office and/or other participating schools. Awardees

may distribute 75 percent or more of awarded funds to centers according

to need.

The State matching provision was included in this new legislation

to promote State funding. The allocation of Federal funds to all

qualifying AHEC programs is intended to provide as broad as possible a

base for the accomplishment of this purpose. The number of qualifying

AHEC centers provides the means for distribution of funds because the

statute requires that 75 percent of the funds are designated to go to

these entities.

Review Criteria

The following review criteria apply to the Basic/Core AHEC

Programs, section 746(a)(1) and the Model State-Sponsored AHEC

Programs, section 746(a)(3).

The review of applications will take into consideration the

following criteria:

1. The degree to which the proposed project adequately provides for

the program requirements set forth in sections 746(a)(1) and 746(a)(3);

2. The capability of the applicant to carry out the proposed

project activities in a cost-efficient manner; and

3. The extent of the need of the area to be served by the proposed

area health education center.

Proposed Additional Review Criteria

The following additional criteria are proposed for review of

applications for these programs:

4. The potential of the proposed AHEC program and participating

centers to continue on a self-sustaining basis; and

5. The extent to which the proposed project adequately responds to

AHEC program performance measures and outcome indicators.

Outcome Measures and Future Directions for the AHEC Program

The development of outcome measures and other types of

effectiveness measures is stressed in the title VII authorization

legislation, the Health Professions Education Extension Amendments of

1992, Pub. L. 102-408. The Division of Medicine of the Bureau of Health

Professions is continuing to identify and develop outcome measures for

ongoing categorical programs. Applicants are encouraged to respond in

their applications to outcomes that have been developed. Outcome

measures are based on legislative intent and strategic directions

adopted by the Division of Medicine. The current strategic directions

include:

Generalism--Increasing the number of generalist physicians

including the coordination and integration of training opportunities

designed to produce generalists;

Workforce Diversity, particularly the training of

minorities;

Strategies to Improve Care for the Underserved;

Improve Primary Care Quality;

Increase Primary Care Faculty and Researchers; and

Emphasize Public Health and Interdisciplinary Training.

Information on Performance Measures and Outcome Indicators

Following are the performance measures and outcome indicators:

A. State/local Funding (100 points). The current level of State

funding or local funding for the proposed or ongoing AHEC program, and

the percentage of funds from nonfederal sources which make up the

annual budget of the AHEC program and/or AHEC center(s).

B. AHEC Program Elements (280 points). (1) 10 percent Clinical

Training with an emphasis on Ambulatory Care Settings (40 points). The

anticipated number of medical students trained annually in AHEC-

supported remote ambulatory care sites, and the percentage (10 percent

or more) of clinical undergraduate training of the medical school

provided at AHEC-supported sites.

(2) Primary Care Residency (40 points). The number of residents

participating in at least one AHEC affiliated primary care residency

(in Family Medicine, General Internal Medicine, or General Pediatrics)

and the percentage of medical school graduates selecting primary care

specialties over a most recent three-year period.

(3) PA/NP Training and Recruitment (30 points). The number of

students participating in at least one AHEC affiliated PA or NP

training program.

(4) Linkages to Other Federal Initiatives--Underserved Sites (30

points). The active working relationships with other federally

supported primary care oriented programs such as CHCs, MHCs, NHSC, and

IHS facilities serving the underserved.

(5) Linkages to other State Initiatives (10 points). Active working

relationships with State supported programs such as state offices of

rural health, state loan repayment programs, state health department,

primary care associations, and other statewide initiatives.

(6) Statewide Consortium (10 points). Participation within a

statewide consortium which addresses health professions training needs

and improvement of access to health services through educational

interventions, including the supply and distribution of primary care

personnel to underserved areas.

(7) Multidisciplinary/Interdisciplinary training (40 points). The

sites, number of trainees and the expected impact on primary care needs

of underserved areas by proposed or ongoing AHEC-supported primary care

multidisciplinary training programs.

