U.S. Department of Health and Human Services Strategic Plan An agency strategic plan is one of three main elements required by the Government Performance and Results Act (GPRA) of 1993 (Public Law 103-62). The basic requirements for strategic plans appear in the Office of Management and Budget (OMB) Circular No. A-11, Part 6, Section 210. According to OMB, “an agency’s strategic plan keys on those programs and activities that carry out the agency’s mission. Strategic plans will provide the overarching framework for an agency’s performance budget.iii In constructing the Strategic Plan, HHS sought to respond to the requirements of both GPRA and OMB. At the same time, HHS incorporated priorities and concepts from the Secretary’s 500-Day Plan, the Secretary’s Ten Health Care Priority Activities, the Departmental Objectives, and the Healthy People 2010 Objectives. Although some of these plans and priorities may change from year to year, the most recent versions appear later in this chapter, in a special section called In the Spotlight: HHS Plans and Priorities. Each of the Department’s operating and staff divisions contributed to the development of this Strategic Plan, from the goals and the broad strategic objectives to the baselines and targets for performance indicators. Representatives from HHS operating and staff divisions provided expert knowledge of HHS’s programs, initiatives, priorities, and performance indicators. This process emphasized creating alignment between the long-range Strategic Plan and annual GPRA reporting in the HHS Annual Performance Plan, Annual Performance Budgets, and Performance and Accountability Report. More information about this alignment appears in Appendix C, Performance Plan Linkage. In developing and selecting performance indicators, HHS sought to include broad health and human service impact measures as well as more intermediate processes and outcomes that have contributed to distal impacts. In several cases, numerous operating and staff divisions play a role in achieving these impacts. Operational and staff division personnel regularly monitor thousands of additional performance indicators to improve program processes and examine effectiveness. However, in this Strategic Plan, HHS focused on a limited set of broad outcomes and impacts to demonstrate Departmental progress. Consultation HHS regularly consults with external stakeholders, as noted in Chapters 2 through 5. In complying with OMB guidance and GPRA, HHS consulted widely with stakeholders to garner input on the Strategic Plan. HHS posted a draft on its Web site (http://www.hhs.gov), invited public comment through a notice in the Federal Register, and briefed a number of State, local, and tribal organizations. HHS also sought input from the U.S. Congress and OMB. During its consultation process, HHS received correspondence from more than 40 individuals or organizations, containing nearly 200 unique suggestions. Input ranged from editorial to more substantive comments. HHS has incorporated many of these changes and additions to the final plan. Department of Health and Human Services HHS Eleven operating divisions, including eight agencies in the United States Public Health Service (USPHS) and three human service agencies, administer HHS’s programs. Eighteen staff divisions provide leadership, direction, and policy and management guidance to the Department. (A complete list of HHS’s operating and staff divisions and a brief description of their activities appear in Appendix F.) HHS works closely with State, local, and tribal governments, and many HHS-funded services are provided at the local level by State, county, local, or tribal agencies, or through grantees in the private sector, including faith-based and community based organizations. HHS accomplishes its mission through more than 300 programs and initiatives that cover a wide spectrum of activities, including the following: Providing Medicare ( • health insurance for Americans who are 65 or older, who are disabled, or who suffer from end stage renal disease) and Medicaid (health insurance for low-income people); * Assuring the safety of food and medical products; * Delivering comprehensive health care for Native Americans; * Promoting access to insurance for the uninsured and necessary health services for medically underserved individuals; * Creating an environment that supports the use of health information technologies; * Preventing disease through immunization; * Promoting healthy lifestyles; * Promoting healthy dietary practices, good nutrition, and regular physical activity; * Improving the oversight of imported food and medical products; * Supporting the prevention and treatment of substance abuse; * Improving maternal and infant health; * Planning and preparing for public health emergencies, including those that result from terrorism; * Providing Head Start (preschool education and services); * Preventing child abuse and domestic violence; * Supporting faith-based and community initiatives; * Improving systems of services in communities to enhance the health and well-being of children and youth with special health care needs and their families; * Providing financial assistance and services for low-income families; * Offering services for older Americans, including home-delivered meals; * Furthering access to health and human services by protecting health information privacy and preventing discrimination in the delivery of these services; and * Conducting, supporting, and overseeing scientific and biomedical research and development related to health and human services. With an FY 2007 budget of $698 billion, HHS represents almost a quarter of all Federal expenditures and administers more grant dollars than all other Federal agencies combined. More than 67,000 people work for HHS. Every 3 years, HHS updates its strategic plan, which describes its operating and staff divisions that work individually and collectively to address complex, multifaceted, and ever-evolving health and human service issues. The HHS mission is to enhance the health and wellbeing of Americans by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services. Standards National standards, neighborhood solutions. Collaboration Collaboration, not polarization. Solutions Solutions transcend political boundaries. Markets Markets before mandates. Privacy Protect privacy. Science Science for facts, process for priorities. Results Reward results, not programs. Change Change a heart, change a nation. Life Value life. Health Care Improve the safety, quality, affordability, and accessibility of health care, including behavioral health care and long-term care. 1 The system needs to make progress in providing the excellent quality of care that all Americans deserve. Today, disease, illness, and disability can be as much a threat to Americans’ financial well-being as they are to Americans’ physical and mental well-being. Every American deserves reliable, high-quality, and reasonably priced health care that will be there when it is needed. Health care has to be available, affordable, portable, transparent, and efficient. Health care in the United States is second to none, but it can be better. Although our Nation’s health care facilities and medical professionals are the best in the world, improving quality, constraining costs, and providing greater access remain key priorities. Americans spend an increasing share of their income on health care. Health care spending in America has increased from 5 percent of Gross Domestic Product (GDP) in 1960 to more than 16 percent in 2006, and is predicted to continue to rise. The increasing burden of health spending on the U.S. economy is unsustainable. Higher spending on public programs such as Medicare and Medicaid strains Federal and State budgets. Higher insurance premiums burden workers with higher health costs and pose a challenge for employers to cover both wage increases and health insurance premiums. The system needs to make progress in providing the excellent quality of care that all Americans deserve. We need to increase the rate at which patients receive recommended services and to reduce the number of unnecessary services. We also must eliminate preventable medical errors. Forty-six million Americans do not have health insurance. These individuals may face barriers to obtaining timely and continuous care. Because of their limited access to the system, their health problems may become more severe and further increase health care costs in the future. One critical part of HHS’s strategy to address these problems is to improve transparency within the health care system. Because third parties such as insurance companies, employers, and governments finance the vast majority of health care spending, most Americans do not know—and do not have access to information about—the cost and quality of health care services in order to decide whether they want to receive those services. Making health care affordable, accessible, and high quality depends on providing consumers with the knowledge they need to make informed choices about their health care coverage. The Federal Government must lead in accomplishing these objectives. We are encouraged that others in the private sector have joined in such efforts; we will continue to pursue these goals, which characterize a value-driven health care system. The increasing costs of health care services, our increasingly older population with multiple chronic conditions, and an increasingly complex health care system challenge us to continue our efforts to develop new strategies to maintain safe and affordable services designed to meet Americans’ needs in their various income, family, and health circumstances. HHS is working to improve the efficiency and quality of health care that it finances and delivers. Promoting greater use of health information technology will ensure that accurate and timely information on a patient’s condition is available to all providers involved in the patient’s care and will reduce unnecessarily redundant diagnostic tests and office visits that add to health care costs. Implementation of value-based purchasing systems that include incentives to providers for treatment outcomes, rather than just reimbursements for treatments, will again help move the system toward more efficient and cost-effective provision of care aimed at improving the health and quality of life of the citizens touched by HHS programs. At the same time, we must ensure that our efforts to reduce the cost of high-quality health care are reflected in more affordable and accessible health insurance coverage, to address the problem of the Nation’s growing number of citizens without health insurance. HHS continues to explore options for increasing the portability and accessibility of health insurance through innovative vehicles such as Health Savings Accounts coupled with high-deductible health plans, which have grown in popularity in recent years. Additionally, HHS is working to increase access to private health insurance for those who do not yet have it through initiatives such as Affordable Choices. Together, these initiatives will assist individuals in maintaining their health and prevent health spending from overburdening the economy. Finally, the need to rebuild the health care infrastructure in New Orleans in the wake of Hurricane Katrina offers the Department and its State and local partners the challenge of coordinating coverage; system capacity; and workforce recruitment, retention, and development in new ways that result in a revitalized health care system for that community. Strategic Goal 1, Health Care, targets the need for people to be able to obtain and maintain affordable health care coverage; receive efficient, high-quality health care services; and access appropriate information for informed choices. HHS’s Administration on Aging (AoA), Agency for Healthcare Research and Quality (AHRQ), Centers for Medicare & Medicaid Services (CMS), Health Resources and Services Administration (HRSA), and Indian Health Service (IHS) have significant roles to play in realizing this goal. In addition, the Food and Drug Administration (FDA), Office of the Assistant Secretary for Planning and Evaluation (ASPE), Office for Civil Rights (OCR), Office on Disability (OD), Office of Public Health and Science (OPHS), and Substance Abuse and Mental Health Services Administration (SAMHSA) play roles in addressing this goal. There are four broad objectives under Health Care: * Broaden health insurance and long-term care coverage; * Increase health care service availability and accessibility; * Improve health care quality, safety, cost, and value; and * Recruit, develop, and retain a competent health care workforce. Below is a description of each strategic objective, followed by a description of the key programs, services, and initiatives the Department is undertaking to accomplish those objectives. Key partners and collaborative efforts are included under each relevant objective. The performance indicators selected for this strategic goal also are presented with baselines and targets. These measures are organized by objective. Finally, this chapter discusses the major external factors that will influence HHS’s ability to achieve these objectives, and how the Department is working to mitigate those factors. Meeting External Challenges: HHS faces a number of challenges in improving the safety, quality, affordability, and accessibility of health care, including shifting demographics, changing trends in demand, increasing costs, and continuing concerns about implementing new technologies. Demographic changes include the aging of the Nation’s population and increasing life expectancy, a growing number of persons with disabilities, and an increasing number of populations who do not speak English and have low literacy. HHS is working to meet the challenge by targeting its outreach materials and media responses to these populations, monitoring trends in access and availability of care for these populations, and continuing to design and implement innovative demonstration programs and initiatives aimed at reducing disparities. For more information about this topic, see Chapter 4’s In the Spotlight: Demographic Changes and Their Impact on Health and Well-Being. With these demographic changes, changes in demand are expected to follow. Enhanced outreach to new populations means that HHS may need to think differently about responding to demands for high-quality, high-value, and accessible health care; behavioral health care; and long-term care. Surges in the Medicare-eligible population related to the aging of the Baby Boomers may strain the ability of the health care delivery system to respond appropriately. Even consumer perceptions about their need for preventive screenings or services impact overall demand. HHS is working to analyze background data from services provided to react to changing beneficiary needs. Evidence-based processes are being utilized to address coverage issues. Education campaigns are being conducted to raise awareness about beneficiary screening services and preventive care, with particular attention to growing racial and ethnic minority populations. Although the above is true, one cannot assume that all costs are avoidable. Some of these costs substitute for the costs of excess mortality or morbidity. The United States continues to have the highest per capita health care spending among industrialized countries. The health care cost per capita for persons aged 65 years or older in the United States is three to five times greater than the cost for persons younger than 65, and the rapid growth in the number of older persons, coupled with continued advances in medical technology, is expected to create upward pressure on health care and long-term care spending. Medical inflation also contributes to the rising cost of providing appropriate quality health services, widening the gap between increased need and available resources. An economic downturn could increase demand for health care and long-term care services from safety net providers and strain the ability of current providers to meet the demand. In response to these concerns, HHS will continue to monitor trends in access to care among uninsured, underinsured, and low-income individuals, and to design and implement innovative demonstration programs that seek to improve health and access to care among these groups. HHS will identify new resources to meet increased demands, focusing on efficiency and effectiveness of health care service delivery. HHS will also continue to cultivate a strong focus on prevention and wellness services (see Strategic Goal 2, Objective 2.3, for more detail). Improving health care and the health of the population through the adoption of health information technology (health IT) is clearly a priority for HHS (see In the Spotlight: Advancing the Development and Use of Health Information Technology). The nationwide implementation of an interoperable health IT infrastructure has the potential to lower costs, reduce medical errors, improve the quality of care, and provide patients and physicians with new ways to interact. However, nationwide health IT adoption can be accomplished only through a coordinated effort of many stakeholders, from State and Federal governments and the private sector. HHS has taken great care to engage representatives from all of these sectors in all of our health IT initiatives—an effort that involves many processes and the work of many hundreds of participants. In September 2005, HHS formed a Federal Advisory Committee (subject to the Federal Advisory Committee Act of 1972 (Public Law 92-463), as amended), the American Health Information Community (AHIC), to advise the Secretary on how to accelerate the development and adoption of health IT and help advance efforts needed to achieve the President’s goal for most Americans to have access to secure electronic health records by 2014. Additionally, the AHIC provides input and recommendations to HHS on how to make health records digital and interoperable and how to protect the privacy and security of those records, in a smooth, market-led way. Health Insurance and Long-Term Care Coverage Broaden health insurance and long-term care coverage. 1.1 HHS is committed to broadening health insurance and long-term care coverage. The multifaceted approach to expanding consumer choices includes strengthening and expanding the safety net through programs such as Medicare, Medicaid, and the State Children’s Health Insurance Program (SCHIP); creating new, affordable health insurance options; and creating new options for long-term care, including State Long- Term Care Partnership Programs. The operating and staff divisions contributing to the achievement of this objective include CMS, SAMHSA, AoA, HRSA, and OD. The growing availability of prescription drugs and their cost have had a significant impact on health insurance. The first selected performance indicator, at the end of this chapter, measures the percentage of Medicare beneficiaries who have insurance coverage for prescription drugs through the Medicare drug benefit (Part D) or other coverage. This enrollment is expected to increase. Also, health care coverage for millions of present and future Medicare participants is protected by ensuring that the level of improper payments in the Medicare Fee-For-Service program remains low. Health Insurance - Medicare: Medicare is a health insurance program for people age 65 years or older, people younger than age 65 with serious disabilities, and most people of all ages with end stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant). Three major categories of Medicare include: Part A, which covers inpatient hospital care, skilled nursing facilities, certain home health care, and hospice care; Part B, which encompasses physicians’ services, outpatient hospital care, and many other medical services; and Part D, the newest component of Medicare, which offers a voluntary prescription drug benefit to beneficiaries. There is also a Part C for Medicare, known as Medicare Advantage, that allows beneficiaries to choose a private health insurance plan that covers the Part A and Part B services and, in most circumstances, additional benefits and/or lower cost-sharing payments than under the traditional Medicare FFS program. Medicare Part D. Part D is celebrated as the most significant improvement to the program since Medicare was created in 1965. More than 39 million Medicare beneficiaries now have prescription drug coverage through Part D or another source, including almost 24 million beneficiaries in Part D plans.vi CMS continues to improve program administration of the Medicare prescription drug benefit and to expand awareness of the program through relationships with States and pharmacists, increased use of electronic technology, and education and outreach efforts with more than sixteen thousand partners. CMS will continue these efforts to ensure that beneficiaries can get the prescriptions they need. In particular, CMS has collaborated with AoA and its grassroots Aging Services Network, consisting of State agencies on aging, area agencies on aging, and local service providers, to provide one-on-one assistance and outreach directly to beneficiaries and their caregivers. A number of other initiatives to broaden access are currently underway or in development, such as the “My Health. My Medicare.” campaign and Medicare Medical Savings Accounts. The “My Health. My Medicare.” campaign helps people with Medicare maximize their understanding of the benefits Medicare offers. CMS promotes beneficiary awareness through mailings, media activities, a strong Internet presence, a 24-hour-a-day toll-free telephone service, grassroots alliances, and enhanced beneficiary counseling with State Health Insurance Assistance Programs. CMS partners in this effort include the National Medicare Education Program Partnership Alliance, AoA and its Aging Services Network, State and local agencies, grassroots organizations, the AARP, Medicare Today, the National Caucus and Center on Black Aged, national disability provider and constituent organizations, and other stakeholders. CMS continues to build committed partnerships at the community level; these partnerships will ensure the agency can successfully build on the “My Health. My Medicare.” campaign, as well as other health-related initiatives, in future years. These partnerships are having a profound impact on helping CMS reach the Medicare population, especially the program’s most vulnerable beneficiaries. For example, in collaboration with AoA, in addition to working with the general Medicare population, special efforts are being made to target minority populations to reduce health disparities in the Hispanic, Asian, and African-American communities, as well as in rural communities. Medicare Medical Savings Accounts. CMS is implementing an enhanced consumer-directed Medicare Advantage product called a Medicare Medical Savings Account (MSA) plan. This type of plan combines a high-deductible health plan with a medical savings account that beneficiaries can use to manage their health care costs. CMS will offer regular MSA plans and new demonstration MSA plans. These plans will provide Medicare beneficiaries with the freedom to exercise increased control over their health care utilization while providing them with important coverage against catastrophic health care costs. CMS is providing increased flexibility with the demonstration MSA plans to make the MSAs more like the popular consumer-directed Health Savings Accounts (HSAs) available in the private sector. Examples of the types of flexibility being made available under the demonstration that are not available under the regular MSA rules include coverage of preventive services during the deductible period, a deductible below an out-of-pocket maximum, cost sharing up to the out-of pocket maximum, and cost differentials between in and out-of-network services. Medicaid: Medicaid is a joint Federal- and State-funded, State administered health insurance program available to certain low-income individuals and families who fit into an eligibility group that is recognized by Federal and State law. Using a variety of State plan options and waivers, each State establishes its own rules and guidelines regarding eligibility and service offerings, subject to approval by CMS. CMS also offers flexible State plan options and community-living incentives. In support of these options and incentives, CMS and AoA will continue to target home- and community-based long-term care services to frail older adults who are at high risk of nursing home placement or at risk of spending down their assets. SAMHSA and CMS also will continue to collaborate on issues regarding Medicaid coverage for substance abuse and mental health services. Children’s Health Insurance: The State Children’s Health Insurance Program (SCHIP), a State-administered program, addresses the growing problem of children without health insurance. SCHIP was designed as a Federal-State partnership, similar to Medicaid, with the goal of expanding health insurance to children whose families earn too much money to be eligible for Medicaid, but not enough money to purchase private insurance. CMS will work with the U.S. Congress to reauthorize SCHIP to ensure that these vital programs continue. Affordable Choices: HHS has begun to work with other Federal departments and with States to increase access to private health insurance for those who do not yet have it through the Affordable Choices initiative and related efforts. This proposal would redirect inefficient institutional subsidies to individuals and would need to be State based and budget neutral, not create a new entitlement, and not affect savings contained in the President’s Budget that are necessary to address the unsustainable growth of Federal entitlement programs. Outreach To Raise Awareness: Health Insurance Enrollment and Long-Term Care Coverage Outreach is a collaboration of CMS, AoA, ACF, HRSA, State and local health departments, State Medicaid and SCHIP agencies, State and area agencies on aging, child care and early education providers, and State departments of agriculture and education. This collaborative effort conducts outreach to raise awareness of public health insurance and long-term care benefits and provides information and access assistance. Demonstrations and Waivers: States have many options, including Federal waivers, for broadening coverage to underserved populations. Using Health Insurance Flexibility and Accountability waivers, States can develop comprehensive insurance coverage for individuals at twice the Federal Poverty Level (FPL) and below, using SCHIP and Medicaid funds. These waiver programs target vulnerable, uninsured populations, such as children on Medicaid and SCHIP, and pregnant women. Emphasis is placed on broad statewide approaches that maximize both private health insurance coverage and employer sponsored insurance. Indian Health Programs: IHS provides a comprehensive health services delivery system for American Indians and Alaska Natives with opportunity for maximum tribal involvement in developing and managing programs to meet their health needs. The mission of IHS, in partnership with American Indian and Alaska Native (AI/AN) people, is to raise their physical, mental, social, and spiritual health to the highest level. The goal of IHS is to ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to all American Indians and Alaska Natives. IHS promotes healthy AI/AN people, communities, and cultures and honors the inherent sovereign rights of tribes as part of the Federal Government’s special relationship through treaty obligations with tribes. In 2005, IHS provided health services to approximately 1.5 million American Indians and Alaska Natives who belong to more than 557 federally recognized tribes in 35 States.vii Both primary care physicians and nurse practitioners provide primary care.viii Those children or adults in fair or poor health with only IHS coverage probably did not see a physician in the past year. Adults in good or excellent health with only IHS coverage were probably less likely to have seen a physician in the past 2 years, compared to similar adults with Medicaid or private insurance.ix IHS access alone does not constitute health insurance coverage. Those not served by IHS may use private or State insurance out of preference or lack of proximity to IHS or tribal facilities. Limitation of contracted health service funds and insurance reduces the use of specialty care physician services for American Indians and Alaska Natives. In response to these and other emerging challenges, IHS is focused on expanding access for American Indians and Alaska Natives to comprehensive primary health care services. In addition, IHS recognizes the importance of retinopathy screening for those with diabetes and colorectal screening for early cancer detection and prevention. CMS has joined in efforts to expand access for American Indians and Alaska Natives to health care services covered by Medicare, Medicaid, and SCHIP. The Indian Health Care Improvement Act of 1976 (Public Law 94-437), as amended, extended the Federal obligation to CMS by authorizing payment for Medicare and Medicaid services provided through IHS facilities. This responsibility includes services provided by tribal governments administering health programs under authorities through the Indian Self-Determination and Education Assistance Act of 1975 (Public Law 93-638), as amended. The Indian Health Care Improvement Act further expanded this responsibility by authorizing 100 percent Federal Medical Assistance Percentage to States for payments to IHS and tribal facilities for Medicaid services. CMS works with IHS and the tribes to ensure they follow the Payor of Last Resort rule. According to this rule, IHS pays