Strategic Plan FY 2005 – 2010

• Printer-friendly HRSA Strategic Plan FY 2005-2010

Budget and Performance Crosswalk
Details of Performance Analysis (PART Recommendations)

• Providing support to nearly 3,600 health center sites serving about 12.5 million people;
• Funding care and treatment services for an estimated 533,000 people living with HIV/AIDS;
• Assisting States and communities, including rural and border areas, and health care organizations in improving services to women and children;
• Overseeing the national system that allocates organs, tissue, and blood stem cells for transplant;
• Working with academic health centers and other training programs to enhance the diversity and distribution of the Nation’s health care workforce;
• Implementing comprehensive systems of services in communities to meet the many needs of children and youth with special health care needs and their families; and
• Participating in global health initiatives such as the President’s Emergency Plan for AIDS Relief.

GOAL 1: Reduce the major threats to the health and well-being of Americans.
GOAL 2: Enhance the ability of the Nation’s health care system to effectively respond to bioterrorism and other public health challenges.
GOAL 3: Increase the percentage of the Nation’s children and adults who have access to health care services, and expand consumer choices.
GOAL 4: Enhance the capacity and productivity of the Nation’s health science research enterprise.
GOAL 5: Improve the quality of health care services.
GOAL 6: Improve the economic and social well-being of individuals, families and communities, especially those most in need.
GOAL 7: Improve the stability and health development of our Nation’s children and youth.
GOAL 8: Achieve excellence in management practices.

From year to year, HRSA’s Strategic Plan is a dynamic and flexible document. Adjustments and changes in direction are inevitable as the Agency moves forward over time with the many complex and varied problems it is seeking to address. New information from customers and the scientific community, along with an annual summary of the Agency’s accomplishments toward achieving its goals, is factored into the Agency’s planning process each year. The Plan provides a framework to assist HRSA in focusing on the highest priority health care issues, meeting the needs of its customers, and assuring effective use of taxpayer dollars.
HRSA’s Strategic Plan begins with a brief background/overview of the Agency and then describes its vision, mission, strategic goals, objectives and strategies. The Plan then includes several sections describing HRSA’s organizational infrastructure, including its operating units, management improvements, challenges posed by a rapidly changing health care system, and evaluation activities undertaken to further inform its planning process. Finally, ongoing partnerships and collaborative activities with other organizations are described.

It should be noted that the Strategic Plan is not a depository for all actions that the Agency might take to achieve an objective. Therefore, implementation strategies under each objective are merely illustrative and not meant as a catalogue of all potential implementation plans; they illustrate the general direction the Agency plans to take. In addition, there are many circumstances in which individuals, families, and communities have needs that go beyond the individual HRSA programs. To help facilitate meeting their needs, HRSA works with a wide range of Federal, State, tribal, and local service providers to coordinate the planning and delivery of services in a way that maximizes resources and provides an integrated approach to health care.

The Plan was developed through a collaborative process maximizing the expertise, experience and perspective of HRSA staff. A staff workgroup with Agency-wide representation developed an initial draft which was reviewed by senior Agency staff. In line with the requirements of the Government Performance and Results Act (GPRA), HRSA’s Strategic Plan is supplemented by Annual Performance Plans and Reports, Office of Management and Budget (OMB) Program Assessment Rating Tools (PART) review, evaluation and grant review activities. Progress and findings from these activities have and will continue to assist HRSA in the ongoing revision of its Strategic Plan.

As the Access Agency, HRSA’s programs reach into every corner of America providing health care services relied upon by millions of people. HRSA works to expand access to high-quality, culturally competent health care; improve health outcomes among America’s minority communities; and enhance direct medical care through the use of information and telehealth technology.

Assuring a safety net for individuals and families who live outside the economic and medical mainstream is a key HRSA role. Our portfolio of programs and initiatives are designed to increase access to care, improve quality, and safeguard the health and well-being of the Nation’s most vulnerable populations.

Building upon this foundation, HRSA has recently implemented two Presidential initiatives of critical importance: the 5-year President’s Health Center Initiative, which will significantly affect 1,200 communities with new access points or expanded health center sites in order to serve an additional 6.1 million patients annually by 2006; and reforming and expanding the National Health Service Corps, which increases staffing levels within many of the Nation’s neediest communities.

