Integrated Care for the Chronically Homeless - CSH...2 History HUD Target Population Approach...
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1 ✦ Team Approach: A multidisciplinary care team is assembled to provide holistic services to the individuals. This team includes primary care providers, behavioral health providers, clinical case managers, medical case managers, community health workers, housing providers, and government agencies providing oversight. ✦ Team Meetings: The interdisciplinary team comes together five days a week to discuss consumer needs and work through any potential ways to address these needs. ✦ Community Health Workers (CHW): CHWs play a major role in supporting the individual with the logistical aspects of managing their physical health, behavioral health, and social needs. They may go to appointments, coordinate the logistics of care, and reinforce treatment adherence. ✦ Community Collaboration: The Houston community has created a highly collaborative system that shows investment beyond integration of care. Partners from different sectors work closely to overcome barriers and create a strategy that will best serve the consumer. ✦ Connection to Housing: Clinical case managers help individuals through the prioritization process to receive housing. Their approach emphasizes the role of housing in stabilizing health care. ✦ Housing Vouchers & Rental Subsidies: The local Continuum of Care and Housing Authority prioritized initiative participants for project based housing vouchers. Rental subsidies are provided through the Houston Housing Authority. ✦ The Houston Integrated Care for the Chronically Homeless Initiative was born out of the Texas 1115 Medicaid Waiver program and the City of Houston Health and Human Services Department. The 1115 Waiver incentivized the development of innovative care delivery models and created new funding pools to ensure providers are reimbursed for providing quality care to vulnerable individuals. The new care delivery models are designed to meet the goals of improved access, increased coordination of care, improved health status, and reduced costs. ✦ Healthcare for the Homeless - Houston (HHH) was chosen as one of the lead Health Centers for the Houston Integrated Care for the Chronically Homeless initiative, which is a joint effort between the health and affordable housing sectors. HHH provides on-site wrap-around services in partnership with SEARCH Homeless Services (homeless service provider in the Greater Houston community), which provides clinical case management, and New Hope Housing, Inc. providing high-quality permanent, affordable housing. ✦ This program targets individuals who are experiencing chronic homelessness and have a minimum of 3 emergency department visits over two years with the goal to improve health status, quality of care, and housing stability for these individuals. ✦ So far, the participants have shown improvement in health functioning and depression scores, and a reduction in emergency department (ED) use and unnecessary hospitalizations. ✦ Challenges: As with any new program, there were some challenges implementing the program including learning to work across sectors and adjusting operational processes. With investment and flexibility, these issues were addressed and the program was strengthened. ✦ Opportunities: A supportive community infrastructure that encourages collaboration, experiences working with vulnerable populations, and opportunities that came out of health reform, such as the 1115 Medicaid Waiver, encouraged the development of this program. INITIATIVE OVERVIEW Integrated Care for the Chronically Homeless Houston, TX | January 2016 KEY FEATURES & INNOVATIONS
Transcript of Integrated Care for the Chronically Homeless - CSH...2 History HUD Target Population Approach...
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✦ TeamApproach:Amultidisciplinarycareteamisassembledtoprovideholisticservicestotheindividuals.Thisteamincludesprimarycareproviders,behavioralhealthproviders,clinicalcasemanagers,medicalcasemanagers,communityhealthworkers,housingproviders,andgovernmentagenciesprovidingoversight.
✦ TeamMeetings:Theinterdisciplinaryteamcomestogetherfivedaysaweektodiscussconsumerneedsandworkthroughanypotentialwaystoaddresstheseneeds.
✦ CommunityHealthWorkers(CHW):CHWsplayamajorroleinsupportingtheindividualwiththelogisticalaspectsofmanagingtheirphysicalhealth,behavioralhealth,andsocialneeds.Theymaygotoappointments,coordinatethelogisticsofcare,andreinforcetreatmentadherence.
✦ CommunityCollaboration:TheHoustoncommunityhascreatedahighlycollaborativesystemthatshowsinvestmentbeyondintegrationofcare.Partnersfromdifferentsectorsworkcloselytoovercomebarriersandcreateastrategythatwillbestservetheconsumer.
