(NACMH) For The - Bureau of Primary Health Care - HRSA

NATIONAL ADVISORY COUNCIL ON MIGRANT HEALTH (NACMH)for the Secretary of Health and Human ServicesCouncil Members in AttendanceAndrea Weathers, MD, DrPH (Chair)Jose L. Lopez (Vice Chair)Frances R. CanalesCarolyn Davis, FNPJose Manuel GaytanGwendolyn E. GouldJames Laughlin, MPHRosa MartinDora MejiaZetti D. Page, III, MD, PhDJesus A. TijerinaWenceslao VasquezNovember 8-9, 2011Albuquerque, NMFederal StaffCDR Sonsy Fermin, LCSW, Chief, Health Services Branch, Office of Special Population Health,Bureau of Primary Health Care, Health Resources and Services Administration, U.S.Department of Health and Human ServicesGladys Cate, Project Officer, Health Services Branch, Office of Special Population Health, Bureauof Primary Health Care, Health Resources and Services Administration, U.S. Department ofHealth and Human ServicesMonique Spruill, MPH, Epidemiologist, Office of Special Population Health, Bureau of PrimaryHealth Care, Health Resources and Services Administration, U.S. Department of Health andHuman ServicesJulie Gross, Project Officer, Health Services Branch, Office of Special Population Health, Bureauof Primary Health Care, Health Resources and Services Administration, U.S. Department ofHealth and Human ServicesPresentersJoseph D. Gallegos, MBA, Senior Vice President, National Association of Community HealthCentersCandace Kugel, FNP, CNM, Director of Performance Improvement, Migrant Clinicians NetworkSuzan Martinez de Gonzales, Chief Executive Officer, La Clinica de Familia, Inc.Hilda Ochoa Bogue, RN, MS, CHES, Resource Development/Policy Analysis Director,National Center for Farmworker HealthDavid A. Roddy, Executive Director, New Mexico Primary Care Association1

Alice Larson, PhD, Larson Assisted ServicesPublicLisa Nieri, Southwest Regional Migrant Health Coordinator, Arizona Association of CommunityHealth CentersTuesday, November 8Call to Order• Andrea Weathers, MD, Council ChairDr. Weathers called the meeting to order at 8:40 a.m. and invited Council members, staff, andguests to introduce themselves. Following the round of introductions, Dr. Weathers reviewedthe agenda for the meeting. Mr. Laughlin moved to approve the agenda. The motion wasseconded by Dr. Page and carried unanimously.The Council reviewed the minutes of the previous meeting (May 2011). Mr. Laughlin moved toapprove the minutes. The motion was seconded by Dr. Page and carried unanimously.Welcoming Remarks• Susan Martinez de Gonzales, La Clinica de Familia, Inc.• David A. Roddy, New Mexico Primary Care Association (PCA)Mr. Roddy welcomed the Council to New Mexico, the Land of Enchantment. He described hisexperience working with migrant and seasonal farmworkers (MSFWs) in New Mexico since1974 and noted that the number of MSFWs in the state had decreased over the years, largelydue to the rise of contract labor in the 1980s.A wide array of programs were launched in the 1960s to improve the quality of life for MSFWsin New Mexico. Many of these programs were extremely successful and laid the foundation fororganizations that continue to provide healthcare and other services for MSFWs today.Mr. Roddy closed by thanking the Council for the work that they do on behalf of farmworkers.Ms. Martinez de Gonzales provided an overview of the work of La Clinica de Familia (LCDF) inDona Ana County in southern New Mexico. Established in 1976, LCDF now has eight medicalsites, five dental sites, a Maternal Health-Healthy Start program, and an Early Head Startprogram.Onions and chiles are the primary crops that are harvested by MSFWs in Dona Ana County. Thecounty is the largest-producing pecan area in the world; the nuts are harvested by seasonalfarmworkers. Cotton is another important crop, and the county has extensive dairy operations.MSFWs in Dona Ana County face numerous barriers to healthcare:2