after Medicare or Medicaid has paid for eligible services, whether IHS and tribes provide services directly or a private source provides them under referred services. Long-Term Care: Long-term care can be required by individuals with disabilities needing assistance with activities of daily living, individuals with frailty and/or dementia associated with aging, individuals with advanced chronic conditions, and other individuals at or near the end of life. The central vision for an efficient long term care system is one that is person centered, i.e., organized around the needs of the individual rather than around the settings where care is delivered. The evolving long-term care system of the future will provide coordinated, high-quality care; optimize choice and independence; be served by an adequate workforce; be transparent, encouraging personal responsibility; be financially sustainable; and utilize health information technology to improve access and quality of care. In an effort to facilitate this system transformation, CMS, in partnership with the U.S. Congress, provides funding to States, territories, and tribal entities to expand choices to persons who need long-term care services. Real Choice Systems Change grants, Medicaid Infrastructure grants, and Systems Transformation grants are a few examples of HHS efforts to assist States in building the needed infrastructure for expanding choices. HHS also works closely with States, territories, and tribal entities to achieve more flexibility in the Medicaid program. To that end, the Money Follows the Person Rebalancing Demonstration project builds on the President’s New Freedom initiative. The Money Follows the Person Rebalancing Demonstration project will help States further address the institutional bias in coverage inherent in the Medicaid program. Selected States will be awarded additional Federal funds to pay for home and community-based services for the first year that individuals transition from institutional care to a community-based setting of their choice. The Long-Term Care Insurance Partnership Program is a federally supported, State-operated initiative that allows individuals who purchase a qualified long-term care insurance policy to protect a portion of their assets that they would typically need to spend down prior to qualifying for Medicaid coverage. Once individuals purchase a long-term care insurance partnership policy and use some or all of their policy benefits, the amount of the policy benefits used will be disregarded for purposes of calculating eligibility for Medicaid. This stipulation means that they are able to keep their assets up to the amount of the policy benefits they purchased and used. For example, in a State that chooses to participate in the partnership program, once individuals have used part or all of their maximum lifetime benefit under their long-term care insurance coverage, their assets would be protected up to the amount used, up to that maximum lifetime benefit. Individuals would not need to spend those assets before qualifying for that State’s Medicaid program. The Aging and Disability Resource Center grant program, a cooperative effort between CMS and AoA, assists States with their efforts to streamline access to long-term care. Program funding supports the development of “one-stop shop” programs to serve as a single, coordinated system of information, assistance, and access. Persons seeking knowledge about long-term care will receive information that will minimize confusion, enhance individual choice, and support informed decision making. Persons seeking knowledge about public and private long-term care options will receive information that will minimize confusion, enhance individual choice, and support informed decision making. Building on this effort, AoA’s Choices for Independence demonstration project aims to provide seniors and their caregivers with information, assistance, and counseling to confront the difficult decisions they face regarding long-term independence in the community, by seeking to reduce the current systemic bias in favor of institutional care. Choices for Independence will target people while they are still healthy and able to plan for their care and will encourage them to take positive steps to maintain their own health. If people need care, Choices for Independence will help them to bolster their own support system and resources before they enter a nursing home and spend down to Medicaid. CMS is working with ASPE and AoA on the HHS Own Your Future campaign, in partnership with six States (Georgia, Massachusetts, Michigan, Nebraska, South Dakota, and Texas). Own Your Future is an aggressive education and outreach effort designed to increase consumer awareness about planning for long-term care. The campaign uses Federal-State partnerships to help individuals from ages 45 to 65 take an active role in planning by evaluating their future long-term needs and resources. Own Your Future provides objective information and resources to help individuals and their families plan for future long-term care needs. To enhance this effort, AoA, ASPE, and CMS have launched the National Clearinghouse for Long-Term Care Information Web site to increase public awareness about the risks and costs of long-term care and the potential need for services. CMS is working with the U.S. Department of Housing and Urban Development to explore options for the provision of long-term care services for beneficiaries living in affordable housing. ASPE and AoA are also collaborating on strategies to develop reverse mortgage programs that will encourage homeowners to use existing assets to acquire long-term care services in the community. CMS is also collaborating with AoA, ASPE, the Administration on Developmental Disabilities (ADD) in HHS’s Administration for Children and Families (ACF), OD, and Federal agencies such as the U.S. Departments of Education and Labor to address long-term care workforce issues. Availability and Accessibility Increase health care service availability and accessibility. 1.2 In addition to broadening health care and long-term care coverage, HHS is committed to increasing the availability and accessibility of health care services. This commitment includes reaching out to vulnerable and underserved populations, such as American Indians and Alaska Natives, people with disabilities, and rural populations. In addition, the Department is committed to enhancing and expanding existing services, such as health centers, long-term care options, substance abuse and mental health treatment programs, and Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) programs. Among the operating and staff divisions contributing to the achievement of this objective are AoA, CMS, HRSA, IHS, OCR, OD, ONC, OPHS, and SAMHSA. Selected HHS performance indicators that best capture the impact of the wide array of HHS services provided under this strategic objective follow: Key aspects of having r • egular access to a source of ongoing care for the entire population; * Receipt of services by American Indians and Alaska Natives, with whom HHS has a special treaty relationship; * Efforts to expand access to publicly funded health centers and substance abuse treatment programs; and * Rates at which programs funded by Title XXVI of the Public Health Service Act as amended by the Ryan White HIV/AIDS Treatment Modernization Act (Ryan White HIV/AIDS Program) serve racial and ethnic minorities, disproportionately affected by HIV/AIDS. The joint planning initiative, Empower Consumer Access to Health Care, Long-Term Care, and Behavioral Health Services, is responsible for development, implementation, and coordination of health care, long-term care, and behavioral health service policies and programs. Ten HHS divisions partner with the U.S. Departments of Agriculture, Education, and Interior, as well as with State and local health departments, Medicaid and SCHIP State agencies, State and area agencies on aging, child care providers, early education providers, and tribal governments. American Indians and Alaska Natives: Health services are provided to American Indians and Alaska Natives through several means. In FY 2006, IHS provided health care services directly at 33 hospitals, 59 health centers, and 50 health stations and supports essential sanitation facilities (including water supply, sewage, and solid waste disposal) for American Indian/ Alaska Native (AI/AN) homes and communities. IHS professional staff include approximately 2,700 nurses, 900 physicians, 400 engineers, 500 pharmacists, 300 dentists, and 150 sanitarians. IHS also employs various allied health professionals, such as nutritionists, health administrators, and medical records administrators. More than half of the IHS budget is now used to provide funding for American Indian Tribes, tribal organizations, and Alaska Native corporations that choose to contract or compact with IHS to provide health care under the Indian Self-Determination and Education Assistance Act of 1975 (Public Law 93-638), as amended. These entities administer 15 hospitals, 221 health centers, 9 residential treatment centers, 97 health stations, and 176 Alaska village clinics. Both IHS and tribal entities purchase additional health care services from private providers. HHS and the U.S. Department of Veterans Affairs (VA) have entered into a Memorandum of Understanding to encourage cooperation and resource sharing between IHS and the Veterans Health Administration. The goal is to use the expertise of both organizations to deliver quality health care services and enhance the health status of AI/AN veterans. An interagency advisory committee, involving IHS and the Office of Minority Health (OMH) in OPHS, identifies health disparities for American Indians and Alaska Natives compared to the general U.S. population. People With Disabilities: The four goals included in The Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities are as follows: * Increase understanding nationwide that people with disabilities can lead long, healthy, and productive lives; * Increase knowledge among health care professionals and provide them with tools to screen, diagnose, and treat the whole person with a disability with dignity; * Increase awareness among people with disabilities of the steps they can take to develop and maintain a healthy lifestyle; and * Increase accessible health care and support services to promote independence for people with disabilities. Virtually every HHS operating and staff division has initiatives to support this critical effort, headed by OPHS’s Office of the Surgeon General (OSG) and OD. Moreover, a broad array of Federal agencies, including the U.S. Departments of Agriculture, Defense, Education, Housing and Urban Development, Interior, Justice, Labor, Veterans Affairs, and the National Science Foundation, the Office of National Drug Control Policy, and the Social Security Administration, as well as many non-Federal stakeholders, have committed to pursuing these goals. Of particular note is HRSA’s effort to provide health and community resource information and peer support to families having children and youth with special health care needs. Family-to-Family Health Information Centers, funded under the Dylan Lee James Family Opportunity Act, will be family-run, statewide centers in every State and the District of Columbia and will be responsible for developing partnerships with those organizations serving these children and their families. They also will be charged with monitoring the progress of programs with responsibility for payment and direct services of this population through a statewide data collection system. Rural Health: Through collaborative initiatives such as the HHS Rural Task Force and the National Advisory Committee on Rural Health and Human Services, HHS works to address the difficulties of providing health care in rural communities. A technical assistance Web site and targeted dissemination of information about innovative models for health services delivery in rural communities are part of HHS’s overall strategy. The HHS Underserved Populations effort focuses on delivery of health care services for underserved populations in rural and urban areas and involves CMS, HRSA, IHS, OD, SAMHSA, State and local health departments, health care providers, and the Tribal Technical Advisory Group. Health Centers: At the beginning of FY 2007, HRSA’s Consolidated Health Center Program was providing comprehensive primary and preventive health care in more than 3,800 sites across the country to an estimated 14.8 million people.xi Most Health Center patients have incomes at or below 200 percent of the FPL. Many Health Center patients have no health insurance, and most patients are racial or ethnic minorities. Health Centers help to improve the availability of health services by providing a range of essential services. As new or expanded sites are funded in medically underserved communities, a major focus will be on poor rural and urban counties consistent with the President’s goal of establishing new Health Centers in the poorest counties in the Nation. Health Centers help to improve the availability of health services by providing a range of essential services, including pharmacy services onsite or by paid referral, preventive dental care, and mental health and substance abuse services at most centers. Mental Health: The final report of the President’s New Freedom Commission on Mental Health (2003) called for a fundamental transformation of how mental health care is delivered in America. SAMHSA’s Center for Mental Health Services will continue to work to transform the mental health system so that Americans understand that mental health is essential to overall health; mental health care is consumer and family driven; disparities in mental health services are eliminated; early mental health screening, assessment, and referral to services are common practice; excellent mental health care is delivered and research is accelerated; and technology is used to help consumers access mental health care and information. New Orleans Health System: Hurricane Katrina incapacitated the Greater New Orleans health care system, ravaged its health care infrastructure, and severely impacted health care delivery in a number of Louisiana parishes. Eighty percent of New Orleans Health Centers were destroyed; the teaching hospitals of New Orleans were devastated; and countless people lost all of their medical records. The Louisiana Health Care Redesign Collaborative strives to build an efficient 21st century health care system implementing technology, transparency, emergency preparedness, and greater personal health care choices. HHS is supporting the Collaborative in its effort by helping to convene stakeholders, providing expert assistance and other HHS resources, removing barriers to progress, and reviewing Medicaid waiver and Medicare demonstration concepts submitted by the Louisiana Health Care Redesign Collaborative in accordance with the guiding principles. The goal is to improve health care by providing every citizen with access to health care that is prevention centered, neighborhood located, and electronically connected. Health care providers could use electronic health records and meet certain quality measures in order to provide care. Success means that Louisiana and New Orleans will have health care systems that can serve as models for the Nation. More information about how HHS is promoting electronic health records is included later in this chapter in, In the Spotlight: Advancing the Development and Use of Health Information Technology. Ryan White HIV/AIDS Program: HRSA’s programs through the Ryan White HIV/AIDS Program currently provide services to approximately 531,000 individuals who have little or no insurance and are impacted by HIV/AIDS.xii Key pieces of this program include its efforts to prioritize lifesaving services, medications, and primary care for individuals living with HIV/AIDS. Providing more flexibility to target resources to areas that have the greatest needs is also a key piece of the Ryan White HIV/AIDS Program. The program also encourages the participation of any provider, including faith-based and other community organizations, that shows results, recognizes the need for State and local planning, and ensures accountability by measuring progress. Substance Abuse Services: SAMHSA’s Center for Substance Abuse Treatment promotes the quality and availability of community based substance abuse treatment services for individuals and families who need them. The Center for Substance Abuse Treatment works with States and community-based groups to improve and expand existing substance abuse treatment services under the Substance Abuse Prevention and Treatment Block Grant Program. The Center also supports SAMHSA’s free treatment referral service to link people with the community-based substance abuse services they need. Among SAMHSA’s efforts to improve the health of the Nation by increasing access to effective alcohol and drug treatment is the Access to Recovery program. Access to Recovery is designed to accomplish three main objectives: to expand capacity by increasing the number and types of providers, including faith-based and community providers, who deliver clinical treatment and/or recovery support services; to require grantees to manage performance, based on patient outcomes; and to allow recovery to be pursued through many different and personal pathways. Vouchers, State flexibility, and executive discretion combine to create profound positive change in substance abuse treatment financing and service delivery. The innovative and unique Access to Recovery program is focused on consumer empowerment. Under Access to Recovery, consumers will continue to have the ability to choose the path that is personally best for them and to choose the provider that best meets their needs, whether physical, mental, emotional, or spiritual. Nondiscrimination and Privacy Protection: OCR ensures compliance with the nondiscrimination requirements of Title VI of the Civil Rights Act of 1964 (Public Law 88-352), as amended, requiring recipients of HHS Federal financial assistance to ensure that their policies and procedures do not exclude or limit, or have the effect of excluding or limiting, the participation of beneficiaries on the basis of race, color, or national origin. These efforts, which reach beneficiaries of all health and human service programs that HHS funds, seek to achieve voluntary compliance and corrective efforts when violations are found. OCR has collaborated with the U.S. Departments of Agriculture and Justice to produce a video and informational brochure in multiple languages to advise service providers and consumers with limited English proficiency about their responsibilities and rights under Title VI. OCR also enforces the federal privacy protections for individually identifiable health information provided by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. Privacy enforcement activities provide consumer confidence in the confidentiality of their health information so that privacy concerns are not a deterrent to accessing care and full and accurate information is provided at treatment and payment encounters. OCR will continue to work with Federal and State partners and with providers and consumer groups, including faith-based and community organizations, to ensure nondiscriminatory access to health and human services, to eliminate health disparities, and to protect the privacy of identifiable health information. Quality, Safety, Cost and Value Improve health care quality, safety, cost and value. 1.3 In the future, American health care will be shaped into a system in which doctors and hospitals succeed by providing the best value for their patients. Value in health care means delivering the right health care to the right person, at the right time, for the right price. Providing reliable health care cost and quality information can empower consumer choice at all levels. Systemwide improvements can occur as providers and payers can track how their practice, service, or plan compares to others. As value in health care becomes transparent to consumers and providers alike, HHS anticipates the following benefits: Costs will stabilize; more people will acquire insurance; more people will get access to better health care; and economic competitiveness will be preserved. Ultimately, this is a prescription for a value-driven system—a prescription of good medicine that works for everyone. HHS will work to achieve this value-based system over the next 5 years. Several HHS operating and staff divisions contribute to this goal of improving the quality, safety, cost and, ultimately, the value of health care, including AHRQ, AoA, CMS, FDA, HRSA, IHS, NIH, ONC, OPHS, and SAMHSA. The performance indicators for this strategic objective, listed in full at the end of this chapter, measure: * Adoption of electronic health care records, which affect the long-term quality, value, and safety of health care; * Quality of care that residents receive in nursing home facilities; and * Number of States implementing specific approaches to improve the quality of Medicaid funded health care, on which many low-income people depend. Health Care Transparency: Health care transparency may restrain the growth of health care costs because consumers will know the comparative costs and quality of their health care—and they will have a financial incentive to seek out quality care at the lowest cost. Consumers will gain control of their health care and have the knowledge to make informed decisions. Health care transparency is built on four interconnected cornerstones: * Connect the System. Every medical provider has a system for keeping health records. Increasingly, those systems are electronic. Standards need to be identified so that all health information systems can quickly and securely communicate and exchange data. * Measure and Publish Data on Quality. Every case, every procedure, has an outcome. Some outcomes are better than others are. To measure quality, HHS must work with doctors and hospitals to define benchmarks for what constitutes quality care. * Measure and Publish Data on Price. Price information is useless unless cost is calculated for identical services. Agreement is needed on what procedures and services are covered in each “episode of care.” * Create Positive Incentives. All parties—providers, patients, insurance companies, and payers— should participate in arrangements that reward both those who offer and those who purchase high-quality, competitively priced health care. Employers committing to these cornerstones would agree to collect quality and price information through its health plan or benefit administrator, using the consensus standards. Employers committing to the goals also would be encouraged to share quality and price information with regional collaboratives, where information from many sources could be aggregated, thus producing the most broad-based and reliable information possible. The employer or its health plan would share quality information with enrollees and would provide specific costs the enrollee would expect to pay under the plan. Six pilot programs to demonstrate how transparency can promote improvements in health care are underway, with support from CMS and AHRQ. These pilot programs are being coordinated under the Better Quality Information Data Aggregation and Reporting project, through a contract with the Maryland Medicare Quality Improvement Organization. The communities were selected using a set of criteria by a representative committee of the public/private entity Ambulatory Care Quality Alliance, which consists of 135 physician organizations, consumers, employers, and health plan representatives. The Alliance makes available quality information about physician care. The purpose is to measure and report on physician practice in a meaningful and transparent way for consumers and purchasers of health care. Personalized Health Care: The future of health care in America is one in which care will be personalized, predictive, preemptive, and participatory. Advances in basic research have positioned us to begin to harness new and increasingly affordable potential in medical and scientific technology. With clinical tools that are increasingly targeted to the individual, our health care system can give consumers and providers the means to make more informed, individualized, and effective choices. Emphasis on personalized health care could make health care safer and more effective for every patient, especially when we are able to use the power of genetic information and health information technology to better understand each patient’s needs and more precisely target therapies. This may mean that the same medical condition requires different treatment for men and women, or for older persons, or for others whose inherited traits may put them at particular risk. Ongoing activities across HHS are working toward the long-term goals of personalized health care, and the convergence of these efforts will act as a powerful force to educate both the patient and the health care provider to improve clinical outcomes. Basic research at NIH is improving the foundational knowledge of diseases; FDA’s Critical Path Initiative is improving the speed and safety of product development; and CDC will use population data to understand the genetic basis of diseases. FDA has initiated the Critical Path to Personalized Medicine, a program designed to modernize and ensure more efficient development and clinical use of medical products. Under the Critical Path Initiative, HHS anticipates being able to dramatically increase the success rate in providing patients with innovative solutions that strike an optimal balance of high benefit and low risk because they are “personalized.” Once both the disease and the person are understood at the molecular level, physicians will be able to provide treatment options uniquely suited to a patient’s particular needs. Electronic Health Records: Patients cannot receive appropriate and efficient care unless clinical information about them is available at the point of care. When patients’ health information is not accessible to providers as they transition through the continuum of care, clinical decisions often must be made without full knowledge of patients’ history and health status. The absence of needed clinical information can lead to a requirement to duplicate tests that not only increase the costs of health care, but also subject patients to unneeded clinical interventions that always carry a degree of risk. Similarly, the absence of needed information could lead to incorrect decisions or medical errors that could result in adverse clinical outcomes. Over time, more advanced electronic health records will have integrated clinical decision support with the latest scientific evidence guiding clinical interventions at the point of care along with environmental data that should also influence many treatment decisions. Increasing the adoption of interoperable electronic health records will decrease these risks to both the efficiency and efficacy of care. Through the collaborative activities of the American Health Information Community, chaired by the Secretary of HHS, much work is underway to identify the functionality and standards that will support the development and adoption of interoperable electronic health records to achieve the President’s vision of making electronic health records available to most Americans by 2014. More information about this effort can be found later in this chapter in In the Spotlight: Advancing the Development and Use of Health Information Technology. Value-Based Purchasing: Value-based purchasing is the use of payment methods and other incentives to encourage substantive improvement for patient-focused, high-value care. At HHS, value-based purchasing is in its early stages of development. The Tax Relief and Health Care Act of 2006 (H.R. 6111) lays the groundwork for CMS to establish many models for financial and nonfinancial incentives used in value-based purchasing programs or strategies. Programs such as Medicare Hospital Pay for Performance, Medicare Demonstration Project to Permit Gainsharing, and the Premier demonstration are viewed as one component of a broader strategy of promoting health care quality. At least 12 States throughout the country have already implemented a wide range of value-based purchasing initiatives under Medicaid. States are using both payment differentials and nonfinancial incentives, such as auto-enrollment and public reporting, to reward performance. CMS will provide technical assistance to those States that voluntarily elect to implement value-based programs. CMS also will encourage States to include an evaluation component to provide evidence of the effectiveness of this methodology. Quality Improvement Efforts: Medicare Quality Improvement Efforts. Improving quality of care and reducing medical errors are important goals in modernizing Medicare. The Medicare Web site will continue to display quality data that allow consumers to make informed choices by comparing the performance of hospitals, nursing homes, home health agencies, and dialysis facilities. Medicaid Quality Improvement Efforts. States continue to advance efforts to improve overall quality of care as they seek new approaches to improve and expand insurance coverage. In many instances, State Medicaid programs have led the way in quality initiatives that have the potential to shape activities of other public and private payers across the country. Several States have implemented value based purchasing programs with the objective of redesigning the payment structures to promote and reward the provision of high-quality care. At least 13 States now publicly report performance measurement data that can be used by State