✦ ConnectiontoHousing:Clinicalcasemanagershelpindividualsthroughtheprioritizationprocesstoreceivehousing.Theirapproachemphasizestheroleofhousinginstabilizinghealthcare.
✦ HousingVouchers&RentalSubsidies:ThelocalContinuumofCareandHousingAuthorityprioritizedinitiativeparticipantsforprojectbasedhousingvouchers.RentalsubsidiesareprovidedthroughtheHoustonHousingAuthority.
✦ TheHoustonIntegratedCarefortheChronicallyHomelessInitiativewasbornoutoftheTexas1115MedicaidWaiverprogramandtheCityofHoustonHealthandHumanServicesDepartment.The1115Waiverincentivizedthedevelopmentofinnovativecaredeliverymodelsandcreatednewfundingpoolstoensureprovidersarereimbursedforprovidingqualitycaretovulnerableindividuals.Thenewcaredeliverymodelsaredesignedtomeetthegoalsofimprovedaccess,increasedcoordinationofcare,improvedhealthstatus,andreducedcosts.
✦ HealthcarefortheHomeless-Houston(HHH)waschosenasoneoftheleadHealthCentersfortheHoustonIntegratedCarefortheChronicallyHomelessinitiative,whichisajointeffortbetweenthehealthandaffordablehousingsectors.HHHprovideson-sitewrap-aroundservicesinpartnershipwithSEARCHHomelessServices(homelessserviceproviderintheGreaterHoustoncommunity),whichprovidesclinicalcasemanagement,andNewHopeHousing,Inc.providinghigh-qualitypermanent,affordablehousing.
✦ Thisprogramtargetsindividualswhoareexperiencingchronichomelessnessandhaveaminimumof3emergencydepartmentvisitsovertwoyearswiththegoaltoimprovehealthstatus,qualityofcare,andhousingstabilityfortheseindividuals.
✦ Sofar,theparticipantshaveshownimprovementinhealthfunctioninganddepressionscores,andareductioninemergencydepartment(ED)useandunnecessaryhospitalizations.
✦ Challenges:Aswithanynewprogram,thereweresomechallengesimplementingtheprogramincludinglearningtoworkacrosssectorsandadjustingoperationalprocesses.Withinvestmentandflexibility,theseissueswereaddressedandtheprogramwasstrengthened.
✦ Opportunities:Asupportivecommunityinfrastructurethatencouragescollaboration,experiencesworkingwithvulnerablepopulations,andopportunitiesthatcameoutofhealthreform,suchasthe1115MedicaidWaiver,encouragedthedevelopmentofthisprogram.
INITIATIVEOVERVIEW
Integrated Care for the Chronically Homeless
Houston, TX | January 2016
KEYFEATURES&INNOVATIONS
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History
Target Population Approach
ParticipantsareidentifiedthroughHouston’sCoordinatedAccessprocess.TheyenterthissystembycompletingtheVulnerabilityIndex(VI)assessmentatoneofthedesignatedassessmenthubs,thecallincenter,orduringaninteractionwithanoutreachteam.Individualswhoareeligibleareprioritizedfortheprogrambasedontheirvulnerabilityandneed.Individualsarethenreferredtothehealthcenterforanassessmentbytheclinicalteam.HealthcarefortheHomeless-Houston(HHH)purchasedtheirelectronichealthrecordthroughthecountypublichealthsystem,whichgivesthemaccesstoHarrisCounty’shealthrecordsandallowsthemtocheckthenumberofemergencydepartment(ED)visitsfornewandestablishedparticipants.Whentheindividualmovesintohousing,thehealthcentercontinuestoprovidewrap-aroundservicesthroughanon-sitecareteamandoffersadditionalservicesoff-site.Theteamconductsregularstaffmeetings-includingmembersofNewHopeHousing’sresidentservicesandpropertymanagementteam-todiscusshealthinformationaswellasotherclinicalandsocialelementsintheindividual’slifetoensuretheyreceivehigh-qualitycarethatmeetstheirneeds.
Integrated Care for the Chronically Homeless: Houston, TX
INITIATIVEDETAILS
CommunityHealthWorkers:Alignphysicalandbehavioralhealthwithsocialneeds.Theymayattendappointments,
reinforcetreatmentadherenceandassistwiththe
logisticsofmedicalcare.