The current political climate places health care reform in jeopardy. The budget for theCommunity Health Center (CHC) program was reduced by $600 million halfway through FY2011. A debt-limit agreement promises more cuts in 2012 and threatens to dismantle Medicaidand end the vital Prospective Payment System (PPS) for health centers.None of the federal appropriations/spending bills was approved for FY 2012. The government isoperating under a Continuing Resolution through November 18, 2011, which includes a 1.5%reduction to all federal agencies. Health centers with grant start dates between November 1and December 1, 2011 were informed that they could expect a 1.5% reduction in their grantaward through November 18, 2011; however, the Bureau of Primary Health Care (BPHC) hadsufficient funding to avoid making these cuts.The current political landscape includes divided chambers of Congress, a strong push to controlspending, and a strong emphasis on a debt ceiling and deficit reduction. The Budget Control Actof 2011 includes $900 billion in discretionary cuts over 10 years, beginning in FY 2012. TheSuper Committee is charged to find $1.2 trillion or more in cuts over 10 years. All programs,both mandatory and discretionary, are on the table. Automatic, across-the-board cuts will beimposed if the Super Committee fails, although some programs—including Medicaid and healthcenters—would be exempt.Patients served by health centers, and those served by Medicaid, are more likely to be poor andhave significant health problems than those served by private providers. Changes to Medicaidalready under consideration include conversion to a block grant programs; per capita spendingcaps; flexibility to states; repeal of the Maintenance of Effort (MOE) provision; and blendedFederal Medical Assistance Percentages (FMAP) funding. Any of these options would lead tomajor reductions in eligibility/enrollment, loss of benefits and coverage, and loss of the FQHCpayment rate.NACHC’s Medicaid priorities are to preserve Medicaid; preserve the PPS and the “MenendezAmendment” to ensure that private insurance plans pay at least the Medicaid PPS; and workwith Congress to protect and strengthen Medicaid. To that end, NACHC launched a Campaignfor America’s Health Centers. The objectives of the campaign are to:1. Restore the annual federal funding for health centers to a level that will ensure theentire Health Center Trust Fund can be used for its intended purpose of serving morepeople in need2. Preserve the vital Medicaid program and ensure that America’s health centers areadequately reimbursed.Health centers and individuals can join the campaign, lobby Congress, sign a petition, tell theirpersonal story, and create an action plan for their health center at the campaign website(http://www.SaveOurCHCs.org).5

NACHC recently submitted comments on the CMS proposed rules for Medicaid, as follows:• Proposed rules under the Children’s Health Insurance Program and Reauthorization Act(CHIPRA): NACHC supports the proposed model of interstate coordination of Medicaidcoverage, which would promote portability of coverage• Proposed rules regarding Medicaid Eligibility changes under the ACA, and residency andeligibility determinations for health coverage under the State Health InsuranceExchange: NACHC urged CMS to limit the amount of flexibility for states to determineresidency and advocated for a simplified and uniform enrollment process for Medicaidand CHIPNACHC’s Migrant Health Conference in May 2012 will celebrate and honor the 50 th anniversaryof the passage of the Migrant Health Act. Mr. Gallegos urged all Council members to attend.DiscussionMs. Davis requested a clarification of discretionary and mandatory funding. Mr. Gallegosreplied that the recurring base funding for the health center program is considereddiscretionary funding. The $11 billion trust fund created by the ACA for health center expansionis considered mandatory funding. The $600 million cut for FY2011 was taken from the basefunding. The House and Senate proposed different approaches for the FY 2012 budget. Ifmandatory funding is eliminated, as proposed by the House, there will be no money for healthcenter expansion.Dr. Page asked how the Council could help NACHC address gaps in understanding around issuessuch as the impact of immigration on access to health care, and the creation of patientcenteredmedical homes (PCMHs) for MSFWs. Mr. Gallegos responded that Migrant HealthCenters (MHCs) have more enabling services in place than most CHCs. These componentssupport the care coordination that is central to a PCMH. Immigration must be addressed. Cropsare rotting in the fields in states that have passed restrictive immigration laws because thereare no workers to harvest them. It would be helpful if the Council could link the work of theMHCs to the issue of immigration.Dr. Weathers asked whether it was wise to advocate for increased funding, given the currentpolitical climate. Mr. Gallegos responded that NACHC was lobbying to maintain the full amountof discretionary spending, because it is essential to build a strong foundation of primary careproviders to ensure access to care for those who will have coverage in 2012. He suggested thatthe Council ask the Secretary to take a strong position for a balanced approach to funding.Dr. Weathers asked how the Council could address the issue of quality and PPS. Mr. Gallegosreplied that health centers represent a proven model of cost-effective care. Every dollar spentfor care provided by a health center avoids $3 in emergency room services. A strongpartnership between FQHCs and the larger healthcare system is imperative to reduce costs.6