agencies, beneficiaries, policymakers, and others to promote transparency and personal responsibility in the care provided. CMS also has launched a Neonatal Care Outcomes Improvement project with an objective of decreasing infant morbidity and mortality. Nursing Home Quality Initiatives. The CMS Nursing Home Quality Initiative is a broad-based effort that includes continuing regulatory and enforcement systems. New and improved consumer information is available through the 1–800–MEDICARE (1-800-633- 42273) line and at the Medicare Web site. In addition, community-based nursing home quality improvement programs, and partnerships and collaborative efforts to promote awareness and support, are underway. The first goal of the initiative is to provide consumers with an additional source of information about the quality of nursing home care by establishing quality measures based on the Minimum Data Set and by publishing information on Medicare’s Nursing Home Compare Web site. The second goal is to help providers improve the quality of care for their residents by giving them complementary clinical resources, quality improvement materials, and assistance from the Quality Improvement Organizations in every State. Collaborative Quality Improvement Initiatives. Two joint planning efforts focus on quality and improvement initiatives. With representation from CMS, CDC, AHRQ, and a number of non-Federal organizations, one effort experiments with approaches to create incentives for hospitals and physicians to provide both high-quality and efficient care (e.g., Gainsharing, Hospital Compare, Surgical Care Improvement Project, and others). The second effort, the Quality Workgroup, consists of CMS, AHRQ, IHS, ONC, the Office of Personnel Management, and a variety of non-Federal organizations representing labor, insurers, hospitals, and other stakeholders. The Quality Workgroup makes recommendations to the American Health Information Community (AHIC) so that health information technology can provide the data needed for the development of quality measures that are useful to patients and others in the health care industry. The Quality Workgroup seeks to automate the measurement and reporting of a comprehensive current and future set of quality measures and to accelerate the use of clinical decision support that can improve performance on those quality measures. In addition, this workgroup makes recommendations on how performance indicators should align with the capabilities and limitations of health information technology. More information about the AHIC’s work is included in the Meeting External Challenges section of this chapter. Medical Home Quality Improvement Initiative. A medical home is primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. In a medical home, a pediatric clinician works in partnership with the patient and his or her family to assure that all the medical and nonmedical needs of the patient are met. Through this partnership, the pediatric clinician can help the patient and family access and coordinate specialty care, educational services, out-of-home care, family support, and other public and private community services that are important to the overall health of the child or youth and family. A HRSA initiative will identify effective strategies currently being used in collaboration with Title V Children with Special Needs programs in the States and will implement quality improvement activities within their medical home activities. The purpose is to enhance infrastructure development, provide quality care, and foster exchange of strategies among families, communities, and State and Federal leaders. Medical Product Safety: FDA is responsible for addressing concerns regarding the safety of medical products, in particular, drugs. As the science of drug development continues to evolve, FDA will continually improve the approach to drug regulation to ensure that care providers and patients can make optimal decisions about the medicines they use to improve their health. FDA’s reform effort will include developing new tools for communicating information to patients and improving the management of the process for how FDA uncovers and communicates important drug safety issues. For example, FDA will focus on improving the safety of drugs on the market in part through its plans to modernize the Adverse Event Reporting System (AERS) and establish “AERS II” as the primary source for drug product adverse event data. These resources also will allow FDA to augment AERS data and further its efforts with CMS to obtain access to valuable drug safety information housed in CMS population-based databases. This collaboration with CMS will be integrated with the Sentinel System, a seamless platform for gathering and evaluating information about adverse events related to the use of medical products. This integration will enable FDA to gather more information from the point of care about potential safety problems and will provide a framework for turning these raw data into useful knowledge about the safe use of medical products. In order to improve current processes and systems for collection of adverse events and errors, FDA is developing MedWatch Plus. This program will provide a single internet portal for anyone needing to report an adverse event resulting from an FDA regulated product, including product complaint reporting. This initiative will improve the collection and processing of adverse event information for all FDA regulated products. The user-friendly electronic submission capability will facilitate submission of adverse events reports to better allow FDA to efficiently and effectively use the information to promote and protect public health. Through these modernization efforts, FDA will continue to ensure that the medical products it regulates are the safest in the world. OPHS coordinates vaccine safety activities among HHS agencies which conduct a broad range of activities aimed at ensuring the safety of vaccines. NIH conducts and funds basic research that leads to the development of vaccines with a major emphasis on safety. FDA has statutory responsibility for licensing vaccines. Additionally, the FDA coadministers the Vaccine Adverse Event Reporting System (VAERS), a passive surveillance system, with CDC. CDC also conducts active surveillance of vaccine associated adverse events through the Brighton Collaboration, and examines vaccine adverse events on the practice level through Clinical Immunization Safety Assessment (CISA) centers. HRSA compensates individuals who may have been injured by vaccines through the Vaccine Injury Compensation Program (VICP). The Federal government has a heightened responsibility to ensure that vaccines are optimally safe as vaccines are recommended for nearly ever child in the U.S. and children are required by state laws to receive vaccines in order to enter school. OPHS is coordinating an interagency strategic plan to enhance HHS vaccine safety activities. Vaccine safety activities will be enhanced in the areas of research and development, post-licensure surveillance, and risk communication. Generic Drugs. Part of FDA’s mission is to make sure that the generic drugs approved for use in the United States are just as safe and effective as the brand-name versions of the drugs. Generic drugs can be very helpful for patients because their price is typically much lower: For the average price of a brand-name prescription drug that is $72, the average price of a generic version is about $17.xiii This is an especially important source of drug savings at this time, because a growing number of important brand-name medications—more than 200 in the next few years—are coming off patent, paving the way for the development of generic versions. FDA’s new final regulation to improve how and when generic drugs can compete with brand-name drugs will lead to saving billions of dollars in drug costs each year. Health Disparities: The Racial and Ethnic Health Disparities Outreach joint planning effort focuses on outreach to raise awareness among minority communities about major health risks prevalent in their specific populations and to provide access to information on how to reduce these risks. AoA, CDC, IHS, NIH, OCR, and OPHS partner with media, State and local health departments, State and area agencies on aging, and tribal governments on this effort. Additional information on HHS’s efforts on this topic can be found later in this chapter in In the Spotlight: Reducing Health Disparities. Workforce Recruit, develop and retain a competent health care workforce. 1.4 In the coming years, the Nation faces shortages of critical health care workers, including nurses and long-term care providers. In addition, all health care workers will need to be flexible and responsive enough to act on new challenges and maximize the potential of new technologies. In addition to strategies to develop its own workforce, HHS is committed to helping the field recruit and retain, as well as train, develop, and support, a competent professional and paraprofessional health care workforce. Among the operating and staff divisions contributing to the achievement of this objective are AoA, ASPE, CMS, HRSA, IHS, OPHS, and SAMHSA. HHS, in the health care programs it operates, faces the same recruitment and retention challenges encountered by health care providers nationwide. The first performance indicator measures HHS’s success in meeting its goal to recruit and retain the Commissioned Corps members needed to provide ongoing health care. The second measures the Corps’ readiness to rapidly respond to medical emergencies and urgent public health needs. Recruitment /Retention Efforts: Commissioned Corps. The mission of the Commissioned Corps of the United States Public Health Service (USPHS; Commissioned Corps) is protecting, promoting, and advancing the health and safety of the Nation. The Commissioned Corps achieves its mission through rapid and effective response to public health needs, leadership and excellence in public health practices, and the advancement of public health science. As one of the seven Uniformed Services of the United States, the Commissioned Corps is a specialized career system designed to attract, develop, and retain health professionals who may be assigned to Federal, State, or local agencies or international organizations. The Commissioned Corps will continue to offer two excellent opportunities for students through the highly competitive Junior Commissioned Officer Student Training and Extern Program and Senior Commissioned Officer Student Training and Extern Program. Indian Health Service. The Indian Health Care Improvement Act of 1976 (Public Law 94-437), as amended, authorized IHS to administer interrelated scholarship programs to meet the health professional staffing needs of IHS and other health programs serving Indian people. In addition, IHS administers a Loan Repayment Program for the purpose of recruiting and retaining highly qualified health professionals to meet staffing needs. The Indian Health Professions Program provides scholarships, loans, and summer employment in return for agreements by students to serve in health facilities serving American Indians and Alaska Natives in medically underserved areas. As a matter of law and policy, IHS gives preference to qualified American Indians in applicant selection and in career development training. National Health Service Corps. Currently, 35 million people live in communities without adequate access to primary health care because of financial, geographic, cultural, language, and other barriers. Since its inception, the National Health Service Corps (NHSC), managed by HRSA, has placed more than 27,000 primary care clinicians, including dental, mental, and behavioral health professionals, in underserved areas across the country including communities with Health Centers. In FY 2007, field strength for the NHSC is estimated to be more than 3,400 people. Approximately half of NHSC clinicians are assigned to service in Health Center sites. Nurses. The Bureau of Labor Statistics estimates that by 2020 the Nation will have a shortfall of up to 1 million nurses, which includes new jobs and “replacement” jobs that are open when today’s nurses retire and leave the field. As the population continues to grow and age and medical services advance, the need for nurses will continue to increase. A report developed by HHS, What is Behind HRSA’s Projected Supply, Demand, and Shortage of Registered Nurses, predicted that the nursing shortage is expected to grow to more than 1 million by 2020. In 2007, HHS nursing programs will support recruitment, education, and retention of nursing students, emphasizing new loan repayments and scholarships. Workforce Support Efforts: Cultural Competence. OPHS’s OMH is mandated to develop the capacity of health care professionals to address the cultural and linguistic barriers to health care delivery and increase access to health care for people with limited English proficiency. The Center for Linguistic and Cultural Competence in Health Care was established in FY 1995 as a vehicle to address the health needs of populations with limited English proficiency. National Standards on Culturally and Linguistically Appropriate Services. These standards have been developed and are primarily directed at health care organizations; however, individual providers also are encouraged to use the standards to make their practices more culturally and linguistically accessible. The principles and activities of culturally and linguistically appropriate services should be integrated throughout an organization and undertaken in partnership with the communities being served. The standards are organized by three themes: Culturally Competent Care, Language Access Services, and Organizational Supports for Cultural Competence. Mental Health and Substance Use Disorders Prevention and Treatment. SAMHSA supports efforts to identify and articulate key workforce development issues in the mental health and substance use disorders prevention and treatment fields and to encourage the retention and recruitment of an effective compassionate workforce. These efforts include support for programs that train behavioral health professionals to work with underserved minority populations, training for mental health and substance abuse providers, and leadership training programs. Support to Family Caregivers. The National Family Caregiver Support Program, developed by AoA, calls for all States working in partnership with local area agencies on aging, faith- and community-service providers, and tribes to offer five direct services that best meet the range of family and informal caregivers’ needs: information about available services; assistance in gaining access to supportive services; individual counseling, organization of support groups, and training to assist caregivers in making decisions and solving problems relating to their roles; respite care to enable caregivers to be temporarily relieved from their caregiving responsibilities; and supplemental services, on a limited basis, to complement the care provided. Direct Support Workforce. To address the emerging “care gap” between the number of long-term care workers and growing demand, providers, policymakers, and consumers are likely to consider a broad range of strategies: improving wages and benefits of direct care workers, tapping new worker pools, strengthening the skills that new workers bring at job entry, and providing more relevant and useful continuing education and training. A key strategy in this mix will be a focus on workforce development—providing workers with the knowledge and skills they need to perform their jobs. In addition, ASPE and its partners in and outside HHS are engaged in a series of research projects aimed at more accurately enumerating the long-term care workforce, describing the types of tasks performed and assessing the impact of workforce development programs. Public Health Promotion and Protection, Disease Prevention, and Emergency Preparedness Prevent and control disease, injury, illness, and disability across the lifespan, and protect the public from infectious, occupational, environmental, and terrorist threats. 2 Throughout the 20th century, advances in public health and medicine resulted in reduced morbidity and mortality from infectious diseases, including influenza, polio, and foodborne and waterborne illnesses. Chronic diseases, such as heart disease, stroke, cancer, and diabetes, replaced infectious diseases as the major cause of illness and death in the United States in the latter part of the 20th century. In the new millennium, the Nation continues to face the challenge of chronic disease because of unhealthy and risky behaviors, environmental exposures, and an aging population. Today, chronic diseases continue to be significant health problems that face Americans. As HHS works to address these health issues, infectious diseases have reemerged as a priority for public health in the United States. For example, risky behaviors such as unprotected sex and injecting drug use continue to result in new HIV/AIDS infections. At the end of 2003, an estimated 1,039,000 to 1,185,000 persons in the United States were living with HIV/AIDS. According to the Centers for Disease Control and Prevention (CDC), approximately 40,000 persons are infected with HIV each year. Injecting drug use is also a common current risk factor for hepatitis C virus (HCV) infection. About 30,000 Americans are infected with HCV each year, and about 3 million are chronically infected with this virus, which is a leading indication for liver transplants and hastens the progression of HIV in those who are coinfected. Foodborne diseases cause an estimated 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths in the United States each year. Other known pathogens account for an estimated 14 million illnesses, 60,000 hospitalizations, and 1,800 deaths annually. Morbidity and mortality from injuries and environmental hazard exposures also continue to affect the health and wellbeing of Americans. Over the past century, public health advances in drinking water, wastewater, and recreational water quality have dramatically improved the health of the American people. However, drinking water from public water systems causes an estimated 4 to 16 million cases of gastrointestinal illness per year. During 2003–2004, 62 waterborne disease outbreaks associated with recreational water were reported by 26 States and Guam. Illness occurred in 2,698 persons, resulting in 58 hospitalizations and 1 death.xix Although malaria is technically preventable and curable if recognized and treated promptly, it remains one of the world’s greatest threats to human health and economic welfare. Each year, malaria kills more than 1 million people—the majority, young children in Africa. In a retrospective analysis, it has been estimated that economic growth per year of countries with intensive malaria was 1.3 percent lower than that of countries without malaria. The 21st century is also marked by the threat of public health emergencies. These threats have become a significant focus for public health at the Federal, State, and local levels. Public health threats and emergencies can ensue from myriad causes—bioterrorism; natural epidemics of infectious disease; terrorist acts that involve conventional explosives, toxic chemicals, or radiological or nuclear devices; industrial or transportation accidents; and climatological catastrophes. Strategic Goal 2, Public Health Promotion and Protection, Disease Prevention, and Emergency Preparedness, seeks to address these problems. There are four broad objectives under Public Health: Prevent the spread of infectious diseases; * Protect the public against injuries and environmental threats; * Promote and encourage preventive health care, including mental health, lifelong health behaviors, and recovery; and * Prepare for and respond to natural and manmade disasters. HHS is positioned to address the public health problems of infectious diseases, injuries and environmental hazards, chronic diseases and behavioral health problems, and public health emergencies through a comprehensive set of strategies. HHS provides leadership on these health issues within the Federal Government and collaborates with numerous partners across the Federal Government to achieve these objectives. These partners include the U.S. Departments of Homeland Security and Defense for public health emergency preparedness; the U.S. Environmental Protection Agency (EPA) and U.S. Department of Labor for environmental and occupational health issues; and the U.S. Departments of Agriculture and Commerce, and EPA, for food safety. Within HHS, multiple operating and staff divisions work together to develop and implement strategies to achieve the goal of preventing and controlling disease, injury, illness, and disability across the lifespan and of protecting the public from infectious, occupational, environmental, and terrorist threats. Key operating and staff divisions that contribute to this goal include the Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), Health Resources and Services Administration (HRSA), Office of the National Coordinator for Health Information Technology (ONC), Office of the Assistant Secretary for Preparedness and Response (ASPR), and Substance Abuse and Mental Health Services Administration (SAMHSA). In addition, HHS’s Administration on Aging (AoA), Centers for Medicare & Medicaid Services (CMS), Office for Civil Rights (OCR), Office on Disability (OD), Office of Global Health Affairs (OGHA), and Office of Public Health and Science (OPHS) play important roles in addressing this goal. Below is a description of each strategic objective, followed by a description of the key programs, services, and initiatives the Department is undertaking to accomplish those objectives. Key partners and collaborative efforts are included under each relevant objective. The performance indicators selected for this strategic goal are also presented with baselines and targets. These measures are organized by objective. Finally, this chapter discusses the major external factors that will influence HHS’s ability to achieve these objectives, and how the Department is working to mitigate those factors. Meeting External Challenges: Within the Public Health Promotion and Protection, Disease Prevention, and Emergency Preparedness goal, changes in population demographics, shifts in burden of disease, uncertainty related to the scope and timing of public health emergencies, and the potential threat of zoonotic diseases will significantly influence the ability of HHS to achieve the objectives related to this goal. As the Nation’s population ages, a greater proportion of Americans will be older and expected to live longer. These shifts will result in an increased chronic disease burden and a greater need for public health interventions to prevent or control these diseases. HHS will work to mitigate these effects by promoting the translation of the evidence base for health promotion and disease prevention for older adults at the community level. HHS also will continue to develop and implement cost-effective models to support increasingly frail older adults in their homes. A shifting distribution in disease burden also affects the ability of HHS to achieve its public health objectives. For example, HIV-related disease and affected populations will result in an expansion of the number of HIV-infected individuals who need treatment and related care. Infections in new subpopulations could be difficult to identify, reach, and serve. HHS is developing improved disease surveillance and outreach strategies to identify and reach newly affected populations in the United States. HHS also is providing assistance to service providers in planning and capacity-building efforts to meet these changes. In the public health emergency preparedness arena, external factors represent both threats and opportunities. First, the unexpected scope of emergencies in terms of probability of occurrence, place, time, and type makes resource allocation and targeting a significant challenge. A hurricane can result in significant public health consequences as Hurricane Katrina did in 2005, or may result in little or no health impact. A bioterrorist attack could be widespread, occur simultaneously in multiple locations, or be limited to one room in one building. HHS is addressing this uncertainty by planning for multiple scenarios in its all-hazards preparedness program. HHS also is providing guidance to help States and localities enhance their capacity to respond to natural or manmade disasters of varying severity and scope. Second, external factors also provide opportunities for shared planning, response, and evaluation. By working with our Federal, State, local, and tribal partners, we can leverage resources and personnel to improve overall level and quality of both preparedness and response. Emerging pathogens, many of which are zoonotic in origin, also affect emergency preparedness. Because the habitats of animals and people are inextricably linked, there is an increased possibility for exposure to zoonotic diseases. HHS understands this link, and is coordinating strategies to mitigate zoonotic diseases that originate in animals in order to protect both animal and human health. HHS collaborates with other Federal departments and agencies and international organizations that focus on animal health, as well as with State governments and academic institutions, to address zoonotic diseases. Infectious Diseases Prevent the spread of infectious diseases. 