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Home My WebLink About20132406.tiffRESOLUTION RE: APPROVE AMENDMENT TO TASK ORDER CONTRACT #1 FOR MATERNAL AND CHILD HEALTH PROGRAM (MCH) AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with an Amendment to Task Order Contract #1 for the Maternal and Child Health Program (MCH) between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Public Health and Environment, and the Colorado Department of Public Health and Environment, commencing October 1, 2013, and ending September 30, 2014, with further terms and conditions being as stated in said amendment, and WHEREAS, after review, the Board deems it advisable to approve said amendment, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Amendment to Task Order Contract #1 for the Maternal and Child Health Program (MCH) between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the on behalf of the Department of Public Health and Environment, and the Colorado Department of Public Health and Environment, be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said amendment. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 26th day of August, A.D., 2013. BOARD DE COUNTY COMMISSIONERS Weld County Clerk to the Board BY: AP Deputy CI -r to the Board O FORM: rl ty Attorney 0 WELD Date of signatureSEP 1 2 2013 JO ouglas Radem can P. Conway USED Freeman LORADO cher, Pro-Tem aR.C1x.— rbara Kirkmeyer 2013-2406 HL0040 TO: Memorandum William F. Garcia, Chair Board of County Commissioners FROM: Mark E. Wallace, MD, MPH, Director Department of Public Health and Environment DATE: August 20, 2013 SUBJECT: Maternal and Child Health Program(MCH) Contract Enclosed for Board review is a Task Order Contract between the Board of County Commissioners of Weld County on behalf of the Weld County Department of Public Health and Environment ("WCDPHE") and the Colorado Department of Public Health and Environment ("CDPHE") for the Maternal and Child Health (MCH) Program. The term of the contract is from October 1, 2013, through September 30, 2014. Total funding for this renewal period will not exceed $193,008.00. The MCH program encompasses four separate and distinct programs as described below. Early Childhood Obesity Prevention The 2010 Colorado Child Health Survey data demonstrates that 22.9% of Colorado children ages 2 to 14 are overweight or obese. It is known that being overweight or obese leads to a variety of health problems, especially later in life. The Weld County Five -Year Community Health Improvement Plan identified obesity prevention as a top priority area to be addressed over the course of the next five years. In partnership with initiatives already underway at WCDPHE, the goal for the strategies addressed in the Early Childhood Obesity Prevention Action Plan is to focus closely upon the maternal and child population and be a voice for maternal and early childhood health in existing partnerships and efforts. Health Care Program for Children with Special Needs (HCP): Care Coordination This program facilitates the development and enhancement of community -based systems of care for children with special health care needs. Services provided will include case finding, community involvement, and interagency collaboration for children and their families who are determined eligible for such services. Eligible children are those who have or are at risk for chronic physical, developmental, behavioral, or emotional conditions. Health Care Program for Children with Special Needs (HCP): Medical Home HCP identified the need for a high level stakeholder committee to address barriers to a Medical Home approach for addressing medical needs of the "resource -challenged" children and families of Weld County. HCP initiated the Weld Child Resource Consortium (WCRC) in February 2013. Our three-year plan for this consortium composed of representatives from 17 Greeley/Weld agencies who will continue in 2013- 2014 to explore opportunities to eliminate barriers to the Medical Home approach and to 2013-2406 expand exploration of resources that will support care needs of all children within the medical home neighborhood of Weld County. Adolescent Health & Injury Prevention This program's focus is directed to the Teen Motor Vehicle Safety program and the successful program of DRIVE SMART Weld County to help meet their goal of decreasing deaths and injuries from motor vehicle crashes. The program will support and expand the DRIVE SMART Weld County community traffic safety coalition, increase knowledge of graduated drivers license laws and willingness to issue citations among law enforcement personnel, continue providing P.A.R.T.Y. (Prevent Alcohol and Risk -related Trauma in Youth) programs to students at Weld County high schools, and provide classes for parents and teens about graduated driver's licensing laws (GDL). Approving the MCH grant would assist our agency to continue to provide education and outreach services in order to prevent more children from becoming overweight and/or obese. It would address healthy eating programs from birth (breast feeding awareness and employer awareness) to adulthood. Approval of the grant would allow the Health Department to continue vital care collaboration, Medical Home, Safety, and Wellness programs that address the Colorado Winnable Battles. These include Early Childhood Obesity Prevention and Medical Home/Medical Neighborhood initiatives. The collaborations will increase medical access for all resource -challenged children and families in Weld County. Funding for this contract will be used to provide health care case management, outreach and support services for children with special health care needs, ages birth to 21. The Department would continue to address the Traffic Safety programs for Youth. In Weld County, unintentional injuries are the leading cause of death among adolescents and a leading cause of medical spending for adolescents aged 11 to 18 years old. The cost of injury can be measured in many ways including medical costs, reduced productivity and years of potential life lost (fatal injuries). Clearly, these costs affect virtually all segments of society from the injury victims and their families to employers, private health insurers, the government and taxpayers. I recommend approval of this Task Order Contract for the Maternal Child Health program. DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT PSD-MCH DEPARTMENT OR AGENCY NUMBER FLA CONTRACT ROUTING NUMBER 14-59156 AMENDMENT FOR TASK ORDERS #1 This Amendment is made this 29th day of JULY 2013, by and between the State of Colorado, acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, whose address or principal place of business is 4300 Cherry Creek Drive South, Denver, Colorado 80246, hereinafter referred to as the "State"; and, BOARD OF COUNTY COMMISSIONERS OF WELD COUNTY (a political subdivision of the state of Colorado), for the use and benefit of the WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, whose address or principal place of business is 1555 North 17th Avenue, Greeley, Colorado 80631 hereinafter referred to as the "Contractor". FACTUAL RECITALS The parties entered into a Master Contract, dated January 17, 2012, with contract routing number 13 FAA 00051. Pursuant to the terms and conditions of the Master Contract, the parties entered into a Task Order Contract, dated August 14, 2012 with contract encumbrance number PO FLA PSD1348090 and contract routing number 13 FLA 48090, collectively referred to herein as the "Original Task Order Contract, whereby the Contractor was to provide to the State the following: Develop, implement and evaluate a comprehensive plan in accordance with state and federal MCH guidelines, to improve the health and well-being of the NICH population, including children with special health care needs. The State promises to pay the Contractor the sum of Three Hundred Thirty Three Thousand Eight Hundred Eighty Six Dollars ($333,886.00) in exchange for the promise of the Contractor to continue to perform the work identified in the Original Task Order Contract for the renewal term of one year, ending on September 30, 2014. NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree as follows: L Consideration for this Amendment to the Original Task Order Contract consists of the payments and services that shall be made pursuant to this Amendment, and promises and agreements herein set forth. 2. It is expressly agreed to by the parties that this Amendment is supplemental to the Original Task Order Contract, contract routing number 13 FLA 48090, collectively referred to herein as the Original Contract, which is by this reference incorporated herein. All terms, conditions, and provisions thereof, unless specifically modified herein, are to apply to this Amendment as though they were expressly rewritten, incorporated, and included herein. 3. It is expressly agreed to by the parties that the Original Task Order Contract is and shall be modified, altered, and changed in the following respects only: A. This Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number 13 FLA 48090. This Amendment is for the renewal term of October 1, 2013 through and including September 30, 2014. The maximum amount payable by the State Page I of 4 Rev 3/16/2010 for the work to be performed by the Contractor during this renewal term is Three Hundred Thirty Three Thousand Eight Hundred Eighty Six Dollars ($333,886.00) for an amended total financial obligation of the State of SIX HUNDRED SEVENTY FIVE THOUSAND ONE HUNDRED SEVENTY EIGHT DOLLARS AND NINETY CENTS ($675,178.90). This is an increase of Three Hundred Thirty Three Thousand Eight Hundred Eighty Six Dollars ($333,886.00) of the amount payable from the previous term. Of the maximum amount for this renewal term Ninety Thousand Eight Hundred Seventy Six Dollars ($90,876.00) are attributable to a funding source of the State of Colorado and Two Hundred Forty Three Thousand Ten Dollars (5243,010.00) are attributable to a funding source of the United States Government (see Catalog of Federal Domestic Assistance (CFDA) number 93.994). Of the amended total financial obligation of the State referenced above Two Hundred Four Thousand Eight Hundred Forty Five Dollars and Forty Cents ($204,845.40) are attributable to a funding source of the State of Colorado and Four Hundred Seventy Thousand Three Hundred Thirty Three Dollars and Fifty Cents ($470,333.50) are attributable to a funding source of the United States Government. The revised Additional Provisions is incorporated herein by this reference and identified as "Exhibit E". The revised Statement of Work is incorporated herein by this reference and identified as "Exhibit F". The revised Budget is incorporated herein by this reference and identified as "Exhibit G". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. 4. The effective date of this Amendment is October 1, 2013 or upon approval of the State Controller, or an authorized delegate thereof, whichever is later. 5. Except for the Special Provisions and other terms and conditions of the Master Contract and the General Provisions of the Original Task Order Contract, in the event of any conflict, inconsistency, variance, or contradiction between the terms and provisions of this Amendment and any of the terms and provisions of the Original Task Order Contract, the terms and provisions of this Amendment shall in all respects supersede, govern, and control. The Special Provisions and other terms and conditions of the Master Contract shall always control over other provisions of the Original Task Order Contract or any subsequent amendments thereto. The representations in the Special Provisions to the Master Contract concerning the absence of personal interest of state of Colorado employees and the certifications in the Special Provisions relating to illegal aliens are presently reaffirmed. 6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND OTHERWISE MADE AVAILABLE. This page left intentionally blank. Page 2 of 4 Rev 3/16/2010 IN WITNESS WHEREOF, the parties hereto have executed this Amendment on the day first above written. x Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's behalf and acknowledge that the State is relying on their representations to that effect. CONTRACTOR: BOARD OF COUNTY COMMISSIONERS OF WELD COUNTY (a political subdivision of the state of Colorado) for the use and benefit of the WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONM Sig r tureo STATE: STATE OF COLORADO John W. Hickenlooper, Governor By: Authorized Officer AUG 2 6 2013 William F. Garcia Print Name of Authorized Officer Chair Print Title of Authorized Officer For the Executive Director DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT PROGRAM APPROVAL: By: aoP 44 ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS §24-30-202 requires the State Controller to approve all State Contracts. This Contract is not valid until signed and dated below by the State Controller or delegate. Contractor is not authorized to begin performance until such time. If Contractor begins performing prior thereto, the State of Colorado is not obligated to pay Contractor for such performance or for any goods and/or services provided hereunder. By: Date: STATE CONTROLLER RoobbertJaro/ss,,, CPA, MBA, JD 9<-/9 Page 3 of 4 Rev 3/16/2010 020/3-ayo6 This page left intentionally blank. Page 4 of 4 Rev 3/16/2010 EXHIBIT E ADDITIONAL PROVISIONS To Task Order Contract Dated 08/14/2012 - Contract Routing Number 13 FLA 48090 — Contract Amendment Routing Number 14 FLA 59156 These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above. 1. The list of acronyms attached hereto as Attachment E -1 may be referenced to in Exhibit E, Exhibit F, and all and any attachments thereof in this Task Order Contract. 2. This Task Order Contract contains federal and state funds (see Catalog of Federal Domestic Assistance (CFDA) number 93.994) 3. The United States Department of Health and Human Services ("USHHS"), through the Health Resources and Services Administration ("HRSA") has awarded federal funds under Award number B04MC25329-01 hereinafter "Award", to perform the following — Maternal and Child Health. If the underlying Award authorizes the State to pay all allowable and allocable expenses of a contractor as of the effective date of that Award, then the State shall reimburse the Contractor for any allowable and allocable expenses of the Contractor that have been incurred by the Contractor since the proposed effective date of this Task Order Contract. If the underlying Award does not authorize the State to pay all allowable and allocable expenses of a contractor as of the effective date of that Award, then the State shall only reimburse the Contractor for those allowable and allocable expenses of the Contractor that are incurred by the Contractor on or after the effective date of this Task Order Contract, with such effective date being the later of the date specified in this Task Order Contract or the date the Task Order Contract is signed by the State Controller or delegee. 4. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 27, Annual Audit, for the purpose of this Task Order, the Contractor is a Subrecipient as defined by Office of Management and Budget (OMB) Circular A-133 (Audits of States, Local Governments, and Non -Profit Organizations). 5. To receive compensation under this Task Order Contract, the Contractor shall submit a signed monthly CDPHE Reimbursement Invoice Form. This form is accessible from the CDPHE internet website http://www.colorado.gov/cs/Satellite/CDPHE-Main/CBON/ 1251622941228 and is incorporated herein by reference. CDPHE will provide technical assistance in accessing and completing the form. The CDPHE Reimbursement Invoice Form must be submitted within forty-five (45) calendar days of the end of the billing period for which services were rendered. Expenditures shall be in accordance with the Statement of Work attached hereto as Exhibit F and incorporated herein and the associated Budget attached hereto as Exhibit G and incorporated herein. All other expenditures shall not be reimbursed without prior written consent of the State. All expenditures must be reasonable and necessary for the performance of this Contract, and must comply with The State of Colorado, specifically the Colorado Department of Public Health and Environment, fiscal guidelines and rules. Submit completed CDPHE Reimbursement Invoice Form to: Colorado Department of Public Health and Environment MCH Generalist Consultant PSD- MCH — A4 4300 Cherry Creek Drive South Denver, CO 80246 To be attached to CDPHE Task Order v1.0 (3/12) contract template Page 1 of 5 Revised: 12/19/06 EXHIBIT E To be considered for payment, billings for payments pursuant to this Task Order Contract must be received within a reasonable time after the period for which payment is requested, but in no event no later than forty-five (45) calendar days after the relevant performance period has passed. Final billings under this Task Order Contract must be received by the State within a reasonable time after the expiration or termination of this Task Order Contract; but in no event no later than forty-five (45) calendar days from the effective expiration or termination date of this Task Order Contract. Unless otherwise provided for in this Task Order Contract, "Local Match", if any, shall be included on all invoices as required by funding source. The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless approved in writing by the appropriate federal agency. 6. Time Limit For Acceptance Of Deliverables. a. Evaluation Period. The State shall have thirty (30) calendar days from the date a deliverable is delivered to the State by the Contractor to evaluate that deliverable, except for those deliverables that have a different time negotiated by the State and the Contractor. b. Notice of Defect. If the State believes in good faith that a deliverable fails to meet the design specifications for that particular deliverable, or is otherwise deficient, then the State shall notify the Contractor of the failure or deficiencies, in writing, within thirty (30) calendar days of: I) the date the deliverable is delivered to the State by the Contractor if the State is aware of the failure or deficiency at the time of delivery; or 2) the date the State becomes aware of the failure or deficiency. The above time frame shall apply to all deliverables except for those deliverables that have a different time negotiated by the State and the Contractor in writing pursuant to the State's fiscal rules. c. Time to Correct Defect. Upon receipt of timely written notice of an objection to a completed deliverable, the Contractor shall have a reasonable period of time, not to exceed ten (10) calendar days, to correct the noted deficiencies. If the Contractor fails to correct such deficiencies within ten (10) calendar days, the Contractor shall be in default of its obligations under this Task Order Contract and the State, at its option, may elect to terminate this Task Order Contract or the Master Contract and all Task Order Contracts entered into pursuant to the Master Contract. 7. Health Insurance Portability and Accountability Act (HIPAA) Business Associate Determination. The State has determined that this Task Order Contract does not constitute a Business Associate relationship under HIPAA. 8. Contractor shall request prior approval in writing from the State for all modifications to the Statement of Work/ Work Plan or for any modification to the direct costs in excess of twenty-five percent (25%) of the total budget for direct costs. Contractor shall submit a Budget Revision Request Form incorporated herein by reference and located at www.mchcolorado.org. Any request for modifications to the Budget in excess of twenty-five percent (25%) of the total budget for direct costs or $250,000.00, whichever is less, shall be submitted to the MCH Generalist Consultant at least 90 days prior to the end of the contract period and may require an amendment in accordance with General Provisions, Section 16, Contract Modifications, of this Contract. The Contractor is required to request and receive prior approval in writing via email by the MCH Generalist Consultant if there are permanent or temporary changes in any MCH- funded line item supporting staff positions. 9. The Contractor shall adhere to the same guidance as the State when considering food and beverage purchases. Food or beverages may be purchased for events related to the MCH action plan such as training, community meetings or events that engage external stakeholders, and/or multi -county regional meetings. Title V and State General funds may not be used to purchase food or beverages while conducting routine staff meetings and specialty clinics. Contact the MCH Generalist Consultant if guidance is necessary. To be attached to CDPHE Task Order v1.0 (3/12) contract template Page 2 of 5 Revised: 12/19/06 EXHIBIT E 10. Contractor shall retain and use all revenues generated by MCH Program for services in those programs. The revenue cannot be used for other programs or purposes. 1 I . Title V, Section 504 (b) (6). Title V funds may not be used to pay for any item or service (other than an emergency item or service) furnished by an individual or entity convicted of a criminal offense under the Medicare or any State health care program (i.e., Medicaid, Maternal and Child Health, or Social Services Block Grant Programs). 12. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 9, Rights in Data, Documents and Computer Software or Other Intellectual Property, unless otherwise provided for, all data collected or produced or derived exclusively from the Contractor's or subcontractor's work under this Task Order Contract shall remain the sole property of the State, whether in individual, aggregate, identified or de -identified form or any other form required by the State. To facilitate follow-up, research, surveillance and evaluation, any such data collected, used or acquired shall be made available in any form required by the State, to the State and any other entity designated by the State. Any such data collected, used or acquired shall be used solely for the purposes of this Task Order Contract. The Contractor and its subcontractors agree not to release, divulge, publish, transfer, sell, or otherwise make known any such data to unauthorized persons without the express prior written consent of the State or as otherwise required by law. This includes a prior written request by the Contractor to the State for submission of abstracts or reports to conferences, which utilize data collected under this Task Order Contract. Notwithstanding the foregoing, the Contractor shall be entitled to retain a set of any such data collected or work papers necessary to perform its duties under this Task Order Contract and in accordance with professional standards. 13. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 9, Rights in Data, Documents and Computer Software or Other Intellectual Property, or Section 23.i, General Provisions, Media or Public Announcements, the State of Colorado, specifically the Department of Public Health and Environment, shall be the owner of all printed materials, graphic representations, educational materials, audio-visual products, or any other media, in whatever form, created under this Task Order Contract. This requirement applies, but is not limited to, any brochure, flyer, presentation, billboard, radio spot, website, banner advertisement. The State reserves the right to require logos, or other wording on any material, representation, product or other media form created under this Task Order Contract. Any material, representation, product or other media form that will use the State's or logo or information must be approved by the State prior to production and distribution. A minimum of ten (10) business days is required for the review and approval process. l4. Notwithstanding the terms contained in the General Provisions of the Master Contract, Section 25, Conformance with Law, the Contractor shall comply with the provisions of Section 601 of Title VI of the Civil Rights Act of 1964, as amended, which states that "no person in the United States shall on the grounds of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program actively receiving Federal financial assistance." The Office for Civil Rights has established that it is the responsibility of any program that is a recipient of federal funds to ensure that any Limited English Proficient (LEP) person or beneficiary have meaningful access to programs, services and information. The Contractor and contract personnel shall adopt and implement policies and procedures in which reasonable steps are taken to provide language assistance in order to ensure equal access to LEP persons or beneficiaries. The Contractor and contract personnel shall advise LEP individuals that language assistance will be provided at no cost to the LEP person or beneficiary. I5. Contractor agrees to provide services to all Program participants and employees in a smoke -free environment in accordance with Public Law 103-227, also known as "the Pro -Children Act of 1994", (Act). Public Law 103-227 requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, To be attached to CDPHE Task Order v1.0 (3/12) contract template Page 3 of 5 Revised: 12/19/06 EXHIBIT E early childhood development services, education or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable Federal funds is Medicare or Medicaid; or facilities where Women, Infants and Children (WIC) coupons are redeemed. Failure to comply with the provision of Public Law 103-227 may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. By signing this Task Order Contract, Contractor certifies that Contractor shall comply with the requirements of the Act and shall not allow smoking within any portion of any indoor facility used for the provision of services for children as defined by the Act. Contractor agrees that it shall require the language of the Act be included in any subcontracts which contain provisions for children's services and that all subcontractors shall sign and agree accordingly. l6. Notwithstanding the terms contained in the General Provisions of the Master Contract, Section 10, Confidential or Proprietary Information, the Contractor shall protect the confidentiality of all applicant or recipient records and other materials that are maintained in accordance with this Task Order Contract. Except for purposes directly connected with the administration of this Task Order Contract, no information about or obtained from any applicant or recipient shall be disclosed in a form identifiable with the applicant or recipient without the prior written consent of the applicant or recipient, or the parent or legal guardian of a minor applicant or recipient with the exception of information protected by Colorado Statute as it applies to confidentiality for adolescent services in which case the adolescent minor and not the parent or legal guardian must provide consent or as otherwise properly ordered by a court of competent jurisdiction. Contractor shall have written policies governing access, duplication, and dissemination of all such information. Contractor shall advise its employees, agents, servants, and any subcontractors that they are subject to these confidentiality requirements. 17. The State of Colorado, specifically the Colorado Department of Public Health and Environment, shall be the owner of all equipment as defined by Federal Accounting Standards Advisory Board (FASAB) Generally Accepted Accounting Principles (GAAP) purchased under this Task Order Contract. At the end of the term of this Task Order Contract, the State shall approve the disposition of all equipment. 18. The Contractor shall not use funds provided under this Task Order Contract for the purpose of lobbying as defined in Colorado Revised Statutes (C.R. S.) 24-6-301(3.5)(a). 19. The State may increase or decrease funds available under this Task Order Contract using a Grant Funding Letter substantially equivalent to Exhibit H. The Grant Funding Change Letter is not valid until it has been approved by the State Controller or designee. 20. The Contractor shall not charge for services those individuals of families at or below the official poverty guidelines, updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. 9902(2), in accordance with Title V, Section 501 (1) (B) and Section 505 (5) (D). The most current version of this document is available on the MCH website: www.mchcolorado.org and the Health Care Program for Children with Special Health Care Needs (RCP) website www.hcpcolorado.org. If the State receives new poverty guidelines from the DHHS during the term of this Task Order Contract, the State shall immediately update the guidelines on the MCH and HCP websites. The Contractor shall use these new poverty guidelines, if any, when posted to the websites. If any charges are imposed for services to clients who are above the one hundred percent (100%) of poverty level, such charges must be on a sliding scale which takes into account the client's family size, income and resources. These charges and the sliding fee scale must be made available to the general public and to all clients and must be based on the agency's usual and customary cost for the service. Clients must understand they shall not be denied services for inability to pay any of the sliding fee charges. 