Mr. Laughlin asked what other big-picture issues the Council should address. Mr. Gallegosnoted that the Supreme Court had not yet ruled on the requirement to have coverage.Regardless of the outcome, the country must address the issue of healthcare. NACHC’s goal willbe the same: to ensure that primary care remains the foundation of the healthcare system.Bureau of Primary Health Care (BPHC)/Office of Special Population Health (OSPH) Update• CDR Sonsy Fermin, OSPHCDR Fermin informed the Council that the draft nomination package for new Council membershad been approved; the final package will be sent to the Secretary. Dr. Page was nominated toserve as Chair. If the new nominations are not approved by the time the next meeting takesplace (February 2012) the members whose terms were due to expire after this meeting (Dr.Weathers, Mr. Lopez, Ms. Segarra, and Mr. Gaytan) would be authorized to serve for anadditional 120 days (starting November 26, 2011) to be able to attend the meeting in February2012.The mission of the BPHC is: “To improve the health of the nation’s underserved communitiesand vulnerable populations by assuring access to comprehensive, culturally competent, qualityprimary health care services.” In the current environment of budget cuts, every decision will bemade in view of its impact on this mission.Uniform Data Systems (UDS) data for calendar year 2010 showed that MHCs served 863,000MSFWs, which is about 2,000 fewer patients than the previous year. MHCs are located acrossthe United States, but they serve only half of the estimated population of MSFWs.The health center program is good for the economy. The dramatic increase in the number ofhealth center patients, jobs, and sites between 2008 and 2010 benefits the communities inwhich the centers are located. Overall, the program employs 131,660 individuals. Enablingservices that are essential for the migrant health program (e.g., case managers, education,outreach, transport) employ 12,128 people.BPHC’s programs focus on primary health care and public health leadership, with an emphasison performance improvement and quality of care. Key national indicators for the health centerprogram are:• Percent of health centers meeting/exceeding Healthy People 2020 goals• Percent of health centers achieving national quality recognition (e.g. nationallyaccredited, Patient Centered Medical Home accreditation)• Percent of health centers with Electronic Health Records (EHR).The latest round of health center grant awards was highly competitive. BPHC received over 800applications, and only 67 were funded. Many applications that received a perfect score werenot funded. All of the funded applications included a special population component, whichclearly demonstrates the impact of the Council’s recommendations.7

The NACMH falls under the Bureau’s Office of Special Population Health (OSPH). OSPHcoordinates programs for three groups identified by legislation as special populations(homeless, MSFW, public housing) and other disadvantaged groups, including AsianAmerican/Pacific Islanders, aging, and Lesbian/Gay/Bisexual/Transgendered (LGBT) individuals.The BPHC was recently realigned to reduce the number of grantees monitored by each ProjectOfficer, which allows them to provide greater attention to each grantee.Migrant health activities coordinated by OSPH include:• National Cooperative Agreements (NCAs) for special populations• National Advisory Council on Migrant Health• Interagency agreements, such as those with the Centers for Disease Control andPrevention (CDD) to provide support for three migrant stream forums per year, and withthe Department of Labor (DOL) for the National Agricultural Worker Survey (NAWS)• Department, Agency, and Bureau-level initiatives and workgroups for minority andspecial populations (e.g., the Federal Workgroup for Promotores).Technical assistance (TA) resources for migrant health grantees include:• National and state-based support for training and technical assistance, including NCAs,PCAs, and Primary Care Offices• Federal support, including Project Officers, TA calls, onsite consultant support, and theBPHC TA website (http://www.bphc.hrsa.gov/technicalassistance)CDR Fermin thanked the Council members for taking time out of their work, their lives, andtheir families for this important effort.DiscussionMs. Canales asked how EHRs would be feasible for MSFWs who receive services from privateproviders through the voucher program. CDR Fermin replied that BPHC was working on thatissue. Ms. Davis noted that contracts for private physicians who participate in a voucherprogram include certain requirements, some of which address portability. Mr. Lopez noted thatNew York State had implemented a new collaboration to network electronic records betweenhealth centers and private sector providers. CDR Fermin stated that the New York system couldpotentially serve as a model for replication. BPHC will examine systems across the country toidentify the best approach to ensure access for MSFWs.Dr. Page suggested that the FY 2012 funding opportunity for Health Center Controlled Networksmight be an area for the Council to develop a recommendation. CDR Fermin stated that thegrant program was primarily intended to make EHR systems more affordable for single-sitehealth centers, but larger organizations would not be excluded.8

