The Health Center Program Application Forms

NEED FOR ASSISTANCE WORKSHEET INSTRUCTIONS AND CRITERIA

1. GENERAL INSTRUCTIONS FOR COMPLETING: Need For Assistance (NFA) Worksheet

All competitive high poverty county new access point applicants must demonstrate that the proposed new access point(s) will serve populations in areas with the greatest need for services. All applicants must submit a completed Need for Assistance (NFA) Worksheet as part of the application.

Guidelines for Completing the NFA Worksheet:

• If no response or data source is provided for a particular barrier or disparity factor, or if the data source and date for the response are not provided, no points will be awarded for that barrier or disparity factor.

• All responses must be expressed in the unit and format requested (i.e., if a percentage is requested, the response must be a percentage; if a rate is requested, the response must be a rate). If the response is not provided in the requested format, the applicant will receive no points for that response.

• All responses must be expressed as a finite number (e.g., 212.5) and cannot be presented as a range (e.g., 31-35).

The scoring of the NFA Worksheet will be based on data about the target population to be served within the proposed service area, as appropriate. (See “POPULATION TO BE SERVED” below for more information.) New start applicants are expected to complete the NFA Worksheet based on the entire proposed scope of their project. Satellite applicants are expected to complete the NFA Worksheet based on their proposed new service delivery site(s) ONLY.

If an applicant proposes to serve multiple sites, populations or service areas, the NFA Worksheet responses should represent the total targeted population within the proposed service area. Different values for different sites/populations/service areas may be combined using population weighting described below. No more than one response should be submitted for each barrier or disparity factor (i.e., only one comprehensive NFA Worksheet will be accepted).

2. CONVERSION OF NFA WORKSHEET SCORE TO APPLICATION SCORE

Applications will have the NFA Worksheet scored by the Objective Review Committee as part of the complete assessment of the application. The NFA Worksheet will be scored using the scoring criteria below. The converted NFA Worksheet score will account for up to 25 points out of 100 total points in the overall score for the application. The NFA Worksheet score of up to 100 points will be converted to the Need: Part A using the following Conversion Table. In general, this can be calculated by multiplying the NFA score by 0.25 and rounding to the nearest integer; the following conversion table yields the same result.

NFA WORKSHEET TO APPLICATION SCORE CONVERSION TABLE

NFA Worksheet Score (Maximum 100 Points)		Application Need: Part A Score (Maximum 25 Points)
100-98  97-94  93-90  89-86  85-82  81-78  77-74  73-70  69-66  65-62  61-58  57-54  53-50  49-46  45-42  41-38  37-34  33-30  29-26  25-22  21-18  17-14  13-10   9- 6   5- 2   1- 0	= = = = = = = = = = = = = = = = = = = = = = = = = =	25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9  8  7  6  5  4  3  2  1  0

3. POPULATION TO BE SERVED:

For all sections of the NFA Worksheet, responses must be based on data for the total target population within the proposed service area, as appropriate, per the following criteria: 

1. Applicants requesting funding to serve the medically underserved population of a service area (under section 330(e) only) must provide responses that reflect the health care needs of the target population for the application. When the service area is a sub-county area (made up of , groups of census tracts, other county divisions or zip codes), but data for a particular Barrier or Disparity indicator are not available at sub-county levels, applicants may use an extrapolation technique to appropriately modify the available county-level or other level data to reflect the service area population. See NFA Data Resource Guide provided online at www.bphc.hrsa.gov for further information regarding the extrapolation technique.

2. Applicants requesting funding to serve ONLY a homeless population (under section 330 (h)), a migrant/seasonal farmworkers population (under section 330(g)) or residents of public housing (under section 330(i)), or any combination of these special populations, may use an extrapolation technique to appropriately modify available data for these special populations to reflect their specific population(s) within the proposed service area. See NFA Data Resource Guide provided online at: www.bphc.hrsa.gov for further information regarding the extrapolation technique.

3. Applicants requesting funding to serve a homeless population (under section 330 (h)), a migrant/seasonal farmworker population (under section 330(g)) or residents of public housing (under section 330(i)) in combination with the medically underserved, general population of a service area (under section 330(e)), must present responses that reflect the total population to be served. In calculating the response, applicants may use extrapolation techniques to appropriately modify available data to reflect the homeless, migrant/seasonal farmworker or public housing population within the service area (as in (b) above), then combine this with data the general population within the defined the service area. As above, where sub-county data are not available, applicants may use an extrapolation technique to modify available county-level or other level data to reflect the service area population. See NFA Data Resource Guide for further information regarding the extrapolation technique.

NOTE: An example of the extrapolation technique is provided in the NFA Data Resource Guide (available online at: www.bphc.hrsa.gov).