(8) Disadvantaged and/or Minority Recruitment/Retention

Institutional Performance--Percent Minority Graduates (40 points). The

relationship of minority recruitment efforts to admission and retention

at specific health career training programs/institutions, and the

percentage of disadvantaged and underrepresented minority graduates of

the programs/institutions.

(9) Evidence of proposed or existing AHEC(s), and participation in

community-based decision-making (20 points). Collaboration of

community-based AHEC centers with medical and other health professions

training programs and a network of primary care training sites.

(10) AHEC Services to enhance the practice environment of program

area (20 points). The range of AHEC services provided to enhance the

practice environment (i.e., learning resources, telecommunications as a

teaching tool), and the number of regional practitioners involved in

the AHEC as adjunct faculty.

C. Expected outcomes in AHEC geographic areas (20 points). A system

is proposed or in place for tracking AHEC-experienced trainees

(students, residents) who eventually practice in primary care in

underserved areas.

Additional Information

Interested persons are invited to comment on the proposed

additional review criteria. The comment period is 30 days. All comments

received on or before January 30, 1995 will be considered before the

final additional review criteria are established. Written comments

should be addressed to: Marc L. Rivo, M.D., M.P.H., Director, Division

of Medicine, Bureau of Health Professions, Health Resources and

Services Administration, 5600 Fishers Lane, Parklawn Building, Room 9A-

25, Rockville, Maryland 20857.

All comments received will be available for public inspection and

copying at the Division of Medicine, Bureau of Health Professions, at

the above address, weekdays (Federal holidays excepted) between the

hours of 8:30 a.m. and 5:00 p.m.

Application Requests

Requests for application materials and questions regarding grants

policy and business management issues should be directed to: Ms. Diane

Murray, Grants Management Specialist (U76), Bureau of Health

Professions, Health Resources and Services Administration, Parklawn

Building, Room 8C-26, 5600 Fishers Lane, Rockville, Maryland 20857,

Telephone: (301) 443-6857, FAX: (301) 443-6343.

Completed applications should be returned to the Grants Management

Branch at the above addesss.

If additional programmatic information is needed, please contact:

Louis Coccodrilli, M.P.H., Acting Chief, AHEC and Special Programs

Branch, Division of Medicine, Bureau of Health Professions, Health

Resources and Services Administration, Parklawn Building, Room 9A-25,

5600 Fishers Lane, Rockville, Maryland 20857, Telephone: (301) 443-

6950, FAX: (301) 443-8890.

Paperwork Reduction Act

The standard application form PHS 6025-1, HRSA Competing Training

Grant Application, General Instructions and supplement for these grant

programs have been approved by the Office of Management and Budget

under the Paperwork Reduction Act. The OMB Clearance Number is 0915-

0060.

Deadline Date

The deadline date for receipt of applications for each of these

grant programs is February 13, 1995. Applications will be considered to

be ``on time'' if they are either:

(1) Received on or before the established deadline date, or

(2) Sent on or before the established deadline date and received in

time for orderly processing. (Applicants should request a legibly dated

U.S. Postal Service postmark or obtain a legibly dated receipt from a

commercial carrier or U.S. Postal Service. Private metered postmarks

shall not be acceptable as proof of timely mailing.)

Late applications not accepted for processing will be returned to

the applicant.

The Cooperative Agreement for Basic/Core Area Health Education

Centers Programs is listed at 93.824 and the Model State-Supported Area

Health Education Centers Programs is listed at 93.107 in the Catalog of

Federal Domestic Assistance. These programs are not subject to the

provisions of Executive Order 12372, Intergovernmental Review of

Federal Programs (as implemented through 45 CFR Part 100) or the Public

Health System Reporting Requirements.

Dated: November 18, 1994.

Ciro V. Sumaya,

Administrator.

[FR Doc. 94-32064 Filed 12-28-94; 8:45 am]

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