Dr. Weathers asked whether the decrease in the number of MSFWs served by health centerswas an unusual trend. CDR Fermin replied that the number had been increasing in recent years;this was the first time it had declined.Ms. Mejia asked for more information on the school-based health center grants. CDR Ferminresponded that the funding was originally intended for program support, but the finalappropriation shifted the emphasis to capital improvements. BPHC has some funds to supportschool-based programs and is looking for additional funds to meet the need for theseprograms.Dr. Weathers asked what issues the Council should consider for its recommendations. CDRFermin suggested that the Council look at quality improvement in health outcomes and theeconomic impact of health centers.Council DiscussionThe Council discussed and agreed upon committee assignments for the current meeting, asfollows:Executive Committee:Andrea Weathers (Chair)Jose LopezZettie PageDora MejiaMigrant Health Services:Frances Canales (Chair)Carolyn DavisZettie PageAndrea WeathersJesus TijerinaAccess, Resources, and Funding:Wenceslao Vasquez (Chair)Dora MejiaJose Manuel GaytanEmma SegarraRosa MartinPublic Policy and Advocacy:James Laughlin (Chair)Juan Carlos OlivaresJose LopezGwendolyn GouldJoan Tronson9

The Council discussed how new members could be most effective, and how the Council couldbenefit from information that is presented at the Midwest Migrant Stream Forum. Dr.Weathers suggested that Council members who attend the conference could inform CDRFermin or Ms. Cate of any pressing issues that arise during the conference. Mr. Lopez describedthe issues he would cover in his presentation at the conference and encouraged Councilmembers to attend the session. CDR Fermin offered to schedule a conference call if the Councilwished to discuss any issues between face-to-face meetings.Public HearingsCouncil members engaged in a dialogue with a group of 16 MSFWs from Dona Ana County,whose participation was coordinated by LCDF. Spanish-English interpretation services wereprovided. Key issues that emerged from the discussions are summarized below.• Farmworkers do not always carry all of the documents that clinics require when theymigrate from one place to another (e.g., W2, etc.). In addition, many MSFWs do nothave proof of income, because their employers do not provide paystubs.• Many farmworkers suffer from multiple chronic conditions, including heart disease,bone pain, diabetes, and respiratory conditions. They often go to the emergency roomfor tests and specialty care that health centers cannot provide. In many cases, they waituntil their condition is severe because they cannot afford to pay for these services.• Many farmworkers do not follow through on referrals, because they do not have moneyto pay for a specialist and they cannot afford to miss work.• Farmworkers with legal immigration status do not qualify for Medicaid because theymake too much money. They receive indigent services at the clinic.• Farmworkers encounter many barriers to health care, including lack of transportation,language barriers, a long waiting list for appointments, a long wait once they are at theclinic, and inability to afford co-payments.• Farmworkers obtain information about pesticides from promotoras, but they are oftenunable to protect themselves when pesticides are being applied. Many farmworkersremain in the field because they need the money and do not want to complain.• The farmworkers who testified were aware of numerous services provided by LCDF,including general medicine, dental care, and counseling for nutrition, smoking cessation,weight loss, and substance abuse.• The farmworkers who testified did not know of other resources in the community andwere unaware of organizations that could connect them with resources.• Evening hours would make it easier for farmworkers to access health care, especially ifthey were offered several times a week.• Several farmworkers who are consumer board members at their migrant health centerstated that their opinions are not always taken into consideration.10