2.1 Although modern advances have conquered some diseases, infectious diseases continue to threaten the Nation’s health. Outbreaks of Severe Acute Respiratory Syndrome (SARS), avian influenza, West Nile Virus, and monkeypox are recent reminders of the extraordinary ability of microbes to adapt and evolve to infect humans. Earlier predictions of the elimination of infectious diseases often did not take into account changes in demographics, migration patterns, and human behaviors, as well as the ability of microbes to adapt, evolve, and develop resistance to drugs. Infectious disease can have significant medical and economic consequences. Addressing foodborne illnesses, vectorborne pathogens, viral hepatitis, HIV/AIDS and other sexually transmitted infections, tuberculosis, antimicrobial resistance, and a possible influenza pandemic is a significant priority for HHS. Although these diseases affect all Americans, many often hit hardest the most vulnerable populations—the low-income population, minorities, children and youth, immigrants, persons who are incarcerated, and other disenfranchised populations. The selected performance indicators at the end of this chapter were chosen to reflect the impact HHS has on these populations. Immunization: HHS has identified several key strategies for addressing the threat of infectious diseases. One of the primary strategies is the use of vaccines. HHS’s vaccine enterprise includes outreach activities and funding support for childhood and adult immunization. HHS, through CDC, will protect Americans from vaccine-preventable diseases by providing health communication messages about vaccination and supporting efforts to increase immunization coverage rates for both children and atrisk adults. OPHS coordinates and ensures collaboration among the many Federal agencies involved in vaccine and immunization activities. The Assistant Secretary for Health (ASH) provides leadership and coordination among Federal agencies, as they work together to carry out the goals of the National Vaccine Plan. The National Vaccine Plan provides a framework, including goals, objectives, and strategies, for pursuing the prevention of infectious diseases through immunizations. In 2007– 2008, HHS will review and revise the existing National Vaccine Plan to ensure that it addresses new scientific and safety issues that have emerged since the first plan was developed. HHS also will continue existing efforts to increase immunization rates for vaccine-preventable illness. Specifically, HHS, through CDC, will develop and disseminate health communication messages about vaccination and support efforts to increase immunization coverage rates for both children and adults. The Vaccines for Children Program (VFC), which provides immunizations for eligible children6 at their doctors’ offices, will continue to be a cornerstone of the HHS infectious disease prevention strategy. VFC also helps children whose insurance does not cover vaccinations when they receive them at participating Federally Qualified Health Centers and Rural Health Clinics. HHS also will work to increase rates of vaccination against influenza and pneumococcal viruses through its National Influenza and Pneumococcal Vaccination Campaign. This joint initiative involves CDC, CMS, FDA, HRSA, IHS, and NIH along with State and local health departments, Medicaid agencies, tribal representatives, health care providers, and the National Coalition for Adult Immunization. It aims to provide vaccinations for influenza and pneumonia to beneficiary populations. HIV/AIDS: OPHS coordinates all HIV/AIDS-related scientific and policy matters, such as new developments and program activities within the areas of research, HIV prevention, HIV care and treatment, and budget development. OPHS also ensures the effective and accountable management of the Department’s HIV/AIDS programs. Building on its existing surveillance, research, and screening activities, CDC applies well-integrated, multidisciplinary programs of research, surveillance, risk factor, and disease intervention to prevent and control the spread of HIV infection. For example, CDC is the source of national data on the epidemic and supports prevention programs in every State, guided by community planning. These programs reach those at highest risk for acquiring or transmitting infection with effective interventions to reduce their risk and protect their health. CDC and HRSA will support efforts to increase knowledge of community capacity to respond to HIV and increase HIV testing status, focusing especially on groups and communities at the highest risk of infection. FDA is responsible for ensuring the safety of the Nation’s blood supply by minimizing the risks of infectious disease transmission and other hazards while facilitating an adequate supply of blood and blood products. Routine and targeted HIV testing will be key strategies for preventing new HIV infections and improving outcomes for those who test positive. Individuals infected with HIV who are aware of their infection are less likely to engage in risky behaviors and are more likely to take steps to protect their partners. Additionally, individuals infected with HIV who are aware of their infection can take advantage of the therapies that can keep them healthy and extend their lives. Additionally, FDA will continue its work with international drug regulatory authorities to promote expedited review of generic antiretroviral drugs under the President’s Emergency Plan for AIDS Relief (PEPFAR). HHS, through its operating divisions, especially CDC and HRSA, is one of the major implementing partners for PEPFAR, and manages prevention, treatment, and care activities in the 15 focus countries of the Emergency Plan and more than 20 others. HHS also provides part of the Federal Government’s financial contribution to the Global Fund to fight AIDS, tuberculosis, and malaria, and is part of the interagency team that guides U.S. policy toward the fund. Zoonotic/Vectorborne Diseases: To address zoonotic and vectorborne diseases, HHS will develop plans to respond to a disease outbreak that encompasses animal, vector, and human experts working in synergy. CDC will develop disease surveillance systems that incorporate animal, vector, and human data to provide an effective public health response that will mitigate the impact of a multispecies outbreak. CDC will develop, test, and deploy improved methods for the detection and control of insectborne viruses and bacteria and will improve the capacity to detect the intentional release of plague, Rabbit Fever (tularemia), and other agents with bioterror potential. FDA will foster the development of preventive vaccines for malaria, dengue fever, and other vector-borne and zoonotic diseases by working with industry and academia. In addition, surveillance, detection, and response systems will be developed and tested to address domestic and international epidemics of vectorborne pathogens with the potential to harm the U.S. population. Foodborne/Waterborne Illnesses: To combat foodborne illness, FDA and CDC will work together to protect public health through preventive strategies that improve surveillance, inspection, tracking, detection, investigation, control, and prevention of foodborne outbreaks and disease; strengthen the enforcement of regulations; and broaden education about these problems. HHS will improve the important national collaborative surveillance and response networks of the FoodNet, PulseNet, and OutbreakNet to make them faster, more responsive, and capable of more detailed investigations. FDA and CDC, along with the U.S. Department of Agriculture, and other organizations, will continue to participate in the Council to Improve Foodborne Outbreak Response, a group created to develop tools that facilitate the investigation and control of foodborne disease outbreaks. Over the next several years, the Council will develop multistate outbreak guidelines, a repository for resources and tools, and performance indicators for the response to enteric disease. To address waterborne diseases, CDC will continue to partner with EPA to fill critical data gaps by providing improved disease surveillance data, creating evidence based guidelines and training for investigations, expanding access to water-related information, collecting data to define the magnitude and burden of waterborne illness, evaluating water-related interventions to improve public health, and developing laboratory sampling and detection methodologies. As part of its preparedness effort, CDC will also develop, improve, and deploy rapid sampling and detection methods for potential waterborne threats. Providing comprehensive public health protection to all community users of water will create a more effective Federal response aimed at reducing the burden of waterborne disease in the United States. Global Health: One key strategy for preventing the spread of infectious disease is preventing it from reaching the United States. HHS will collaborate with the World Health Organization (WHO) and other international partners to provide epidemiologic and laboratory support to assist countries in addressing disease threats through improved disease detection. HHS also will provide programmatic expertise, training, and funding support to assist with surveillance, control, elimination, and eradication activities for diseases such as measles, polio, avian influenza, and HIV/AIDS, as well as the provision of technical assistance with safe and healthy water and improved sanitation. Immunization has revolutionized child health in countries throughout the world. WHO estimates that almost 40 percent of child deaths for children younger than 5 years of age are potentially preventable by vaccines.xxi HHS has been a major supporter of global initiatives to eradicate polio; control measles; and introduce new vaccines for pneumoccocal diseases, rotavirus, and possibly in the near future, malaria and even HIV. HHS remains committed to achieving global polio eradication and meeting the global target to achieve a 90 percent reduction in measles mortality by 2010 as compared to 2000. Efforts to combat vaccine- preventable diseases overseas not only assist global efforts at lowering child mortality, but also help to protect U.S. children from susceptibility to these debilitating diseases. One specific set of activities that HHS will continue in support of its global health strategy is in the area of malaria prevention. CDC supports prevention and control of malaria throughout the world in partnership with local, State, and Federal agencies in the United States; medical and public health professionals; national and international organizations; and foreign governments. Specific strategies include conducting malaria surveillance, prevention, and control activities in the United States; providing consultation, technical assistance, and training to malaria-endemic countries to change and implement proven policies to decrease malaria burden; conducting multidisciplinary research in the laboratory and in the field, to develop new tools and improve existing interventions against malaria worldwide; and translating research findings into appropriate global policies and effective practices through the Roll Back Malaria Partnership and other international partners. HHS will continue to work with other Federal partners to control malaria through participation in the President’s Malaria Initiative (PMI), an intergovernmental initiative led by the United States Agency for International Development (USAID), CDC, NIH, the U.S. Departments of State and Defense, and the National Security Council. The goal of PMI is to reduce malaria deaths by half in each target country after 3 years of full implementation. The initiative helps national governments deliver proven, effective interventions—insecticide-treated bed nets, indoor residual spraying, prompt and effective treatment with artemisinin-based combination therapies, and intermittent preventive treatment to people at greatest risk, pregnant women and children younger than 5 years old. As of June 2007, work is ongoing in the first three PMI countries (Angola, Tanzania, and Uganda) as well as the four added in 2006 (Malawi, Mozambique, Rwanda, and Senegal). Later in 2007, activities will begin in the final eight countries (Benin, Ethiopia, Ghana, Kenya, Liberia, Madagascar, Mali, and Zambia), which will bring the program to its full complement of 15 countries with a high burden of malaria in Africa. Additional information about HHS’s efforts in global health can be found later in this chapter in In the Spotlight: Global Health Initiatives. Injuries and Environmental Threats Protect the public against injuries and environmental threats. 2.2 Injuries are the leading cause of death among children and adults younger than 44 years of age in the United States. About 160,000 people die each year in the United States from injuries; millions more are injured and survive; and nearly 30 million people sustained injuries serious enough to require treatment in an emergency room. Many injured people are left with long-term disabilities. HHS has a particular responsibility to provide the science base needed to reduce occupational injuries; the performance indicators at the end of this chapter measure this progress. CDC conducts the majority of injury prevention activities that support this objective. CDC focuses on strategies to address interpersonal violence, residential fires, falls, and workplace injuries and mortality. These include identifying risk factors, conducting surveillance, and supporting implementation activities. Workplace Injuries: CDC promotes safe and healthy workplaces through interventions, recommendations, and capacity building. To achieve the objective of protection against injuries in the workforce population, CDC actively engages employers to promote commercial motor vehicle safety by providing technical assistance and disseminating Hazard Alerts and Fact Sheets that present practical prevention strategies in both English and Spanish. CDC also works with the Mine Safety and Health Administration on the joint committee examining how the newly developed personal dust monitor (PDM) can be utilized on a daily basis in underground coal mines. The PDM, recently developed by CDC in collaboration with manufacturers, labor, and industry, assesses coal miners’ exposure to coal dust in underground mines and represents the first advancement in more than 30 years for monitoring exposures. Fire-Related Injury Prevention: CDC will continue to support State programs to monitor, identify, and track fire-related injuries and to expand smoke alarm installation and fire safety education programs in communities at high risk. Environmental Hazards: Interactions between people and their environment also pose a risk to their health. Environmental health hazards include water pollutants, chemical pollutants, air pollutants, mold, and radiation from natural, technologic, or terrorist events. HHS works in collaboration with other Departmental-level agencies, including EPA and the U.S. Department of Labor’s Occupational Safety and Health Administration, to address environmental hazards. To support this larger Federal effort, HHS will conduct targeted prevention and surveillance activities aimed at raising awareness of, monitoring, and mitigating threats. CDC and FDA will support this effort by using existing technologies and methods to measure the exposure to environmental chemicals in humans and the food supply. CDC also will investigate new technologies and methods to expand the number of chemicals measured in humans. Childhood Lead Poisoning Prevention: CDC is addressing the problem of childhood lead poisoning through provision of funding and technical assistance to State and local childhood lead poisoning prevention programs. These programs are working to ensure that screening, lead-hazard reduction, model legislation, and other prevention mechanisms occur throughout the country. CDC will build on these efforts by developing and disseminating guidance for the proper treatment of children after they are identified as having elevated blood levels. Violence Against Women: HHS has developed a Violence Against Women Steering Committee, which coordinates the HHS response to issues related to violence against women and their children. This committee, led by ASH, comprises representatives from ACF, AoA, CDC, FDA, HRSA, NIH, OPHS, the Office of the Secretary, and SAMHSA. The committee is also responsible for coordinating HHS violence-related activities with those of other Federal agencies. This steering committee will work to refine and focus HHS’s activities on addressing violence against women. More information about HHS’s efforts to address family violence can be found in Strategic Goal 3, Objective 3.1. Youth Violence Prevention: CDC funds Academic Centers of Excellence to develop and implement community response plans to prevent youth violence. These Centers also train health professionals and conduct youth violence prevention research projects. CDC will continue funding these Centers. The agency also will identify modifiable risk factors that protect adolescents from becoming victims or perpetrators of violence and will increase public awareness regarding dating violence among adolescents through interactive programs such as Choose Respect. Preventive Health Care Promote and encourage preventive health care, including mental health, lifelong healthy behaviors, and recovery. 2.3 Chronic diseases—such as heart disease, cancer, and diabetes—are among the leading causes of death and disability in the United States. These diseases account for 7 of every 10 deaths and affect the quality of life of 90 million Americans. Although chronic diseases are among the most common and costly health problems, they are also among the most preventable. AHRQ, AoA, CDC, CMS, FDA, HRSA, IHS, OD, OPHS, and SAMHSA currently support a variety of programs and initiatives aimed at reducing the prevalence of chronic diseases and helping people with chronic conditions manage their diseases more effectively. State and local health departments, national and international health organizations, philanthropic foundations, and professional, voluntary, and community organizations are key partners in these health promotion and disease prevention activities. In the period of 2007–2012, these agencies will continue to support these activities and will work to expand, enhance, and improve their effectiveness. The Department selected key performance indicators that represent a broad array of activities, including cardiovascular health, cancer screening, and programs to reduce substance abuse and suicide. Preventive Services: A paradigm shift has occurred in health care, resulting in a renewed emphasis on prevention. To reap the benefits of prevention, both health care providers and health care consumers must first understand what those benefits are. The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 (Public Law 108-173) expanded Medicare’s menu of preventive benefits by covering an initial preventive physical examination. This benefit, also referred to as the “Welcome to Medicare” visit, allows new Medicare beneficiaries to get up-to-date information on important screenings and vaccinations, as well as to talk with their health care provider about their medical history and how to stay healthy. All beneficiaries enrolled in Medicare Part B with effective dates that begin on or after January 1, 2005, will be covered for this benefit. The Welcome to Medicare visit enables the health care provider to provide a comprehensive review of his or her patient’s health, to identify risk factors that may be associated with various diseases, and to detect diseases early when outcomes are best. The health care provider is also able to educate his or her patient about the Medicare-covered services they need in order to prevent, detect, and manage disease; to counsel them on identified risk factors and possible lifestyle changes that could have a positive impact on their health; and to make referrals or followup appointments for necessary care. CMS will continue to support and conduct outreach related to the Welcome to Medicare benefit to increase beneficiaries’ utilization. Although Medicare pays for many critical preventive screenings, fewer than 1 in 10 adults aged 65 or older receive all recommended screenings and immunizations. CDC’s Healthy Aging Program will continue to support a model program, Sickness Prevention Achieved through Regional Collaboration (SPARC), which has shown significant success in broadening the use of preventive services. SPARC promotes public access to services, helps medical practices provide preventive services, and strengthens local accountability for service delivery. AHRQ accomplishes adoption and delivery of evidence based clinical prevention services to improve the health of Americans through two main avenues: work in support of the United States Preventive Services Task Force (USPSTF) and Prevention Portfolio efforts aimed at dissemination and implementation of the Task Force’s recommendations. As the USPSTF makes evidence-based recommendations, it is the job of AHRQ to get the word out to clinicians and the general public as rapidly as possible. Accomplishing this goal more quickly puts actionable information into the hands of clinicians, guiding them to perform indicated services and not to perform services for which the evidence indicates more harm than benefit. Getting the word out increases the delivery of appropriate clinical preventive services. Clinicians and policymakers across the Nation hold the work of the USPSTF in high regard. Heart Disease and Stroke: Heart disease and stroke are the most common cardiovascular diseases. For both men and women in the United States, heart disease and stroke are the first and third leading causes of death, respectively, accounting for nearly 40 percent of annual deaths. Although these largely preventable conditions are more common among people 65 years or older, the number of sudden deaths from heart disease among people aged 15 years to 24 years has increased. The economic impact of cardiovascular disease on the Nation’s health care system continues to grow as the population ages. A key strategy for HHS in addressing heart disease and stroke and its risk factors is educating health practitioners and the public about the importance of prevention, about the signs and symptoms of heart attack and stroke, and about the importance of calling 911 quickly. To make women more aware of the danger of heart disease, the National Heart, Lung, and Blood Institute at NIH has collaborated with other organizations to sponsor a national campaign called The Heart Truth. The campaign’s goal is to raise women’s awareness about their risk of heart disease, and has resulted in striking improvements in women’s awareness of heart disease and their acknowledgment of personal risk. CDC’s Heart Disease and Stroke Prevention Program will continue to help States control high blood pressure and high blood cholesterol, both of which are risk factors for cardiovascular diseases, among residents; increase awareness of the signs and symptoms of heart attack and stroke; improve emergency response; improve quality of care; and eliminate health disparities. Medicare’s preventive services cover cardiovascular disease screenings. HHS will continue to provide national leadership to prevent death and disability from heart disease and stroke and to expand support to State cardiovascular disease prevention efforts. FDA also contributes to prevention of heart disease through its food labeling regulations. For example, the recent requirement for trans-fat information on food labels provides consumers with additional information on the fat content of packaged foods. Reductions in consumption of trans-fatty acids are expected to reduce the risk of heart disease significantly. Cancer: Cancer is the second leading cause of death in the United States and costs approximately $210 billion annually.xxv Cancer does not affect all racial or ethnic groups equally. African-Americans are more likely to die of cancer than any other racial or ethnic group, revealing a large health disparity related to this disease. CDC’s National Comprehensive Cancer Control Program funds States, territories, and tribes to build coalitions, assess the burden of cancer, determine priorities, and develop and implement comprehensive cancer control programs. These programs help communities across the country to reduce cancer risks, detect cancers earlier, improve cancer treatment, and enhance quality of life for cancer patients. CDC is supporting these programs to ensure that cancer prevention and control reaches those at highest risk of developing cancer and in the greatest need of assistance. CDC’s National Program of Cancer Registries collects data on the occurrence of cancers through State and territorial registries. CDC is supporting cancer registries throughout the United States to enable public health professionals to better understand and address cancer and its causes. Making cancer screening, information, and referral services available and accessible to all Americans is essential for reducing the high rates of cancer and cancer deaths. CDC’s National Breast and Cervical Cancer Early Detection Program will continue to support screening and diagnostic exams for low income women with little or no health insurance. The program will also support education and outreach, and case management services. CDC’s prostate cancer control initiatives support information dissemination to the public, physicians, and policymakers about the risks and benefits of prostate cancer screening. FDA advances cancer prevention through the development and licensure of cancer prevention vaccines. Included in Medicare’s menu of preventive services are screenings for colorectal and prostate cancer, as well as annual mammograms for women 40 years and older. Overweight and Obesity Over the last 20 years, rates for overweight and obesity have increased dramatically in the United States. Obesity has now reached epidemic proportions. CDC reports that two-thirds of noninstitutionalized U.S. adults age 20 and older are overweight or obese; a third are obese. The epidemic is not limited to adults, however. The percentage of young people who are overweight has more than doubled in the last 20 years. People who are obese are at increased risk for heart disease, high blood pressure, diabetes, and some cancers. CDC, FDA, and OPHS are the primary HHS operating divisions working to reduce obesity and overweight in the United States, with a focus on improving nutrition and increasing physical activity. CDC will continue to support efforts to address obesity through provision of technical assistance, training, and consultation to funded State programs. CDC and its partners create, evaluate, and monitor programs, policies, and practices to prevent and control obesity. CDC will expand communication efforts to promote physical activity and good nutrition in worksites, schools, and health care settings. FDA also contributes to obesity control through its food labeling regulations and education programs. For example, Make Your Calories Count, FDA’s Webbased learning program, helps consumers make informed choices that contribute to lifelong healthy eating habits. The OD physical fitness program, I Can Do It, You Can Do It, targets the obesity and overweight challenges of children and youth through physical exercise based on the awards system of the President’s Committee on Physical Fitness and Sports Program. The program includes a mentee-mentor relationship and an evaluation component. In addition, Dietary Guidelines for Americans provides science-based advice to promote health and to reduce risk for major chronic diseases and conditions, through diet and physical activity. Major causes of morbidity and mortality in the United States are related to poor diet and a sedentary lifestyle. Combined with physical activity, following a diet that does not provide excess calories, according to the recommendations in this document, should enhance the health of most individuals. As a companion to the Dietary Guidelines for Americans, HHS will work over the next 2 years to develop comprehensive guidelines, drawn from science, to help Americans fit physical activity into their lives. The Physical Activity Guidelines for Americans will be issued in late 2008. The Physical Activity Guidelines will summarize the latest knowledge about activity and health, with depth and flexibility targeting specific population subgroups, such as older adults and children. This work is inspired by the President’s personal dedication to physical fitness and his desire that every American have access to science-based guidelines. Diabetes: In the last 15 years, the number of people in the United States with diagnosed diabetes has more than doubled, reaching 14.6 million in 2005.xxvii Diabetes, which is also associated with overweight and obesity, can cause heart disease, stroke, blindness, kidney failure, pregnancy complications, lower extremity amputations, and deaths related to influenza and pneumonia. In addition to the millions of Americans with diabetes, an estimated 41 million adults aged 40 to 74 are prediabetic and are at high risk of developing diabetes. The increasing burden of diabetes and its complications is alarming. However, much of this burden could be prevented with early detection, improved delivery of care, and better education on diabetes self-management. CDC monitors the burden of diabetes nationally and will continue to explore better ways to collect diabetes data on groups most at risk. CDC also provides funding for capacity building and program implementation to States and territories for diabetes prevention and control programs. Over the next 5 years, CDC will expand the number of implementation grants after first developing grantee capacity through phase one capacity grants. CDC also works with NIH to support diabetes education. These operating divisions will continue to collaborate to enhance the network of more than 200 public and private partners who work to increase knowledge about diabetes and its control among health care providers and people with or at risk for diabetes. IHS also will support diabetes prevention and control through mobilizing and involving American Indian/Alaska Native communities to promote diabetes management strategies. For Medicare beneficiaries diagnosed with prediabetes and those previously tested who have not been diagnosed with prediabetes, or those who have never been tested for the disease, diagnostic screening tests are available. For Medicare beneficiaries with diabetes, Medicare offers Diabetes Self-Management Training and Medical Nutrition Training. Oral Health: Mouth and throat diseases, which range from cavities to cancer, cause pain and disability for millions of Americans each year. This fact is disturbing because almost all oral diseases can be prevented. For children, cavities are a common problem that begins at an early age. Tooth decay is also a problem for U.S. adults, especially for the increasing number of older adults who have retained most of their teeth. Despite this increase in tooth retention, tooth loss remains a problem among older adults. CDC is the lead Federal agency responsible for promoting oral health through public health interventions. CDC has and will continue to assist States in strengthening their oral health programs, reaching people hardest hit by oral diseases, and expanding the use of measures that are proven effective in preventing oral diseases. CDC currently provides 12 States with funds, technical assistance, and training to build strong oral health programs. Eight of the 12 States receive funding to develop and coordinate community water fluoridation programs or school based dental sealant programs. With CDC support, States can better promote oral health, monitor oral health behaviors and problems, and conduct and evaluate prevention programs. Substance Use/Abuse: The use of alcohol, tobacco, and illicit drugs exacts a significant health and economic toll on individuals and communities in the United States. In 2005, 19.7 million (8.1 percent) Americans aged 12 years and older used an illicit drug, 71.5 million (29.4 percent) used a tobacco product, and 126 million (51.8 percent) used alcohol. Tobacco use is the leading preventable cause of death in the United States, resulting in approximately 440,000 deaths each year. CDC supports basic implementation programs to prevent and control tobacco use in the States, territories, and tribal areas. CDC also works with a variety of national and international partners to promote action through partnership in tobacco control efforts with WHO and WHO Member States. Building on these existing activities and partnerships, CDC will work to engage business sectors in supporting comprehensive tobacco prevention and control programs, including the benefits of tobacco-free workplaces and the importance of access to cessation services to employees who are trying to quit smoking. For Medicare beneficiaries who use tobacco, cessation counseling is a covered preventive service. As part of its efforts to reengineer its approach to substance abuse prevention, SAMHSA has created a strategic framework that is built on science-based theory, evidence-based practices, and the knowledge that effective prevention programs must engage individuals, families, and entire communities. SAMHSA’s new Strategic Prevention Framework (SPF) sets into place a step-by-step process that empowers States and communities to identify their unique substance use problems, build or enhance infrastructure to support solutions, and implement the most effective prevention efforts for their specific needs. It also includes monitoring and evaluation to ensure accountability and effectiveness of the program effort. SAMHSA will continue to utilize the SPF and expand its use through its State and local grant programs. Suicide Prevention: For every two victims of homicide in the United States, there are three Americans who take their own lives. Suicide is a potentially preventable public health problem. Studies of youth who have committed suicide have found that 90 percent had a diagnosable mental and/or substance abuse disorder at the time of their death. SAMHSA supports activities authorized by the Garrett Lee Smith Memorial Act of 2004 (Public Law 108- 355), which support statewide youth suicide intervention and prevention strategies in schools, institutions of higher education, juvenile justice systems, substance abuse and mental health programs, foster care systems, and other youth support organizations. Additionally, OD is working on an initiative to understand and help prevent suicide among persons with disabilities and those who incur disabilities. Risk Reduction: Chronic conditions currently limit activities for 12 million older people living in community settings in the United States; 25 percent of these individuals are unable to perform basic activities of daily living, such as bathing, shopping, dressing, or eating. Furthermore, falls are the leading cause of injury-related deaths and hospital admission among older people and account for between 20 billion and 30 billion health care dollars in the United States each year. These numbers will increase dramatically in the coming years with the aging of the Baby Boom Generation. AHRQ, AoA, CDC, CMS, and NIH contribute to research, demonstrations, the setting of national standards and guidelines, and the provision of grants and technical assistance to help older adults manage their chronic diseases and prevent falls and to encourage them to live healthy and active lifestyles. For example, AoA funds an Evidence-Based Disability and Disease Prevention grant program and public/ private partnership which deploys proven disability and disease prevention programs at the community level that empower older individuals to make behavioral changes that will reduce their risk of disease, disability, and injury. AHRQ and AoA, in collaboration with CDC, CMS, and NIH, are developing and testing a special Knowledge Transfer program targeted at State and local agency staff to promote and facilitate the utilization of evidence-based disease prevention programs for older people at the community level. CDC funds fall prevention research, research dissemination, and research translation and implementation that help decrease falls and increase stability in mobile older adults. CMS is demonstrating a health promotion and disease prevention program through the Medicare Senior Risk Reduction Demonstration to determine whether health risk reduction programs that have been developed, tested, and shown to be effective in the private sector can be tailored to the Medicare program to help beneficiaries improve their health and thus reduce the need for health care services. Disasters Prepare for and respond to natural and manmade disasters. 