RN
ClinicalCaseManager
CommunityHealthWorker
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AssessmentbyClinicalTeam
ClinicalTeam:PrimaryCareProvider,BehavioralHealthProvider,MedicalCaseManager,ClinicalCaseManager,
andCommunityHealthWorker
CoordinatedAccessSystem
CallCenter
AssessmentHub
OutreachTeam
PrioritizedbasedonVIScore
3ormoreemergencydepartmentvisitsintwoyears
IdentifiedandPrioritizedthroughCoordinatedAccess
ChronicallyHomelessHUDDefinition
*HUDisimplementinganewdefinitionofChronicHomelessnesseffectiveJanuary16,2016.
2012HealthcarefortheHomeless-HoustonHospitalInreachProjectincorporatedtwocommunityhealthworkerswhichallowedtheagencytovaluetheworkofCHWsandexpandto
have9CHWsinvariousprograms.
2008TheseedsofsupportivehousingaresownwhenNewHopeHousingand
SEARCHattendaCSHtraininginstitute.
2010HealthcarefortheHomeless-Houstonstudy
foundthathomelesspatientshavehigher
hospitalreadmissionratesthandomicilepatients.
TheTexas1115MedicaidWaiver
approvedinlate2011creatednewfundingpoolsandincentivized
innovativecaredeliverymodels.
Houstonwasnameda
HUDPriorityCommunity
in2011.
In2012,theHouston
ContinuumofCareadoptedan
updatedStrategicPlantoEnd
Homelessness
Citygoaltohouse2,500peopleaspartofthisinitiativewith
HHHtakingon200individualsfromthisproject.NewHope
Housing,Inc.hascommittedtohousing200individuals.
HoustonMayor’sOfficeandCityHealthDepartmentdevelopedajointprojectthatpairedhealthcentersandhousing.It
includedtheHealthDepartment,HoustonHousingAuthority,andtheCityHousingDepartment.HealthcarefortheHomeless-Houstonwaschosenasaleadhealthcenter.NewHopeHousinghasbeentheleadingproviderofaffordablehousingunits.TheprojectcontractswithSEARCHHomelessServicestoprovide
clinicalcasemanagement.
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Goals: The1115MedicaidWaiverProgramwillserve2,500chronicallyhomelessindividuals.200willbeservedbythiscareteam.
Outcomes
Forinformationonavailablescreeningtools,visittheSAMHSA-HRSACenterforIntegratedHealthSolutionsordownloadthePHQ-9athttp://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf.FormoreinformationontheSF-36,visithttp://www.rand.org/health/surveys_tools/mos/mos_core_36item.html.
OUTCOMES
Integrated Care for the Chronically Homeless: Houston, TX
WhilethereisanexpectedincreaseinappropriateEDvisitsandhospitalizations(medically
necessaryvisits)ashealthconditionsarestabilized,thereisanoticeabledecreaseininappropriate(non-
emergency)EDuse.
EDUse
Attheendofthefirstyear,participantsshowedameaningfuldifferenceinhealthfunctionalstatusonbothphysicalandmentalhealth,withagreaterimprovementinmentalhealth
status.
SF-36
Withinoneyearofprogramstart-up,participantsare
showingclinicallysignificantresponseinoveralldepressionscoresas
measuredbythePHQ-9.