2I . The State may require forms attached to this Task Order Contract and incorporated herein by reference be To be attached to CDPHE Task Order v1.0 (3/12) contract template Page 4 of 5 Revised: 12/19/06 EXHIBIT E updated during the term of this Task Order Contract. The Contractor will be informed of the new forms as they are developed. Forms may be sent to contractors or will be available on the MCH web site: www.mchcolorado.org or the HCP web site www.hepcolorado.oru To be attached to CDPHE Task Order v1.0 (3/12) contract template Page 5 of 5 Revised: 12/19/06 Attachment E-1 Commonly Used Acronyms and Abbreviations That May Be Referenced In the Scope of Work: ACS American Cancer Society ACNS Alamosa County Nursing Service ACF Administration for Children and Families ADA Americans with Disabilities Act ADAD Alcohol and Drug Abuse Division AHA American Heart Association AIDS Acquired Immune Deficiency Syndrome ALA American Lung Association ALA(C) American Lung Association (of Colorado) AMCHP Association of Maternal Child Health Programs ANR Americans for Non -Smokers' Rights ARC Addiction Recovery Centers ARRA American Recovery and Reinvestment Act ASC Adams State College ASSIST American Stop Smoking Intervention Study ASTHO Association of State and Territorial Health Office B&G Boys & Girls BACCHUS BACCHUS Peer Education Network BAG Build a Generation BBLHC Boulder Broomfield Latino Health Coalition BC Boulder County BCCP Breast and Cervical Cancer Program BCHD Bent County Health Dept BCPH Boulder County Public Health BCPHA Baca County Public Health Agency BCDSS Baca County Dept Social Services BCTEPP Bent County Tobacco Education Prevention Partnership BGC Boys & Girls Club BGCMD Boys & Girls of Metro Denver BHS Broomfield High School BMTF Baby & Me Tobacco Free BOCES Board of Cooperative Educational Services BOH Board of Health BRFSS Behavioral Risk Factor Surveillance System BVBAG Buena Vista Build a Generation BVSD Boulder Valley School District Bx Biopsy C Choice CAD Coronary Artery Disease CASB Colorado Association of School Board CB Community -based System CBE Clinical Breast Exam CBO Community -based Organization CC Clear Creek CC Custer County CC Community Coordination/Coordinator CCAP Larimer County Child Care Assistance Program CCC Colorado Cancer Coalition CCCHE Colorado Community Coalition for health Equity CCGC Colorado Clinical Guidelines Collaborative CC IAA Colorado Clean Indoor Air Act CCMC Colorado Clinical Managed Care Network CCMC Commission for Case Manager Certification CCPD Cancer, Cardiovascular, and Pulmonary Disease Page 1 of 6 Attachment E -- CC ILl Colorado Chew Tobacco Collaborative Initiative CCTEPP Custer County Tobacco Education Prevention Partnership CDC Centers for Disease Control and Prevention CDE Colorado Department of Education CDPHE Colorado Department of Public Health and Environment CDU Chronic Disease Unit CEC Career Education Center CEO Chief Executive Officer CFDA Catalog of Federal Domestic Assistance CFFC Colorado Foundation for Families and Children CFPI Colorado Family Planning Initiative CHIN Community Health Information Network CICP Colorado Indigent Care Program CJD Colorado Judicial Department CM Case Management CMC Colorado Mountain College CMS Contract Management System CMS Creative Media Solutions CNCC Colorado Northwestern Community College CNS County Nursing Service CO Colorado COD Colorado Donated Dental Services Program COPAN Colorado Physical Activity and Nutrition Program COV Colorado Van Program CPCF Colorado Parent and Child Foundation CPHA Colorado Public Health Association CPT Current Procedural Technology CRC Colorectal Cancer CRCCP Colorectal Cancer Screening Program CRUE Culturally Responsive Urban Education CSAP Colorado Student Assessment Program CSH Coordinated School Health CSU Colorado State University CSU-P Colorado State University -Pueblo's CTC Connect to Care CTEPA Colorado Tobacco Education and Prevention Alliance CTFK Campaign for Tobacco -Free Kids CTRP Colorado Tobacco Research Program CTP Crossroads Turning Point CU University of Colorado, Boulder CWCCI Colorado Women's Cancer Control Initiative CY Contract Year DAISI Denver At-home Intervention Service Initiative DASH Division of Adolescent & School Health (CDC) DCMH Delta County Memorial Hospital DH= Denver Health DHHA Denver Health and Hospital Authority DHS Department of Human Services DHHS Unites States Department of Health and Human Services DOR Department of Revenue DOS Delta Opportunity School DSS Department of Social Services E&I Education and Information EM' Employee Assistance Program EBHV Evidence -Based Home Visiting to Prevent Child Maltreatment Grant Program ECC Early childhood council ECC Electrocardiogram ECCLC Early Childhood Council of Larimer County Page 2of6 Attachment E-1 ECLC E.D. EHR EHS EMR EMT EPA EPE ESL ETS FIRC FICA FDA FIT/FOBT FNA FPP FPL FRCC FTE FTP FY FYI GASO GED GASP Get R!EAL (GR) GLBT GYN HCP HCYS HHS HIPPA HIPPY HIT HIV HPV HR hr HRSA HSL ID IlK ISHT IT JAC KIS KMH KPC LAHCDHD LBW LC LGBT LEM LHA LHD LLC LRCC LRPC Early Childhood Leadership Council/Commission Executive Director Electronic Health Record Early Head Start Electronic Medical Record Emergency Medical Technicians Environmental Protection Agency Epidemiology Planning and Evaluation English as a Second Language Environmental Tobacco Smoke (a.k.a. secondhand smoke) Family and Intercultural Resource Center The Federal Insurance Contribution Act Food and Drug Administration Fecal Immunochemical Test/Fecal Occult Blood Test Final Needle Aspiration Family Planning Program Federal Poverty Level Front Range Community College Full Time Equivalent File Transfer Protocol Fiscal Year Family Youth Initiatives Great American Smoke -out General Education Development CO Group to Alleviate Smoking Pollution of Colorado Resist! Expose Advertising Lies (Youth Empowerment Program) Gay, Lesbian, Bisexual, and Transgender Gynecological Health Care Program For Children with Special Needs Huerfano County Youth Services Health and Human Services Health Insurance Portability and Accountability Act of 1996 Home Instruction for Parents of Preschool Youngster Health Improvement Team Human Immunodeficiency Virus Human Papillomamavirus Human Resources hour Health Resources and Services Administration High School Leadership Identification Invest in Kids Interagency School Health Team Information Technology Juvenile Assessment Center Keeping in STEPP Keefe Memorial Hospital Kevin Patrick Caleum Las Animas Huerfano Counties District Health Department Low Birth Weight Learning Community Lesbian, Gay, Bisexual, Transgender Latinas en Movimiento Local Health Agency Local Health Department Limited Liability Company Latino Regional Community Coalition Latino a Research and Policy Center Page 3 of 6 Attachment E-1 LST Life Skills Training LSTPEN Latino Statewide Tobacco Prevention and Education Netw LWB Live Well Broomfield MCHA Montezuma Housing Authority MCHD Montezuma County Health Department MCHS Montezuma -Cortez High School MCPN Metro Community Provider Network MCRC Media Campaign Resource Center — CDC MD Medical Doctor MHCBBC Mental Health Center Serving Boulder and Broomfield Counties MIECHV Maternal, Infant and Early Childhood Home Visiting Program MO Month MOB Medical Office Building MOU Memorandum of Understanding MPA Master of Public Administration in Health and Human Services MPH Master of Public Health MRI Magnetic Resonance Imaging Scan MS Master of Science MSA Master Settlement Agreement MUH Multi-user Housing MYAT Multi -Disciplinary Youth Assessment Team N/A Not Applicable NACCHO National Association of County and City Health Officials NACR Native American Cancer Research NAQC North American Quitline Consortium MASSE National Association of State Board of Education NCCRT National Colorectal Cancer Round Table NCI -ED Northeast Colorado Health Department NCI National Cancer Institute NE North East NFP Nurse -Family Partnership NFPNSO Nurse -Family Partnership National Service Office NHVP Nurse Home Visitor Program NIDA National Institute on Drug Abuse NIH National Institute of Health NJH National Jewish Medical and Research Center N -O -T Not -on -Tobacco, (ALA's Youth Smoking Cessation Program) NP Nurse Practitioner NPP Nurturing Parenting Program NRT Nicotine Replacement Therapy NSBA National School Boards Association OSH Office on Smoking or Health (CDC) OTC Over the Counter PA Physician's Assistant PAC Prevention Awareness Crew PACT Partners Assessing Chew Tobacco PAT Parents as Teachers PCCHD Pueblo City -County Health Department PPC Personal Care Providers PE Presumptive Eligibility PEN Parent Engagement Network PVCHC Peak Vista Community Health Center PHN Public Health Nurse PIO Public Information Officer PM Peer Mentor PMC Parkview Medical Center PMR Planning Management Region PN Patient Navigator Page 4 of 6 Attachment E -I PO Purchase Order PPC Policy Partner Committee PPFC Pikes Peak Family Connections PPN Prevention Policy Network PRA Policy Resource Alliance PRAMS Pregnancy Risk Assessment and Monitoring Survey PRIDE Pure Respect Initiative Direct Education PSA Public Service Announcement PSD Prevention Service Division PTEPP Pueblo Tobacco Education and Prevention Partnership PVC Prairie View Clinic QI Quarter One Q2 Quarter Two Q3 Quarter Three Q4 Quarter Four QI Quality Improvement QOL Quality of Life RDAC Regional Disparities Advisory Council RFA Request for Applications RFP Request For Proposals RIE Reach, Implementation and Effectiveness RIHEL Regional Institute for Health and Environment RMC Rocky Mountain Center for Health Promotion & Education RMRH Rocky Mountain Rural Health RMYC Rocky Mountain Youth Corps RN Registered Nurse Rx Prescription RY Reconnecting Youth SafeCare SAMHSA Substance Abuse Mental Health Services Administration SB School -based System SBAG Salida Build A Generation SBHC School -Based Health Centers SCYC School Community Youth Coalition SCRHC Southern Colorado Regional Health Collaborative SD Service Delivery SECH Southeast Colorado Hospital SEMHS Southeast Mental Health Services SES Socio-Economic Status SEW School Employee Wellness SGR Surgeon General's Report SHAC Smoke -free Housing Action Committee SHI School Health Index SHS Secondhand Smoke SIDS Sudden Infant Death Syndrome SLV San Luis Valley SMART Staying Motivated at Reducing Temptations SMART OUTCOME OBJECTIVE Specific, Measurable, Achievable, Realistic, Time -Bound SMSU Self Management Service Unit SRO School Resource Officer STD Sexually Transmitted Disease STEPP State Tobacco Education and Prevention Partnership STW Straight -to -Work SVVSD St. Vrain Valley School District SWOT Strengths, Weaknesses, Opportunities, Threats SYNAR Synar Regulation TA Technical Assistance TABS Tobacco Attitudes and Behavior Survey Page 5 of 6 Attachment E-1 TAG Technical Advisory Group (for evaluation & TPEG) TANF Temporary Aid to Needy Families TARP Tobacco Advocacy and Resource Partnership TBD To Be Determine TCP Tobacco Control Partners TDAC Tobacco Disparities Advisory Council TDG Tobacco Disparities Grant TDS Tobacco Disparities Subcommittee TEACH Teaching Equity to Advance Community Health TEFAP The Emergency Food Assistance Program TEPCGP Tobacco Education Prevention and Cessation Grant Program TEPP Tobacco Education Prevention Partnership TFCCI Tobacco -Free Colorado Communities Initiative TFLC Tobacco Free Larimer County TFS Tobacco -Free Schools TFS Law Tobacco -Free Schools Law TGYS Tony Grampsas Youth Services Title V Title V of the Social Security Act TND Project Toward No Drug Abuse TPEG Tobacco Program Evaluation Group TPI Tobacco Prevention Initiative TRC Tobacco Education and Prevention and Cessation Program Review Committee TRI Tobacco Rapid Improvement Activity TRIA Tobacco Rapid Improvement Assessment TTI Tony Grampsas Tobacco Initiative UCD University of Colorado —Denver UCDHSC Health Sciences Center at UCD (sometimes abr. UCHSC) UCDHSC University of Colorado at Denver and Health Sciences Center URL Uniform Resource Locator US United States of America USSTC US Smokeless Tobacco Company VP Vice President Well COA Wellness Councils of America WHU Women's Health Unit WIC Women, Infants, Children WWC Women's Wellness Connection Y@C Youth at Crossroads YE Youth Empowerment YPH Youth Partnership for Health Yr Year YRBS Youth Risk Behavior Survey YSAP Youth Substance Abuse Prevention Coalition YTS Youth Tobacco Survey YVMC Yampa Valley Medical Center 5 A's Ask, Advise, Assess, Assist, Arrange 2A's R Ask, Advise, Refer Page 6 of 6 EXHIBIT F STATEMENT OF WORK To Task Order Contract Dated 08/14/2012 - Contract Routing Number 13 FLA 48090 — Contract Amendment Routing Number 14 FLA 59156 These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above. 1. Project Description: The Colorado Maternal and Child Health Program contracts with local public health agencies (LPHAs) to develop, implement and evaluate evidence -based MCH Action Plans, HCP Care Coordination services, and HCP Specialty Clinics. Contractors are responsible for contributing to the improvement of 10 state and 18 national MCH performance measures and outcomes. II. Definitions: • CRSCN - Colorado Responds to Children with. Special Needs • CYSHCN - Children and Youth with Special Health Care Needs • HCP - Health Care Program for Children with Special Health Care Needs • HCP Care Coordination — The state HCP-developed intervention model for providing care coordination for families of children and youth with special health care needs. • LPHAs - Local Public Health Agencies • MCH - Maternal and Child Health • MCH Action Plans — Action Plans are work plans that Contractors select or develop and describe the goals, objectives, key activities, persons responsible, and timelines of the MCH effort. Action Plans may be state -developed and related to the MCH priorities or developed by the Contractor. MCH Generalist Consultants —The primary MCH Program staff who monitor LPHAs' MCH contracts and who provide technical assistance and consultation to Contractors on program development and implementation. III. Performance Requirements/Deliverables: Contractor is required to notify its MCH Generalist Consultant within 15 business days of any significant changes to their MCH Action Plan, budget, or budget narrative. Changes include, but are not limited to, the following: changes in staffing including vacancies, changes in plan activities, agency changes or development that directly impact MCH activities or plans, or community developments that directly impact MCH activities or plans. Maternal and Child Health Program L The Contractor shall perform in accordance with the FY14 Action Plans: Early Childhood Obesity Prevention, referenced herein as Attachment F-1 and Teen Motor Vehicle, referenced herein as Attachment F-2. 