2.4 The Pandemic and All-Hazards Preparedness Act of 2006 (PAHPA; Public Law 109-417) codified the HHS Secretary’s role as lead for the Federal public health and medical response to emergencies and incidents covered by the National Response Plan (NRP), and authorizes HHS’s operational control of Federal public health and medical response assets during these events.8 In addition, the development of the Homeland Security Council’s National Strategy for Pandemic Influenza has stressed the importance of preparedness for natural and manmade disasters that have public health impact. Many of the strategies undertaken by HHS to achieve preparedness and response capability are done in concert with or in support of other Federal departments and agencies, State and local governments, and private sector entities. This collaborative approach is vital given that public health emergencies have the potential to affect nearly every sector of society. One of HHS’s largest investments is to develop and stockpile the countermeasures needed to respond to the most serious disasters. Consequently, a performance indicator listed at the end of this chapter assesses the readiness of States to utilize these supplies. A second indicator focuses on the extent to which State emergency management plans cover the broad array of individuals with special needs, specifically measuring plans for those with disabilities. The Office of the Assistant Secretary for Preparedness and Response (ASPR) is the single office responsible for preparedness and response activities within HHS. As the principal advisor to the Secretary on all matters related to public health and medical preparedness and response emergencies, ASPR leads and promotes a collaborative approach with many partners, including ACF, AoA, CDC, CMS, FDA, HRSA, OPHS, and SAMHSA. For additional information on this topic, see In the Spotlight: Emergency Preparedness, Prevention, and Response. Key strategies that will be used to enhance public health and medical emergency preparedness and response include: Developing the National Health Security Strategy, starting in 2009; * Awarding cooperative agreements to States or other eligible entities to conduct the activities of the National Health Security Strategy; and * Reintegrating the National Disaster Medical System within HHS. A major focus of preparedness activities will be the implementation of the Biomedical Advanced Research and Development Authority (BARDA), and countermeasures development. The international preparedness activities include the International Health Regulations, which will come into force in June 2007. These regulations require members to develop, strengthen, and maintain core surveillance and response capacities to detect, assess, notify, and report public health events to WHO and respond to public health risks and public health emergencies. WHO, in turn, will evaluate members’ public health capacities, promote technical cooperation, offer logistical support, and facilitate the mobilization of financial resources for building capacity in surveillance and response. Workforce Readiness: HHS will identify, put on a roster, and train deployable teams of medical and public health providers, including HHS personnel (both commissioned officers and civil service employees), other Federal employees, and voluntary staff. HHS meets regularly with its ESF-8 Federal partners to identify missions, form teams with the skills needed to meet the missions, identify training and equipment requirements, and initiate training. HHS has identified the logistical support needs for these teams and has developed specific tasks for meeting these logistical needs. Examples of these needs include medical supplies, equipment, housing, and food requirements. This activity builds upon the transformation activities of the Commissioned Corps of the USPHS (Commissioned Corps). The Commissioned Corps provides a unique source of well-trained, highly qualified, dedicated public health professionals who are available to respond rapidly to urgent public health challenges and health care emergencies. The Commissioned Corps’ response to Hurricane Katrina is a powerful example of what its officers can do. In response to Hurricane Katrina, the Commissioned Corps deployed more than 2,000 officers—the largest deployment in its history—and still has personnel in the field providing care in Louisiana today. The transformation will facilitate force management improvements that are necessary for the Commissioned Corps to function even more efficiently and effectively. The current activity using rosters is aimed at structuring officers into teams, and then training them as a team. This approach defines clarity of roles and expectations, and assures that leadership and management of the officers in the deployed situation are well understood and their roles are executable. These teams will interface with the Disaster Medical Assistance Teams (DMATs) fielded under the National Disaster Medical System (NDMS). The greatest utility of the DMATs is in immediate emergency response, and they are considered the initial responders for emergency medical needs during the first 72 hours after an event. HHS and other Federal agencies will be responsible for the other requirements in the continuum of health needs, including some aspects of health services delivery during evacuation, hospital care, low-intensity facility-based care for populations with special needs (such as chronic diseases and disability), and other health outreach activities. Threat Agent Identification: CDC and FDA will continue to develop and support laboratory capacity expansion to improve analysis of biological or toxic substances that uses validated, proven methods for different sample matrices. CDC and FDA will also support the development and validation of laboratory methods for priority biological and toxic substances through the Laboratory Response Network. Emergency Preparedness: HHS administers two major grant programs that support State and local capacities, as well as capabilities to prepare for and respond to public health emergencies. Over the next 5 years, these programs will shift dramatically, from a focus on capacity building to improving targeted capabilities. ASPR administers the National Bioterrorism Hospital Preparedness Program, which, through States, enhances the ability of the health care system, including hospitals, to prepare for and respond to bioterrorism and other public health emergencies. Program priority areas over the next 5 years include improving bed and personnel surge capacity, decontamination capabilities, isolation capacity, and pharmaceutical supplies, as well as supporting training, education, drills, and exercises. CDC administers the Public Health Emergency Preparedness Cooperative Agreement Program, which provides funds to States and localities for State and community-level preparedness. Over the next 5 years, HHS will place increased emphasis on achieving benchmarks and standards for preparedness by recipients of both funding streams as required by PAHPA. Countermeasures: HHS, through all of its operating divisions, seeks to shape and execute a comprehensive medical countermeasures program to protect our citizens against the threats of today and into the future. This mission encompasses the breadth of activities required to accomplish that goal, including threat agent monitoring and disease surveillance and detection, as well as research, development, acquisition, storage, deployment, and utilization of medical countermeasures. NIH leads the effort for medical countermeasure basic research, early stage product development, and clinical research. FDA is committed to facilitating the development and availability of safe and effective medical countermeasures. CDC has responsibilities including disease monitoring through its infectious disease surveillance program and medical countermeasure storage and deployment through its Strategic National Stockpile (SNS) program. The SNS procures and stores large quantities of medicine and medical supplies to protect the American public if there is an emergency (e.g., terrorist attack, influenza pandemic, or earthquake) severe enough to cause local supplies to run out. HHS will continue to invest in research and development of medical countermeasures, procure safe and effective materials for the SNS, and work with States to ensure that they are prepared to request, receive, and utilize SNS materials in the case of a public health emergency. Pandemic Influenza: HHS pandemic influenza implementation activities support the larger National Strategy for Pandemic Influenza, and many are conducted in concert with or in support of other Federal departments and agencies. The key strategies for pandemic influenza preparedness focus on international activities; domestic surveillance; public health interventions; medical response; vaccines, antivirals, diagnostics, and personal protective equipment; passive and active surveillance for vaccine safety; communication; and support for State, local, and tribal preparedness. HHS, primarily through ASPR, CDC, FDA, NIH, and OPHS, will continue to support the National Strategy by completing actions in these strategy areas. One major area of focus will be building the prepandemic and pandemic influenza vaccine production capacity and vaccine supply. In April 2007, FDA approved the first U.S. vaccine for humans against the H5N1 influenza virus. FDA will continue to facilitate advanced product development of both seasonal and pandemic influenza medical countermeasures, including novel vaccines, antivirals, and rapid diagnostics. This will be accomplished by providing assistance to industry partners on domestic manufacturing capabilities, accelerating the reviews of seasonal and pandemic influenza related products, and issuing guidance to external stakeholders on various regulatory subjects, including clinical requirements for licensure of seasonal and pandemic influenza vaccines. HHS agencies also will work closely with other Federal agencies and international partners, such as WHO and the ministries of health in target countries. HHS has forward deployed a quantity of Tamiflu in Asia for the purposes of mounting a containment operation to attempt to halt a potential influenza pandemic. In addition, HHS is engaged in a number of international pandemic preparedness activities, through the International Partnerships on Avian and Pandemic Influenza, the Security and Prosperity Partnership of North America, and the Global Health Security Initiative. People With Disabilities: Under Executive Order 13347, all Federal emergency preparedness efforts must address the needs of individuals with disabilities and other vulnerable populations. HHS has taken a leadership role in engaging the disability community and providing guidance to partners to address the unique health needs of individuals with disabilities and other vulnerable populations, including children and youth with special health care needs. In 2006, HHS and the U.S. Department of Homeland Security cosponsored a working conference for State emergency preparedness, public health, aging, and disability agencies to facilitate dialog and collaboration among these organizations toward the common goal embodied in the Executive Order. The result has been a living laboratory for State and Federal cooperation and shared learning around the issue of emergency preparedness for vulnerable populations. OD and ASPR will implement and monitor the use of the disability-based preparedness toolkit and public health staff training modules— developed by a broad-based HHS workgroup—to ensure that the needs of children, youth, and adults with disabilities and chronic conditions are fully understood by first responders and other emergency response providers at the Federal, tribal, State, and local levels during all emergency situations. ASPR, OD, and OCR are working with the American Red Cross to develop an intake and assessment tool that will be used at shelters to evaluate the functional needs of all individuals, including individuals with disabilities. This tool will help ensure that individuals with disabilities have equal access to shelter services and are served in the most integrated setting appropriate. On the local level, OCR’s 10 regional offices are working with other offices in HHS and States to provide technical assistance and resources to plan for and respond to needs of individuals with disabilities in the event of an emergency. Protected Health Information. In its review of State and local emergency plans issued in the summer of 2006, the U.S. Department of Homeland Security identified misunderstanding and confusion surrounding the application of the HIPAA Privacy Rule protections to information sought for emergency response planning purposes. OCR has implemented a new Web-based interactive decision tool designed to assist emergency preparedness and recovery planners in determining how to access and use health information consistent with the HIPAA Privacy Rule. The tool guides emergency preparedness and recovery planners through a series of questions regarding how to apply the HIPAA Privacy Rule. The tool is available on OCR’s Web site along with bulletins containing information for emergency providers on the disclosure of protected health information to assist with disaster relief efforts. Equal Access: OCR has taken steps, consistent with a Federal Governmentwide effort, to help ensure that individuals with Limited English Proficiency (LEP) have equal access to information, shelters, and other evacuation and relief efforts. For example, OCR is working with ASPR and the American Red Cross to develop an intake and assessment tool that will be used at shelters to identify and address communication needs of individuals with LEP. On the local level, OCR’s regional offices are working with HHS partners and States to provide technical assistance and resources to plan for and respond to the needs of individuals with LEP in the event of an emergency. Information Technology Support: HHS will be developing a deployable, interoperable first responder electronic health record system. The electronic health record system for disasters will maintain the security and confidentiality of health information. The intention is to field test possible platforms during the 2007 hurricane season to gain insight into their benefits and limitations. There are few existing systems and standards in the broader health environment to interact with at this time, so the expected benefits are to ensure quality of care and continuity of information sharing during a public health emergency and its aftermath. Wider health sector standards development and endorsement by the Health Information Technology Standards Panel and the Secretary will be completed to capitalize on the desired benefits of this approach toward continuity and quality of care. Human Services Promote the economic and social well-being of individuals, families, and communities. 3 Welfare reform stands as a flagship achievement in social policy reform in the mid-1990s. Through welfare reform, many Americans were helped in breaking the cycle of dependency and encouraged to pursue self-sufficiency. Since the reforms were passed in 1996, the employment rates of current and former welfare recipients have risen and caseloads have declined dramatically. Earnings for current welfare recipients have increased, as have earnings for female headed households in general. In addition, child poverty rates have declined substantially since the start of the Temporary Assistance for Needy Families (TANF) program. States are using their flexibility to focus a growing portion of welfare dollars on helping individuals retain jobs and advance in their employment. Despite these achievements, self-sufficiency remains elusive for many. Only a third of adults in the TANF caseload are fully meeting work requirements. The Deficit Reduction Act (DRA) of 2005 (Public Law 109- 171), which includes language reauthorizing TANF through 2011, challenges and encourages States to engage the remaining adult TANF recipients in workrelated activities to move them up the economic ladder. Addressing the needs of vulnerable children continues to be a priority of HHS. The most recent annual HHS Child Maltreatment Report (covering 2005) indicated that each year an estimated 899,000 children in the United States are victims of abuse or neglect. At the end of FY 2005, there were 513,000 children in foster care; 114,000 of these children were waiting to be adopted. Nearly 2 million children have a parent in a Federal or State correctional facility, a number that more than doubled over the 1990s. Since 1996, the percentage of children born out of wedlock to teens has dropped but still remains unacceptably high. In addition, more adults are choosing to have children outside the protective bonds of marriage. Research suggests that, all other things being equal, children who grow up in healthy married, two-parent families do better on a host of outcomes; for instance, they are less likely to engage in criminal activity or abuse drugs and alcohol than those who do not. HHS’s multicomponent Healthy Marriage Initiative works to help couples who have chosen marriage to gain access to services where they can acquire the skills and knowledge necessary to form and sustain healthy marriages. Making marriage education accessible and appropriate for families is a major component. Children are not alone in their need for support. As the American population ages, enhanced efforts are needed to help the growing number of older persons remain active and healthy. An aging society means that the number of persons requiring long-term care services will increase. The availability of these services in the home and other community-based settings will be increasingly important if people are to maintain their independence and quality of life. People with disabilities, refugees and other migrants, and other vulnerable populations also need assistance and protection to achieve and sustain economic independence and self-sufficiency, as well as social well-being. Strategic Goal 3, Human Services, seeks to protect life, family, and human dignity by promoting the economic and social well-being of individuals, families, and communities; enhancing the safety and well-being of children, youth, and other vulnerable populations; and strengthening communities. The Administration for Children and Families (ACF), Administration on Aging (AoA), Center for Faith-Based and Community Initiatives (CFBCI), Office on Disability (OD), and Substance Abuse and Mental Health Services Administration (SAMHSA) are among the operating and staff divisions primarily responsible for achieving this strategic goal. In addition, HHS’s Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration (HRSA), and Office for Civil Rights (OCR) play important roles. There are four broad objectives under Human Services: Promote the economic independence and social well-being of individuals and families across the lifespan; * Protect the safety and foster the well-being of children and youth; * Encourage the development of strong, healthy, and supportive communities; and * Address the needs, strengths, and abilities of vulnerable populations. Below is a description of each strategic objective, followed by a description of the key programs, services, and initiatives the Department is undertaking to accomplish those objectives. Key partners and collaborative efforts are included under each relevant objective. The performance indicators selected for this strategic goal are also presented with baselines and targets. These measures are organized by objective. Finally, this chapter discusses the major external factors that will influence HHS’s ability to achieve these objectives, and how the Department is working to address those factors. Meeting External Challenges: Within the human service goal, changes in economic conditions, specifically downturns, have been shown to be the most influential external factor influencing how successful HHS’s strategies are in accomplishing its stated objectives. Historically, when negative economic conditions occur, welfare recipients, low-income people, and persons with disabilities are more vulnerable to unemployment; and fewer local resources and safety nets exist for these populations. Decreases in State and local revenue could result in a reduction in funding for home and community based placements for individuals with disabilities. Family stress is greater as economic situations deteriorate, leading to increased potential for violence and family breakup. Noncustodial parents may lose jobs or income resulting in fluctuations in income support ability. To mitigate these effects, HHS works at the State level to enhance States’ capacity to coordinate a broad range of services, conducts research, provides technical assistance, and identifies best practices that focus on elimination of barriers for the hard-to-employ and cost effective service delivery. Additionally, HHS can assist community action agencies, community development corporations, and other community groups in leveraging Federal, State, local, and philanthropic resources to strengthen neighborhoods; build social capital by developing community leadership and strengthening community-based organizations; and support asset development projects for residents of distressed communities. On the individual level, HHS provides information and support for consumers and their caregivers and ensures individuals and families are connected to safety net programs for which they are eligible through outreach and referral. HHS also provides support for child care services, working to connect families with the most appropriate child care setting (also called parental choice) and helping families moving into work to remain connected to other safety net programs for which they are eligible. Child support enforcement activities can also be coordinated with opportunities for job training and supported work activities. Individuals and Families Promote the economic independence and social well-being of individuals and families across the lifespan. 3.1 HHS is committed to helping individuals and families achieve economic independence and social well-being, through individual efforts of ACF, AoA, OCR, OD, and SAMHSA, and in concert with the U.S. Departments of Justice and Labor, States, territories, tribes, and other interested stakeholders. The focus is twofold. First, HHS will collaborate with States in moving disadvantaged families to work and economic self-sufficiency, using indicators to measure the movement of individuals from welfare to work, as well as increases in child support collection. Second, HHS supports interventions that help individuals and families who are disadvantaged improve their economic and social well-being across the lifespan; an indicator at the end of the chapter measures the success of services to individuals with developmental disabilities. The narrative below describes the efforts, initiatives, programs, and collaborations that the Department will implement in the next 5 years to address this strategic objective. Many of these are continuations and expansions of existing programs. Work and Economic Self-Sufficiency: Temporary Assistance for Needy Families. Temporary Assistance for Needy Families (TANF), a block grant administered by ACF’s Office of Family Assistance, provides temporary assistance and work opportunities to needy families by granting States the Federal funds and wide flexibility to develop and implement their own welfare programs. TANF provides funding annually to States, territories, and eligible tribes for the design of creative programs to help families transition from welfare to self-sufficiency. States have tremendous flexibility in determining how to use their TANF dollars to achieve program goals. Reauthorization of TANF in 2006 requires that States implement more meaningful work participation rate requirements in the coming years. Child Care. To support working families, ACF provides States, territories, and tribes with direct child care assistance payments to low-income families when the parents work or participate in education or training. In collaboration with the U.S. Department of Education, ACF’s Office of Head Start, and HRSA, ACF’s Child Care Bureau promotes State flexibility in developing child care programs and policies that meet the needs of children and parents within each State; supports research and evaluation of innovative child care subsidy policies and Web-based access to reports, data, and other research-related information; and helps families to achieve and maintain self-sufficiency by improving access to affordable, high-quality child care. Assets for Independence. The Assets for Independence (AFI) program uses asset-building strategies to assist low-income families in achieving economic independence. The program helps participants save earned income in special-purpose, matched savings accounts called Individual Development Accounts (IDAs). Every dollar in savings deposited by participants into an IDA is matched by the AFI program. The IDA mechanism promotes savings and enables participants to acquire a lasting asset after saving for a few years. AFI program families use their IDA savings, including the matching funds, to acquire a first home, capitalize a small business, or enroll in postsecondary education or training. In addition to helping participants with their IDA savings, all AFI programs provide basic training and supportive services related to family financial management. AFI continues to develop new partnerships to assist families. SCORE, a U.S. Small Business resource partner, helps AFI grantees saving for small business startups. Moreover, the 360 IDAs Initiative now helps increase the availability of IDAs to people with disabilities and their families. Programs of the Administration for Native Americans. The Administration for Native Americans (ANA) in ACF promotes the goal of self-sufficiency by providing social and economic development opportunities. ANA programs offer training, as well as financial and technical assistance, and support a range of projects for eligible tribes and Native American organizations. ANA supports the creation of new jobs, development or expansion of business enterprises and social service initiatives, and formulation of environmental ordinances and training in the use and control of natural resources. Future grants will continue to support social and economic development strategies and healthy marriages to improve the well-being of children. Child Support Enforcement. The Child Support Enforcement (CSE) program is a joint Federal, State, and local partnership that seeks to ensure financial and emotional support for children from both parents by locating noncustodial parents, establishing paternity, and establishing and enforcing child support orders. Child support services, as