PHQ-9
200chronicallyhomelessindividualswillbeplacedintosupportivehousingandconnectedtointegratedcareteamwithprovidersfromHHH,SEARCHHomelessServices,andNewHopeHousing,Inc.toachievethefollowinggoals:
Reductioninnon-essentialEDvisitsandhospitalstays
ImprovedHealthStatusasmeasuredbytheSF-63and
PHQ-9StabilizationinHousing
QualityImprovementIncreasedincomethroughSSI/SSDI,Outreach,Access&RecoverytrainedCHWs
HousingRetention
IncreasedSupportiveServicesandProgram
Participation
ImprovedQualityofLife
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Challenges ✦ LearningtoUnderstandEachOther:HealthCenters,socialserviceproviders,andhousingprovidersallspeakdifferent
languagesandareregulatedbydifferentgoverningbodies,whichcanaddstraintotherelationshipbetweenproviders.InHouston,SEARCHHomelessServicesclinicalcasemanagersweregivenaccesstoparticipant’smedicalrecordsbuttherewasasteeplearningcurvetounderstandingthelanguageandcoding.Attimes,HHHclinicalstafffeltisolatedbecausetheirprimaryfocus(primarycare)differsfromthatoftheotherorganizations(casemanagement)andtheyareaccountabletoadifferentsetofregulations(statemedicallawsandHRSAprogramrequirements),andthereforehaddifferentpriorities.Ittakestime,investment,andworkingasateamtoovercomeconflictsthatmayarisebytryingtonavigatethedifferentsystemstoachievetheoverallgoal.
✦ ChaoticNatureofaStart-upProgram:Inastart-upprogram,suchasthisone,thereistheconstantneedtoreevaluateandsometimesrestructure,processesandrolestoensurethattheprogramisaseffectiveaspossible.Thiscanbestressfulforstaffastheprogramcontinuestoevolve.
• StaffRoles:Astheprogramdevelopsandexpands,staffrolesmaychangetomeetconsumerneeds.ThisprogramfoundthatCHWsneededtoallowmoretimeforlogistics,suchasschedulingappointments,andaspecificfocusonhealth-relatedmatters,includingworkingwithparticipantstoprepareforsurgery.
• AddressingandAdjustingCurrentPractices:Withtheadditionofanewprogram,currentpracticesofparticipatingorganizationsmayhavetobeupdatedtobetterserveapatientpopulationthathasdifferentneeds.Forexample,HealthcarefortheHomeless-Houstonfoundthattheyneededtoreconsidertheirclinicalmodelthathadpreviouslyfocusedonepisodiccarethroughnecessitybutnowhastheopportunitytofocusoncontinuityofcare.
✦ ExpectationsandResponsibilities:Alongwithlearningtounderstandthelanguageandprioritiesofeachorganization,theremaybeconflictingideasofwhataretheresponsibilitiesofeachagency.Forexample,clinicalprovidersandhousingprovidersdefinecasemanagementdifferently,makingitnecessarytoreconcilewhatresponsibilitieswillfallontheclinicalcasemanager(briefinterventions,housingnavigation,andassessments)andwhatwillbethehousingprovider’sresponsibility(supplementalhousingsupports).
✦ DealingwithIncreasedNumberofCrises:WhileHealthcarefortheHomeless-Houstonhasalwaysservedvulnerablepopulations,theshiftinfocusforthisprojectbroughtwithitanincreasednumberofhealthcrisesandchronicillnesses.Theyhadtodevelopprocessestohandlethischangeaswellassupportthestafftopreventburnout.
✦ Technology:Whenserviceprovidersareworkingremotely,thenetworksdidnothavethecapacitytomanageadditionalusertraffic.Providershadtohavepersonaltechnologyhotspotsathousingsitesinordertousetheirreportingsoftware.
Opportunities ✦ 1115Waiver:The1115MedicaidWaiverinTexasprovidedanopportunitytodevelopthecollaborativeproject.
✦ CommunityPlan:Thedevelopmentofacommunityplantoaddresshomelessnessprovidedabackdroptoencouragemyriadorganizationalparticipationintheprogram.ThePlanalsoestablishedPermanentSupportiveHousingandtheHousingFirstmodelasapriorityandensurethathousingvoucherswereavailableforprojectparticipants.
✦ ExperiencewithOtherProjects:HealthcarefortheHomeless-Houston’sexperiencewithanotherprogramtargetingchronicallyhomelessindividualsexitingthecriminaljusticesystemwithamentalhealthdiagnosisallowedthemabasisforprogramdevelopmentandhelpedtoinformstaffexperiences.