• Many farmworkers in southern New Mexico find it easier to access health care inMexico, because it costs less, it is easy to get an appointment, and they do notexperience language or cultural barriers.• Many farmworkers are not aware of their rights and the services that are available.Promotoras provide good information, but in a border area it is difficult to keep up withthe number of new workers who arrive each day.• When asked for one suggestion to improve migrant health services, nearly all of thefarmworkers cited the need for more doctors to reduce waiting times. Othersuggestions included:o Extended hours, including evenings and weekendso Lower fees for specialistso More clinics and specialists in the areas where farmworkers are locatedo Fewer documentation requirementso More promotoras.The farmworkers described problems with sanitation in the fields and asked whether theCouncil could address that situation. Council members responded that this could be a relevantissue for recommendations to the Secretary. CDR Fermin noted that HRSA communicates withother federal agencies and organizations that could take a more direct role in addressing thissituation.Dr. Weathers thanked the guests for the information they shared. The farmworkers expressedtheir appreciation to the Council for listening to their concerns.Dr. Weathers adjourned the meeting for the day at 3:55 pm.Wednesday, November 9Call to Order and Recap of Previous Day• Andrea Weathers, MD, Council Chair• Jose Lopez, Council Vice-ChairDr. Weathers called the meeting to order at 8:55 a.m. and asked Mr. Jose Lopez, to provide arecap of the presentations and discussions of the first day of the meeting. Following the recap,Dr. Weathers provided an overview of the agenda for the day.Patient-Centered Medical Home Concept and Migrant Health Centers• Candace Kugel, FNP, CNM, Migrant Clinicians NetworkMs. Kugel provided an overview of the Patient-Centered Medical Home (PCMH) concept,described the criteria for CHCs to qualify as a PCMH, and discussed how the PCMH model couldbe adapted for migrant populations.11

The PCMH is an approach to providing comprehensive primary care that facilitates partnershipsbetween individual patients and their personal clinicians by replacing episodic care based onillnesses and patient complaints with coordinated care and a long-term healing relationship.Medical homes have been shown to improve access to healthcare; improve involvement ofpatients in their own care; increase satisfaction with care; decrease preventable hospitaladmissions; improve outcomes; reduce mortality rates; lower overall costs of care/lowerutilization; and reduce disparities.The PCMH model includes the following key elements:• Each patient has a personal clinician trained in primary care• Clinician-directed practice• Whole-person orientation, including family, work• Care is coordinated and/or integrated• Quality and safety (e.g., case management, evidence-based clinical guidelines, patientinvolvement, use of data)• Enhanced access (e.g., expanded hours, email correspondence)• Population-based payment.The National Committee for Quality Assurance (NCQA) established a set of voluntary standardsthat constitute the criteria for recognition as a PCMH:• Standard 1: Enhance Access and Continuity• Standard 2: Identify and Manage Patient Populations• Standard 3: Plan and Manage Care• Standard 4: Provide Self-Care and Community Support• Standard 5: Track and Coordinate Care• Standard 6: Measure and Improve Performance.Each standard has two or more associated elements, each of which has three to six factors.There are six must-pass elements that are considered to be critical concepts of a PCMH.Recognition entails a licensing and application fee, based on the number of clinicians in thepractice). There are three levels of qualification, depending upon the number of points that areawarded.NCQA is conducting training for health centers that wish to earn PCMH recognition. To date,approximately 200 FQHC sites have qualified. BPHC received applications from 904 CHCs for therecent funding opportunity to support efforts to earn PCMH recognition.PCMH 2011 standards are aligned with the CMS Meaningful Use standards for EHRs. A practicethat meets the standards for Meaningful Use will meet the associated standards for PCMH, andvice versa.12

