Management Challenge 9: Effectively Operating Public Health and Human Services Programs

Why This Is a Challenge

A nurse checking a young boy with her stethoscope

The Department funds and operates public health and human services programs to promote health and economic and social well-being. These include programs to prevent, track, and treat acute and chronic diseases; respond to natural and man-made disasters; protect against hazardous biological agents; and protect, care for, and educate children. Many of these programs serve vulnerable populations. Effective management is essential to ensure that the programs achieve their goals and best serve the programs' intended beneficiaries.

Public Health Preparedness and Emergency Response. Effective protection against public health threats requires a well-coordinated public health infrastructure that can rapidly respond to emergencies at home and internationally. The Department must ensure that health care facilities and personnel are prepared and trained to address emerging infectious diseases and that the proper protocols are in place to foster response coordination with domestic and international partners. Experiences responding to natural disasters, such as Superstorm Sandy, illustrated the important service of first responders and other health care professionals, but also identified gaps in natural disaster emergency planning and execution. Shortcomings related to federal, state, and community organization collaboration; response team communication; shelter operations; and health care coverage were identified. Furthermore, the Department must ensure that select agents (e.g., anthrax, smallpox) remain safe and secure. CDC is tasked with overseeing the handling of select agents in private and government facilities. However, security vulnerabilities identified at many Department research facilities attest to the continuing problems with how these agents are inventoried and handled.

Access to and Quality of Services. The Department must ensure that intended beneficiaries of public health and human services have access to services and that these services meet quality standards. Access to quality services has proven especially challenging in IHS, where one hospital recently lost its Medicare provider enrollment after being found to pose immediate jeopardy to patients. Illustrating the challenges of adequately serving another vulnerable population, nearly a third of children in foster care who were enrolled in Medicaid did not receive at least one required health screening, and the Administration for Children and Families (ACF) did not ensure that these children received the required screenings according to state schedules.

Protecting Vulnerable Populations. The health and safety of children served by ACF's Child Care and Development Fund (CCDF) program – serving approximately 1.6 million children – continues to be an unaddressed vulnerability for the Department. Vulnerabilities in states' standards for and monitoring of childcare providers jeopardize safety. A total of 454 violations of state licensing requirements were identified, including noncompliance with requirements related to physical conditions, inspection procedures, registration, criminal records or protective service checks, and child abuse and neglect registry checks. In addition, states' onsite monitoring of providers was infrequent, and states did not have enough inspectors to meet the national standard. In 2014, there was an unprecedented, and unpredicted, increase of unaccompanied children arriving in the United States, which required ACF's Office of Refugee Resettlement, in coordination with interagency partners, to implement emergency response measures to quickly expand capacity and provide shelter for a significant number of children. (For general information about challenges associated with grants management and contract administration, see Management Challenge 4.)

Progress in Addressing the Challenge

The Department is undertaking several initiatives to strengthen federal, state, and community disaster response. The Assistant Secretary for Preparedness and Response (ASPR) launched the Technical Resources Assistance Center and Information Exchange, an emergency preparedness information gateway designed to ensure that all stakeholders have access to information and resources to improve preparedness, response, recovery, and mitigation efforts. With respect to deficiencies in responding to homebound individuals dependent on electrically powered medical equipment, ASPR released the emPOWER map as a tool to help communities plan for the disaster needs of these individuals. CMS is also developing more comprehensive emergency preparedness requirements. In December 2014, CMS published a proposed rule establishing emergency preparedness requirements for Medicare- and Medicaid-participating providers.

The Consolidated and Further Continuing Appropriations Act, 2015, provided $2.7 billion in emergency funding to HHS for Ebola preparedness and response activities. Of this, $1.77 billion was allocated to CDC to prevent, prepare for, and respond to Ebola domestically and internationally. Through its Hospital Preparedness Program cooperative agreements, ASPR has designated nine health departments and associated partner hospitals to become special regional treatment centers for patients with Ebola or other severe, highly infectious diseases. Through the newly announced National Ebola Training and Education Center, CDC and ASPR will support health care provider and facility training and management of Ebola and other emerging infectious diseases.⁸

The Department has made progress in improving physical security and employee training related to safe and secure storage and handling of select agents. CDC has revised its Vaccines for Children (VFC) Operations Guide, published a Storage and Handling Toolkit, and provided additional grantee and provider training to improve vaccine storage and handling practices. CDC also now requires grantees to perform unannounced visits to providers' offices, which was the technique that the OIG used to initially identify VFC program storage and handling vulnerabilities.

The Child Care and Development Block Grant Act of 2014 (P.L. No. 113-186) reauthorized the CCDF program and improved childcare health, safety, and quality requirements. The law requires states to perform an initial onsite monitoring visit and at least one annual unannounced onsite visit of licensed providers that have received CCDF subsidies, as well as annual inspections for license-exempt CCDF providers. The law also requires childcare providers to submit background checks at least once every 5 years for each childcare staff.

Since the sharp increase of unaccompanied children referred to HHS in the Spring/Summer of 2014, ACF has continued to support and participate in the DHS-led Unified Coordination Group, which monitors all aspects of unaccompanied children arrivals, including HHS and Department of Homeland Security (DHS) programs, along with the collaboration of other federal partners such as the Department of State and the Department of Defense. ACF has also awarded new contracts to support the operations of temporary surge shelters, should they need to be deployed in the future.

What Needs To Be Done

The Department should continue to promote federal, state, and community collaboration during major disasters. While it may not be possible to predict when and where disasters will strike, the Department should prepare for a range of potential emergency scenarios and be ready to rapidly and effectively respond. Additionally, improvements in the adoption and interoperability of health IT can facilitate medical care for displaced patients by ensuring continuity of access to health records. (For more information on the secure exchange of health information, see Management Challenge 3.)

The Department should move swiftly toward finalizing emergency preparedness regulations. In conjunction with these regulations, detailed and clear guidance should be developed for surveyors assessing compliance with federal regulations. In addition, clear guidance should be developed for the transport of Medicaid patients across state lines. The Department must ensure the sufficiency and training of medical staff for disasters and severe infectious diseases to prepare them to maintain patient care during periods of poor conditions.

The Department will need to continue efforts to improve its inventory control policies and procedures for select agents to resolve vulnerabilities.

ACF should expand the scope of its Child and Family Services Reviews to determine whether children in foster care receive required screenings according to the timeframes specified in states' plans. Furthermore, ACF should work with states to identify the barriers that prevent children in foster care from receiving required screenings and identify, disseminate, and implement strategies for overcoming those barriers. ACF must continue to effectively implement the Child Care and Development Block Grant Act of 2014 to strengthen the Department's oversight of the health and safety of children. OIG continues to recommend that the Department continue coordination with partner agencies, such as the Department of Homeland Security, to improve its ability to adequately care for unaccompanied children.