mandated in Title IV-D of the Social Security Act of 1935 (Public Law 74-271), as amended, are available for all families with a noncustodial parent, regardless of welfare status. Child support collections play an important role for families transitioning from welfare to self-sufficiency, particularly in light of time limits on receipt of cash assistance. By securing support from noncustodial parents on a consistent and continuing basis, families may avoid the need for public assistance, thus reducing government spending. The CSE program continues to make strong gains in child support order and paternity establishment, as well as in collections of current and back support. The Deficit Reduction Act (DRA) of 2005 (Public Law 109- 171) includes a series of provisions to strengthen and improve the program. Overall, DRA provisions will both strengthen existing collection and enforcement tools and allow States the option to provide additional support to families who need it most. These provisions include State options to direct more child support collections to children and families that ever received TANF; new efforts to increase collections such as expanding passport denial, mandatory review and adjustment of support orders, and improving medical support by requiring States to consider both parents’ access to health insurance coverage when establishing child support orders; and an annual user fee for child support cases when enforcement efforts are successful for families who have never received TANF assistance. Well-Being Across the Lifespan: Healthy Marriage and Responsible Fatherhood. The DRA provides funding for research and demonstrations that support healthy marriage. Approximately 125 Federal grants were awarded to States and communities to test new ways to promote and support healthy married-parent families. Grant funds will be used to test promising approaches to encourage healthy marriages and provide marriage education, marriage skills training, public advertising campaigns, high school education on the value of marriage, and marriage mentoring programs. HHS supports several other healthy marriage activities and research, including Building Strong Families, Supporting Healthy Marriages, and the Community Healthy Marriage Initiative. The purpose of the Building Strong Families project is to evaluate healthy marriage services for romantically involved low-income, unwed parents around the time of the birth of a child. The purpose of Supporting Healthy Marriages is to inform program operators and policymakers of the most effective ways to help married parents to strengthen and maintain their marriages. The Community Healthy Marriage Initiative evaluates broad-based community level coalitions that help couples who choose marriage for themselves to develop the skills and knowledge to form and sustain healthy marriages. In collaboration with the U.S. Department of State, HHS also promotes programs and policies at international organizations to strengthen families and marriages and to promote the preservation of human life and dignity. The Promoting Responsible Fatherhood Initiative promotes responsible fatherhood by funding programs that support healthy marriage activities, enhance responsible parenting, and foster economic stability. The initiative will enable fathers to improve their relationships and reconnect with their children. It will help fathers overcome obstacles and barriers that often prevent them from being the most effective and nurturing parent possible. Although the primary goal of the initiative is to promote fatherhood in all of its various forms, an essential point is to encourage fatherhood within the context of marriage. Grant funds will be allocated to promote involved, committed, responsible fatherhood through counseling, mentoring, marriage education, enhancing relationship skills, parenting, and activities to foster economic stability. Family Violence. ACF’s Family Violence Prevention and Services Program, administered by the Family and Youth Services Bureau (FYSB), provides grants to States and tribes to prevent incidents of family violence, provide immediate shelter and related assistance for victims of family violence, and support prevention services for perpetrators. FYSB also supports programs that offer safe havens and access to services for victims of domestic violence, a national toll-free hotline to provide information and assistance to victims of domestic violence, maternity group home services, and runaway and homeless youth shelters. Several collaborative efforts both within HHS and in partnership with other departments and stakeholders support this effort to prevent family violence. The National Advisory Committee on Violence Against Women is an advisory body cochaired by the Attorney General and the Secretary of HHS. National Advisory Committee members meet periodically to share their thoughts, ideas, and expertise and to submit recommendations on a variety of priority issues as the Federal Government develops its policies to address the crimes of domestic violence, sexual assault, dating violence, and stalking. The Greenbook initiative, a joint project of HHS and the U.S. Department of Justice, supported six demonstration projects, helping child welfare and domestic violence agencies and family courts work together more effectively to help families experiencing violence. Now that the funding cycle has been completed, HHS will partner with the U.S. Department of Justice and with the National Council of Juvenile and Family Court Judges to provide technical assistance and support to communities interested in implementing the Greenbook’s recommendations. Support for Older Adults in Home and Community Settings. AoA’s Home and Community-Based Supportive Services program provides an array of services to older adults and their caregivers, including access services such as transportation, case management, and information and referral; in-home services such as personal care, chore, and homemaker assistance; and community services such as adult day care, respite care, and disease prevention, health promotion, and physical fitness programs. Together, these services strive to help older adults maintain their independence and enable them to stay in their homes and communities for as long as possible, delaying the need for costly institutional care. New Freedom Initiative and Olmstead Decision Response. The HHS Office on Disability (OD) was created in 2002 as an outcome of President Bush’s New Freedom Initiative. The New Freedom Initiative commits the United States to a policy of community integration for individuals with disabilities. OD and OCR are involved in a variety of efforts to enhance the independence and quality of life of persons with disabilities, including those with long term needs. OD, through the New Freedom Initiative, ensures a coordinated interagency and intergovernmental approach in support of community integration to tear down barriers on behalf of individuals with disabilities. In Olmstead v. L.C. (1999), the U.S. Supreme Court held that States unjustifiably segregating qualified persons with disabilities in institutions is a form of discrimination prohibited by Title II of the Americans with Disabilities Act of 1990 (Public Law 101-336). OCR has the authority to enforce the Olmstead decision, and has done so through hundreds of complaint investigations, voluntary compliance efforts, outreach initiatives, and technical assistance projects. Through these efforts, OCR ensures that, when appropriate, States provide individuals with disabilities access to services in the community. OCR will continue its Olmstead-related efforts, ensuring that individuals with disabilities return to or remain in their communities with adequate supports. Low Income Home Energy Assistance Program. ACF’s Low Income Home Energy Assistance Program (LIHEAP) will continue to provide home energy assistance through grants to States, tribes, and territories. Of the households receiving heating assistance, about one-third include a member 60 years or older; about half have at least one person with a disability; and about one-fifth include at least one child 5 years old or younger. For the past several years, almost 5 million households per year received LIHEAP assistance to help them through the winter months. The program also provides cooling assistance to about 400,000 households and weatherization assistance to about 90,000 more. Children and Youth Protect the safety and foster the well-being of children and youth. 3.2 HHS is committed to protecting the safety and fostering the well-being of children and youth, through the combined efforts of ACF, SAMHSA, HRSA, and OD, and in partnership with other Federal departments, such as the U.S. Departments of Education and Justice, the Corporation for National and Community Service (CNCS), and other interested stakeholders. Several of the Department’s efforts relate to child maltreatment and safe and permanent living situations for children and youth, as represented by the performance measure at the end of this chapter, which focuses on the adoption rate for children involved with the child welfare system. Other programs and collaborations focus on child care and fostering school readiness, as measured by the percentage of Head Start programs that have a positive impact on verbal and mathematical abilities. Additional initiatives, including mentoring, abstinence education, youth development, and suicide prevention, foster positive behavior, as represented in the indicator focusing on the lack of interaction with law enforcement. Although many of these programs are not new, they will continue and will be strengthened during the period covered by this Strategic Plan. Child Maltreatment: The Child Abuse State Grant Program plays a key role in the prevention of child abuse and neglect by funding post investigative services such as individual counseling, case management, and parent education. The Child Welfare Services program helps State child welfare agencies improve their services with the goal of keeping families together. Grants also are provided to develop and improve education and training programs and resources for child welfare professionals through the Child Welfare Training program and to prevent the abandonment of infants and young children exposed to HIV/AIDS and drugs through the Abandoned Infants Assistance Program. Over the next several years, funds for new regional partnership grants will assist State and local agencies in building cooperative efforts addressing the range of issues presented by families whose substance abuse impairs parenting and places their children at risk. The Independent Living Education and Training Vouchers program provides up to $5,000 for costs associated with college or vocational training for youth ages 16 to 21 in foster care. Two interagency workgroups focus on the issue of child abuse and neglect and provide settings within which Federal agencies coordinate and collaborate. The first, the Federal Interagency Work Group on Child Abuse and Neglect, led by the Office on Child Abuse and Neglect of ACF/Children’s Bureau, engages ACF, CDC, HRSA, IHS, NIH, and SAMHSA, as well as the U.S. Departments of Agriculture, Defense, Interior, Justice, and Labor, State staff, and other partners, in its discussions on child abuse prevention, child welfare, and independent living support services. The group shares information, plans and implements joint activities, makes policy and programmatic recommendations, and works toward establishing complementary agendas in the areas of training, research, legislation, information dissemination, and delivery of services as they relate to the prevention, intervention, and treatment of child abuse and neglect. The second, NIH Neglect Consortium, develops and supports research on child neglect, with support from ACF and the U.S. Department of Education. ACF/Children’s Bureau is working with OD in supporting necessary research to understand the impact of child maltreatment on children and youth with disabilities residing in long-term care facilities and with families (including foster care). Safety and Permanency: The Adoption and Safe Families Act of 1997 (Public Law 105-89) established that a child’s health and safety must be of paramount concern in any efforts made by a State to preserve or reunify a child’s family. ACF’s Foster Care, Adoption Assistance, and Independent Living programs have demonstrated success in improving safety, permanency of living arrangements, and well-being of children. Working with the States, these programs minimize disruptions to the continuity of family and other relationships for children in foster care by decreasing the number of placement settings per year for a child in care. The programs also met goals to provide children in foster care with permanency and stability in their living situations by improving the timeliness of reunification, if possible, and promoting guardianship or adoption when reunification is not possible. In recent years, the Children’s Bureau within ACF has pioneered a results-focused approach to monitoring Federal child welfare programs. The second round of these Child and Family Service Reviews began in 2007 and will hold States accountable for the safety, permanency, and well-being of children involved with child welfare authorities. Additionally, the Promoting Safe and Stable Families (PSSF) program, a capped entitlement program authorized through the Promoting Safe and Stable Families Act of 1997 (Public Law 105-89), assists States in coordinating services related to child abuse prevention and family preservation. These services include community-based family support, family preservation, time-limited reunification services, and adoption promotion and support services. Inspired by research showing that regular caseworker visits are related to the achievement of important child and family outcomes for children in foster care, new funding within the PSSF program provides resources to States to help them ensure that caseworkers visit children monthly. Through the Adoption Incentives program, States will be able to earn bonus payments by increasing the number of adoptions of children in foster care over previous years. The Adoption Opportunities program supports grants that facilitate the elimination of barriers to adoption, and the adoption awareness programs support adoption efforts, including adoption of children with special needs, through training and a public awareness campaign. Adoption incentives added in the 2003 reauthorization of the Adoption Incentive Payments Program focus on adoptions of children age 9 and older who face particularly long waits for adoptive homes. Early Care and Education: ACF’s Head Start and Early Head Start programs are comprehensive child development programs that serve children from birth to age 5, pregnant women, and their families. Head Start is designed to foster healthy development and school readiness in low income children. Head Start programs help ensure that children are ready to succeed at school by supporting social and cognitive development. Head Start programs provide comprehensive child development services, including educational, health, nutritional, and social services, primarily to low-income families. They also engage parents in their child’s preschool experience by helping them achieve their own educational and literacy goals as well as employment goals, supporting parents’ role in their children’s learning, and emphasizing the direct involvement of parents in the administration of local Head Start programs. Early Head Start has a triple mission. It promotes healthy prenatal outcomes, enhances the development of infants and toddlers, and promotes healthy family functioning. HHS will continue to explore how to maximize the use of technology to disseminate information and research in ways that will improve programs and performance. HHS will investigate ways that Head Start and child care can collaborate with other State and local partners, such as State prekindergarten programs, to ensure that children enter school ready to succeed. Several collaborative efforts between HHS and the U.S. Department of Education support early childhood programs and research. The Good Start, Grow Smart interagency workgroup, with HHS representatives from ACF/Office of Head Start, ACF/Child Care Bureau, NIH, and ASPE, focuses on enhancing early childhood programs and fosters better collaboration among agencies serving young children at risk. The Interagency School Readiness Initiative engages the same operating and staff divisions from HHS and the U.S. Department of Education to focus on enhancing early childhood research. Another interagency collaboration, the Early Childhood Workgroup on English Language Learners, involves ACF and ASPE in developing strategies for coordination of early childhood programs aimed at English Language Learners. Mentoring: Research indicates that children with parents who are incarcerated are seven times more likely than the general population to become incarcerated themselves and are more likely to display a variety of behavioral, emotional, health, and educational problems. Through ACF’s Family and Youth Services Bureau (FYSB), HHS supports the Mentoring Children of Prisoners program, through which public and private organizations establish or expand projects that provide one-on-one mentoring for children of parents who are incarcerated and those recently released from prison. OD promotes physical fitness for children and youth with disabilities in conjunction with the President’s HealthierUS Initiative and the President’s Council on Physical Fitness and Sports awards system, through its “I Can Do It, You Can Do It” mentoring program. This program features one-on-one mentoring for children and youth with disabilities across the Nation to enhance their physical fitness, with the goal of serving 6 million children with disabilities. HHS also participates on the recently formed Federal Mentoring Council, an offshoot of the Coordinating Council on Juvenile Justice and Delinquency Prevention (see the section, Collaborative Efforts to Support Youth, for more information on this Council). Convened and staffed by the CNCS, the Council seeks to improve coordination and better leverage resources among all the mentoring programs that exist in the Federal Government. The Council includes representatives from the U.S. Departments of Defense, Education, Interior, Justice, Labor, and many others. The Council works to identify key ways in which the Federal Government can advance the goal of involving 3 million new mentors by 2010, and then act on those findings. Abstinence Education ACF administers two abstinence education programs— the Community-Based Abstinence Education program and the State Abstinence Education program. ACF’s abstinence education programs provide grants to community-based organizations, including faith-based organizations, as well as to States, to develop and implement abstinence programs. The Community- Based Abstinence Education program focuses on adolescents, ages 12 through 18, and targets the prevention of teenage pregnancy and premarital sexual activity. The Community-Based Abstinence Education program also supports a national public awareness campaign designed to help parents communicate with their children about health risks of early sexual activity. The State Abstinence Education program enables States to create or augment existing abstinence education programs and, where appropriate, provide mentoring, counseling, and adult supervision to promote abstinence from sexual activity, with a focus on those groups most likely to bear children out of wedlock. ACF expects that all grantees will present medically accurate information. ACF is requiring Community Based Abstinence Education grantees to certify that curricula are medically accurate and is conducting reviews for medical accuracy as part of the grant award process. Within OPHS, the Adolescent Family Life Program (AFL) also supports abstinence education activities. Through Title XX of the Public Health Service Act (42 U.S.C., 300z et seq.), AFL authorizes two types of demonstration projects: (1) care projects to develop, implement, and evaluate innovative, comprehensive, and integrated approaches to the delivery of health care, education, and social services for pregnant and parenting adolescents and their families; and (2) prevention projects to develop, implement, and evaluate program interventions to promote abstinence from sexual activity among preadolescents and adolescents. AFL also places a strong emphasis on ensuring that educational materials are medically accurate. OPHS, through an interagency agreement with ACF, has launched an initiative that focuses on the importance of parental communication. The Parents Speak Up National Campaign (PSUNC) is an educational campaign aimed at encouraging parents to talk with their children early and often about abstinence. This interactive campaign will include radio, print, and television advertisements to raise awareness. All PSUNC products direct parents to the 4Parents.gov Web site for further information and skills on talking early and often with their children about sex and abstinence. 4Parents.gov provides concise, helpful health information regarding the importance of parent teen communication. The Web site also provides specific information on sexually transmitted diseases and teen pregnancy, benefits of abstinence from sexual involvement, drugs and alcohol, development of healthy teen relationships, and preparation for future marriage and family. Collaborative Efforts for Youth: Positive Youth Development is an approach to youth programming based on the understanding that all young people need support, guidance, and opportunities during adolescence, a time of rapid growth and change. FYSB’s Positive Youth Development State and Local Collaboration Demonstration grants will continue to develop and support innovative youth development strategies. Together with nine other Federal agencies, HHS also supports the First Lady’s Helping America’s Youth initiative, which focuses on the importance of connecting caring adults with youth in order to help youth make better choices that lead to healthier, more successful lives. The Community Guide to Helping America’s Youth helps communities build partnerships and assess their needs and resources. It also offers information about evidence based youth program designs that could be replicated in their community. In the coming years, the Community Guide will continue to be enhanced so that it serves the needs of local youth-focused partnerships. Representatives from several operating and staff divisions within HHS also participate with nine other Federal agencies and eight practitioner members on the Coordinating Council on Juvenile Justice and Delinquency Prevention. The Council’s primary functions are to coordinate Federal juvenile delinquency prevention programs, Federal programs and activities that detain or care for unaccompanied juveniles, and Federal programs relating to missing and exploited children. The Council works to implement several of the recommendations from the 2003 report of the White House Task Force on Disadvantaged Youth. In the coming years, the Council will conduct an inventory of comprehensive community initiatives and will investigate how to support collaboration among Federal, State, and local partners, to determine how best to invest Federal resources to serve youth. HHS will continue to participate in the Federal Government delegations that attend the meetings of the Executive Board of the United Nations Children’s Fund. The Department also will promote programs and policies at international organizations to protect the interests and well-being of children and their families. Communities Encourage the development of strong, healthy, and supportive communities. 3.3 HHS is committed to encouraging the development of strong, healthy, and supportive communities. ACF, CDC, OD, OPHS, and SAMHSA fund comprehensive community initiatives to help distressed communities address the most intractable problems. The Center for Faith-Based and Community Initiatives (CFBCI) works to develop the capacity of faith-based and community based organizations to respond to community needs. In the performance indicator section at the end of this chapter, the Strategic Plan uses family cohesiveness as a proxy for the strength of communities. Below is a sampling of the Department’s efforts related to faith-based and community initiatives, capacity building, and comprehensive community initiatives. Faith-Based and Community Initiatives HHS has made great strides in improving current faith-based and community partnerships, providing opportunities for new partnerships with faith based and community organizations, and removing existing barriers to the inclusion of these groups in HHS programs. Through the HHS CFBCI, technical assistance has been provided throughout the country to increase the capacity of faith-based and community organizations working with vulnerable and needy populations. HHS has reached out and collaborated with religious and neighborhood organizations that for decades have been bringing solutions to bear on some of the Nation’s most intractable problems. CFBCI works with operating and staff divisions across the Department to eliminate barriers to the participation of faith-based and other community organizations; these barriers include regulations, policies, and procedures. CFBCI also works with operating and staff divisions to propose the development of innovative pilot and demonstration programs. Finally, HHS staff have received training to understand how to reach out and partner with these organizations more effectively. Capacity-Building Efforts: The Compassion Capital Fund advances the efforts of community and charitable organizations, including faith-based organizations, to increase their effectiveness and enhance their ability to provide social services where needed. Grants support intermediary organizations that provide training and technical assistance to grassroots organizations in accessing funding sources, administering programs, expanding services, and replicating promising approaches. In addition, targeted capacity-building minigrants help grassroots organizations more effectively deliver services to the most vulnerable populations including youth at risk, persons experiencing homelessness, families transitioning from welfare to work, and prisoners reentering the community. Comprehensive Community Initiatives: SAMHSA funds several comprehensive community mental health services grants for children and youth with serious emotional disturbances and their families. Grants are used to implement a “systems of care” approach to services, based on the recognition that the needs of children with serious mental health challenges can best be met within their home, school, and community, and that families and youth should be the driving force in the transformation of their own care. The grants will be used to provide a full array of mental health and support services organized on an individualized basis into a coordinated network in order to meet the unique clinical and functional needs of each child and family. OD is coordinating an interagency and interdepartmental 2-year seamless program, the Young Adult Program. This program promotes integrated support systems spanning education, health, assistive technology, employment, transportation, and housing for young adults 14 to 30 years with disabilities in six demonstration States through the National Governors Association and is documenting outcomes through a process and impact evaluation. Vulnerable Populations Address the needs, strengths, and abilities of vulnerable populations. 