Several key elements of a PCMH are already standard practice at MHCs, including a wholepersonorientation, clinician-directed medical practice, quality and safety, enhanced access, andpayment for added value work. It will be more challenging for MHCs to provide a personalclinician and coordinated/integrated care for migrant populations. Meeting those standardsmight require a team of providers in several locations who are connected through virtualnetworks.Developing a PCMH for MSFWs will also entail an emphasis on self-management of chronicillnesses and patient navigation/case management systems. This will require a paradigm shift,in which the use of outreach workers and alternative practice models such as voucher programsare seen as integral components of clinical service delivery.The PCMH requires a team approach that is best accomplished when health centers redesigntheir work flow and assign quality indicators to specific staff groups, such as making front officestaff responsible for properly identifying all patients who are MSFWs.EHRs are an essential component of the PCMH and provide an opportunity for MHCs to collectdata that can demonstrate the value of their services. Long-term goals for EHRs include auniversal, seamless exchange of information, virtual patient navigation, and records transfer.The MCN Health Network helps to fulfill some elements of the PCMH and can serve as a“bridge” case management system for MHCs. The goal of the Health Network is to eliminatehealth disparities due to patient mobility and respond to challenges in providing continuity ofcare. Services are provided free of charge to patients and clinicians, with toll-free access toexpert, bilingual, culturally competent staff.DiscussionMr. Lopez asked for more details regarding population-based payment. Ms. Kugel replied thatpopulation-based payment creates incentives for wellness and prevention, as opposed topayment per-visit. This approach creates a shift toward payment for improvement in outcomes.Mr. Laughlin asked whether the criteria for PCMH designation include any factors to ensurethat health centers that receive migrant health funding provide enabling services, and what theCouncil could do in that regard. Ms. Kugel noted that BPHC already requires MHC grantees toprovide enabling services, and she suggested that the Council advocate for recognition of theadded value and associated costs of serving migrant populations.Dr. Page noted a recent funding opportunity to support outreach programming for rural healthcenters. He asked whether MCN’s assistance to MHCs was coordinated with the efforts ofHealth Outreach Partners (HOP). Ms. Kugel replied that MCN and HOP are both members of theFarmworker Health Network. MCN is working with HOP and Migrant Health Promotion todevelop tools for integrating outreach services.13

Responding to a question from Ms. Davis, Ms. Kugel said that she was not aware of any CHCsreceiving migrant funding that were unable to meet PCMH standards.Out-of-School Youth Initiative• Hilda Ochoa Bogue, RN, MS, CHES, National Center for Farmworker HealthMs. Ochoa Bogue described the Out-of-School Youth (OSY) Initiative, which is a collaborativeeffort of the federal Migrant Education Program (MEP) and the National Center for FarmworkerHealth (NCFH).The MEP is mandated to provide education for migratory children ages 3-21. The program facesnumerous challenges that impact the recruitment, retention, and academic achievement ofmigrant children, including mobility of the target population; recruitment and retention; latearrivals; early withdrawals; poor attendance; various state standards (e.g., academic content,grade promotion, assessment and accountability systems); and financial and family pressures.Those challenges increase for secondary school-aged migrant youth, who are the fastestgrowingand least-served group of students.The OSY Initiative includes strategies to increase data collection; inclusion of OSY in the stateeducation agency funding formula; inclusion of the OSY group in the Comprehensive NeedAssessment (CAN) process; increase recruitment and retention; and expand education optionsfor OSY.The intersection between the MEP and the Migrant Health Program (MHP) is significant.Approximately 500,000 children age 12 and older work in agriculture. Unaccompanied minorscreate liability issues for CHCs because they are at a vulnerable age for abuse and riskybehaviors, and they often work many hours in tasks that are inappropriate for their age. Inaddition, they often lack knowledge about health promotion, disease prevention, and healthcare systems, and they have limited English proficiency.NCFH is working with the MEP and the OSY Initiative to:1. Complete the development of bilingual, low literacy mini-educational lessons for OSY tobe used for English as a Second Language (ESL) classes in the areas of basic health2. Review the CAN and Service Delivery Plan (SDP) of every state MEP to determine howprograms are addressing the health needs of the migrant student population, includingOSY3. Identify best practices between MEP/OSY and the MHP4. Share information with stakeholders to stimulate dialogue and collaboration5. Create an up-to-date database of contact information for both migrant health andmigrant education programs to facilitate local collaboration14