4. DATA SOURCES:

For each section of the NFA Worksheet, applicants are encouraged to utilize one of the sources identified in the NFA Data Resource Guide (available online at: www.bphc.hrsa.gov) in developing responses.

To maintain comparability, applicants MUST utilize the population appropriate data sources provided in the NFA Data Resource Guide for the following barrier factors: 

Barrier (b): Percent of Population at or below 200 Percent of Poverty

Barrier (g): 12-Month Average Unemployment Rate

While the data sources specified in the NFA Data Resource Guide are preferred, applicants may use an alternate data source to provide a response for any other Barrier or Disparity on the NFA Worksheet only under the following guidelines:

1. The response must be expressed in the same units of analysis identified in the NFA Worksheet for that specific Barrier or Disparity (e.g., cannot use mortality ratio to provide a response to age-adjusted death rate);

2. Alternate data must be from a reliable and independent source, such as a State or local government agency, professional body, foundation or other well-known organization using recognized, scientifically accepted data collection and/or analysis methods;

3. Applicants are encouraged to use resources in the Data Resource Guide unless alternate data is available that is more specific to the proposed target population and/or more current data are available.

In utilizing an alternate data source, applicants must provide the following as part of the NFA Worksheet:

• the specific alternate data source;

• the year or date to which the alternative data apply; and 

• an explanation as to why that alternate data source is more accurate and more appropriate for describing the total target population(s) within the proposed service area than the sources recommended in the NFA Data Resources Guide (available online at: www.bphc.hrsa.gov).

NFA WORKSHEET SCORING: (Maximum 100 points)

Each NFA Worksheet will be scored out of a total possible 100 points. If no response or data source is provided for a Barrier or Disparity, no points will be awarded.

SECTION 1: CORE BARRIERS (Maximum 45 points)

A response is required for all three (3) Barriers listed. The points awarded for each Barrier response will be calculated using the point distributions provided below.

 

SECTION 2: OTHER BARRIERS (Maximum 30 points)

A response is required for two (2) of the five (5) Barriers listed. The points awarded for each Barrier response selected will be calculated using the point distributions provided below.

SECTION 3: CORE DISPARITIES (Maximum 15 points)

A response is required for one (1) indicator in each of the five (5) Disparities categories. At least four (4) specific indicators are defined for each Disparity category, with a national benchmark and severe benchmark and data sources identified in the NFA Data Resource Guide. Applicants will receive two (2) points for each Disparity category response if it exceeds the corresponding national benchmark and an additional one (1) point if the response also exceeds the corresponding severe benchmark provided below. If an applicant believes that none of the specified indicators well represent the applicant’s service area or target population, the applicant may propose to use an “Other” alternative for that Disparity category. In such a case, the applicant must specify the Disparity category indicator definition to be used, data source used, proposed benchmark to be used, source of the benchmark, and rationale for using this alternative Disparity category indicator. However, if an “Other” Disparity category indicator is used, the applicant will not be eligible for any additional point for exceeding a “severe” benchmark. (See below for more instruction on completing SECTION 3: CORE DISPARITIES of the NFA Worksheet).

SECTION 4: OTHER DISPARITIES (Maximum 10 points)

Applicants must select a total of five (5) of the ten (10) Disparities factors listed. Applicants will receive two (2) points for each Disparity factor response that exceeds the corresponding national benchmark provided below. Alternatively, applicants can propose up to two (2) of the identified Disparity factors using an “Other” Disparity indicator. For each “Other” Disparity indicator (up to two (2)), applicants must specify the Disparity factor definition, data source used, proposed benchmark to be used, source of the benchmark, and rationale for using this Disparity factor in place of one of those specified.

 

5. NFA WORKSHEET SCORING CRITERIA

SECTION 1: CORE BARRIERS (Maximum 45 points)

Applicants must provide a response for each of the following three (3) Barriers. This response must be based on data for the proposed target population, as appropriate.  (See “POPULATION TO BE SERVED” discussion above.)

a. Population to Primary Care Physician FTE Ratio

 

Ratio when FTE Count  1	Ratio when FTE Count < 1	Points
0-1899	0-3399	0
1900-1949	3400-3449	1
1950-1999	3450-3499	2
2000-2049	3500-3549	3
2050-2099	3550-3599	4
2100-2199	3600-3699	5
2200-2299	3700-3799	6
2300-2399	3800-3899	7
2400-2499	3900-3999	8
2500-2799	4000-4299	9
2800-3099	4300-4599	10
3100-3399	4600-4899	11
3400-4199	4900-5699	12
4200-4999	5700-6499	13
5000-5799	6500-7299	14
 5800	7300	15

b. Percent of Population at or below 200 percent of poverty

REMINDER: Applicants must use the data source on poverty provided in NFA Data Resource Guide.