2. The Contractor shall perform in accordance with the FY14 MCH Guidelines and shall follow the policies, procedures, and program expectations set forth in the FY14 MCH Guidelines. The FY14 MCH Guidelines are incorporated and made part hereof by reference, and are located on the MCH web site under MCH Guidelines and Forms at www.mchcolorado.or, 3. The MCH Guidelines are periodically updated and the Contractor will be notified by email when updates/revisions are made. The Contractor is responsible for complying with any updates/revisions. Revised MCH Guidelines would be posted to the MCH web site referenced in [[[.1. 4. The Contractor shall apply the public health approach throughout the process of developing, implementing, and evaluating its MCH Action Plans in order to serve the MCH population in the Page of5 Exhibit F -Statement of Work V1MIAR2012 EXHIBIT F community. Brownson's evidence -based public health approach is described in the FY14 MCH Guidelines and involves the following steps: o Community assessment o Quantify the issue o Develop a concise statement of the issue o Determine what is known through the scientific literature o Develop/identify and prioritize program and policy options o Develop an Action Plan and implement interventions o Evaluate the program or policy 5. The Contractor shall contribute to the accomplishment of the MCH state priorities, and state and national performance measures and outcomes that are outlined in the FY14 MCH Guidelines. 6. The Contractor shall focus at least 20% of total MCH/HCP funds on MCH-priority Action Plans, including the medical home priority. 7. The Contractor shall focus a majority of their effort and funding for each Action Plan on population - based and infrastructure -building strategies from the MCH pyramid, per the review and approval by the state MCH Program. Enabling services are allowable if they are evidence -based and enhance the population -based and infrastructure -level work in the Action Plan. Enabling services should not comprise a majority of the effort, with the exception of HCP Care Coordination. For definitions of the different levels of the MCH Pyramid, see the FY14 MCH Guidelines available online on the MCH web site under MCH Guidelines and Forms at www.mchcolorado.org. 8. The Contractor shall use evidence -based strategies / programs to address issue in the community. A strategy or program is considered evidence -based if: a. It is based on a sound theoretical approach such as health behavior change theory or peer - reviewed literature; b. And/or if there is research or program evaluation data that supports the effectiveness of the approach. 9. During the contract term, the Contractor shall follow the timelines identified in FY14 Action Plans to implement and evaluate work performed under the Action Plans. 10. The Contractor shall participate in and submit the following processes or reports, incorporated by reference. These processes and reports, including instructions for completion and submission, are available in the FY 14 MCH Guidelines located online on the MCH web site under MCH Guidelines and Forms at www.mchcolorado.ora a. Progress check -in meetings (3) MCH Generalist Consultants conduct three progress check -in meetings with the Contractor during the contract period in order to monitor the Contractor's progress on the FY14 Action Plans as well as to provide technical assistance and support during plan implementation. During the progress check -in, the Contractor and MCI -I Generalist Consultant use a standardized set of questions to discuss the Contractor's progress and/or challenges of planning, implementing or evaluating the MCH Action Plans and to review any relevant work products developed as part of the plan, such as team charters, reports, community road maps, etc. The standardized questions are available in a document called MCH Progress Call Guide on the MCH web site under MCH Guidelines and Forms at www.mchcolorado.oro Page 2 of 5 Exhibit F -Statement of Work V IMIAR2012 EXHIBIT F The MCH Generalist is responsible for scheduling the check -in with the Contractor. The format (via phone or in person) of the check -in is at the discretion of the MCH Generalist Consultant and will be communicated to Contractor in advance. The MCH Generalist Consultant will send a follow-up summary of the check -in meeting and will highlight any issues that require follow- up. Three progress check -in meetings or phone calls will take place during the fiscal year. The first check -in will occur in October. Another check -in will take place in January. Finally, a meeting will occur in April/May. b. MCH Annual Report on FY I4 Action Plans The FY14 MCH Action Plan Annual Report is due October 31, 2014 for the period of October 1, 2013 to September 30, 2014. The Contractor shall submit the completed report via the MCH database accessible at www.mchplanningcolorado.com. For annual reporting, update the following sections of the MCH priority -related action plans: Evaluation of Objective — provide a brief narrative on the progress of the objective, including successes and challenges. Discuss how the strategy contributed to moving the objective forward. Include assessment of "as measured by" indicators that correspond to "criteria for success" in this section. Activity Monitoring Plan Completion — comment if the activity was met or unmet. For annual reporting, update the following sections of the "other" MCH action plans: Evaluation of Measure — provide the actual measure of progress for the measure/indicator previously selected Evaluation of Objective — provide a brief narrative on the progress of the objective, including successes and challenges. Discuss how the strategy contributed to moving the objective forward. Activity Monitoring Plan Completion — comment if the activity was met or unmet. c. HCP Annual Report for FY 14 The FY I4 HCP Annual Report is due October 31, 2014 for the period of October I, 2013 to September 30, 2014. The FYI4 HCP Annual Report Form will be available on the MCH web site under MCH Guidelines and Forms at www.mchcolorado.org. The Contractor shall submit the completed report via the MCH database accessible at www.mchplanningcolorado.com. d. MCH Core Services Final Report for FY14 The Final Report for MCH Core Services should be reported on Part B of the MCH Budget form that will be available on the MCH web site under MCH Guidelines and Forms atwww.mchcolorado.org. The report is due October 31, 2014 for the period of October 1, 2013 to September 30, 2014. The Contractor shall submit the completed report via the MCH database accessible at www.mchplanningcolorado.com. For each of the Contractor's FY14 Planning Budgets, review the objectives and activities included in the corresponding MCH Action Plan(s), report on the percentage of total budget funds expended on the different levels of the MCH pyramid. Direct Services Enabling Services Page 3 of S Exhibit F -Statement of Work V I/MAR2012 EXHIBIT F • Population -based Approaches • Infrastructure Building Approaches For the Contractor's FY 14 HCP Care Coordination Planning Budget, enter the actual number of children and youth with special health care needs who received HCP Care Coordination services with an action plan. Next enter the actual number of children who received information only. 11. The Contractor shall develop or revise, according to the FY 15 MCH Guidelines, the Contractor's MCH Action Plans and Budgets for FY15. [2. The Contractor shall notify the State of programmatic changes that might affect the viability, effectiveness or productivity of the programs, including but not limited to: changes in personnel; physical facilities in which services are provided; scope of services that deviates from those proposed by the Contractor in the MCH Action Plans; sources of funding and support as declared in the Contractor's submitted proposal for funding; and local interagency or political circumstances that might impact the MCH Program. Notification shall be in writing within fifteen (15) business days of the said change. Children and Youth with Special Health Care Needs (CYSHCN) 1. The Contractor shall perform in accordance with the FY14 Action Plan: Medical Home, referenced herein as Attachment F-3. 2. The Contractor shall attend scheduled HCP Policy Advisory Committee (H -PAC) meetings, HCP Annual Meetings, and quarterly scheduled activities for HCP Practitioners to promote learning and increase skills, as scheduled by CDPHE HCP Program and as referenced in the HCP Policy and Guidelines. The HCP Policy and Guidelines are located on the HCP web site under Guidelines and Forms for LPHAs at www.hcpcolorado.org. 1. The local HCP Coordinator shall provide orientation, technical assistance and ongoing training for other HCP agency staff by referencing the HCP Policy and Guidelines, the HCP CYSHCN Data System User Manual, and other HCP Resources available online on the HCP web site at www.hcpcolorado.org. 2. The Contractor shall engage families with CYSHCN and community family leaders to solicit consumer feedback when serving the CYSHCN population by referencing the Colorado MCH Medical Home Action Guide available online on the HCP web site under Guidelines and Forms for LPHAs at www.hcpcolorado.org. HCP Care Coordination I. The Contractor shall provide HCP Care Coordination to ensure a medical home approach for CYSHCN residing in the counties the agency is contracted to serve according to the HCP Care Coordination Policy and Guidelines, available online on the HCP web site under Guidelines and Forms for LPHAs at www.hcpcolorado.org. 2. The Contractor shall complete required data documentation in the HCP CYSHCN Data System for HCP Care Coordination services according to the HCP Care Coordination Policy and Guidelines and the HCP CYSHCN Data System User Manual available online on the HCP web site under Guidelines and Forms for LPHAs at www.hcpcolorado.org. 3. The HCP Care Coordination Policy and Guidelines, and the HCP CYSHCN Data System User Manual are periodically updated and the Contractor will be notified by email when updates/revisions are made. The Contractor is responsible for complying with any updates/revisions. Revised HCP Care Coordination Policy and Guidelines and the HCP CYSHCN Data System User Manual are available online on the HCP web site under Guidelines and Forms for LPHAs at www.hcpcolorado.org. Page4of5 Exhibit F -Statement of Work V IMLAR2012 EXHIBIT F 4. The Contractor shall participate in consultation, technical assistance, oversight and training by state HCP staff on using the HCP CYSHCN Data System for documentation of HCP Care Coordination. HCP Specialty Clinics I. The Contractor agrees to provide clinic coordination for regional HCP Specialty Clinics according to the HCP Specialty Clinic Benchmarks and HCP Specialty Clinic Policy and Guidelines located on the HCP web site under Guidelines and Forms for LPHAs at www.hcpcolorado.org. 2. The Contractor shall provide clinic coordination with a medical home approach for all CYSHCN attending HCP Specialty Clinics according to the HCP Specialty Clinic Policy and Guidelines, located on the HCP web site under Guidelines and Forms for LPHAs at www.hcpcolorado.org. IV. Monitoring: CDPHE's monitoring of this contract for compliance with performance requirements will be conducted throughout the contract period by the Program's MCH Generalists and HCP Care Coordination Nurse Consultants. Methods used will include review of documentation reflective of performance to include progress meetings, site visits, and data reports. The Contractor's performance will be evaluated at set intervals and communicated to the contractor. A Final Contractor Performance Evaluation will be conducted at the end of the life of the contract. V. Resolution of Non -Compliance: The Contractor will be notified in writing within 30 calendar days of discovery of a compliance issue. Within 45 calendar days of discovery, the Contractor and the State will collaborate, when appropriate, to determine the action(s) necessary to rectify the compliance issue and determine when the action(s) must be completed. The action(s) and time line for completion will be documented in writing and agreed to by both parties. If extenuating circumstances arise that requires an extension to the time line, the Contractor must email a request to the MCH Unit Manager and receive approval for a new due date. The State will oversee the completion/implementation of the action(s) to ensure time lines are met and the issue(s) is resolved. 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O N O a N o= t C T U V@ 0 a > E U@ O N C O- r N O L O N C .0 Q U@ 0 O)r _- N S a T 0 0 0 0 3 U N p 4 C N_ C _ p a" C O a) -o.