The United States still faces significant challenges with regard to assuring access to care. Among these challenges, HRSA’s programs address the following health care problems and issues:

• 45 million Americans lack health insurance—many of whom are racial and ethnic minorities;
• Approximately 50 million people live in communities—rural and poor urban neighborhoods—without sufficient access to primary health care;
• African American infants are 2.4 times as likely as white infants to die before their first birthday;
• An estimated 850,000 to 950,000 people are living with HIV in the U.S., with approximately 40,000 new infections occurring in the U.S. every year;
• Over 83,000 Americans are waiting for an organ transplant; and
• 12.8 percent or 9.4 million children are estimated to have special health care needs.

HRSA Vision
HRSA envisions optimal health for all, supported by a health care system that assures access to comprehensive, culturally competent, quality care.

Mission
HRSA provides national leadership, program resources and services needed to improve access to culturally competent, quality health care.

Goals
As the Nation’s Access Agency, HRSA focuses on uninsured, underserved, and special needs populations in its goals and program activities:

• Put People First
  First and foremost, all our actions must benefit America’s people who are uninsured, underserved, vulnerable and living with special needs.
• Deliver Results
  Deliver results that are useful to the people and communities directly served by HRSA’s programs and to the taxpayers who pay for these programs.
• Be Accountable
  Be accountable for HRSA’s programs and the efficiency and quality of services provided.
• Focus on Prevention
  Focus on health promotion and prevention of disease, illness, and social problems, including prevention and correction of unlawful discrimination in providing health and human services.
• Create Collaborations
  Create useful, effective forms of collaboration with partners, within and beyond the health sector, in regulation, research, service delivery and evaluation, and management.
• Provide Information
  Provide accurate, reliable, understandable, and timely information to our partners, customers and the public.
• Apply Evidence Based Scientific Knowledge
  Apply the most current scientific knowledge when making decisions that affect public well-being.
• Foster Flexibility and Innovation
  Foster flexibility and encourage innovation in the effective delivery of health and human services programs.
• Establish a Respectful and Supportive Work Environment
  Encourage creativity, diversity, innovation, teamwork, accountability, continuous learning, a continuous quality improvement loop inclusive of all employees, a sense of urgency, enthusiasm, trust, celebration of achievement, and the highest ethical standards.
• Maintain a Work Place that is Free from Discrimination
  Maintain a work environment that is free from discrimination in any of the Agency’s policies, procedures or practices.
• Work as One HHS
  Actively participate in the Department’s effort to work as a single entity through a “One HHS” approach to management. With a statutory emphasis on special needs, underserved, and vulnerable populations, HRSA works to accomplish its mission through the separate and collaborative efforts of its Bureaus and Offices.

• Increase the number of available access points providing care to underserved, vulnerable and special needs populations.
• Increase the range of services available through access points and other program efforts to include such expanded services as mental health, genetic, oral health, substance abuse, chronic disease management, and preventive services.
• Enhance and expand services that address and target populations with particular needs (e.g., older adults; people who are homeless or living with HIV/AIDS).
• Promote incorporation of distance learning and telehealth into HRSA-funded grantee sites.

• Increase recruitment, training, distribution, and retention of under-represented minorities into the health care professions.
• Provide training opportunities and technical assistance for existing health care workers to reduce potential barriers to care (e.g., cultural competence; health literacy; limited English proficient (LEP) clients).
• Facilitate the infusion of cultural competence into health professions training.
• Promote training in cross-cultural communication for providers.
• Promote distance learning and the use of information technology and telehealth by HRSA-funded grantees.

• Identify and address the health professions workforce shortages, with periodic updates of Health Professions Shortage Area (HPSA) designations.
• Increase recruitment of health care workers willing to enter practice in underserved, rural, and border areas.
• Increase retention of health care workers currently working in underserved, rural and border areas.

Objective 1.4: Promote access to health insurance and maximize use of available reimbursements for health care services
How We Will Accomplish Our Objective

• Provide technical assistance to HRSA grantees and programs regarding ability to maximize appropriate third party reimbursement or prospective payment for service.
• Encourage grantees to facilitate the enrollment of eligible individuals into Medicaid, SCHIP, Medicare and other appropriate health insurance programs.
• Promote health care financing systems and approaches that increase access to care by reducing barriers to payment.

• Increase participation of eligible underserved, vulnerable, and special needs individuals receiving comprehensive, culturally competent, quality primary health care services.
• Target available Ryan White CARE Act resources to underserved communities, uninsured and underinsured people disproportionately impacted by HIV/AIDS.
• Promote utilization of HRSA funded health care services by underserved maternal and child populations, including children with special health care needs.
• Increase organ and blood stem cell donation and access to transplantation.
• Target available genetic service resources to underserved and underinsured communities to assure equal access to those subspecialty services.
• Support community and grantee efforts to identify underserved, vulnerable and special needs populations.