6. Create a set of recommendations, strategies, and resources to improve access to healthcare for school-age migrant children and migrant OSY.Progress to date includes a review of 32 documents from 19 states with MEPs for referencesregarding health, nutrition, vision, dental, mental health, etc., and for references to the healthneeds of OSY. Preliminary results reveal a large variation in the degree to which those statesaddress the needs of migrant children.Next steps for the project are to complete the analysis of documents from all states with MEPs,seek guidance from key informants, create a report, and share the results in various venues.NCFH believes the results of this initiative will help the Council determine appropriaterecommendations to address this issue.DiscussionDr. Page asked whether NCFH was gathering data on the outcomes and progress of OSY.Ms. Ochoa Bogue stated that one of the goals of the Initiative is to determine the number ofOSY (including unaccompanied minors), identify strategies to reach them, and developprograms to serve them once they come to a clinic.Dr. Weathers stated that the Council would welcome a follow-up presentation at theconclusion of the project. Ms. Ochoa Bogue stated that this would be possible in eight months.Dr. Weathers asked what assistance the Council could provide for the Initiative. Ms. OchoaBogue suggested that the Council develop recommendations about the need for more targetedoutreach and a coordinated national policy to serve these children.Report on the HPSA/MUA/MUP Negotiated Rule Making Subcommittee and Final Meeting• Alice Larson, PhD, Larson Assisted ServicesThe ACA established the Negotiated Rule Making Subcommittee to update three definitionsused in programs funded by HRSA: Health Professional Shortage Area (HPSA), MedicallyUnderserved Area (MUA), and Medically Underserved Population (MUP). The committee had28 members representing the interests of all groups that would have a stake in the definitions,including HRSA. Dr. Larson advocated for the interests of special populations, including MSFWs.Special populations, including MSFWs, were written into the draft definitions. The presence ofany MSFWs in a health center’s service area would automatically qualify the center for HPSAand MUP designations, with no minimum threshold number.Definitions on which the committee achieved consensus were to be published in the FederalRegister as draft regulations. However, despite numerous incentives, the committee wasunable to reach consensus on any of the definitions. As a result, the draft definitions developed15

y the committee have the status of recommendations, and HRSA is under no obligation toadopt them.DiscussionDr. Weathers asked whether the interests of MSFWs would be protected. Dr. Larson repliedthat when it became clear that overall consensus would not be possible, the committee votedon each element individually. The language regarding special populations received strongsupport.Ms. Davis asked about next steps. Dr. Larson stated that the committee’s report had beensubmitted to the Secretary. In the report, the committee strongly recommended that HRSAestablish an advisory committee to assist in developing new regulations. Although HRSA is notobligated to act on the committee’s recommendations, it is likely to receive significant negativefeedback if it develops regulations that differ significantly from those drafted by the committee.Dr. Weathers noted that it would be important for the Council to remain informed. Dr. Larsonstated that OSHP was following the process closely and would inform the Council if there wasany cause for concern.Migrant Health Centers UDS 2010 Update• Monique Spruill, Epidemiologist, OSPHThe Uniform Data System (UDS) is a reporting requirement for grantees of HRSA primary healthcare programs, including MHCs. The UDS tracks a variety of information, including patientdemographics, services provided, staffing, clinical indicators, utilization rates, costs, andrevenues. UDS data are reported at the grantee, state, and national levels.In 2010, the UDS definition of agriculture was updated to align with the Health Center Programstatute. HRSA plans to review the definition and develop additional guidance based on nationalstandards and feedback from health centers to support reporting in the 2011 UDS manual.The total number of MHCs grew from 135 in 2005 to 156 in 2010, representing a 15.6%increase. MHCs fared very well in the 2010 New Access Point (NAP) awards, with 25 new sites,including three new OSPH grantees and two new BPHC grantees. The NAP awards brought thetotal number of migrant health sites to 162.The UDS defines “patients” as individuals who have at least one reportable visit during thereporting year. The definition does not include individuals who have limited contacts, such asimmunization programs, screening programs, or health fairs. In 2010, health centers served862,775 migrant patients. The vast majority (93%) were served by MHCs. The total number ofclinic visits by MHC patients increased by 15.5% between 2005 and 2010.16