— O —>' o C O) N CI) O N aE = 'O U O` = c U O) ^;° n = Ens°- Eck @ d 0 a N U U N a) N 0 N C C O a) Q E o200 a) Qmoo Urtnggn Uafl ATTACHMENT F-1 key risk and protective factors for early childhood obesity. Local public health agencies can use these messages for this strategy or the 5,2,1,0 message (Eat 5 servings of fruits and vegetables, spend no more than 2 hours engaged in screen media, spend at least 1 hour in physical play, drink zero sugar sweetened ' beverages). Data Source(s) I WIC and Child Health Survey State Performance Measure(s) Percentage of live births where mothers gained an appropriate amount of weight during pregnancy according to pre -pregnancy BMI (Birth certificate). Percentage of live births to mothers who were overweight or obese based on BMI before pregnancy (Birth certificate). National Performance Measure(s) The percent of mothers who breastfeed their infants at 6 months of age. Percent of children, ages 2 to 5 years, receiving WIC services that have a BMI at or above the 85th percentile. Vl Reduce the prevalence of overweight and obesity among low-income children ages 2-5 years. O C9 w 2 uJ 2 I U / ¢ Lead: Mike Schwan Email/Phone: mschwan@weldgov.com 970-304-6420 X 2343 Target Population: Local employers of a low -wage workforce in Weld County As Measured by: • Comparison of records of training • attendance with list of targeted employers • Records of Pre and Post -training assessment instrument Evaluation of Objective: Completed during annual reporting Monitoring Plan During airnual'reporting Comment for each rowtf met/uni4et iii : 2 / Document scan Responsible Persons/Group § Mike Schwan Objective A: By September 30, 2014, at least 50% of targeted local employers in Weld County are aware of the workplace accommodation for nursing mother laws and healthy weight practices in the workplace, and have intention to adopt policies in these areas. (Core Objective for Workplace Strategy) 0 « ± Criteria for Success: • 50% of targeted local employers receive lactation accommodation and healthy weight supportive workplaces training. • Local employers indicate intention to adopt the minimum practices of the workplace accommodation for nursing mother laws and key healthy weight promotion practices. Target Completion Date 0 09/30/2013 CV Ui I- A- u0_ w 2 / \ Milestones / Key Activities Identify at least 5 potential partners with community members and organizations that have an interest in promoting health in the work place, specifically in the area of lactation accommodation. • Potential Weld Partners: - WCDPHE lactation consultant - WCDPHE Worksite Wellness Coordinator - North Colorado Medical Center - Nurse Family Partnership - WIC - Sunrise Monfort Family Clinic - Colorado Breastfeeding Coalition - United Way of Weld County - Weld Chamber of Commerce Complete a scan of workplace lactation accommodation and healthy weight promotion initiatives already underway in the community. ===OR\ �0E-°O2 /am22:22 >, 7 a 2�'3f3E/$\ °»2282E 0 0 ci- 2 G CL I J 2 0 / ATTACHMENT F-1 Document employers who attend the workshop training. Maintain survey results Track local employers and geographical areas of workplaces Document completion of pre -training assessment and summarize assessment results Document training delivery, location, and attendees Document completion of post -training assessment and summarize assessment results Track education provided and track results of discussions with employers. Mike Schwan c as t U (I) a) Y_ f Mike Schwan Mike Schwan Mike Schwan Mike Schwan Mike Schwan 09/30/2013 1 Q N O CO a O 01/30/ 2014 02/30/2014 02/30/2014 02/30/2014 06/30/2014 Provide "Accommodating Nursing Mothers at Work" training at annual worksite wellness workshop and utilize contacts made to offer additional consultation to individual employers. Select a sample of at least 3 targeted employers of a low wage workforce (selected from the "Weld County Major Employers" list) and assess their awareness and compliance with the workplace accommodation for nursing mother laws, and associated perceived barriers (survey tool provided by CDPHE). Potential targeted employers may include: — JBS Swift & Company — StarTek, Inc. — Afni, Inc. Using outreach tools provided by CDPHE, recruit least one low -wage employer to attend lactation accommodation and healthy weight supportive workplaces training. Conduct pre -training awareness assessment of participating employer(s), provided by CDPHE. Arrange and deliver lactation accommodation and healthy weight supportive workplaces training (resources provided by CDPHE). Conduct post -training awareness and intention assessment, provided by CDPHE. Collaborate with community partners to educate woman of reproductive age on the Colorado Workplace Accommodating Nursing Mothers Act and empower them to discuss lactation support policies and practices with employers. Receive feedback on results of discussions with employers. M rr 4. O tn bA .71 ATTACHMENT F-1 k 0 E 0 Mike Schwan k 0 f5 b o w E2 k o ▪ k e kE2 0 2= 0C Mu)_ 0< 20\ •i!J2$$\ .2 c2 ag k: &$ �k �0 $ Et -0 E 2uoW k// Lead: Mike Schwan Email/Phone: mschwan@weldgov.com 970-304.6420 X 2343 Target Population: Local employers of a low -wage workforce who attend the training described in Objective A As Measured by: • Records of technical assistance provided to each employer • Post -intervention assessment tools Evaluation of Objective: Completed during annual reporting Monitoring Plan IDurrng ' a nn'ual -reportng comment Nreach rn:W if metiun et Document outreach contacts made. If a community award system is developed, document system Maintain documentation of baseline assessments Responsible Persons/Group Mike Schwan Mike Schwan Objective B: By September 30, 2015, at least 25% of targeted local employers who attend the training described in Objective A have policies and practices established that comply with workplace accommodation for nursing mother laws and at least two additional healthy weight promotion practices. (Core Objective for Workplace Strategy) Criteria for Success: • 25% of local targeted employers in this group receive coaching in the areas of lactation accommodation and healthy weight supportive practices and policies. • 25% of local targeted employers in this group comply with workplace accommodation for nursing mother laws and have at least two additional healthy weight promotion practices. Target Completion Date To be addressed in 2015 To be addressed in 2015 Milestones / Key Activities Based upon the post -training awareness and intention assessment completed as part of Objective A, identify employers with intention of adopting policies and offer follow-up coaching and technical assistance. Using CDPHE as a resource, consider a community award system to incentivize local employers. In partnership with the employer, conduct a baseline workplace assessment in the areas of lactation accommodation and healthy weight, using tools provided by CDPHE. Ch 2 Gii._ C 0 CD (a a a°2°°ca 2�°2222 aci e 2 E e e c ± o' 2 E e °»%@S§E» 2 a @ 2 O A- ATTACHMENT F-1 Monitoring Plan PO:i g annUa-0r t+ng` umment fgr: atih row,f Inet/r�a�►i ret Document connections made and information obtained from contacts \\2 //k 'E2 CI).� L) 0 \oc M S E Documentation of training of the coaches Monitor using database of area child care centers Responsible Persons/Group Mike Schwan / CO ± t- -C $ ± Mike Schwan Target Completion Date 09/30/2013 COMPLETED 0 n CNI -I d R S Q # \ d Q 02/28/2014 Milestones / Key Activities Connect with Early Childhood Council of Weld County, Head Start of Weld County, and WCDPHE staff members responsible for safety and sanitation inspections of child care facilities, to begin learning about the opportunities for early childhood obesity prevention work in the child care setting. • Attend monthly council meetings to assess work that is already underway in the community. With guidance and partnership with CDPHE and local early childhood networks, identify at least three community -based partners or LPHA staff members interested in and willing to expand their expertise to include early childhood obesity prevention and provide coaching regarding these practices with child care center staff. • Potential Weld Partners include: — United Way of Weld County Promises for Children staff — Head Start of Weld County staff — WCDPHE health inspector -- Local early childhood educators Using the tool box provided by CDPHE, provide training and resources for the identified partners or LPHA staff members regarding the assessment process, goal setting, content of the core areas, and Child and Adult Care Food Program outreach. This tool box will include resources such as Let's Move Child Care, ChildcareMAPP, NAPSACC, Caring for Our Children, and Colorado Childcare Champions. The training and provision of resources should be sufficient for him/her to provide coaching to the child care centers in the core areas. Identify target child care centers in low-income areas to receive coaching. >. 3 ea @ C>k2ce U) C cl U) O -C S E $ ° 2 % a_ _ 2 col- ®&ef2�/ o o u c 1 E/cG2%m OO-- 0_ oa�- LL H Z W 2 2 U H Q Obtain contacts made by the coach and document them Collect the baseline assessments and document summarized results Collect documentation of goals, plans, and technical assistance provided Collect the post - intervention assessments and document summarized results Activity Met Collect the baseline assessments and document summarized results Collect documentation of goals, plans, and technical assistance provided Mike Schwan Mike Schwan Mike Schwan Mike Schwan Mike Schwan Mike Schwan Mike Schwan 06/30/2014 v a N O Cr) co O v 0 N O CO (O O v 0 N O M 0) O 04/30/2013 COMPLETED 09/30/2013 COMPLETED 02/30/2014 Assist the identified partners or LPHA staff members to connect with other professionals working with the identified centers to promote awareness of the effort and supportive messaging (examples: Division of Child Care licensing specialist, child health nurse consultant, health inspector, early childhood council, Qualistar coach). Prior to beginning coaching, the partners or LPHA staff members will conduct a baseline assessment with the child care center staff (assessment tools provided by CDPHE), of core area knowledge, skills, and practices of child care center staff (multiple roles if possible) of participating centers. Based upon the assessment, the partners or LPHA staff members will work collaboratively with center staff to establish desired and reasonable goals and a plan to improve weaknesses in the core areas. He/she will provide on -going support, technical assistance, and resources to help the center meet the goals. The partners or LPHA staff members will facilitate a post -intervention assessment, provided by CDPHE, of core area knowledge, skills, and practices of various child care center staff of participating centers. From these assessments the LPHA will draw conclusions about change in knowledge, skills, and practices. Identify target child care home associations in low-income areas to receive coaching. Prior to beginning coaching, the partners or LPHA staff members will conduct a baseline assessment (assessment tools provided by CDPHE), of core area knowledge, skills, and practices of child care home providers. Based upon the assessment, the partners or LPHA staff members will work collaboratively with home childcare associations to establish desired and reasonable goals and a plan to improve weaknesses in the core areas. He/she will provide on -going support, technical assistance, and resources to help the childcare home providers meet the goals. ATTACHMENT F-1 ATTACHMENT F-1 O CC c O U co P N E 0 TI3 CO Ca CD E O • a) -0 U C 1 E O u) run • U O O O > O N = l a C O Activity Met. Will be promoting 5210 message Document plan Document education provided Document education provided • f4 L U co a) Y_ M Mike Schwan Mike Schwan Cindy Kronauge, Health Data Analyst Kim Koeltzow, Clinic Services Manager Mike Schwan Mike Schwan 0 co W o w N J a a M 2 O o V 05/30/2013 COMPLETED o N O co o 06/30/2014 E, O N O M 0 Utilizing existing partnerships representing multiple sectors in the community identify community partners willing to carry out the consistent messaging effort in their settings. • Weld partners may include: UNC MPH and Human Services Students — United Way Early Childhood Council — Head Start of Weld County — Weld County School District 6 — Guadalupe Shelter — Sunrise Monfort Family Clinic — Monfort Children's Clinic — Salud Community Health — North Range Behavioral Health Select the appropriate EC0P messages to promote throughout the community (messages tested by CDPHE or the 5,2,1,0 message). In partnership with CDPHE and partners, develop a 5210 message dissemination plan for use among partners, and for delivery to the target population. This dissemination may take the form of materials that may already exist, use of messages in counseling, as in primary care offices or public health programs, or using social media, depending upon the resources available through the combined partnership. Provide education surrounding the 5210 message to 20% of parents of children participating in Head Start as part of the dissemination plan. Provide education surrounding the 5210 message to 20% of parents of M.O.P.S. groups as part of the dissemination plan. >+ 0, w 0) w a) en o r : N E 'E O 7 O E E N Y N o C .0 V U M 0 N N bD ca R. ATTACHMENT F ATTACHMENT F-2 2 § 3S$ 2m% . 13 -C • c co o # • ±� .§ • a) U) J$$ 2 o _c - 0 _°� RS • < $$> E - < o a) _& 0 o m 2 o ko0 \ C.) N .N U) G E c &G@ c®$ So q f o•/ \ E 1 S - '- • O mom c = 7 /0 Egg .7) 2 • \.— -u) a) E � EGg45 O o e > //\� ? eoc =_=e E�/ o c- \\w)\ E cci o w > o E •2 ° \ ± R. E « e @ @ 2/0 CD E2 a) '0 c E • F2 a) $ 112 & O • o *_• o 0 E -C f3 -co • k)� S2' ca� / $0 LT tv00 $ 6 \\0 2k E®E5 E o 2 So GJ/ - E.Q 22 < ��o • E = nE2c - • S S 2 X7/0 ce b o § \ E a)7 $ 4') \ o k > al a)• _asso , m ° c 0. Eu. • ,n co 3 .N & 2• \u) »R e 6' o ° § n > / »°/ ▪ a C0 >C2asE 13_■ C > >� /csi 0.A / E o a) c E c o '5 o..2 E >«' C / 220 Motor Vehicle Death Rates, Weld & Colorado Teens Aged 15- co •\�> rst § § e e m a m e g r o _e 6T -St PV 000'00T Jad silleaCI cri rfi M LO crs cd ATTACHMENT F-2 Table 1. Teen motor vehicle injury hospitalizations: Age 15 - 19 Total Weld Weld Colorad hospitalizations rate o Rate 2005-2009 118 122.9 100.4 • The motor vehicle injury hospitalization rate is higher than Colorado's rate. • About 120 teens are hospitalized per year due to a motor vehicle injury. Data Source(s) CDOT Problem Identification Report Weld County Sheriffs Department Traffic Reports COHID-Vital Statistics Death Certificate Data Weld County Coroner's Annual Reports Hospital Discharge Data Emergency Department Data State Performance Measure(s) Rate of hospitalization for injuries per 100,000 teens ages 15 through 19. (Hospital discharge dataset) Rate of deaths per 100,000 teens ages 15-19. (Death certificate data) National Performance Measure(s) Q Z Goal(s) Reduce the rate of crashes caused by teen drivers (ages 15 -19) in Weld County. Reduce the rate of teen motor vehicle (ages 15-19) fatalities in Weld County Reduce the rate of teen motor vehicle hospitalizations (ages 15-19) in Weld County Reduce the rate of teen motor vehicle emergency department visits (ages 15-19) in Weld County 0 0 0 O 4. 0 M Q) b0 al A. ATTACHMENT F-2 Lead: Kelly Campbell Email/Phone: kcampbellOweldgov.com (970-304-6470 ext. 2325) Target Population: Weld County Sheriff's Department, Greeley Police Department, Weld County Department of Public Health and Environment, Prevention Partners, UNC Police, All State, State Farm, NCMC Ambulance Services, NCMC Trauma Department, Anschor Driving School, Greeley Fire, State Patrol, Greeley/Evans School District 6, Weld Re -9, Re -4, Re -3J, Re -1, Re -8, and St. Vrain Valley School Districts. evaluation of Measures; t • increase in number of established community; partnerships,' coalition resources...,.,, and financial assets over the grants three: yeartime period � n Evaluaation of 0bJ t1v x Completed:.; Completed Monitoring Plan Coalition Membership List Team Charter Document Coalition Action Plan Responsible Persons/ Group Drive Smart Core Coalition Members Drive Smart Core Coalition Members Drive Smart Core Coalition Members Objective A: By September 30, 2015, motor vehicle partners in Weld County will report increased levels of coordination, collaboration to support the implementation of evidence -based programmatic and policy strategies related to reducing teen motor vehicle fatalities. As Measured by: • A collaboration survey indicating strengthened alliances and financial contribution of partners to achieve teen motor vehicle safety goals. Target Completion Date On -going 10/01/12 - 09/30/15 09/30/13 Completed 09/30/14 Key Activities A.1.1: Maintain and expand DRIVE SMART Weld County (a multi- disciplinary motor vehicle traffic safety coalition. A.1.2: Update DRIVE SMART Weld County's team charter document to include: coalition vision, goals and objectives; member roles and responsibilities; meeting frequency; and communication protocols. A.1.3: Partner with the motor vehicle traffic safety coalition to update their action plan for FY 13-14 to identify annual coalition activities and the role of different agencies in accomplishing them. Strategy A R /2k§ c : w °- 2..