Integrated Care for the Chronically Homeless: Houston, TX
CHALLENGESANDOPPORTUNITIES
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Health Center: Healthcare for the Homeless - Houston (HHH) Roles:✦ On-sitePrimaryCare✦ MotivationalInterviewing✦ BriefInterventionsincludingCognitiveBehavioralTherapy✦ GroupTherapy✦ PrimaryCareBehavioralHealthConsultationlocatedattheHealthCenter
• TheHealthCenterhasachievedlevel6integrationthroughtheabilitytoaddBehavioralHealthConsultants.✦ SubstanceUseandBehavioralHealthCounselingavailableattheHealthCenter✦ CommunityHealthWorkerstoassisttheconsumerinmanagingtheirhealthneeds.
Homeless Services Provider: SEARCH Homeless Services Roles:✦ ClinicalCaseManagementincludingmorein-depthMotivationalInterviewingandCognitiveBehavioralTherapy✦ WorkcloselywithCoordinatedAccess✦ AssistinnavigationbetweenbeingidentifiedinCoordinatedAccessasapotentialprogramparticipantandgettingintohousing✦ Conductinitialandfollow-upassessmentinthelocalHomelessManagementInformationSystem(HMIS)
• Follow-upassessmentsarecompletedeverysixmonths
Housing Provider: New Hope Housing, Inc. Roles:
✦ PropertyManagement• Thehousingproviderhasdedicatednearly450unitsoftheirportfoliotopermanentsupportivehousing.
✦ Supplementalsupportiveservicestoresidents✦ Coordinationwithserviceproviders✦ Institutedahousingfirstmodel
Integrated Care for the Chronically Homeless: Houston, TX
INITIATIVEPARTNERS
OPERATIONALEXPERIENCES&LESSONS
✦ UsingAssessmentScores:StaffhasbeenabletouseSF-36andPHQ-9scoresasateachingmomentbothonindividualandaggregatepopulationlevels.Inworkingwithconsumers,theycanusethesescorestoprovidefeedbackandusethemaspartofbriefintervention,inhopesofimprovingthescoreovertime.Onthepopulationlevel,staffisabletolookatlargerchangesoveralltoidentifysuccessesandchallenges.
✦ AdvancedAssessment:Itiseasiertoassessindividualsintheclinicpriortoenrollingthemintothehousingprogramastotheirabilitytoliveindependently.Insomecases,therehavebeenindividualswhohaveneededahigherlevelofcarethanisfeasibletoprovideinsupportivehousing.Thiscouldbeaphysicalhealthconditionthatneedssupervisiontomaintainstability.Inthiscase,individualsareconnectedtoamoreappropriatehousingoptionthatmeetstheirneedsthroughtheContinuumofCare.
✦ AcuityofPhysicalHealthConditions:TheHealthCenterwassurprisedbytheacuityofthehealthneeds.Basedontheliterature,theyhadexpectedbehavioralhealthneedstospikeuponenteringhousing,buttheywerenotpreparedfortheacuityofphysicalhealth.Whentheprogrambegan,stafffeltasthoughtheyweremovingfromcrisistocrisisandexperiencedadeathwithinthefirsttwoweeks.Theyhadtoadapttoprovidethecarepatientsneededandsupportfortheirstaff.
✦ OrganizationalPolicyChanges:Thehousingproviderfoundthatbynatureofworkingwithamorevulnerablepopulation,theyhadtoaddresssomeoftheirpolicies.Theyhaveazerotolerancefightingpolicyformostoftheirhousingunitsbuthadtoadaptamoretolerantpolicytoensurehousingstabilityforprogramparticipants.Inaddition,NewHopeHousingadoptedahousingfirstmodelforthisprogram,allowingindividualswhoareactivelyusingsubstancestoobtainandremaininhousing.
✦ SteppingoutoftheOrganizationalComfortZone:Thehousingproviderfoundthatjoininginacollaborativepartnershiprequiredthattheorganizationopenupandisvulnerableinordertobepartofthelargerconversation.Theyhadtomovepastnegativeexperienceswithattemptedproviderpartnershipsandworktodevelopastrongerrelationshipwithnewpartners.
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Funding Sources Start-upFundingOpportunities:CurrentFunding:
PotentialFundingOpportunities:
Costs Savings Costsavingshavebeenobservedbutarenotyetquantifiableasthisisthefirstyearoftheprogram.