3.4 HHS is committed to addressing the needs, strengths, and abilities of vulnerable populations, including people with disabilities, American Indians and Alaska Natives, refugees and other entrants, victims of human trafficking, persons experiencing homelessness, and people affected by natural or manmade disasters. ACF, AoA, CDC, OCR, OD, and SAMHSA have developed programs and initiatives tailored for these particularly vulnerable populations. The two selected performance indicators at the end of this chapter that focus on this issue look at services provided to homebound older people and newly arrived refugees. Below are a few of the Department’s efforts. People With Disabilities: A number of interagency collaborations have developed to support the economic independence and social well-being of people with physical, sensory, behavioral, cognitive, and developmental disabilities. One is the joint planning effort between AoA, CMS, HRSA, IHS, NIH, OCR, OD, SAMHSA, and non-Federal organizations, including State developmental disability agencies, longterm care providers, tribal governments, State and local agencies on aging, and State and local Medicaid agencies. These agencies and organizations work to increase the independence and quality of life of persons with disabilities, including those with long-term care needs. Another collaboration, the Committee for Employees with Disabilities, with representation from 14 HHS operating and staff divisions, represents the issues and needs of the Department’s employees with disabilities; provides proactive advice, guidance, and recommendations to the Secretary in planning, implementing, monitoring, and evaluating the Department’s affirmative action program on employment of individuals with disabilities; and serves as a focal point for the concerns of employees with disabilities on matters affecting their employment to help resolve Departmentwide problems in this area. American Indians and Alaska Natives The Administration for Native Americans (ANA) promotes economic and social self-sufficiency for American Indians, Alaska Natives, Native Hawaiians, and other Native Pacific Islanders by providing funding for community-based short term projects through three competitive discretionary grant programs to eligible tribes and nonprofit Native American organizations. The three program areas are Social and Economic Development Strategies for Native Americans; Native Language Preservation and Maintenance; and Environmental Regulatory Enhancement, which focuses on building the capacity to identify, plan, and develop environmental programs consistent with Native culture. Coordination with HHS is fostered by the Intradepartmental Council on Native American Affairs, cochaired by the Director of IHS and the Commissioner for the ANA. The purposes of the Council are to develop and promote policies to provide greater access and quality services for American Indians and Alaska Natives; identify and develop legislative, administrative, and regulatory proposals that promote effective policy; develop a comprehensive strategy that promotes self-sufficiency and self-determination; promote the tribal/Federal Government-to-government relationships on a Departmentwide basis; and ensure that the HHS policy on tribal consultation is implemented by all HHS divisions and offices. Within HHS, all operating divisions and many staff divisions are engaged in this important collaborative effort. People Affected by Disasters: For victims of natural disasters, immediate priorities are access to water, food, shelter, medical care, and security. As individuals attempt to recover and rebuild their lives, they must also contend with stressors on their mental health, which can linger for weeks or months. Almost everyone who lives through disastrous events experiences feelings of sadness and depression. Depending on the individual, these feelings can vary in intensity and duration. This is true not only for the residents of the cities and towns devastated by natural disasters, but also for the thousands of rescue workers, emergency medical personnel, and disaster recovery experts engaged in search-and-rescue operations. SAMHSA is focused on providing resources to aid in the recovery process, to assist both the people in areas damaged by natural disasters and the workers who are taking care of them. SAMHSA’s Disaster Technical Assistance Center helps ensure that our Nation is prepared and able to respond rapidly when events increase the need for trauma-related mental health and substance abuse services. AoA offers a comprehensive set of technical assistance materials to help prepare and plan for the management of major emergencies or disaster events. AoA has developed a technical assistance guide, which includes many tools to assist those with the responsibility for the safety and continued independence of the Nation’s older population. The guide helps State agencies and local providers work through the intricate planning and collaborative efforts needed in an emergency. Using this guide, emergency teams will be ready to begin work immediately should a disaster or emergency occur. The Office on Disability, in conjunction with ASPR and ACF’s Administration on Developmental Disabilities, has implemented and monitored the use of a disability based toolkit, shelter assessment tool, and public health staff training modules. Together with the HIPAA Privacy decision tool for emergency preparedness planning, created by OCR, these resources ensure that the needs of persons with disabilities are understood by first responders and other emergency response providers at the Federal, State, and local levels during all emergency situations. Interruptions in child care services during an influenza pandemic may cause conflicts for working parents that could result in high absenteeism in workplaces. Some of that absenteeism could be expected to affect personnel and workplaces that are critical to the emergency response system. A checklist created by CDC will help child care and preschool programs prepare for the effects of a flu pandemic and will help them protect the health of their staff and the children and families they serve. Many of these steps can also help in other types of emergencies. For more information on this topic, see In the Spotlight: Emergency Preparedness, Prevention, and Response. Refugees and Other Entrants: The Office of Refugee Resettlement (ORR) in ACF offers a variety of services to support refugees, migrants, and other entrants, including victims of human trafficking. Assistance to refugees includes transitional cash assistance, health benefits, and a wide variety of social services, provided through ORR grants. The primary focus is employment services such as skills training, job development, orientation to the workplace, and job counseling. The priority is to find employment early after arrival, because it not only leads to early economic self-sufficiency for the family, but also adds greatly to the integrity of families who seek to establish themselves in a new country and provide for their own needs. In addition to economic assistance to adults, ORR supports the Unaccompanied Refugee Minors program, which delivers child welfare services in a culturally sensitive manner. Specifically, the program assists refugee and entrant youth younger than 18 who are without a responsible adult in developing appropriate skills to enter adulthood and to achieve economic and social self-sufficiency. The Unaccompanied Alien Children program provides a safe and appropriate environment for minors during the interim period between the minor’s transfer into a shelter care facility and the minor’s release from custody by ORR or removal from the United States. Victims of Human Trafficking: The Trafficking Victims Protection Act of 2000 (Public Law 106-386), as amended, designates HHS as the Federal Agency responsible for helping victims of human trafficking become eligible to receive benefits and services so that they may rebuild their lives safely in this country. As part of this effort, HHS has initiated the Rescue & Restore Victims of Human Trafficking campaign to help identify and assist victims of human trafficking in the United States. The intent of the campaign is to increase the number of identified trafficking victims and to help those victims receive the benefits and services needed to live safely in the United States. By initially educating health care providers, social service organizations, and the law enforcement community about the issue of human trafficking, HHS will encourage these intermediaries to look beneath the surface by recognizing clues and asking the right questions because they might be the only outsiders with the chance to reach out and help victims. A critical component of the campaign is the creation of the Trafficking Information and Referral Hotline, which connects victims of trafficking to nongovernmental organizations that can help victims in their local areas. The hotline helps intermediaries determine whether they have encountered a victim of human trafficking, helps connect victims to resources, and coordinates with local social service organizations to protect and serve victims of trafficking. People Experiencing Homelessness: The delivery of treatment and services to persons experiencing homelessness is included in the activities of the Department, both in 5 programs specifically targeted to such individuals and in 12 nontargeted, or mainstream, service delivery programs. To improve the response of HHS programs to homelessness, a crosscutting Departmental workgroup, the Secretary’s Work Group on Ending Chronic Homelessness, meets quarterly to develop, lead, and coordinate a comprehensive Departmental approach to addressing homelessness. The group also supports the Secretary in his role as a statutory member of the United States Interagency Council on Homelessness (USICH). The USICH coordinates the Federal response to homelessness across 20 Federal departments and agencies and provides leadership for activities designed to assist families and individuals who are experiencing homelessness with the goal of preventing and ending it in the Nation. The Secretary chairs the USICH in 2007. HHS coordinates extensively with its Federal partners in developing research and program initiatives that will improve access to housing and treatment resources and contribute to ending homelessness. SAMHSA’s Projects for Assistance in Transition from Homelessness (PATH) program is a formula grant program that funds the 50 States, District of Columbia, Puerto Rico, and 4 territories to support service delivery to individuals with serious mental illnesses, as well as individuals with co-occurring substance use disorders or other disabilities, who are homeless or at risk of becoming homeless. SAMHSA provides technical assistance to States and local providers funded by the PATH program, including onsite consultation, collection of annual reporting data, development of an annual report to the U.S. Congress, holding of biannual meetings of PATH program contacts, and identification and dissemination of best practices from the program. HRSA’s program, Health Care for the Homeless centers, provides individuals and families experiencing homelessness with access to comprehensive preventive and primary care services, including oral health, mental health, and substance abuse services. These services are provided in a variety of settings that promote access, including homeless shelters and mobile clinics. The program currently serves as the source of care for approximately 600,000 people per year. Scientific Research and Development Advance scientific and biomedical research and development related to health and human services. 4 Disease and injury are constant threats to humankind and are never static. Diseases, such as HIV/AIDS, SARS, pandemic influenza, obesity, and many other conditions can emerge at any time. Twenty years ago, the impact of Alzheimer’s disease was not fully appreciated, and its causes were not known. Bioterrorism did not figure prominently in the scientific research and development agenda in 2001, but is now a top priority for numerous HHS divisions, including FDA, NIH, and CDC. As a result of success in preventing and treating acute and short- term conditions such as heart attacks, stroke, cancer, and many infectious diseases, people are living longer. The increasingly older population faces the new challenge of multiple chronic conditions that now consume about 75 percent of health care expenditures. The Nation is in a continuous race against the overwhelming health and economic consequences of disease and human suffering. Therefore, we must utilize research and development to its maximum capacity to transform health care, public health, and human service practice efforts. The 21st century is an era of great scientific opportunity. Advances in the understanding of basic human biology allowed NIH to sequence the human genome by 2003, 2 years ahead of schedule, and to complete the haplotype map, showing the variation between individual humans, in October 2005. New advances enable new treatments that could lead to the transformation of medical treatment in this century. The hope is to usher in an era in which medicine will begin to be predictive, personalized, and preemptive. Personalized medicine has the potential to transform health care through earlier diagnosis, more effective prevention and treatment of disease, and avoidance of drug side effects. Basic science is the foundation for improved health and human services. However, once a basic discovery is made, the findings must be applied and translated into practice for health and human service improvement to result. This continuum from basic and applied research to practice is a significant emphasis of HHS’s scientific research and development enterprise. Strategic Goal 4, Scientific Research and Development, seeks to connect this path from basic research to practice through four broad objectives: Strengthen the pool of qualified health and behavioral science researchers; * Increase basic scientific knowledge to improve human health and development; * Conduct and oversee applied research to improve health and well-being; and * Communicate and transfer research results into clinical, public health, and human service practice. A number of HHS operating and staff divisions, including the Agency for Healthcare Research and Quality (AHRQ), Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA) and, most significantly, the National Institutes of Health (NIH), sustain and contribute to a full spectrum of scientific research and development activities. NIH supports and conducts investigations across the full range of the health research continuum, including basic research, which may be disease oriented or related to the development and application of breakthrough technologies; observational and population-based research; behavioral research; prevention research; health services research; translational research; and clinical research, as well as research on new treatments or prevention strategies. FDA supports the research and development goal as a scientific regulatory agency. It is responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, and the Nation’s food supply. FDA also ensures the safety of cosmetics and products that emit radiation. FDA advances the public health agenda by helping to speed innovations to market that make medicines more effective and to provide the public accurate, science-based information needed regarding medicines and foods to improve its health. FDA plays a significant role in addressing the Nation’s counterterrorism capability and in ensuring the security of the food supply. FDA conducts applied and translational research that enables it to develop regulatory standards and risk assessment criteria to reach sound, science-based public health decisions on regulated products. All of these activities are conducted in collaboration with numerous public and private partners, including academic research institutions; nonprofit foundations; and vaccine, pharmaceutical, and medical device industries. CDC focuses primarily on epidemiological and public health practice research. AHRQ has established a broad base of scientific research and promotes evidence-based improvements in clinical practice and in the organization, financing, and delivery of health care services. Below is a description of each strategic objective, followed by a description of the key programs, services, and initiatives the Department is undertaking to accomplish those objectives. Although HHS supports a wide array of research and development activities, these represent the major areas of the emphasis for the Department over the next 5 years. Key partners and collaborative efforts are included under each relevant objective. The performance indicators selected for this strategic goal are also presented with baselines and targets. These measures are organized by objective. Finally, this chapter discusses the major external factors that will influence HHS’s ability to achieve these objectives, and how the Department is working to mitigate those factors. Researchers Strengthen the pool of qualified health and behavioral science researchers. 4.1 The average age of first-time (new) principal investigators of research funded by NIH has risen to 42 years for Ph.D. degree holders and 44 years for M.D. and M.D./Ph.D. holders. This trend must be curtailed in order to capture the creativity and innovation of new independent investigators in their early career stages to address the Nation’s health-related research needs. The National Research Council of the National Academies of Science issued two reports in 2005 about research training and career development with calls for immediate action. NIH will continue to respond to this need to assist and mentor creative young researchers through existing programs. NIH is also developing new initiatives to complement existing efforts to strengthen the pool of qualified health and behavioral science researchers. NIH will continue to support the Ruth L. Krischstein National Research Service Award Research Training Grants and Fellowships Program. This program provides grant and fellowship funding for individual investigators with or working on a research-related or health-profession doctorate degree. Individual awards promote diversity in health-related research fields across NIH. HHS will use the retention rate of these trainees and fellows as an indicator of its success in improving the pool of qualified researchers. NIH will also support the Pathway to Independence Award Program. This program is an innovative and new opportunity for promising postdoctoral scientists to receive both mentored and independent research support from the same award. NIH will also continue to work with IHS to support the Native American Research Centers for Health to increase the number of AI/AN researchers. Scientific Knowledge Increase basic scientific knowledge to improve human health and human development. 4.2 Basic research contributes significantly to personalized health care and to increasing understanding of human makeup and biological processes. Current and future basic research projects in HHS focus on those areas with the greatest potential for reduction in excess morbidity and mortality, including brain function, human development, asthma and other respiratory diseases, cancers, dementia, influenza strain mapping, and antimicrobial resistance. The performance indicators for this strategic objective highlight research efforts related to major diseases, including cardiovascular disease and Alzheimer’s, and imaging tools for the early detection of diseases, including cancer. Brain Research: The rising public health impact of disorders of the nervous system makes neuroscience one of the most important scientific frontiers for biomedical and behavioral research in this century. Discoveries in the areas of pain, alcoholism, drug abuse, autism, schizophrenia, depression, and other mental disorders are increasing dramatically. NIH will build on these discoveries by continuing to support research to better understand the processes of the brain, including improving imaging technologies to be able to visualize brain processes as they happen. The increased understanding of the nerve circuits will pave the way for improved diagnosis and treatment of common diseases such as depression, stroke, and epilepsy and reduced burden on the Nation in terms of both suffering and health care costs. NIH will also support the Autism Phenome Project, which will identify various clinical characteristics and subtypes of autism to facilitate research on genetic and other potential causes of autism and to guide applied research related to treatment approaches. Alzheimer’s Disease: Alzheimer’s disease, the most common cause of dementia among people older than 65, is one of the most serious threats to the Nation’s health and economic well-being. Currently, 4.5 million Americans are affected by the disease; that number is expected to almost triple by 2050. Those suffering from Alzheimer’s disease advance inexorably, from early, mild forgetfulness to a severe loss of mental function and inability for self-care. Existing research suggests that Alzheimer’s disease pathology begins to develop in the brain long before clinical symptoms yield a diagnosis. The ability to make an accurate early diagnosis of Alzheimer’s disease would allow targeted intervention before cognitive loss becomes significant. NIH is searching for valid, easily attainable biological markers that could help identify biological markers for early disease. For example, NIH will support research to examine one promising approach that involves using coated gold nanoparticles as bioprobes to measure the concentrations of substances that correlate with Alzheimer’s disease. NIH will also continue to support the Alzheimer’s Disease Neuroimaging Initiative. The 5-year, 50-site project represents the most comprehensive effort to date to develop neuroimaging and other biomarkers for the changes associated with mild cognitive impairments and Alzheimer’s disease. The ongoing Genetics Initiative will also support the development of resources necessary for identifying late-onset risk factor genes, associated environmental factors such as physical activity and diet, and their interactions. Human Development: NIH is committed to funding a diverse portfolio of basic and translational research that addresses the physical, psychological, psychobiological, language, behavioral, social-emotional, and educational development of children. For example, the National Institute of Child Health and Human Development (NICHD) at NIH has taken a leadership role in advancing scientific knowledge regarding the acquisition of reading and mathematics skills, related learning disabilities, and language development and second language acquisition, as well as child maltreatment, childhood obesity, and the attainment of school readiness skills. Additionally, understanding normative brain development and its relationship to cognitive, social emotional, and behavioral development is important in finding the causes of myriad childhood disorders related to mental retardation, mental illness, drug abuse, and pediatric neurological diseases, which can continue into adulthood. To define the healthy ranges in brain growth and development patterns in children as they mature, NIH-funded researchers are creating the Nation’s first database of Magnetic Resonance Imaging measurement of normal brain development over time in children and adolescents in the United States. NIH is bringing together a diverse array of researchers to design and support a large scale longitudinal study that uses state-of-the-art brain-imaging technologies and that collects clinical and behavioral data, which will be used to develop analytical software tools. A special effort will be made to disseminate these data, and as a result, the scientific community will have access to a Web-based, user friendly resource that integrates neuroanatomical and clinical/behavioral data to examine brain-behavior relationships and relationships between physical maturation and brain development. Cancer Research: NIH investment in cancer research is helping to make a real difference. In the United States, death rates from all cancers combined dropped 1.1 percent per year from 1991 to 2001. Yet cancer remains a major public health problem with more than 1 million Americans per year diagnosed with some form of cancer. Despite significant progress, the cancer challenge remains formidable, and NIH investment in basic cancer research remains critical. NIH will continue to support a broad range of basic research to expand the understanding of cancer. Through the Cancer Genome Atlas Project, NIH will expand the capacity of the cancer community to utilize information on cancer genes. NIH also will focus on a growing area of interest—understanding the reaction of the body’s immune system to a developing tumor— because chronic inflammatory immune responses are known to exacerbate certain cancers. Asthma: NIH supports a comprehensive asthma program to develop new approaches to prevent, treat, and control asthma. Asthma exacerbations cause many of the negative effects of asthma, and management of asthma exacerbations accounts for a large proportion of the estimated annual cost to the Nation’s economy. In contrast to the understanding of the origins of asthma, little is known about the processes that occur during an acute episode; how worsening attacks are resolved; the effect of attacks on future severity and frequency; and the long-term effects on lung physiology, function, and disease progression. In order to develop new interventions to prevent and help resolve acute or worsening asthma episodes, NIH initiated a set of basic, clinical, and translational studies to determine the molecular, cellular, and genetic causes of asthma exacerbations. The long term goal is to identify and characterize two molecular pathways of potential clinical significance that may serve as a basis for discovering new medications for preventing and treating the progression of this disease. The studies will address diverse areas including the role of environmental triggers in enhancing airway hyper responsiveness; the relationship of environmental factors to frequency and severity of asthma attacks; specific effects of initiating events on lung physiology and inflammation; genetic approaches to individual susceptibility for worsening attacks; and the role specific immune and lung cells play in asthma disease classification, chemistry, and physiology. Pandemic Influenza: HHS is working intensely against influenza. The center of this work is the development of multiple vaccines against influenza virus. At the level of basic science, however, NIH is collaborating with numerous public and private partners on an influenza sequencing project. This project will determine the complete genetic sequences of thousands of influenza virus strains, providing the scientific community with data vital to development of new vaccines, therapies, and diagnostics. Antimicrobial Resistance: Microbes once easily controlled by antimicrobial drugs are causing infections that no longer respond to treatment with these drugs. In addition, new, serious, and unforeseen infectious disease threats have emerged, including those posed by agents of bioterrorism. Because the existing repertoire of antimicrobial medications may not provide an effective defense against newly emerging and resistant organisms and bioterrorism agents in the future, there is a need to develop new treatments that may be effective against a range of pathogens. NIH is working to develop a universal antibiotic, a drug effective against a wide spectrum of infectious diseases, to help address these challenges. NIH also is expanding its capacity for medicinal and combinatorial chemistry, library and database resources, and screening assays for use in identifying novel antimicrobial drugs. Applied Research Conduct and oversee applied research to improve health and well-being. 