%&7272 0 o = = c E @ «-u)00E« a2#0Ecm> cma22C�p M c t a 2 0_ S§ E 2/ G& 0. Completed 13 4. at \ "\\\ Collaboration Baseline Survey P- - {\22 f)[Q#) ))\\) i/d — G/;.« Coalition Progress Report; Follow -Up Collaboration Survey Results 15 co !<m - -7!)§a - : -§2#3± 7{)\k\))}]$f/ Kelly Campbell / Cindy Kronauge % 0 ±{f( ±o5G Kelly Campbell / Cindy Kronauge 112 })R $<-e _,o0 o=o» 09/30/13 Completed \\ eE ao v — \ El ea to —�_ \on \ )\ A.1.4: Conduct a baseline collaboration survey with the coalition to include items related to how different members of the coalition currently contribute financially to teen motor vehicle programming, Measures of the coalition's effectiveness, the strength of member alliances, and member satisfaction, A.1.5: Based on the results from the collaboration survey to strengthen alliances: • Coalition members will invite at least 2 new community partners with similar goals and compatible interests to attend a DRIVE SMART coalition meeting, community presentation, Parent of Teen Drivers Class or P.A.R.T.Y. program • Coalition will determine incentives to offer groups or individuals for their collaborative efforts. A.1.6: Evaluate the progress of the coalition on its annual work plan and measure coalition collaboration by conducting a follow-up collaboration survey. A.1.7: Implement complimentary activities to support and enhance traffic safety throughout Weld County by conducting at least two seatbelt checkpoints, participating in at least one community traffic safety event, awarding at least four driver's education scholarships and by exhibiting crashed car educational displays at all scheduled teen driving safety programs and at two additional community safety events each year. / 5 Lead: Kelly Campbell Email/Phone: kcampbellqweldgov.com (970) 304-6470 ext. 2325 Target Population: Weld County Sheriff's Department, Greeley Police Department, Weld County Department of Public Health and Environment, Prevention Partners, UNC Police, All State, State Farm, NCMC Ambulance Services, NCMC Trauma Department, Anschor Driving School, Greeley Fire, State Patrol, Greeley/Evans School District 6, Weld Re -9, Re -4, Re -3J, Re -1, Re -8, and St. Vrain Valley School Districts. valu*tllon of Me sur : � `1 rcent cI ge be ert baseline --survey and b� enn al follow-up'surveys ... .. ...:.... ........ .. ..�. .. .. .... ... ...,::.., :' ter+...:. r�. 6 - - • Y .. \ ii-:} \:.\\. .A..., \ . m v�� \} \ a , .«, \ /? C § y.,. { exi:y . m< ' \ Monitoring Plan Baseline Survey Results Stakeholder Log : 0 E a) ■--a>\2 oco— -E � rm2=U7 ToR�\E2% o\V) &cv2 Responsible Persons/ Group Kelly Campbell/ Cindy Kronauge Kelly Campbell / DRIVE SMART Weld County Coalition O_ Objective B: By September 30, 2015, motor vehicle partners in Weld County will report increased local support for strengthening Colorado's GDL Law and establishing primary seat belt legislation. E 0 >' $ As Measured by: • A stakeholder analysis indicating shifts in support for best practice policies. Target Completion Date 09/30/13 Completed 09/30/13 Completed # \ k Key Activities B.1.1: Conduct a baseline survey to assess the local coalition's support for strengthening Colorado's GDL Law and passing primary seatbelt. B.1.3: Indentify local stakeholders who could be influential in promoting best practice child motor vehicle policies. B.1.3a: Invite newly identified local stakeholders to monthly DRIVE SMART coalition meetings and invite them to collaborate on appropriate program activities including: • Partnering with Greeley Police Department to implement one student lead traffic safety program within a Greeley/Evans Dist. 6 High School • Hosting one chamber business event to promote DRIVE SMART Weld County's interests and goals and to recruit new coalition members. Strategy B.1 2=7W co as 7 e 0 a 2 §- 7 t�� \�°§SE\ 5 c o. E w%> at, -222&3 E E G e E . 0 � O / v a O Stakeholder Analysis Summary of stakeholder key informant interviews Signed document indicating LPHA support for the Injury Prevention Winnable Battle Attendance at technical assistance events County -specific factsheet Coalition meeting agenda and completed PowerPoint Presentation a E a) = U jK-? o 2'E¢gm p0 o Y �NUU E N O) U>.= -o m >`60 U Y ...... Y Kelly Campbell Kelly Campbell Q) p) .Q o a as ?,Eac 3@ c o YUUY Cindy Kronauge v 0 co o Ln 0 co 0) 0 09/30/13 Completed On -going 10/01/12 - 09/30/15 v 0 co 85 p 09/30/13 Completed B.1.4: Conduct a stakeholder analysis of local partners. For each stakeholder indicate their level of interest in the problem and level of political power regarding child motor vehicle policies. • A minimum of two letters to the editor about the benefits of GDL strengthening will be submitted by coalition identified stakeholders to local media partners. B.1.4: Members of the local motor vehicle safety coalition should conduct at least eight stakeholder interviews to gauge local support, determine barriers, and inform the development of local talking points related to GDL and seatbelt policies. • Coalition members to give at least two presentations to local civic groups using local talking points related to GDL and seatbelt policies B.1.5: Schedule a meeting with the WCDPHE executive director to discuss evidence -based programmatic and policy strategies to reduce teen motor vehicle fatalities. Gain executive director support for promoting Colorado's Injury Prevention Winnable Battle Milestones / Key Activities B.2.1: Participate in a minimum of three policy -related technical assistance opportunities offered by the Injury, Suicide and Violence Prevention Branch and/or the Colorado Teen Driving Alliance. B.2.2: Using county (or regional ) information from the CDOT Problem Identification Report, death data, hospitalization data, emergency department data (when available), and information from local stakeholder interviews create a county -specific fact sheet about the burden of teen motor vehicle crashes and unbelted drivers. The fact sheet will include cost information supplied by the Colorado Teen Driving Alliance. B.2.3: Present information about evidence -based motor vehicle policies to the local motor vehicle safety coalition. This presentation will include information about GDL and primary seatbelt laws. N a W m L N c) N O N E9 O N i d 2 N T J > O m a ATTACHMENT F-2 List of coalition members willing to educate decision makers Presentation List of individuals or groups that coalition members talked to about motor vehicle policies Attendance at workshop meetings List of groups survey was distributed to Kelly Campbell Kelly Campbell / Cindy Kronauge DRIVE SMART Weld County Core Coalition Kelly Campbell Kelly Campbell a co O a co O a CO a c s a C O On -going 10/01/12 - 09/30/15 B.2.4: Identify at least two local motor vehicle traffic safety coalition members who are willing to educate key decision makers in the community about the importance of GDL and primary seat belt laws. B.2.5: Develop a presentation for the identified spokespeople to use when talking with stakeholders about GDL and primary seat belt laws. B.2.6: Work with the local motor vehicle traffic safety coalition to identify three groups or individuals to present information about evidence -based motor vehicle policies. B.2.7: Participate in the local community workgroup of the Colorado Teen Driving Alliance. 6.2.8: Assist the Colorado Teen Driving Alliance in promoting statewide stakeholder opinion surveys (when applicable). / \ \ Lead: Kelly Campbell Email/Phone: kcampbell@weldgov.com (970) 304-6470 ext.2325 Target Population: Low Enforcement Officers in Weld County _ » 2 ... _Zee::30 \/\\/ 46 °SE Ta • } ........:...< d 1 . Monitoring Plan Baseline survey results List of law enforcement agency presentations Number of GDL Cards distributed and list of agencies that received them Follow-up survey results and Parent of Teen Drivers sign -in sheets Responsible Persons/ Group Kelly Campbell / Cindy Kronauge Kelly Campbell Kelly Campbell Kelly Campbell / Cindy Kronauge Objective C: By September 30, 2015, law enforcement in Weld County will report increased knowledge of graduated drivers license laws and willingness to issue citations. As Measured by: • Increased GDL knowledge/awareness among law enforcement officers • Increased willingness to enforce the GDL and issue citations 7. - Target Completion Date 09/30/13 Completed IIco On -going 10/01/12 — 09/30/15 , \ m Key Activities C.1.1: Conduct a baseline survey of local law enforcement officers to determine their understanding of the current GDL laws and their willingness to issue citations for the law. C.1.2: Using the roll -call video and PowerPoint developed by the Colorado Teen Driving Alliance, conduct at least one presentation for local law enforcement to educate them about the current GDL law and encourage enforcement. C.1.3: Distribute the GDL Cheat Sheet Cards developed by the Colorado Teen Driving Alliance to local law enforcement officers. C.1.4: Conduct a follow-up survey of local law enforcement to determine their understanding of the current GDL laws and their willingness to issue citations for the law. • Increase the pool of patrol officers willing to speak at a Parent of Teen Drivers class within their community about the GDL by a minimum of one new officer. Strategy C.1 ±); \}® it- f , ) ( y - e / [{t[` / { 00 /!eE'2E-2;ta, o;]Raa,aE ,atG4! 3sac,t§2a;a=§\E:« /\� , oo02. /\\)i C.1.5: Encourage local law enforcement officers to do increased enforcement of the GDL law around schools. • Encourage local law enforcement and/or school resource officers to assist with conducting seatbelt check points before P.A.R.T.Y. programs 0 04 ATTACHMENT F-2 Lead: Kelly Campbell E O c) O 0 •_a a) C O L a 0 E E ca Y 304-6470 ext. 2325 ti rn Co O a) C a) (La m ai 0) v O C a) co (a a) U C 0 O 05 a) C _T Q) 5 J J I) O C N (a (3 C 0) (n C C u)v .— a a) O a) II o E O (ca Target Population: Parents of teens ages 15-19 a) 8.. C a, .y a) a) O is L � T 3 — v a) > O1 C 2 m o 0 0 a C (a o a- ft (6 O Q) 7 a. Q "a w • As Measured by: Increased GDL knowledge/awareness among all class participants Increase in parents intention to do a parent -teen driving contract with their teen U O O Evaluation o a a) a) a E O U Monitoring Plan (1) a) � c U O (a Q) N U C C a) 0 N O (a C 0_ QJ J0 O is a`) co E v O a) U C C a) 4a O N (O0 0_ C J O O O T a) C u 2 E a) co N O C a a. 0 N L O L as a.0 v LUF TO X200 0cnoo F— a) 1 a Q Y (a (.1) 0 C a.O wO n T > -o = m a WCDPHE — N l0 4- O O CO O O) O C O _ a) m a 6) _ a) iv O co O 0) C_ O 0) C O 0) C O D) ( C O N LO O O c) a a r d 0) C O O) C O Key Activities v N 0 U C (a U) v) a) Q) H C as Ea y O QC 2 O C W L C (T QJ O Q" O a)(a O N rn O O J ;3 O U 0 U a O C C a) C O ?� Uca J O O c (a rn U C a• a)O a- U 0) C s 5 as a) J Co 0 a' L a) O - U E O O C v E O a) C N ?7,"). 1 O v U co w C C , o c v E'a) O v E -a (a s o N a w a — a) CO O o > y L o o v Y E �r C (a a) U (c'" a) CD W to N O 4.rti 9 O C > O _C O O ID C S 0 (a E v o ca E eL0 U a) a) a) _ O C CL C o (n 0 o a) a) Ca w ATTACHMENT F-2 ATTACHMENT F-2 Lead: Kelly Campbell ai O aLit E O O a) N C? N (970) 304-6470 ex n: Teens ages 15 — 19 Target Populati 0 a .E 5 U) a)o 15 L a) O U O c C o U co al a O C O_ a3 is As Measured by: Increased GDL knowledge/awareness among all teens Prevalence of impaired driving practices compared to 0% among teen drivers Increased seatbelt usage among all teens Evaluation of Objectiv a) a) a E O U Monitoring Plan E C C ° a o 0 a a) U U) a) L 'C a) �� n EE - o_ E- o 0 0 0 ° Z oc.c o E a) T a) :Y a) w a_ a) H a) lY T Jo Q s N O c O 6 0. W U .2 im) v&,o � > a) Q . a—. O O O rn C 0 O) C 0 r 6 O CO 0 6) 0 CO O F- T C c!) o c w U .a > -o= a)m o C) 0 O) 0 LO r O O CO o 0) O N F o ((f a a a W C U i (B r Q 0 - E 0 J U 0 o) O o (6 (II a °tea a) RS O 2 a`) O 71 _ V) O U O ca u) 8a c (0 U (0 E N Ol_o a)<co C .0 (B •> o 0)a o N .? a) 0 V) a (1) Q) U (6 03 0 0 p 2 W o U s u) m N O u)O O cB _a a) -0 (T3 o Q - U E a)a o a) "-a3 Q CCU Q) ., a) w L U) 3 ro _o J U) ❑ u) � U) (I) -C O ❑- ° CO a) 4 U O)TD a a oOC c CO nj ` c y W Cr CD U) Educate about the current GDL laws. c ° C (12 0 N O a Q N � O � O C 0 a)r o a tL a) O (11 U Q as o D_ (I) n- co > RS N � O O O a. 0) _ a O c } V7 E c O cc L U U E c T a ca c o U a 0 Q) a) W 0' ens at selec m a) u) v, o (9 al O O L O O `O U) O - u) > : (I) .C - N o o a a) N N oa O C a) ca c > M rr ATTACHMENT F-2 ATTACHMENT F-3 Local Public Health Agency Action Plan Template Medical Home O N U) E (I) cc L Y a Z z `1 w C Z @ W a w a p @ c °6 Q U < A CC O O 0. 0_ o.weld.co. u Agency: Weld County Department of Public Health and Environment C L y C N .L.. 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O U N • N C@~ s_ "' s E E@ E C a) t @° @ L a)• >'c-`aa°)a)�>' gs1® E m o o- ° - a s,_@ L@ta° O L N Y o U .� N m 'L' 0 o> y N .@O Y O >' a7 U@ y 0 p 3 V o a) c o a) @ N N 0) Q o N ° �Z o p p -p a o c aa) N m o E m m %ii cg o2a a) N o� c >.riC m a a g cci s° s a c�i m2 ° maw = ▪ o p c O a) N m a. ;C J4 E N -O @ .L al @ 13 N U @ @ -a m N @ • a) E [6 '' O O O p L N T O E Y U Y Y C p -a C' LI- N .8 • cu - 0 — LY 0 o a aN) N.L.. o n •y U ° m o m( m a m _ Y = To 'N i n@ .6 .N 'a a L_ J d J J J L J L> N cm N EU�5am@ oc'.fl tiEsEaa))=• a W • °UO>TY UTIO GENL WO an al o 0 tin l) C- a ATTACHMENT F-3 en ma ° c ° o a) -O m C T O) N o L a as c N T d c m ° .C ≥ a C - m m 0 C m" O)5 N o C O TC E N ,L c U N 0 co 0 ° a N C C O O E 3 a a an a O) m y aaj m 0 0 0 0 EE 0 O O L N C O N m m> .o O C U o N "O o 0— m a L O u' {a a U >. a CO L O L 00 2i E C a O E a m en as> m N Y co m N y 5,m ma C m O a L 5 a6 T m V co N= 0 N in OU N L a m oU U CO T m C ca 0 C .- `o o u) N Ea En C >,C LE 712 C dN'q L> — o 'N 0 U N a o m L O o c_ Oo C E X 0 c CD m m U o 0) J o ..> o m c E a) o N O) 0 O O) N N p C C E N UO c o m 0 0°@ 0 0-.a) 'c c T L s a L C o o> -- o '5 --C.2 m cl C N >, 0 0 m y 0 _— _ N V N d al o m U- U NO 0 O) 0 U C E _ N N -C C a) 90 is = Q U .C "� O m 4Le E m o o C m U N U a a m _ L y o a) 0) 0 C y o m 0_ a) m Y� O a N Y T o L O a m C a a - ca m a 0 r ° U� C m C� U— C T., -c O o, 0 0 o o �....=.. m CO 5 CT 4- a) a) C0> 0 c OXm�-o��Ecu a E a N w Q a) m N° a c a m mco a C co 0- (0 O 0 > o 0 0° L 0 N L a L U °- E C C 0 N o o 'o � a o'a 0 L O Y m C °U CL oCO > w y OC C O N S O w a _C O) o o L N= U CM C a o E N> o c O' Da' a O CD C o a m -a0 aa))an a ca (000 aY° C N°° 3 — c -° W N_ a) o O N .O 0 CO C N C c m a) _ m N O a CO N o m 0 N >, O r)U a0 m 0 O. 0 52-O5c1---5 m O~ C O T T p .T- E a) C) L> UT) )/' o 0 E= C C U r C -E E C m a) o 0 C E O U O = W— vi .E O Y as c oa cU C O O m N N J o N L -° aOT N N-- L a) 0.T N N c CL -, _c O 0 0 E N 3 co -° C, N N° a C O- — c C v - C c >, 0 a CD C N U C c0 .0 0 O a c a 0 -O ai a °' N+- o E o o `o a E m Na @.