• Increase participation of eligible individuals receiving care through HRSA funded programs having preventive and chronic disease management services (e.g., routine screening such as newborn screening for congenital disorders, immunization, prenatal care, utilization of family history, health counseling, etc.).
• Increase use of effective complementary and alternative therapies by health care providers.
• Identify and share solutions for increasing prevention and disease management services with grantees, program officials and policy/decision makers.
• Promote the Health Disparities Collaborative approach to disease management throughout the health center system.

• Ensure HRSA funded programs providing clinical services meet or exceed accepted quality and accreditation standards.
• Ensure HRSA funded programs implement and maintain a proactive system to identify, monitor and correct medical errors/sentinel events.
• Assure HRSA funded programs providing clinical care implement appropriate follow-up and referral services.
• Ensure that HRSA funded programs providing clinical care have demonstrated ability to deliver culturally competent care.
• Promote and support performance improvement efforts of HRSA grantees, providing performance reviews and assistance.

• Ensure HRSA funded programs providing clinical services develop and implement a quality management and improvement program.
• Improve key health status indicators that reflect quality of safety net programs.
• Develop and implement patient-centered standardized tools that HRSA grantees can use to improve quality of health care. ? Enhance monitoring and compliance of Title VI of the Civil Rights Act of 1964.
• Increase awareness and utilization of National Practitioner Data Bank (NPDB) and Health-care Integrity and Protection Data Bank (HIPDB) by health care delivery sites.
• Increase awareness of HRSA grantees about issues relevant to consumer and patient protections, rights and responsibilities.

• Develop appropriate health care information in collaboration with family, faith-based and community partners that takes into consideration cultural values, linguistic differences, and health literacy.
• Disseminate health care information materials in collaboration with family and community partners that take into consideration cultural values, linguistic differences, and health literacy.

• Identify and document best/innovative practice models of HRSA grantees.
• Disseminate best/innovative best practices among HRSA grantees.
• Encourage adoption and utilization of appropriate evidence-based clinical practice guidelines by HRSA grantees providing clinical services

• Focus HRSA program efforts to reduce incidence of low birth weight for populations that are disproportionately affected.
• Focus HRSA program efforts to reduce infant mortality for populations that are disproportionately affected.
• Direct HRSA program efforts to increase the percentage of children who are screened early and continuously for special health care needs and linked to medical homes, appropriate follow-up and early intervention.
• Focus HRSA program efforts to reduce deaths due to AIDS in populations that are disproportionately affected.

• Establish outreach/partnering efforts related to raising awareness about major health risks, including genetic and environmental risk factors, and how to reduce these risks.
• Partner with minority institutions, faith-based and other community-based organizations to help reach diverse populations most affected by health disparities concerning major health risks and prevention in their communities.
• Direct HRSA program efforts to increase organ and blood stem cell donation and the
  likelihood of receiving a transplant among minorities.

• Assure that program and grant guidances reflect an emphasis on promoting cultural competency.
• Support cultural competence training for HRSA program staff, grantees, and provider community.

• Inform policy decisions by using the most current public health and health care data available, including global, national and State trend data.
• Provide technical assistance to States related to the health care workforce, including projected supply and demand.
• Improve the performance of HRSA funded programs, providing performance reviews, analyzing performance trends/issues and providing feedback on the impact of policies on program implementation and performance within communities and States.

• Increase coordination among public health and private sector organizations to improve impact of HRSA programs.
• Help assure a coordinated approach in addressing public health developmental issues in U.S. territories and other U.S.-associated island jurisdictions.
• Assure the development of a strategic, coordinated approach that addresses technical assistance for global health issues, especially HIV/AIDS, maternal and child health, health workforce, and other areas of HRSA expertise.
• Increase capacity of the public health and health care systems in rural and border areas.
• Promote and support cross-program, performance improvement efforts within communities and States through State/community strategic partnership reviews.
• Increase collaboration between HRSA-funded programs and State governments.

• Enhance the provision of clinical services at grantee delivery sites with distance learning programs, electronic transmission of medical data or electronic links with experts in distant communities.
• Increase technical assistance (e.g., guidance, manuals, training) to HRSA grantees related to management information systems, including hardware and software issues.
• Develop, monitor and evaluate electronic resources (e.g., web sites, list servs, data systems) for HRSA grantees and funded programs.
• Promote integration of public and community-based child health information systems to facilitate the assessment for and prompt provision of requisite services to ensure an optimal healthy start for all children and improve the health of children.
• Support development of electronic health records.
• Collaborate with the President’s Health Information Technology initiative.

