TO: HRSA Administrator

Recommendations for Capital Grants for School Based Health Centers (SBHC) August 27, 2010 California School Health Centers Association

The California School Health Centers Association has sought input from various stakeholders throughout California to develop recommendations for the upcoming capital grants program for SBHCs. The majority of these recommendations were developed by stakeholders in Los Angeles but were also reviewed by others in Alameda and West Contra Costa counties.

Los Angeles Unified School District, (LAUSD) LA County Department of Health Services (LACDHS) and community clinics health centers have been partnering in multiple efforts to renovate existing SBHCs, build new SBHCs and modify existing school structures to become SBHCs over the last few years. The recent SBHC expansions take advantage of Joint Use Bonds through LAUSD, one-time only LACDHS funds for primary care expansion and matching funds raised by community clinics which have significant experience with Capital Improvement Program and Facilities Improvement Program funding through ARRA. LAUSD has made a major commitment to use Joint Use Bonds to build at least 12 new SBHCs over three years.

LAUSD has determined that the cost of building a 2,000 sq ft green modular SBHC from planning to opening is $2-3M. Renovations of existing school space can be less costly if vacant space is available on a campus. LAUSD has provided a developmental and timing analysis included at the end of this document to further inform the new federal capital grants program.

Recommendations for Capital Grant Program

1. Allow large districts to propose multi-site, multi partner agency projects.

2. Develop and implement two grant programs: planning and implementation

3. Provide planning grants that: a. Require applicants to meet the following threshold:  School and school district approval as demonstrated by a school administrator and district board letter of support  Designated chief facilities administrator with staff in place to oversee;  Project requirement definition (due diligence) completed  Verifiable cost estimate  Preliminary design  SHC operator identified by Memorandum of Understanding b. Allow the following costs:  Environmental Impact Study and mitigation in accordance to CEQA Guidelines Requirements  A portion of the district personnel dedicated to the project  Up to 30% of the architect’s fee for the total project

4. Provide Implementation grants that: a. Require applicants to meet the following threshold:  School district board final approval  Designed to meet state licensing standards where applicable  Compliant with state department of architecture where applicable or demonstrate that project is exempt from DSA requirement or available for over-the-counter review  Timeline included to accommodate district benchmarks—20 months minimum  Architects in place/under contract b. Allow the following costs:  No more that 70% of architects fee  A portion of district personnel dedicated to project  Environmental impact mitigation if timeline demonstrates appropriateness  Secured access to clinic for students’ entrance to clinic  Access to clinic from the community  Infrastructure of clinic including security alarm, data lines, utility connections and alerts notifications  Site preparation cost  Construction and all applicable licenses cost  Medical devices and equipments  Furnishing

5. Exempt projects from Notice of Federal Interest (NFI). In a proposal to use the Capital Improvement Program (CIP) funding for a school based health center, CIP required the school district to sign a NFI for the site. The school district did not want to give any ownership of its property to the federal program, and so it balked at this request. The NFI requirement will be an ongoing issue as the SBHC expansions will be for sites with multiple owners and operators.

6. Allow equipment funding in conjunction with capital grants. Particularly for building and funding dental and x-ray expansions, linking these two funding programs would enhance proposers’ ability to add these services.

7. Set grant programs timeline at minimum of 3 years. California’s current budget crisis has resulted in furloughed state and county workers that will extend the process of getting state and local approvals. We suggest:  Up to 1 year planning, development, agency approval process, including public comment period  Up to 2 years design and construction  Allow maximum flexibility for timeline variation to accommodate unforeseen events, e.g. environmental mitigation  See Attachment: Project Timeline 8. Recommended funding levels  Planning -- $100-150K  Construction and related capital expenses – up to $400K depending on the size of the clinic

9. Grant Submission Scoring  Award additional points for the following:  District/applicant matching, including low interest loans and bonds  Regions that have no SBHCs  Projects that demonstrate unmet need  Including other social support components for multi-service centers  Ensure a objective review process by giving clear guidance and expectations to the objective review committee.  Allow applications for school-linked sites (i.e., not on school grounds) but develop a rigorous scoring system to ensure that the linkage is meaningful. A school- linked site should not simply be a community-based site that accepts referrals from a school.

10. Avoid aspects of the federal Capital Improvement Program (CIP) that hampered other ARRA expenditures Community clinics and health centers in LA County moved quickly to improve and expand health services in LA County with funds from the American Recovery and Reinvestment Act (ARRA). While the opportunity has been great, operational barriers have slowed implementation of projects and draw-down of ARRA funds. Clinics face local and state grant requirements that are a seemingly insurmountable challenge, as well as challenges in meeting/navigating the grant requirements. Some of these challenges include:

Requirements do not seem appropriate to projects. For example: o A clinic with a renovation project has been told that it must meet requirements for projects over the $500,000 threshold, even though its project is under that amount. This includes having the landlord file a Notice of Federal Interest (NFI), which is not a requirement for grants under the threshold. The Landlord Letter of Consent (LLOC) template sent by HRSA includes a statement that the landlord will agree to file an NFI. The clinic cannot get a commercial Real Estate Investment Trust to file the NFI. While the clinic has explained this to HRSA, they have been told they must submit an NFI. o For a leased space in an existing shopping center, a clinic must meet National Environmental Policy Act and State Historic Preservation Act grant conditions.

Problematic timing for requirements. For example: Clinics have to complete quarterly reports even if no money has been received. A clinic was told to request equipment and furniture even though it had not yet put in the scope of work change for the new site. However after receiving the grant award, the clinic was then told it could not draw down the funds for the equipment and furniture until it had completed a scope of work change which was not approved in a timely manner and delayed opening of the site. A clinic needs to get a California Environmental Quality Act waiver for its project. The clinic needs the studies now, however LA Building and Safety states the project must be in the plan check phase before it will issue the waiver.

Reporting/Communication Challenges. Clinics cite several issues in reporting. Clinics cannot save a document on federalreporting.gov and continue in the writing process like on the Electronic Hand Book (EHB). Instead, when someone saves a document, the website signs the user out and sends the user emails indicating a document has been saved. Although both EHB and federalreporting.gov require the same information, there should be more joint communication between the two beyond sending emails indicating a deadline is approaching or something is late. In general, too many emails are sent out, and some of them are erroneous. For example, after filing both reports on time, a clinic received emails indicating they had not yet been filed. This resulted in wasted time to clarify reports were indeed received. Project Timeline for Los Angeles Unified School District

School Based Health Clinic Timing Development Steps Partner’s business development Presumably already exists Agency to develop master plan based on areas of Presumably already exists need Project Begins Initial contact with agency, district and school site 2 months FQHC proposal development 2 months Enter into MOU 1 month Project Development 4 months Agency or Board Approval Process 3 months Allocate funding/creating funding lines 1 month Design, notice to proceed to architects 6 months Agency reviews designs before submitting to DSA 1.5 months DSA Over-the-counter process if stand-alone 2 months structure that has PC#, OR DSA regular process if project is a tenant 5 months improvement to an existing building Prepare bid package 1-2 months RFP construction contract 2 months Award construction contract 1 month Begin construction 6 months Substantial construction completion & punch-list 2 months Occupancy (included) TOTAL TIME Average 3 years