° C °o -0 L° O 0 O a C E U Li a CL o 0 Cla 3 U o 0 a° N -00 Q _C N T CAN co L;ra > QOL O] N >. 2 L uJ N D.� R> `o m ._ J U-0 a) L co a) ID �L`. = C L 0= C. U N 08.00-0.60,0 ,0 o f0 CO a) o U m U o ,C o m 'cc o a a O CL a) SENa m --O) > O)a) O)a amL am 0 oCO a°o N J m fa) w 3 E -c m al o cmi co) `o_� L� c.-. 0 0)> _c a. O -O E c-0 L= O'6O m L2� Co_U °Co To 2 G m r O U c = N O N �0 w= a -UTj "O 0 o 0 O o T O a N O N E'- -) C - o-y CWT° CD Ems° a�coEy�aaic aa)) C a) mw ° u.E o C� UU m a>i m oc E 3t a a o E Oa) c oNn a i _c -.-.. cm�o.om� y3 o a o .C a 'U 0= 0 Q 0 a 0 C 2 u) C o C c c V l6 c a a o n a O C 0 +� C O O N ° m o o 0 o m ornE ° Zit N °) 2 m N �"o 0E m OO-. p L >," 00 U C .5,4" T` 0.5 i 6-al O L °�W Uaa_c a)m comma) aCCCo0E(5�U 1C -C N E 0 .- U E U R in o .T. o c a) '- U a N .O y (6 o a w6 (a T O a e o 'C O O) 2_ ° N a 0 a- 0).C (n 0 E O U° m m o m N O Oo4= ,aa`m) E 0000E 5c�Eaioa)aE)-a 2',..7.,ea c ° oai a) m E o N m `o u a m c m u)ccun HUw Z -c UIL—oo Jm.cmmc0ac oen C 0 0 0. U d F E- < Data Source(s) Colorado Child Health Survey: State level data for this measure available. County/regional data will be available in spring/summer 2012. National Child Health Survey and National Survey of Children with Special Health Care Needs: state level data only. Local medical home data: Largely anecdotal; we are finding that everyone is asking the same questions. No formal data has been collected on this topic in the expanding at risk populations of this county. See Objective A State Performance Measure(s) None appropriate at this time. National Performance Measure(s) National Performance Measure 3: The percent of children with special health care needs age 0 to 18 who receive coordinated, ongoing, comprehensive care within a medical home. CSHCN National Outcome 2: All children will receive comprehensive, coordinated care within a medical home. in — Increase the number of children and youth, including those with special health care needs, who receive comprehensive, coordinated care within the medical home neighborhood in Weld County. Improved communication, collaboration and enhanced support network amongst medical home projects and initiatives in Weld County. O 0 0 ao O M as to 073 LL ATTACHMENT F-3 Lead: Kathy Smith-Stillson, PhD, RN el C2 ti ccd o Co= E rni § o en U cif >/} o r ID C COO Eo 3 \\�\ /{/[ a)E c}(\ k Oct $})} /}f2 c)\o0 $A)«* 2c0 )3722 co ra S _ -2 o' 2307 3 `E ©] §,g 20 I \\\\\ 3 Z 23 2 k' -a2 CoLL0C \)&/C- \)2)C3). — _c . 8 5`�)\ ®GC C0C ®®° (§ 8 8I Io'row 20 -o 0 o0 02=E° ©°)a E —a O C50 0 o\ { (§ -2._ 080 g° E°\e§# 2)/\t) /r# )ag co ZIT,'®)\ aGi R3///2 As Measured by: Documentation of - / key medical home stakeholders and strategies for engaging identified and prioritized barrier(s) existing resources and resource gaps that need to be filled in order to impact the identified barrier collaborative action steps for addressing the barrier(s) a) { \sc / o.. 4:. p� ,'.fir :. ..k'} '" :.7 .'.t%'44;:'.:i`;• �..r.. �rier.� .... Monitoring Plan C O .�' O W e co crd t I T.. E o c ea �'2 c .-ia o _o m to a Icu- co s_ u) O0 3.-F- O c0 o W •U ,_ N.0_c= 4- O O ca c') m O N c3 cn U�Cl_= .Q t4 O�� L= •0 J N .. � O cu fn m$ O 'O O O 72 o ,- N '--c U w L3 o- Th 3c 6 o` x$ o c toe U c c:• Q c�'�p2U46 c N_ J Vi 1:2-J N U C C2 w V j 0 c U c U .0 O a O L cap C (6 — G U 0 f:/, 32 c'am OTo c o� m o?_'E a`;a.`vw -t u 't-_a�-c Eu °J , > o-� o --- c o V Z ca c -c o o0•E E c o c o caz o. --o >-c ca E o m c �'`�U c a) ca o a) = cut' O — O as O O O .tn O a) •O a) -E a) -c OL O a) o o d o c- .-> -o i a) U2U(>UJC720007UL-UUUOUSW cUZUQ-Z2UU(.7U I u>W Oco Responsible Persons/ Group .C r2 E°- >., O Yfn+Y Target Completion Date Ni- _ 0 el Key Activities L a Cr) a r c 4- m O co O N O O •-' a) to y ° C. �O c o C_ III O a o n �' u) a 0 l0 O a) W - r c r c to co a) U UpO U) cs.≥ o0 E� o N c co a a) -41-A Ua ?.'.6 m O a) V) O U , cif),O a (6 C 01 0 a) la al o CZ a) N C C EO E cn a) Q Q N �c � •� -- � a m a) E p c4 ca E w. a w c E o o co U c r `a> to ca.0 ( E Eo N o f o c C RI U c C O p 0 U :cA O c U) O a) c a) 's3 o°OE E43No £nE 0 �.4"c_ (13 743 0 a) L ,? .C "O L OM > .0 u) a a) E oco- > cos r ci) o°aE >a o c Tu o a > co (. s o 0 . 'O 'U U) ,_ .r., -0 a ra c 0 (I) Z 0 U Z a) O 0 ., L +•. -C N a) = N- (0 Y a > a) 0) O 0) a) o. •5 o 0 C r E o c a ERS a O C co 0 70 '- C OL N a N U O ,o o >' c O O a) E O c (0 E N V r co U C a) 0 p r j .O .mom a c 'c] c o c O' a) rn 3 >. 1.155,- Q) 7 O o O O: c0 L ♦+ CL N> O 2 L) N < U) UJ U W a) C. IZ (0 2 Q) O U L cn • Q p d tta I. (.) 0 (t) a) c..Cc Ea N H O CU to "=C as U U U k24., M L O LO •O f3 O R to O a) O +- 2 ..2 0 15 E a.E Kathy Smith- Team charter Completed Stillson, PhD, document during Annual RN, Amy Reporting Antuna BSN, RN, and established consortium 11.5 N C 03 E S Q U -K `o m -a N 'p N N T C -O O N ) N 0.) > .�® T... NON O Nom. C6='.� -N.. =0200_ Em'E 3®0 o b b- E 3 Z -2 t O_ _0 m W o) Q) a O-.- o -O 0 Z - -- CO 72, E E a >.m r = CI, C E cn Ul e ›.0<.03,0 nu)@. 71:1:.. Z G Z U) O (nKQ� m U 7 CO) r d CO 1� A.1.2: Monitor progress of stakeholder group in relation to established team charter document that includes the following components: vision; goals and objectives; member roles and responsibilities; meeting frequency; and communication protocols. • Based on template provided by the Medical Home MIT, discuss team charter questions and finalize document • Reassess stakeholder commitment to participating in stakeholder group for the second year • Will continue to utilize Wilder Collaboration Assessment tool. A.1.3: Partner with the stakeholder group to assess and prioritize systemic barriers to a medical home approach in the community. • Engage stakeholder group in discussion of current local barriers to medical home using local community assessment, key informant interview data and guiding questions provided in the Medical Home Priority Resource Document. • Prioritize barriers based on group discussion and input as identified enumerated in WCRC charter. • Collaboratively develop action steps that address prioritized barriers. GO O U b➢ N 0 m c to m <-7- Q 3 co Q m Ua Cr ≥ O O 0) ' OCO T C C `O N N D_ C C co M C CO `D • N 7 EONS -CNNU O O O U) CO ..... C O � ._ , , C ..N., O O C N ..c J a o_ 2 en ID N C 0) O O C N N 3 C N C Y P N _w J,d Z C �� N co Q. C to° Y -O _E N -6 '00 'u@i N O r C CLa op O a _e0 za mo@ m� fE a> m C1 C O m C O O N N.C S �o O o' C a— N C N f >%O¢ . E U CL O'C'O_a O o m J _ o E C C e °=E002 (0 :C, Z— Z N o -o m o (5 -Es= O w o Y(n CCQCC=Owd ZUUU o O O 0_ co 0E I:J d >,m - N r C E ro C >-.0<c c0_p O L= J to co N .^' Z C Z 41 0 Y co d' Q K N O a co N V co A.1.4: Partner with the stakeholder group to develop and implement new and/or enhanced collaborative action steps to reduce the barrier(s). Partner with the stakeholder group to identify funding and other resource needs to support identified action steps, such as applying for grants, braiding funding, leveraging staff time, etc. • The key stakeholder group that remains beyond the initial 1 -year phase will engage in a discussion about funding and resource needs and opportunities. • Key stakeholders discuss the role of their respective organization in identifying opportunities for additional resources as well as cross -system collaboration. • Opportunities are identified for key stakeholders to collaboratively meet the identified need. • Challenges to meeting these needs are identified. • Additional stakeholders are engaged as needed. A.1.5: The roles of each participating agency/organization and the role of public health are described in relation to implementation of identified collaborative action steps. • Engage stakeholders in on -going discussion about role expectations from the perspective of each stakeholder as well as from group leaders to determine individualized commitment to services to be provided. • Discuss the role of the LPHA in supporting progress toward goals • Identify themes from discussion on role expectations for each stakeholder and for public health e LT - c.4 2 U 77 } ' { = ms9 m DC : z w :S J 3 » ' ,S' y< g y « Q s,. s,: sa.w*. o' U , - . ; % y:zm' T G` / y v x a� " 3 3 a.za , \Z : .7 E 4 co = a) e a) \§��/ »/) Iii G1E§70Eo.c0 �\ caco,_ 0 227Qkt \S\//�/ 0_k/\crJ Medical Home learning opportunities. \�>,CO // u)■ee2�� .2'_= C a=ZCZ 0 YmM«■■u Kathy Smith- Stillson, PhD, RN, Amy Antuna BSN, RN « / 9/30/14 A.1.6: Conduct a 1 -year collaboration survey with the stakeholder group to help measure the stakeholder group's effectiveness, the strength of member alliances, and member satisfaction. • Utilize tool to measure key stakeholder collaboration at 1 -year (Wilder Collaboration Factors Inventory) • Update the timeline and process for collecting on -going information and evaluation of consortium. • Administer 1 -year collaboration measure to key stakeholders. • Administer a point in time survey at quarterly meetings such as CoalitionsWork; Coalition Meeting Checkup. A.1.7. Will attend Medical Home Training and Assistance webinars and conferences as appropriate and relevant. a) k 2 00 C 00 EXHIBIT G Colorado Department of Public Health and Environment Colorado Department of Public Health and Environment PREVENTION SERVICES DIVISION- BUDGET JUSTIFICATION FORM To Task Order Contract Dated 08/14/2012 - Contract Routing Number 13 FLA 48090 - Contract Amendment Routing Number 14 FLA 59156 FY14 Maternal and Child Health Planning Budget Agency Name Weld County Department of Public Health & Environment Budget Period October 1, 2013 - September 30, 2014 Identify the population for this budget CYSHCN - HCP Care Coordination (CC) Identify all action plans related to this budget Date Completed: 6/13/2013 Program Contact Name & Amy Antuna, RN, HSN, HCP Supervisor Title Phone & 970-304-6420 ext 2322, as ntuna@co.weld.co.us Email Fiscal Contact Name & Tanya Geiser Director, Title Administrative Services Phone & 970-304-6410 ext 2122 tgeiser@co.weld.co.us Email Expenditure Categories Total Amount Required Other Of Applicable) Total Amount Requested from CDPHE Personnel Services Grossor. Annual. Salary Fringe . Percent of .FTE Position Title/Employee Name Description of Work List MCH action plans & objectives this budget item supports Community Health Manager/Kathy Smith- Stillson Provides oversight of HCP program and HCP staff, participates in reporting and evaluation of HCP program. $67,414.26 $26,244.60 2.50% $2,341.49 $2,341.49 0 HCP SupervLsor/Amy Antuna Provides direct oversight and supervision of HCP care coordination program and staff, directs care coordination activities, oversees HCP support group activities, participates in HCP program outreach and represents HCP an several community groups/coalitions, responsible for reporting and evaluation of HOP program. $63,290.34 $24,638.93 90.00% $79,136.34 79,136 Administrative Assitant/Victoria Zacharko Administrative project support to HCP team. Responsibilities include interpretation, data entry, materials preparation, assists HCP staff with care coordination activities, etc. $29,977.03 $11,670.06 80.00% $33,317.67 $33,317.67 0 Public Health Social Worker/Aurora Medina Provides psychosocial care coordination services to HCP clients, coordinates and facilitates monthly HCP support group, HCP program outreach and represents HCP an several community groups/coalitions. $59,641.20 $23,218.32 80.00% $66,287.62 $22,000.00 44,288 Public Health Nurse/Tenney Thomas Provides care coordination services to HCP clients, assists with HCP program outreach and attends HCP community meetings. $52,155.37 $20,304.09 100.00% $72,459.46 $36,135.24 36,324 Public Health Nurse/Cynthia Luark Provides care coordination services to HCP clients, assists with HCP program outreach and attends HCP community meetings. $52,155.37 $20,304.09 50.00% $36,229.73 $36,229.73 0 For all above listed employees: fringe includes medicare, unemployment, workers' compensation, PERA, life/AD&D insurance, health insurance, accrual -vacation, accrual -holiday, accrual -sick. . - $0.00 0 Total Personnel Services (including fringe benefits) $324,634.17 $126,380.08 4.025 $289,772.30 $130,024.13 159,748 Supplies & Operating Expenses Item Description of Item List MCH action plans & objectives this budget item supports Total Amount Required Other (if applicable) Total Amount Requested from CDPHE Supplies & Operating Expenses HCP program outreach, marketing, and systems building activities, printing, postage, office supplies, computer services (network fees, software, and printers), phone services, facility fees for official HCP functions. MCH - HCP Care Coordination $1,000.00 $1,000.00 Total Supplies & Operating Expenses $1,000.00 $1,000.00 0 Page 1 of 8 EXHIBIT G Colorado Department of Public Health and Environment Colorado Department of Public Health and Environment PREVENTION SERVICES DIVISION- BUDGET JUSTIFICATION FORM To Task Order Contract Dated 08/14/2012 - Contract Routing Number 13 FLA 48090 - Contract Amendment Routing Number 14 FLA 59156 FY14 Maternal and Child Health Planning Budget Agency Name Weld County Department of Public Health & Environment Budget Period October 1, 2013 - September 30, 2014 Identify the population for this budget CYSHCN - HCP Care Coordination (CC) Identify all action plans related to this budget Travel Item Description of Item List MCH action plans & objectives this budget Item supports Total Amount Required Other (if applicable) Total Amount Requested from CDPHE Mileage MCH - HCP staff will travel to MCH/HCP meetings at various sites and participate in outreach meetings related to HCP program. Annual HCP team travel average 3669 miles; reimbursement at $.545/mile MCH - HCP Care Coordination $2,000.00 $2,000.00 Total Travel $2,000.00 $2,000.00 0 Contractual (payments to third parties or entities) Item Subcontractor Entity Name and Description of Item List MCH action plans & objectives this budget item supports Total Amount Required Other (if applicable) Total Amount Requested from CDPHE $0.00 0 Total Contractual $0.06 $0.00 0 SUB -TOTAL BEFORE INDIRECT 159,748 Indirect $292,772.30 $133,024.13 Item Description of Item Indirect Rate 1198% $35,074.12 $15,936.29 19,138 Indirect Type Negotiated Indirect Rate with CDPHE Total Indirect $35,074.12 $15,936.29 19,138 TOTAL MATCH OR IN KIND $327,846.42 $148,960.42 TOTAL 178,886 Date Completed: 6/13/2013_ Program Contact Name & Amy Antuna, RN, 85N, HCP Supervisor Title Phone & 970-304.6420 ext 2322, aantuna@co.weld.co.us Email Fiscal Contact Name & Tanya Geiser Director, Title Administrative Services Phone & 970-304-6410 ext 21.22 tgelser@ca.weld.co.us Email ;Core Services. What percentage of funding from the budget total is allocated to work at each level of the MCH pyramid? Direct