• Promote collaboration and establishment of comprehensive health care systems (hospitals, health centers, trauma, emergency medical services, and poison control centers) to plan for evacuations, triage and treatment of mass casualties, including for those with special health needs (e.g., those at home on ventilators) and increase their capacity in the event of bioterrorism or other public health emergencies.
• Enhance the ability of the Nation's health care system to effectively detect and report bio-events and respond to bioterrorism and other public health emergencies.
• Develop education and training programs for healthcare professionals to effectively respond to bioterrorism and other public health emergencies.
• Promote the establishment of secure and redundant communication systems to ensure connectivity among professionals to effectively respond to bioterrorism and other public health emergencies.
• Enhance the capability for special needs populations to have access to lifesaving medications, equipment, and medical services during public health emergencies.

• Develop critical benchmarks to measure system improvement with regard to preparation for bioterrorism and other public health emergencies.
• Assess training needs of health professionals to respond to bioterrorism and other public health emergencies on a periodic basis.

• Conduct ongoing workforce planning, including recruitment and retention of key staff.
• Implement EEOC’s Management Directive-715, which provides policy guidance and standards for establishing and maintaining effective affirmative programs of equal employment opportunity.
• Implement an “emerging internal workforce” recruitment program (e.g., details, developmental assignments, and mentoring programs), the HRSA Scholar’s Program, which targets mission-critical positions in the GS-5,7 and 9 grade levels, and focusing on an active external hiring of highly educated adaptable individuals.
• Participate actively in the HHS Emerging Leaders program.
• Increase employee accountability for achieving measurable results through performance contracts.
• Enhance training and career development opportunities for HRSA employees.
• Conduct studies that examine selected HRSA functions for cost comparisons to identify opportunities for increased efficiency and effectiveness.

• Support development of an electronic grant application and progress report system.
• Provide a secure and trusted IT environment.
• Enhance the quality, availability, and delivery of HRSA information and services to citizens, employees, businesses, and governments.
• Support the Department’s implementation of an enterprise approach to IT infrastructure and common administrative systems that will foster innovation and collaboration.
• Enable and improve the integration of health and human services information.
• Achieve excellence in IT management practices.
• Support development of www.grants.gov

• Implement a new integrated Department-wide financial management system—the Unified Financial Management System (UFMS) that supports financial analysis, performance measurement and operational decision making.
• Comply with the Department’s accelerated annual audit reporting guidelines and standards.
• Conduct assessments of applicant organizations and grantees and resolve audit findings.
• Conduct reviews of HRSA programs, procedures, and activities.
• Conduct an orderly phase-out of HRSA’s active loan portfolio.

• Develop policies and procedures to ensure consistent administration of grants.
• Document program performance improvement by HRSA grantees reviewed by HRSA’s Office of Performance Review (OPR) or by a nationally recognized accrediting body.
• Implement objective review requirements applicable to competitive grants and cooperative agreements.
• Plan, award, and manage the Agency’s portfolio of grants and cooperative agreements.
• Consolidate HRSA grants processing with NIH.

• Support collaborative efforts within the Agency designed to address cross-cutting policy issues.
• Develop bilateral and multicultural working relationships to enhance HRSA’s knowledge base and the dissemination of information in support of its global and domestic activities.

The Bureau of Health Professions (BHPr) provides national leadership in coordinating, evaluating, and supporting the development and utilization of the Nation’s health personnel. The Bureau also manages the National Health Service Corps and the National Practitioner Data Bank.

The Bureau of Primary Health Care (BPHC) provides national leadership in assessing the Nation’s health care needs of underserved populations and in assisting communities to provide primary health care services to the underserved in moving toward eliminating health disparities. The major program component is the Consolidated Health Center Program. The Bureau also administers the Black Lung Clinics program, the Native Hawaiian Health Care Program, the Healthy Communities Access Program, the Radiation Exposure Screening and Education Program, and the National Hansen’s Disease Program.

Healthcare Systems Bureau (HSB) provides national leadership and direction in several key functional areas: 1) the procurement, allocation and transplantation of human organs and blood stem cell; 2) the facilitation of the development of State, territorial, and municipal preparedness programs to enhance the capacity of the Nation’s hospitals and other healthcare entities to respond to mass casualty incidents caused by terrorism and other public health emergencies; 3) the provision of programmatic, financial and architectural/engineering support for healthcare facilities construction/renovation programs; 4) the reduction in numbers of uninsured persons through the State Planning Grants Program; and 5) the management and operation of the national programs for childhood vaccine and smallpox vaccine injury compensation.