Percent of Population at or Below 200% of Poverty	Points
0-27	0
28-29	1
30-34	2
35-39	3
40-41	4
42-44	5
45-46	6
47	7
48	8
49	9
50	10
51	11
52	12
53	13
54	14
 55	15

c. Percent of Population Uninsured

Percent of Population Uninsured	Points
0-14.0	0
14.0-14.5	1
14.6-15.1	2
15.2-15.7	3
15.8-16.4	4
16.5-16.9	5
17.0-17.6	6
17.7-18.2	7
18.3-18.8	8
18.9-19.4	9
19.5-20.1	10
20.2-20.7	11
20.8-21.3	12
21.4-21.9	13
22.0-22.6	14
 22.7	15

SECTION 2: OTHER BARRIERS (Maximum 30 points)

Applicants must provide a response to two (2) of the following five (5) Barriers. This response must be based on data for the proposed target population, as appropriate.  (See “POPULATION TO BE SERVED” discussion above.)

d. Distance (miles) OR travel time (minutes) to nearest primary care provider accepting new Medicaid patients and/or uninsured patients

Average distance (miles)	Average Travel time (minutes)	Points
0-11.9	0-19.9	0
12-13.4	20-22.4	1
13.5-14.9	22.5-24.9	2
15-16.4	25-27.4	3
16.5-17.9	27.5-29.9	4
18-19.4	30-32.4	5
19.5-20.9	32.5-34.9	6
21-22.4	35—37.4	7
22.5-23.9	37.5-39.9	8
24-25.4	40-42.4	9
25.5-26.9	42.5-44.9	10
27-28.4	45-47.4	11
28.5-29.9	47.5-49.9	12
30-31.4	50-52.4	13
31.5-32.9	52.5-54.9	14
 33	 55	15

e. Percent of Population Linguistically Isolated

Percent of people 5 years and over who spoke a language other than English at home	Points
0-4	0
5-8	1
9-12	2
13-16	3
17-20	4
21-24	5
25-28	6
29-32	7
33-36	8
37-40	9
41-44	10
45-48	11
49-52	12
53-56	13
57-59	14
 60	15

f. Age-Adjusted Death Rate

Age-Adjusted Death Rate	Points
<891	0
891-904	1
905-918	2
919-932	3
933-946	4
947-960	5
961-974	6
975-988	7
989-1002	8
1003-1016	9
1017-1030	10
1031-1044	11
1045-1058	12
1059-1072	13
1073--1085	14
1086	15

g. 12-Month Average Unemployment Rate

REMINDER: Applicants must use the data source on poverty provided in NFA Data Resource Guide.

12-Month Average Unemployment Rate	Points
< 5.0%	0
5.0%-5.2%	1
5.3%-5.6%	2
5.7%-5.9%	3
6.0%-6.3%	4
6.4%-6.6%	5
6.7%-7.0%	6
7.1%-7.3%	7
7.4%-7.6%	8
7.7%-8.0%	9
8.1%-8.4%	10
8.5%-8.7%	11
8.8%-9.1%	12
9.2%-9.5%	13
9.6%-9.9%	14
 9.9%	15

h. Waiting Time for Public Housing where public housing exists

Waiting time	Points
< 90 days	0
90-134 days	1
135-179 days	2
180-224 days	3
225-269 days	4
270-314 days	5
315-359 days	6
360-404 days	7
405-449 days	8
450-494 days	9
495-539 days	10
540-584 days	11
585-629 days	12
630-674 days	13
675-719 days	14
 720 days	15

SECTION 3: CORE DISPARITIES (Maximum 15 points)

Applicants must provide a response to one (1) Disparity measure indicator from within each of the Disparity categories numbered 1 through 5.  For each response, applicants must provide the current value for the total target population within the proposed service area as appropriate.  (See “POPULATION TO BE SERVED” discussion above.)

Applicants may elect to provide an alternate indicator to each of the Disparity categories under "Other," rather than respond to one of the identified indicators within the Disparity category. If providing an “Other” Disparity category indicator, the applicant must specify the Disparity category indicator definition to be used, data source used, proposed benchmark to be used, source of the benchmark, and rationale for using this alternative Disparity category indicator. NOTE:  if an alternate Disparity category indicator is used under "Other," the applicant will not be eligible for the additional point for exceeding a severe benchmark.