The Council discussed the issue of competition between CHCs and noted that an optimal payormix is crucial for all health centers.The Council discussed issues related to the Regional Migrant Health Coordinators and agreed toreaffirm or build on previous recommendations in this area.A round-robin discussion of priorities identified the following issues for recommendations:• Enabling services (funding; monitoring; incentivizing funding )• Communication among health centers regarding patient care, resources, programs• Assurance/accountability• Access to specialty care• Board development and accountability• More providersThe Council agreed that outreach was an essential value-added service for MHCs. This issueincludes aspects such as performance standards, incentivizing funding, and PCMH recognition.The Council’s previous recommendations emphasized the need to fund outreach. Since then,the issue has evolved to encompass an expanded role for outreach, including coordination ofcare.The Council broke into subcommittees to discuss potential recommendations.Report-back from SubcommitteesThe subcommittees reported the key points that emerged from their discussions, as follows:Access, Resources, and Funding• Allocate more funding for enabling services, such as promotoras, outreach, andextended hours• TA for MHC Boards of Directors regarding their role and responsibilities• TA to help MHC staff identify MSFWs so they can receive services that meet their needsPublic Policy and Advocacy• Immigration is a major barrier that creates fear of real or perceived repercussions• Intra- and inter-agency coordination and communicationo Inter-agency (e.g., Agriculture/Education/Labor; also local level)o Intra-agency (e.g., HRSA rural health outreach grants; FDA; CMS)• Advocacy: Educate/monitor/incentivize for enabling serviceso Board responsibilitieso Outreacho PCMHo Care coordinationo Transportation19

Migrant Health Services• Outreach and enabling services are an essential component of ensuring the success of aPCMH for MSFWso Funding/compensation for outreach considered as a value-added serviceo Standardized training and job descriptions to ensure the quality of enablingserviceso Performance standards for consistency of services and accountabilityThe Council agreed that the recommendation letter should focus on outreach, and incorporatereferences to other issues. The letter would summarize the context of the Council’s discussion,to illustrate how this emerged as a central issue. It would emphasize the need for a paradigmshift, to include incentives and accountability for providing outreach and enabling services.The Council agreed on a process and timeline to develop the recommendation letter:• Dr. Page will prepare an initial draft and submit it to the review team (Mr. Laughlin, Ms.Davis, Dr. Weathers, Mr. Vasquez, Ms. Canales) by November 23• Review team members will submit their comments to Dr. Weathers by November 30• Dr. Weathers will prepare the final draft and submit it to CDR Fermin and Ms. Cate byDecember 5• CDR Fermin will distribute the final draft to the entire Council for review before it issubmitted to the Secretary.Next Council MeetingCouncil members proposed to hold their next meeting on February 7 and 8, 2012 in Crystal City,Virginia. Travel dates would be February 6 and 9.The Council suggested the following topics for the agenda:• Presentation by the Department of Labor (update on NAWS; definition of agriculture)• Panel on voucher programs (at least 3 perspectives)• Presentation by Farmworker Justice and Roger Rosenthal• Update from NACHC• Update on Regional Migrant Health Coordinators (Israel Garcia)• Presentation by the MD, DC, or VA PCA regarding health care for MSFWsLogistical Information• Gladys Cate, OSPHMs. Cate reviewed the requirements and procedures for reimbursement of travel expenses andurged Council members to submit their forms and receipts to Ms. Josette Rufus as soon aspossible.20

Council members thanked Dr. Weathers for her excellent leadership as Chair.Mr. Laughlin moved to adjourn the meeting. The motion was seconded by Dr. Page and passedunanimously on a voice vote. The meeting was adjourned at 4:55 p.m.21