The HIV/AIDS Bureau (HAB) provides leadership in the delivery of high quality clinical care and supporting services for uninsured and underinsured individuals living with and families affected by HIV/AIDS. It includes the Office for Advancement of Telehealth, the HRSA-wide developer of telehealth, including the use of electronic information and telecommunications technologies for all types of health-related activities. It also includes HRSA’s Center for Quality which strengthens and improves the quality of health care, especially related to Agency programs and service populations.

The Maternal and Child Health Bureau (MCHB) provides national leadership, in partnership with key stakeholders, to improve the physical and mental health, safety and well-being of the maternal and child health (MCH) population. The MCH population includes all of the Nation’s women, infants, children, adolescents, and their families (including fathers), and children with special health care needs. The Bureau also manages the HRSA Office of Women’s Health.

The Office of Rural Health Policy (ORHP) serves as a focal point within the Department and as a principle source of advice to the Administrator and Secretary for coordinating efforts to strengthen and improve the delivery of health services to populations in the Nation’s rural areas and border areas.

The Office of Performance Review (OPR) serves as the Agency’s focal point for reviewing and enhancing the performance of HRSA supported programs within communities and States to improve access to quality health care and reduce health disparities. Through an Agency-wide performance review process, OPR strives to improve program administration through

1. the assurance of efficient and effective use of resources;
2. promotion of effective coordination; and
3. reduction of barriers to performance.

The Office of Administration and Financial Management (OAFM) provides Agency-wide leadership, program direction, and coordination to all phases of management including financial management, policy and regulations, and administrative management.

The Office of Planning and Evaluation (OPE) coordinates the Agency’s strategic, evaluation, and research planning activities; prepares policy analysis papers; analyzes budgetary data with regard to planning guidelines; assesses the information needs of the Agency; and serves as the focal point for health systems organization and financing issues with particular emphasis on the Agency’s relationship with the Centers for Medicare and Medicaid Services and safety net providers.

The Office of Minority Health (OMH) provides leadership and guidance to the Agency in assisting it to improve the health status of racial/ethnic minorities.

The Office of Legislation (OL) serves as the Administrator’s primary staff unit and principal source of advice on legislative affairs.

The Office of Communications (OC) builds support for HRSA’s activities by explaining to the American public, the press and health care organizations how the Agency’s programs expand access to comprehensive, quality health care for all.

The Office of Federal Assistance Management (OFAM) provides national leadership, oversight, and financial integrity assurances for the administration of HRSA’s Federal assistance programs; provides leadership, direction and coordination to all phases of grants policy, administration and independent review.

The Office of Information Technology (OIT) delivers innovative information technology tools and essential services to enable HRSA and its customers to be continually more effective.

The Office of Equal Opportunity and Civil Rights (OEOCR) ensures that all of HRSA employees’ and applicants’ rights are protected in every aspect of their employment and protects the rights of all beneficiaries who use the programs and services funded by HRSA.

The Office of International Health Affairs (OIHA) serves as a focal point within HRSA for leadership, coordination, and advancement of international health activities relating to health care services for vulnerable and at-risk populations and for training programs for health professionals.

Management Improvement
To accomplish the program goals and objectives in its Strategic Plan, HRSA must achieve excellence in management through ongoing improvements in management practices. To this end, HRSA is directing strategies to accomplish the management objectives outlined in the HHS Strategic Plan, including those objectives that are consistent with the President’s Management Agenda (Competitive Sourcing, Strategic Management of Human Capital, Improved Financial Performance, Expanded Electronic Government, and Budget and Performance Integration).

Support a Unified HHS Committed to Functioning as One Department
To support the unification of HHS, HRSA is an active participant in several ongoing activities including:

1. consolidation of HHS operations, including facilities management, human resources and administrative services;
2. coordination with other HHS agencies to better leverage collective resources;
3. reduction in management to speed decision making;
4. establishment of uniform information systems to standardize enterprise functions (e.g., financial systems; electronic communications); and
5. implementation of initiatives to consolidate acquisitions and utilize strategic purchasing.