DISPARITY CATEGORIES & INDICATORS	National Benchmark 2 Points Awarded	Severe Benchmark 1 Additional Point Awarded
1. Diabetes, Obesity
1(a) Diabetes Short-term Complication Hospital Admission Rate	46.7 per 100,000	82 per 100,000
1(b) Diabetes Long-term Complication Hospital Admission Rate	112.6 per 100,000	180.2 per 100,000
1(c) Uncontrolled Diabetes Hospital Admission Rate	27.2 per 100,000	61.1 per 100,000
1(d) Rate of Lower-extremity Amputation Among Patients with Diabetes	37.5 per 100,000	65.7 per 100,000
1(e) Age Adjusted Diabetes Prevalence	6.5%	7.8%
1(f) Adult Obesity Prevalence	23%	24.5%
1(g) Diabetes Mortality Rate1	26 per 100,000	35 per 100,000
1(h) Other	Provided by Applicant
2. Cardiovascular Disease
2(a) Hypertension Hospital Admission Rate	50.2 per 100,000	99.5 per 100,000
2(b) Congestive Heart Failure Hospital Admission Rate	502.8 per 100,000	753.6 per 100,000
2(c) Angina without Procedure Hospital Admission Rate	82.3 per 100,000	160.3 per 100,000
2(d) Mortality from Diseases of the Heart2	240.8 per 100,000	271 per 100,000
2(e) Proportion of Adults reporting diagnosis of high blood pressure	24.8%	27.7%
2(f) Other	Provided by Applicant
3. Asthma, Respiratory Disease
3(a) Adult Asthma Hospital Admission Rate	98.4 per 100,000	177.6 per 100,000
3(b) Pediatric Asthma Hospital Admission Rate	164.6 per 100,000	347.1 per 100,000
3(c) Chronic Obstructive Pulmonary Disease Hospital Admission Rate	344.3 per 100,000	622 per 100,000
3(d) Bacterial Pneumonia Hospital Admission Rate	503.9 per 100,000	810.7 per 100,000
3(e) Three Year Average Pneumonia Death Rate3	1 per 10,000	1.4 per 10,000
3(f) Adult Current Asthma Prevalence	7.6%	8.3%
3(g) Adult Ever Told Had Asthma	13.2%	14.5%
3(h) Other	Provided by Applicant
4. Prenatal and Perinatal Health
4(a) Low Birth Weight Rate, 5 year average	6.0%	9.8%
4(b) Infant Mortality Rate, 5 year average	6.9/1000 births	9.1/1000 births
4(c) Births to Teenage Mothers (15-19)	6.3% of births	9.2% of births
4(d) No First Trimester entry into prenatal care	16%	20%
4(e) Cigarette use during pregnancy	10.7%	14.3%
4(e) Other	Provided by Applicant

5. Mental Health/Substance Abuse/Behavioral Health
5(a) Depression Prevalence	9.1%	12.8%
5(b) Suicide Rate	11/100,000	16/100,000
5(c) Youth Suicide attempts requiring medical attention	2.6%	3.6%
5(d) Adults with Mental disorders not receiving treatment	52%	63%
5(e) Any Illicit Drug Use in the Past Month (Adults)	8.25%	9.3%
5(f) Heavy alcohol use 12 and over	6.8%	7.5%
5(g) Homeless with severe mental illness	25%	30%
5(h) Other	Provided by Applicant

SECTION 4: OTHER DISPARITIES (Maximum 10 points)

Applicants must provide responses to five (5) out of the ten (10) of the Disparities listed.  Applicants will receive two (2) points for each Disparity factor response that exceeds the corresponding national benchmark provided below. Alternatively, applicants can propose up to two (2) of the identified Disparity factors using an “Other” factor. For each “Other” Disparity indicator (up to two (2)), applicants must specify the Disparity factor definition, data source used, proposed benchmark to be used, source of the benchmark, and rationale for using this Disparity factor in place of one of those specified.

DISPARITY FACTORS	National Benchmark 2 Points Awarded
6. Oral Health - % without dental visit in last year	56.5%
7. HIV Infection Prevalence	0.4%
8. Percent of children not receiving recommended immunizations 4-3-1-3-34	17.95%
9. Percent Elderly (65 and older)	15.2%
10. Cancer Screening – No Pap test in past 3 years; women 18+	14.0%
11. Cancer Screening – No Mammogram in past 3 years; women 40+	25.3%
12. Cancer Screening –No FOBT within the past 2 years; adults 50+	73.5%
13. Unintentional Injury Deaths	35/100,000
14. Other	Provided by Applicant
15. Other	Provided by Applicant

1Number of deaths per 100,000 reported as due to diabetes as the underlying cause or as one of multiple causes of death (ICD-9 Code 250).

2 Total number of deaths per 100,000 reported as due to heart disease (includes ICD-9 Codes I00-I09, I11, I13, and I20-I51).

3 Three year average number of deaths per 100,000 due to pneumonia (includes ICD-9 Codes 480-486).

4 4 DTaP, 3 polio, 1 MMR, 3 Hib, 3 hepatitis B