4.3 The application of basic scientific findings in the health and human service areas marks the next step along the continuum from basic research to practice. Numerous divisions within HHS conduct and provide oversight of applied research. These activities range from clinical trials for promising new pharmaceuticals and vaccines to behavioral research to identify effective approaches for reducing risky behaviors associated with infectious and chronic diseases. The performance indicators highlight clinical trials focused on improving treatment to those with both cardiovascular disease and diabetes and/or chronic kidney disease. Birth Defects/Developmental Disabilities: CDC conducts a variety of applied research studies to advance the understanding of factors associated with birth defects and developmental disabilities in both children and adults. Over the next 5 years, CDC will identify and evaluate the role of new factors for birth defects and developmental disabilities. CDC also will initiate new and continue existing studies of candidate risk and protective factors associated with birth defects and developmental disabilities to identify potential intervention strategies. Substance Abuse Treatment: Although research has demonstrated that substance abuse treatment can be effective in reducing substance use and addiction, few science-based interventions have been developed and tested widely within the health care field. The reasons for this are, in part, related to cultural and institutional barriers. In an effort to narrow the substance abuse treatment gap, recent substance abuse treatment studies have focused on deploying interventions in communities. NIH has adapted and is testing three substance abuse treatment approaches in an effort to bring research-based treatments to communities more rapidly. These substance abuse treatment protocols, Brief Strategic Family Therapy, Seeking Safety, and Motivational Enhancement Treatment, are designed to reach specialized populations that are frequently underrepresented in drug and alcohol abuse research and are often underserved in drug and alcohol abuse treatment centers. The populations served include adolescents at high risk for substance addiction and their families and abused women, as well as members of minority groups. Lung Cancer: Lung cancer is one of the leading causes of death in the United States, with an estimated 160,000 deaths occurring annually and an estimated incidence of 173,000 newly diagnosed cases each year. Only one-third of newly diagnosed cases are identified at a stage early enough to allow for effective therapeutic intervention, while more advanced stages of the disease are characterized by a median survival rate of less than 1 year. The development of new drug treatments for lung cancer has been slowed by difficulty in both early detection and measurement of early therapeutic drug response. NIH is supporting research to evaluate, validate, and compare varying functional imaging methods that could serve as more sensitive approaches to the measurement of early drug response than standard or conventional anatomic imaging techniques that are based on significant tumor shrinkage. NIH is striving to validate and to compare three imaging methods that could offer increased sensitivity over computed tomography as a means of assessing lung cancer response to therapy. Obesity: Obesity is associated with numerous serious diseases, including type 2 diabetes, heart disease, stroke, osteoarthritis, gallstones, breathing problems, and certain cancers. Type 2 diabetes, formerly viewed as a disease of older adults, has been increasingly reported among children. NIH is exploring lifestyle-based approaches to obesity prevention, including behavioral or environmental interventions, in settings such as schools, communities, and homes. NIH will support at least two studies that will evaluate the effects on weight control of worksite interventions that include environmental components, and at least three studies will evaluate the effects of interventions delivered in primary care settings to treat and/or prevent obesity in children. Because maintenance of weight loss is a critical yet particularly difficult element of obesity treatment and prevention, NIH also will investigate novel ways to help individuals who have intentionally lost weight to keep the weight off for at least 2 years. Complementing these areas of investigation relevant to lifestyle interventions is research to evaluate the efficacy of different types of diets and physical activities. Cardiovascular Disease: To improve the treatment of cardiovascular disease, NIH is working to develop and clinically apply one new imaging technique that will enable tracking the mobility of stem cells within cardiovascular tissues. Scientists are now devoting considerable effort to understanding the role of cytokine production by stem cells rather than focusing solely on assessing their differentiation state and location in vivo. Despite the new focus on cytokine production, the importance of understanding stem cell differentiation remains a basic, important problem in regenerative medicine. A promising new approach for assessing differentiation has recently been reported in the literature. Scientists have inserted a reporter of calcium transients into stem cells, allowing scientists to determine whether stem cells are coupled productively to the normal heart during the regeneration process. Control of differentiation will be critical for the eventual success of cardiovascular cell-based therapy. Imaging methods to detect and monitor the differentiation process are now the focus of efforts in numerous laboratories. NIH is undertaking a multimodality imaging effort to develop tools to track cardiovascular stem cells in vivo, and ultimately in patients. Public Health Protection: CDC’s applied research portfolio targets four interrelated areas: healthy people in every stage of life, healthy people in healthy places, people prepared for emerging health threats (infectious, occupational, environmental, and terrorist threats), and healthy people in a healthy world. In support of the goals directed research strategy, CDC has developed the Advancing the Nation’s Health: A Guide to Public Health Research Needs, 2006-2015. This Research Guide is a comprehensive resource of critical national and global public health research priorities that will advance science and practice toward greater health impact. The array of public health research priorities includes infectious diseases, public health preparedness, chronic diseases and disabilities, safety of environments, global public health, health information and communication, crosscutting research, and health disparities. Over the next 5 years, CDC will progress toward achievement of the health protection goals and will address the research themes in the Research Guide. Within the infectious disease area, research will focus on antimicrobial resistance; bioterrorism-related environmental microbiology, and zoonotic and vectorborne diseases; vaccines and immunization programs, including vaccine supply issues; and special populations. Within the preparedness area, research will focus on vulnerable populations, including predictive strategies for risk and recovery after an extreme event, infrastructure and workforce preparedness, and detection and diagnosis of hazards and their medical consequences. The chronic disease applied research portfolio will focus on pregnancy planning and preconception care; optimal child and adolescent development; identification of effective health promotion strategies; and reduction of the burden of, disparities in, and risk factors for, chronic disease among older adults. In order to create safe places to live, work, and play, CDC will conduct research on environmental risk factors such as lead exposure and health, safe workplace design, effective strategies to prevent injuries and violence, and risk and protective factors for interpersonal violence and suicidal behavior. Food, Drug, and Device Safety: Under its Critical Path Initiative, FDA will stimulate and facilitate a national effort to modernize the scientific process through which a potential human drug, biological product, or medical device is transformed from a discovery or “proof of concept” into a medical product. FDA will continue to conduct research on resistance of foodborne pathogens to antimicrobial drugs and to provide for the safe use of antimicrobials in food animals, while ensuring that the usefulness of critical human drugs is not compromised or lost. FDA’s National Center for Toxicological Research (NCTR) will undertake applied research studies that support and anticipate current and future regulatory needs, including integrated toxicological research and support for the Critical Path Initiative. Communication and Transfer Communicate and transfer research results into clinical, public health, and human service practice. 4.4 The implementation of research results in the health care Americans receive every day is the last step of productive research. The performance indicators at the end of this chapter highlight three ongoing efforts to improve prevention efforts among older adults, reduce infant mortality among minorities, and implement evidence-based practices in clinical care. Community Preventive Services: The Guide to Community Preventive Services serves as a filter for scientific literature on specific health problems that can be large, inconsistent, uneven in quality, and even inaccessible. This Community Guide summarizes what is known about the effectiveness, economic efficiency, and feasibility of interventions to promote community health and prevent disease. The Task Force on Community Preventive Services, convened by HHS, makes recommendations for the use of various interventions based on the evidence gathered in the rigorous, systematic scientific reviews of published studies conducted by the review teams of the Community Guide. The findings from the reviews are published in peer-reviewed journals and made available on this Internet Web site. HHS will continue to support the Community Guide and will disseminate its systematic review findings via its Web site. Clinical Preventive Services: The Guide to Clinical Preventive Services provides recommendations on screening, counseling, and preventive medication topics and includes clinical considerations for each topic. This new pocket guide provides general practitioners, internists, family practitioners, pediatricians, nurses, and nurse practitioners with an authoritative source for making decisions about preventive services. HHS will continue to support the Guide to Clinical Preventive Services and disseminate its systematic review findings via its Web site. HHS also supports a joint Clinical Decision Support program/project planning and coordination effort. This project will provide recommendations and an action plan designed to advance the development, widespread adoption, and value of clinical decision support in improving health and the quality and safety of health care delivery. AHRQ, CMS, IHS, and ONC are collaborators within HHS. The project also includes non-Federal partners, including the Certification Commission for Healthcare Information Technology, Thomas Macromedia, Brigham and Women’s Hospital, Partners HealthCare, American Medical Informatics Association, and Oregon Health & Science University. Dissemination of Findings: AHRQ plays an important role in translational research and dissemination of research findings. AHRQ conducts and supports research on value-based purchasing to help meet these information needs, including articles for the field on how to design, implement, and evaluate value-based purchasing programs. AHRQ’s studies and reports will expedite the cycle of research so that purchasers have quicker access to findings on value-based purchasing and will provide guidance on decisionmaking related to value-based purchasing. AHRQ’s Accelerating Change and Transformation in Organization and Networks program will promote innovation in health care delivery accelerating the development, implementation, dissemination, and uptake of demand-driven and evidence-based products, tools, strategies, and findings. AHRQ’s Innovations Clearinghouse, an online searchable database and repository of innovations in health service delivery, will capture effective methods of disseminating and sustaining improvements in the delivery of health care. In addition, the Innovations Clearinghouse will serve as a forum for learning about innovation and change. It will provide a national-level, publicly accessible mechanism for obtaining objective, detailed information on health care innovations and tools and will promote their dissemination, replication, adaptation, and use. Dissemination of Information: HHS also develops and disseminates information and guidelines based on applied research results. For example, NIH continues to develop and disseminate guidance related to Sudden Infant Death Syndrome (SIDS). SIDS, a syndrome of unknown cause, is defined as the sudden death of an infant younger than 1 year of age, which remains unexplained even after a thorough case investigation, autopsy, and review of the clinical history. SIDS is the leading cause of postneonatal mortality in the United States. Led by NIH in collaboration with various sponsors, the National Back to Sleep public health education campaign was launched in 1994 after the American Academy of Pediatrics recommended back sleeping as the safest sleep position for infants younger than 1 year of age. Since the launch of the campaign, the SIDS rate has dropped by 50 percent. However, despite the overall success of the campaign, African-American infants are placed to sleep on their stomachs more often than are White or Caucasian infants. The SIDS rate for African-American infants is two times greater than that of White or Caucasian infants. In collaboration with African-American organizations, NIH has developed comprehensive strategies to reduce SIDS in African-American communities. First, NIH launched a multiyear project to disseminate the American Academy of Pediatrics safe sleep guidelines in Mississippi. The project has multiple components, including training public health workers to convey SIDS risk reduction messages, developing partnerships with State and local stakeholders, and providing minigrants to community and faith-based organizations to assist with their outreach efforts. Second, a continuing education curriculum has been developed for nurses on safe sleep guidelines and effective ways to convey the risk reduction message. This curriculum will be implemented at regional and national conferences. Evidence-Based Practices: Several HHS operating divisions support grant programs that facilitate the utilization of evidence based approaches. SAMHSA’s Strategic Prevention Framework State Incentive Grants, e.g., require State grantees and their subrecipients to identify their substance use-related problems and to develop and implement evidence-based programs, policies, and practices that have been proven effective in addressing these issues. AoA funds a grant program and public/ private partnership to increase older people’s access to programs that have proven to be effective in reducing their risk of disease, disability, and injury. The partnership involves a variety of Federal agencies and private foundations that are coordinating their efforts to support the implementation of evidence based disease prevention programs at the State and community levels. In addition, the President’s Budget for FY 2008 requests $10 million in new funding under the Child Abuse Prevention and Treatment Act to fund competitive grants. These grants will support the development of a statewide infrastructure to implement, monitor, and sustain highquality, evidence-based nurse home visitation programs. Funds will be used to support and enhance collaboration and coordination across multiple State and private agencies that already receive Federal or State funding to implement various home visitation models. This new funding will be used for investments in cross-agency collaboration, program development, quality-assurance systems, training, technical assistance, workforce recruitment and retention, evaluation, and other administrative mechanisms needed to successfully implement and sustain high-quality, evidence-based home visitation programs that have strong fidelity to proven effective models. These programs demonstrate how the results of research from HHS divisions, including NIH, CDC, and AHRQ, can be effectively translated into practice at the community level through service providers. HHS will continue its commitment to infuse evidence into practice through such discretionary programs. National Registry: SAMHSA supports the National Registry of Evidence based Programs and Practices, a Web-based system designed to disseminate timely and reliable information about interventions that prevent and/or treat mental and substance use disorders. Programs in the Registry have undergone a rigorous review. The Registry provides detailed descriptions of each intervention as well as outcome data. Stewardship and Management Responsible Stewardship and Effective Management 5 This section of the Strategic Plan highlights the means and strategies employed by HHS’s operating and staff divisions to support the achievement of the Department’s goals. Many of these functions and activities are not seen by the citizens we serve; however, they are critical to our stakeholders and the HHS employees who implement our programs. As the goals of this Strategic Plan make clear, HHS’s core mission is to protect the health of all Americans and provide essential human services, especially for those who are least able to help themselves. Signs of the positive results of this mission come to light every day, as HHS employees develop cures for devastating diseases; research critical trends in public health; assist children, families, and older adults in living better lives; and perform countless other services for the Nation and the world. Less visible is the framework of planning, administration, and management that facilitates all of these accomplishments. The success of HHS’s scientists, researchers, caregivers, inspectors, and technicians depends on the solid foundation provided by managers, contracting officers, analysts, accountants, human resource specialists, attorneys, and all the other support staff across the Department. A robust and reliable system of administrative support provides the necessary groundwork for the Department to remain dedicated to, focused on, and unhindered in its programmatic work. A critical factor in the Department’s achievement of its mission and goals is its ability to formulate, implement, execute, and manage effective administrative support for its programs—from exercising responsible stewardship of taxpayer dollars to managing employees effectively. Our underlying approach will be an interactive, ongoing effort to formulate policy and strategies, monitor progress and results, reward excellence, correct mistakes, and adjust to changing circumstances. HHS continuously reviews and refines management practices as needed to ensure that the Department has the resources to provide first-rate administrative support. Through aligning its strategic plans, budgets, and performance plans and establishing measures that assess our progress and results, HHS clearly defines its intended outcomes, and effectively projects and manages resources required to implement programs. This section of the Strategic Plan outlines the management means and strategies that HHS will employ to facilitate program success. In carrying out these strategies, the Department places the utmost importance on fostering a culture of leadership and accountability. All employees are expected to assume leadership roles in their areas of responsibility by exhibiting a willingness to develop and coach others, a commitment to teamwork and collaboration, and a drive to meet challenges with innovation and urgency. Human Capital Effective Human Capital Management - Recruit, develop, retain, and strategically manage a world-class HHS workforce. 5.1 Implement rigorous recruiting strategies to ensure the hiring of top talent. Approximately a quarter of all HHS nonsupervisory employees, and about half of all HHS managers, will be eligible for retirement within the 5 years covered under this Strategic Plan. To ensure that future workforce needs are met, HHS has identified its mission-critical and core competencies and will continue highly targeted recruitment efforts. Among the strategies the Department will use are Cooperative Education Programs, the Direct-Hire Program, the Federal Career Intern Program, the HHS Emerging Leaders Program, the Presidential Management Fellows Program, and the Retired Annuitants hiring process. HHS will aggressively identify robust technology systems that will enable the Department to compete with private industry for top talent. In addition, HHS will continually examine recruitment processes to ensure that it improves the quality of the candidates recruited and is able to hire them in the quickest timeframe possible. Strengthen the workforce by developing staff skills, improving competencies, and retaining talent. HHS will develop an effective learning and development strategy that leverages current capabilities at HHS University and also takes advantage of training opportunities in the operating divisions. Emphasis will be placed on achieving better results through more effective utilization of the Department’s train ingrelated financial resources. To ensure that resources are allocated to produce maximum effectiveness in an optimal timeframe, HHS will support this activity through traditional classroom training, online self study, development programs, and career counseling. In addition, the HHS Web-based, Departmentwide Learning Management System supports closing competency gaps (core and technical) in mission critical occupations. Ensure that the HHS workforce reflects the diversity of the Nation it serves. A diverse workforce capitalizes on the contributions of persons of distinct ethnicities, races, cultures, and backgrounds. Leveraging these differences enhances the social and business workplace environment, helps to eradicate discrimination, and increases organizational efficiency and productivity. Through personal leadership and involvement, all HHS employees will proactively support and promote the Department’s Equal Employment Opportunity (EEO) and Diversity Management programs to achieve a more diverse workforce and promote a workplace free of discrimination. Through program accountability, training, outreach, recruitment, and use of flexible hiring techniques, HHS will ensure that representation of minorities and persons with disabilities at HHS reflects the Nation as a whole. HHS has some specific initiatives to recruit underrepresented populations. HHS, through its partnership with the U.S. Department of Defense Computer/Electronic Accommodations Program and the U.S. Department of Labor Workforce Recruitment Program, plans to leverage these resources to increase hiring of people with disabilities. In addition, HHS minority outreach initiatives include participation in a number of student intern programs, such as the Asian Pacific American Institute for Congressional Studies, Bilingual/Bicultural Program, Federal Career Intern Program, HHS Emerging Leaders Program, Hispanic Association of Colleges and Universities National Internship Program, International Leadership Foundation, and the Organization of Chinese Americans Government Internship Programs. In the area of training, HHS has developed the EEO and Diversity Academy, which offers courses designed to instill in hiring managers, as well as all in HHS employees, recognition of the intrinsic value a diverse Federal workforce brings to a Department with a diverse customer base. Ensure the highest level of efficiency and effectiveness of HHS organizations, through regular competition with the private sector. In accordance with OMB Circular A-76,XL HHS will continue to ensure that the most efficient organization carries out the Department’s commercial functions. HHS will utilize a combination of standard studies, streamlined studies, and restructuring efforts to implement competitive sourcing. The savings generated from competitive sourcing studies will continue to provide benefits to HHS programs and the American taxpayer. Ensure that all HHS employees are accountable for results. Guided by the Department’s Human Capital Accountability System Policy, HHS will continue to monitor, manage, and evaluate its formal Departmentwide, integrated human capital accountability system to ensure mission-aligned human capital goals are achieved effectively, efficiently, and within merit system principles and related regulations. All HHS employees will have an approved performance plan in place within 30 days of hire and will receive at least one midyear progress review annually. The Senior Executive Service and Organizational Performance Management System and the Performance Management Appraisal Program will connect expectations to mission and link performance ratings with measurable outcomes. Performance plans for all HHS employees are designed to cascade from the goals and objectives outlined in the Strategic Plan and operating division strategic plans, to ensure that performance expectations throughout the entire agency are aligned with the HHS mission and oriented toward achieving results. Information Technology Effective Information Technology Management - Provide a well-managed and secure enterprise information technology environment. 5.2 Development of a comprehensive plan that optimizes the use of resources in support of all strategic and management goals and objectives. The Clinger-Cohen Act of 1996 (Public Law 104-106) requires that every Federal agency develop an Enterprise Architecture (EA). EA ensures that the business and technical architectures for the Department support the HHS mission and outcome objectives by establishing relationships between and among business operations and the information systems and resources that enable those operations. EA takes a comprehensive view of the enterprise, including strategic planning, organizational development, relationship management, business process improvement, information and knowledge management, and operations. EA will enable the Department to achieve more effective planning and control over investments for information technology by enhancing flexibility and interoperability across information systems; reducing redundancies; and improving access to accurate, timely, and consistent information. Maintain a secure environment in which all aspects of security, privacy, and confidentiality are addressed. HHS is an attractive high-profile target for hackers and those with malicious intent seeking sensitive medical information, homeland security first responder information, patent and intellectual property worth billions of dollars, and much more. In order to address these immediate challenges and comply with Federal legislation, HHS has developed a proactive, enterprisewide information technology (IT) security program (Secure One HHS) to help protect the HHS IT infrastructure against potential threats and vulnerabilities. The Secure One HHS IT Security Program was designed to increase the baseline IT security posture across all HHS operating divisions while reducing reporting burdens for compliance with Federal mandates. The creation of this new security program, which spans the HHS IT community, Headquarters, and the operating divisions, is an important step in protecting HHS’s ability to provide mission-critical services and maintain the public’s trust and confidence in the quality of HHS services and business operations. Manage information technology projects and investment to demonstrate results and consistently provide the value intended. This activity will require the successful completion of all aspects of project and investment management rigor that are described in the HHS Enterprise Performance Life Cycle (the integration of management, business, and engineering life-cycle processes that span the enterprise to align IT with the business). This success will be measured by the HHS Capital Planning and Investment Control process, which structures budget formulation and execution, ensures that investments consistently support the strategic goals of the agency, and includes the evaluation of effective earned value management. Resources Effective Resource Management - Use financial and capital resources appropriately, efficiently, and effectively. 5.3 Ensure the integrity of HHS financial management processes. Financial management systems that meet Joint Financial Management Improvement Plan certification standards will be in place Departmentwide by 2010, with all but Medicare Parts C and D covered by the beginning of FY 2010. HHS also will address all identified outstanding material weaknesses and internal control deficiencies. Manage financial resources wisely and appropriately through the reduction of improper payments. According to the Improper Payments Information Act of 2002 (Public Law 107-300), improper payments occur when funding is provided to the correct recipient in the incorrect amount, when the wrong recipient receives funds, or when funds are used by the recipient improperly. HHS will continue its efforts to reduce the rates of improper payment in three of its largest programs, Medicare, Head Start, and Foster Care. At the same time, the agency will develop improved information on payment error rates for other large programs such as Medicaid, State Children’s Health Insurance Program (SCHIP), and Temporary Assistance for Needy Families (TANF). Strategically manage the acquisition, leasing, construction, operation, maintenance, and disposal of HHS’s real property assets. HHS will oversee effective real property acquisition and operations and maintenance practices, right size the real property portfolio, and realize cost savings through increased efficiency and strategic investments. Efficiency and effectiveness of real property assets will be maximized by disposing of excess property and reducing underutilization and overutilization. HHS will improve both the condition of HHS’s buildings and facilities and environmental management through greater energy conservation, enhanced occupational safety and health, and sustainable development. Create a seamless integration of acquisition policies, procedures, systems, and contract vehicles to better serve employees, customers, and vendors. Through the Acquisition Integration and Modernization initiative, HHS will develop a uniform way of conducting business, minimize duplication and improve efficiency, and provide excellent customer service to HHS stakeholders. In addition, HHS will facilitate mobility among HHS acquisition personnel as well as personnel interfacing with the acquisition community, leverage spend opportunities and drive cost savings, capture knowledge and share best practices within the acquisition community, ensure sufficient resources to conduct acquisition activities, and ensure an optimal allocation of these resources as efficiencies are realized. Improve coordination of grant activities across the Department. HHS will implement a grant announcement planning and review process (linked to budget plans) that ensures alignment of planned grant announcements with Departmentwide priorities, identifies opportunities for collaboration across the Department, and gives the public advance information on grant announcement plans. Planning, Oversight, and Communications Effective Planning, Oversight, and Strategic Communications - Improve the management of HHS by providing ongoing oversight, evaluation, and analysis of policies and programs and by ensuring effective strategic communications. 5.4 Provide ongoing oversight, evaluation, and analysis of policies and programs. We will monitor our programs to ensure that the Department is fulfilling its statutory, regulatory, and fiduciary responsibilities and intergovernmental commitments in an ethical and legal manner. In addition, we will conduct independent and objective audits, evaluations, analysis, and investigations to assess the effectiveness and efficiency of policy and program implementation. Improve communication with the public, employees, and stakeholders about HHS’s mission, goals, and performance, as well as the benefits and services that the Department provides. We will improve communications by proactively developing, maintaining, and widely disseminating comprehensive and accurate information about our plans, activities, and accomplishments in a timely manner to our employees, stakeholders, and customers. In addition, we will endeavor to respond promptly to requests for information from members of the U.S. Congress, our other stakeholders and partners, local and national media, and the public regarding HHS policies and programs. Effective human capital, information technology, resource management, and management oversight and communications are HHS’s most critical means to provide support for the Department’s goals and strategies. HHS will continue to analyze its practices and procedures to ensure that the management strategies defined for the future meet the needs of the Department and, most importantly, its customers: the American people. 2007-10-01 2012-09-30 2010-01-19 http://aspe.hhs.gov/hhsplan/2007/planpage.shtml Owen Ambur Owen.Ambur@verizon.net