Improve the Strategic Management of Human Capital
By fiscal year (FY) 2006, 37 percent of HRSA’s civilian workforce and 49 percent of our Commissioned Corps workforce will be eligible to retire. HRSA is addressing this anticipated change in its workforce through its strategic management of human capital. Current and ongoing activities in this area include:

1. ongoing workforce planning, including the recruitment and retention of key staff;
2. implementation of EEOC’s Management Directive-715 which provides policy guidance and standards for establishing and maintaining effective affirmative programs of equal employment opportunity;
3. implementation of an “emerging internal workforce” recruitment program (e.g., details, developmental assignments, and mentoring programs), the HRSA Scholar’s Program, which targets mission-critical positions in the GS-5,7 and 9 grade levels, and focusing on an active external hiring of highly educated adaptable individuals;
4. increase in employee accountability for achieving measurable results through performance contracts;
5. enhancement of training and career development opportunities for HRSA employees; and
6. conduct of studies that examine selected HRSA functions for cost comparisons to identify opportunities for increased efficiency and effectiveness.

Enhance the Efficiency and Effectiveness of Competitive Sourcing
HRSA is enhancing its competitive sourcing activities through the development of a competitive sourcing plan which determines studies to be done of commercial functions each year. The implementation of this plan allows HRSA to set FTE targets and develop studies for its commercial functions as identified in the annual HRSA FAIR Act Inventory process. This enables HRSA to identify performance efficiencies and continuous improvement for the studied functions. Contracts resulting from the studies for either public or private entities are performance based and include a process for vigorous monitoring and measuring of the contractor’s performance.

Improve Financial Management
HRSA continues an ongoing improvement in its financial management through several major efforts:

1. implementation of a new integrated Department-wide financial management system—the Unified Financial Management System (UFMS) that supports financial analysis, performance measurement and operational decision making;
2. compliance with the Department’s accelerated annual audit reporting guidelines and standards; and
3. standardization of processes and procedures related to grant awards, management, and oversight within the Agency, including reduction of payment errors.

Enhance Use of Electronic Commerce in Service Delivery and Record Keeping
HRSA uses electronic commerce both internally for archival and record keeping and externally to improve communication with its grantees and other interested parties. By enhancing the use of electronic resources, HRSA is making it easier for entities to apply for grants and ultimately bring primary health care services to individuals and families, especially those in underserved areas.

In addition, HRSA supports all e-government initiatives with e-government productivity measures, strong Information Technology (IT) security, and integrated enterprise architecture. Finally, HRSA implements the HHS IT Strategic Plan, with its goals to: provide a secure and trusted IT environment; enhance the quality, availability, and delivery of HRSA information and services to citizens, employees, businesses, and governments; support the Department’s implementation of an enterprise approach to IT infrastructure and common administrative systems that will foster innovation and collaboration; enable and improve the integration of health and human services information; and achieve excellence in IT management practices.

Achieve Integration of Budget and Performance Information
HRSA continues to integrate more closely performance and budget information so that program results inform budget decisions. Along with HHS, HRSA has developed a fully integrated fiscal year (FY) 2006 performance budget.

Reduce Regulatory Burden on Providers and Consumers
In an effort to reduce regulatory burden, HRSA will examine the findings and recommendations from the Advisory Committee on Regulatory Reform. It will also solicit advice from stakeholders to identify confusing regulations, strategies and seek suggestions to clarify and simplify these regulations. HRSA has also initiated an Agency wide performance review process to eliminate multiple on-site reviews for grantees with one or more HRSA funded programs, placing a greater focus on program performance and outcomes.

Challenges and External Factors
There are many factors that pose challenges to the effective implementation and accomplishment of HRSA’s goals. The factors/issues described in this section highlight the challenges posed by the overall environment within which HRSA is striving to improve the health of all Americans. The Agency has and will continue to address these challenges as it moves forward to accomplish its mission.

Demographic Trends
Changes in the demographics of the Nation’s population have an impact on the delivery of health care services, both overall and through the health care safety net. The U.S. population is aging; current estimates indicate a 150 percent increase in the number of individuals over 65 by the year 2020. With improvements in medical care, the life expectancy of these individuals is longer. Although life expectancy at birth is 77 years, if an individual lives to 65, his/her life expectancy increases to 83. Both the aging of the population and the increase in life expectancy pose significant challenges to the delivery of medical care in the 21st century. In addition, the increasing diversity (racial, ethnic, linguistic, and literacy rates) and mobility of the population both at a State and national level pose additional challenges in rural, urban and border areas to the delivery of health care.

Changing Disease Burden
There is a current and ongoing change in the nature and impact of both chronic and infectious disease both globally and in the United States. These changes are reflected in several factors including: 1) the