Program Costs
FINANCES
Integrated Care for the Chronically Homeless: Houston, TX
Roughly90%ofprogramcoststotheHealthCenterandSEARCHareforstafftime
Remaining10%includes:StaffTrainingandEducationPharmaceuticalsTransportationSuppliesITCostsAdministrativeTimeSF-36costs
Transportationincludescostforbothstaffmileageandpatienttransportationcosts.
ITCostsincludelaptops,hotspotsandmobilephonesneededtoprovidecareawayfromthehealthcenter.
1115Waiver:TheMedicaid1115WaivercreatedtheDeliverySystemReformIncentivePayment(DSRIP).ProvidersareabletoreceiveDSRIPpaymentsiftheyparticipateinanapprovedinnovativecaredeliverymodelandmeetcertainoutcomemeasures.
ThehealthcenterisintalkswiththelocalMedicaidManagedCareOrganizations(MCOs)aboutthepossibilityofreceivingpaymentforcarecoordination.
ThehealthcenterwasabletoemploytheirfirsttwoCHWsthroughapartnershipwiththeNationalHealthCarefortheHomelessCouncilaspartofaCMSHealthCareInnovationAward.
MedicaidBilling:ThehealthcenterbillsforservicesthatarecoveredbyMedicaid.However,sinceTexasisanon-expansion
state,mostservicesandindividualsarenotcovered.
HRSAHealthCenterProgramFunding:HealthCenterprogrambasefundingisalargeportionof
theHealthCenter’soverallfundingandisusedtofinancestaffand
operations.
HousingVouchers:TheHoustonHousing
AuthorityprioritizedProjectBasedHousingVouchersforprogram
participants.
Grants&PrivateFunding:Aportionofcasemanagement
serviceswereprovidedthroughvariousoutside
fundingsources.
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Integrated Care for the Chronically Homeless: Houston, TX
CSHtransformshowcommunitiesusehousingsolutionstoimprovethelivesofthemostvulnerablepeople.Weoffercapital,expertise,informationandinnovationthatallowourpartnerstousesupportivehousingtoachievestability,strengthandsuccessforthepeopleinmostneed.CSHblendsover20yearsofexperienceanddedicationwithapracticalandentrepreneurialspirit,makingusthesourceforhousingsolutions.CSHisanindustryleaderwithnationalinfluenceanddeepconnectionsinagrowingnumberoflocalcommunities.WeareheadquarteredinNewYorkCitywithstaffstationedinmorethan20locationsaroundthecountry.Visitcsh.orgtolearnhowCSHhasandcanmakeadifferencewhereyoulive.
ABOUTCSH
TheNationalHealthCarefortheHomelessCouncilisanetworkofdoctors,nurses,socialworkers,patients,andadvocateswhosharethemissiontoeliminatehomelessness.Since1986wehavebeentheleadingorganizationtocallforcomprehensivehealthcareandsecurehousingforall.Weproduceleadingresearchinthefieldandprovidethehighestleveloftrainingandresourcesrelatedtocareforpersonsexperiencinghomelessness.Wecollaboratewithgovernmentagenciesandprivateinstitutionsinordertosolvecomplexproblemsassociatedwithhomelessness.Additionally,weprovidesupporttopublichealthcentersandHealthCarefortheHomelessprogramsinall50states.Visitnhchc.orgtolearnmore.
ABOUTNHCHC
AllphotosdepictstafforconsumersreceivingservicesfromHealthCarefortheHomeless-Houston,NewHopeHousing,Inc.orSEARCHHomelessServices.
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Integrated Care for the Chronically Homeless: Houston, TX
“ThisprojectwassupportedbytheHealthResourcesandServicesAdministration(HRSA)oftheU.S.DepartmentofHealthandHumanServices(HHS)undercooperativeagreementnumber#U30CS26935,TrainingandTechnicalAssistanceNationalCooperativeAgreement(NCA)for$325,000with0%ofthe
totalNCAprojectfinancedwithnon-federalsources.Thisinformationorcontentandconclusionsarethoseoftheauthorandshouldnotbeconstruedastheofficialpositionorpolicyof,norshouldanyendorsements
beinferredbyHRSA,HHSortheU.S.Government.”