Services Enabling Services 100% Population -based Approaches Infrastructure Building Approaches Total to equal 100% 100% HCP CARE COORDINATION ONLY What is the estimated number of children/youth with special health care needs who will receive HCP Care Coordination services in FY14? # with an HCP Care Coordination Action Plan: 8 who will receive information only: CRCSN notifications: Does your agency wish to receive them? Opt -in X Opt -out 75 40 Page 2 of 8 EXHIBIT G Colorado Departmenc of Public Health and Environment Colorado Department of Public Health and Environment PREVENTION SERVICES DIVISION- BUDGET JUSTIFICATION FORM To Task Order Contract Dated 08/14/2012 - Contract Routing Number 13 FLA 48090 - Contract Amendment Routing Number 14 FLA 59155 FY14 Maternal and Child Health Planning Budget Agency Name Weld County Department of Public Health & Environment Budget Period October 1, 2013 - September 30, 2014 Identify the population for this budget Adolscents 14-19 years old Identify all action plans related to this budget CASH Date Completed: Program Contact Name & Kelly Campbell, Health Communication Supervisor Title Phone & 970-304-6470 ext 2325 kcampbell@wektgov.com Email Fiscal Contact Name& Tanya Geiser Director, Title Administrative Services Phone & 970-304-6410 ext 2122 tgeiser@co.weld.co.us Email Expenditure Categories Total Amount Required Other Of Applicable) Total Amount Requested from CDPHE Personnel Services Gross or Annual Salary ry Fringe Percent of FrE Position Title/Employee Name Description of Work List MCH anion plans & objectives this budget item supports Cindy Kronauge, Health Data Specialist Coordinate grant evaluation and data analysis. Assist with stakeholder interviews, creation of county specific fact sheets and development of community educational presentations. CASH -All Ojectives $82,941.31 $32,289.05 5.00% $5,761.52 $0,00 5,762 Marjorie Hanson, Office Tech III Clerical support including data entry, copying and printing, inventory control, supply ordering, meeting coordination, graphic design and website updating. CASH -All Ojectives $37,871.49 $14,743.37 25.00% $13,153.72 $1,412.19 11,742 Kelly Campbell, Health Communication Supervisor Primary MCH liaison; provides management of MCH project deliverables, supervises MCH staff, directs work plan activities, monitors grant expenditures, and responsible for reporting and evaluation of MCH programs. CASH -All Ojectives $61,484.46 $23,935.90 20.00% $17,084.07 17,084 Fringe Benefit Calculation: ' $0.00 0 Medicare 145 ,. , $0.00 0 Unemployment 0.09 : - .. $0.00 0 Workers' Compensation 0.08 ." $0.00 0 PERA 13.7 _, $0.00 0 Life/AD&D Insurance 0.33 .. $0.00 0 Health Insurance 12.14 ,:. $0.00 0 Accrual -Vacation 4.61 . ,: $0.00 0 Accrual -Holiday 4.23 .. $0.00 0 Accrual -Sick 2.3 $0.00 0 Total Percentage: 38.93 $0.00 0 Total Personnel Services (including fringe benefits) $182,297.26 $70,968.32 0.50 $35,999.31 $1,412.19 34,587 Supplies & Operating Expenses Item Description of Item List MCH action plans & objectives this budget item supports Total Amount Required Other (if applicable) Total Amount Requested from CDPHE Printing/copying supplies To print flyers,00sters and evaluation surveys for Parent of Teen Drivers classes. To print agendas and materials for coalition meetings, county specific traffic data fact sheets and Driver's Education Scholarship applications. CASH - All Objectives $500.00 $500.00 0 Meeting Expenses To purchase refreshments for coalition meetings, Parent of Teen Drivers classes, focus groups and stakeholder meetings. CASH- Objectives A, B, D $500.00 $500.00 0 Survey Monkey Membership Fee To purchase a one year platinum membership to survey monkey to be used to conduct immediate feedback and 8 week post feedback surveys for the PARTY programs CASH -Objectives E, F, G. H $800.00 $800.00 0 Incentives for High School Students To purchase items selected by student groups at the high schools to use as incentives for teens who sign seat belt pledges, no testing while driving pledges and/or participate in traffic safety activities. CASH -Objectives 0, F, G. H $500.00 $500.00 0 Advertising and Meeting Notices To purchase ads in the local newspapers promoting Parent of Teen Drivers classes and to publish information about stakeholder meetings, focus groups and coalition gatherings and events. CASH -Objective A, B, D $1,000.00 $1,000.00 0 Total Supplies & Operating Expenses $3,300.00 $3,300.00 0 Travel Page 3 of 8 EXHIBIT G Colorado n eltis a[ of Public Health and Environment Colorado Department of Public Health and Environment PREVENTION SERVICES DIVISION- BUDGET JUSTIFICATION FORM To Task Order Contract Dated 08/14/2012 - Contract Routing Number 13 FLA 48090 - Contract Amendment Routing Number 14 FLA 59156 FY14 Maternal and Child Health Planning Budget Agency Name Weld County Department of Public Health & Environment Budget Period October 1, 2013 - September 30, 2014 Identify the population for this budget AdoLscents 14-19 years old Identify all action plans related to this budget CASH Item Description of Item List MGH action plans & objectives this budget item supports Total Amount Required Other (if applicable) Total Amount Requested from CDPHE Mileage Local Travel in State (avg. 200 miles/month @ .545/mile ) CASH -Objectives 0, E, F, G, H $1,308.00 $1,308.00 0 Total Travel $1,308.00 $1,308.00 0 Contractual (payments to third parties or entities) Item Subcontractor Entity Name and Description of Item List MCH action plans & objectives this budget item supports Total Amount Required Other (If applicable) Total Amount Requested from CDPHE Subcontractor Lyn Tausan -Pubic relations/Marketing professional to promote programs, coordinate media campaigns, coordinate the implementation of the P.A.R.T.Y. program at participating high schools and assist with stakeholder and law enforcement advocacy campaigns. Contractor will serve as the community fiason and media contact for DRIVE SMART Weld County. $5,000.00 $5,000.00 0 Total Contractual $s,odo.oa $5,000.00 0 SUB -TOTAL BEFORE INDIRECT 34,587 Indirect $45,607.31 $11,020.19 Item Description of Item Indirect Rate 15.65% $7,137.54 $1,724.66 5,413 Indirect Type Negotiated Indirect Rate with CDPHE Total Indirect $7,137.54 $1,724.66 5,413 TOTAL MATCH OR IN KIND $52,744.85 $12,744.85 TOTAL 40,000 Date Completed: Program Contact Name & Kelly Campbell, Health Communication Supervisor Title Phone & 970-304-6470 ext 2325 kcampbell@weldgov.com Email Fiscal Contact Name & Tanya Geiser Director, Title Administrative Services Phone & 970-304-6410 ext 2122 tgelser@co.weld.co.us Email $erviC25': r What percentage of funding from the budget total is allocated to work at each level of the MCH pyramid? Direct Services Enabling Services Population -based Approaches 50% Infrastructure Building Approaches 50% Total to equal 100% 100% HCP CARE COORDINATION ONLY What is the estimated number of children/youth with special health cam needs who will receive HCP Care Coordination services in FY14? It with an HCP Care Coordination Action Plan: It who will receive information only: CRCSN notifications: Does your agency wish to receive them? Opt -in Opt -out Page 4 of 8 EXHIBIT G Colorado Department of Public Health and l:aviroamcnt Colorado Department of Public Health and Environment PREVENTION SERVICES DIVISION- BUDGET JUSTIFICATION FORM To Task Order Contract Dated 08/14/2012 - Contract Routing Number 13 FLA 48090 - Contract Amendment Routing Number 14 FLA 59156 FY14 Maternal and Child Health Planning Budget Agency Name Weld County Department of Public Health & Environment Budget Period October 1, 2013 - September 30, 2014 Identify the population for this budget Women of reproductive age and infants/children birth to age 5 Identify all action plans related to this budget Early Childhood Obesity Prevention Date Completed: Program Contact Name & Kimberly Koeltzow, Clinical Services Manager Title Phone & 970-304-6420 X2337 kkoeltzow@weldgov.com Email Fiscal Contact Name & Tanya Geiser Title Director, Administrative Services Phone & 970-304-6410 ext 2122 Email tgeiser@co.weld.co.us Expenditure Categories Total Amount Required Other (If Applicable) Total Amount Requested from CDPHE Personnel Services Gross or Annual Sala ry Fringe Percent'of FIE • Position Title/Employee Name Description of Work List MCH action plans & objectives this budget item supports Mike Schwan, HCS II Coordinates, plans, and implements ECOP according to Weld's action plan Objectives A, C, G $53,20a06 $20,710.78 100.00% $73,910.84 73,911 Kim Koeltzow, Clinical Services Manager Supervise, assist, and participate in ECOP workplan objectives Objectives A, C, G $65,741.66 $25,593.23 20.00% $18,266.98 $2,876.16 15,391 Cindy Kronauge, Health Data Spec. ECOP data specialist Objectives A, C, G $82,941.31 $32,289.05 5.00% $5,761.52 $5,761.52 0 For all above listed employees: fringe includes Medicare, paid time off, workers comp insurance, unemployment insurance, health insurance, life/AD&D insurance, and PERA. , $0.00 0 Total Personnel Services (including fringe benefits) $201,863.03 $78,593.06 1.25 $97,939.34 $8,637.68 89,302 Supplies & Operating Expenses Item Description of Item List MCH action plans & objectives this budget item supports Total Amount Required Other (if applicable) Total Amount Requested from CDPHE Supplies Training materials, 5210 toolkits for childcare providers and health care agencies, 5210 pamphlets, recognition plaques. ECOP Objectives A,B, C, and G $2,000.00 $2,000.00 0 Media Increase awarness of ECOP (billboard, bus bench, buses, and news paper advertisement) ECOP Objectives A,B, C, and G $2,000.00 $2,000.00 0 Training/Professional Development ECOP education ECOP Objectives A,B, C, and G $600.00 $600.00 0 Total Supplies & Operating Expenses $4,600.00 $4,600.00 0 Travel Item Description of Item List MCH action plans & objectives this budget item supports Total Amount Required Other (if applicable) Total Amount Requested from CDPHE Travel expenses Mileage ECOP Objectives A,B, C, and G $600.00 $600.00 0 Total Travel $600.00 $600.00 0 Contractual (payments to third parties or entities) Item Subcontractor Entity Name and Description of Item List MCH action plans & objectives this budget item supports Total Amount Required Other (if applicable) Total Amount Requested from CDPHE $0.00 Total Contractual $0.00 $0.00 0 SUB -TOTAL BEFORE INDIRECT 89302 Indirect $103,139.34 $13,837.68 Item Description of Item Indirect Rate 11.98% $12,356.09 $1,657.75 10,698 Page 5 of 8 EXHIBIT G Colorado Department of Public Health and Envuotuncm Colorado Department of Public Health and Environment PREVENTION SERVICES DIVISION- BUDGET JUSTIFICATION FORM To Task Order Contract Dated 08/14/2012 - Contract Routing Number 13 FLA 48090 - Contract Amendment Routing Number 14 FLA 59156 FY14 Maternal and Child Health Planning Budget Agency Name Weld County Department of Public Health & Environment Budget Period October 1, 2013 - September 30, 2014 Identify the population for this budget Women of reproductive age and infants/children birth to age 5 Identify all action plans related to this budget Early Childhood Obesity Prevention Date Completed: Program Contact Name & Kimberly Koeltzow, Clinical Services Manager Title Phone & 970-304-6420 X2337 kkoeltzow@weldgov.com Email Fiscal Contact Name & Tanya Geiser Title Director, Administrative Services Phone & 970-304-6410 ext 2122 tgelser@co.weld.co.us Email Indirect Type Negotiated Indirect Rate with COPHE Total Indirect $12,356.09 $1,657.75 10,698 TOTAL MATCH OR IN KIND $115,495.43 $15,495.43 TOTAL 100,000 What percentage of funding from the budget total is allocated to work at each level of the MCH pyramid? Direct Services Enabling Services Population -based Approaches 40% Infrastructure Building Approaches 60% Total to equal 100% 100% HCP CARE COORDINATION ONLY What is the estimated number of childrentyouth with special health care needs who will receive HCP Care Coordination services in FY14? # with an HCP Care Coordination Action Plan: # who will receive information only: CRCSN notifications: Does your agency wish to receive them? Opt -in Opt -out Page 6 of 8 EXHIBIT G Colorado Department of Public Health and goviroanscut Colorado Department of Public Health and Environment PREVENTION SERVICES DIVISION- BUDGET JUSTIFICATION FORM To Task Order Contract Dated 08/14/2012 - Contract Routing Number 13 FLA 48090 - Contract Amendment Routing Number 14 FLA 59156 FY14 Maternal and Child Health Planning Budget Agency Name Weld County Department of Public Health & Environment Budget Period October 1, 2013 - September 30, 2014 Identify the population for this budget CYSHCN - Medical Home Identify all action plans related to this budget Medical Home Date Completed: 8/2/2013 Program Contact Name& Amy Antuna, RN, 85N, HCP Supervisor Title Phone & 970-304-6420 e2322, aantuna@co.weid.co.us Email Fiscal Contact Name & Tanya Geiser Director, Title Administrative Services Phone & 970-304-6410 ext 2122 tgeiser@co.weld.co.us Email Expenditure Categories Total Amount Required Other (if Applicable) Total Amount Requested from CDPHE Personnel Services • Gross or Annual Salary ry Fringe Percent of ETE Position Title/Employee Name Description of Work List MCH action plans & objectives this budget item supports Community Health Manager/Kathy Smith- Stilison Provides oversight, co -facilitation, coordination of Medical Home project/WCRC. MH-All objectives $67,414.86 $26,244.60 10.00% $9,365.95 9,366 HCP Supervisor/Amy Antuna Provides co -facilitation and coordination of Medical Home project/WCRC MH-All objectives $63,290.34 $24,638.93 7.00% $6,155.05 $2,125.75 4,029 Total Personnel Services (including fringe benefits) $130,705.20 $50,883.53 0.17 $15,521.00 $2,125.75 13,395 Supplies & Operating Expenses Item Description of Item List MCH action plans & objectives this budget item supports Total Amount Required Other (if applicable) Total Amount Requested from CDPHE Supplies/Meeting & Operating Expenses Medical Home - WCRC project outreach, marketing, systems building activities, printing, office supplies, computer services (network fees, software, and printers), and phone services. MH - All objectives $600.00 $600.00 Total Supplies & Operating Expenses $600.00 $600.00 0 Travel Item Description of Item List MCH action plans & objectives this budget item supports Total Amount Required Other (if applicable) Total Amount Requested from CDPHE Mileage - MH program staff MCH - MH staff will travel to WCRC meetings at various sites and participate in outreach meetings related to MH - WCRC project. Round trip will average 10 miles; 1 car will be taken, reimbursement at $.545/mile (16 meetings). MH - All objectives $87.20 $87.20 Total Travel $87.20 $87.20 0 Contractual (payments to third parties or entities) Item Subcontractor Entity Name and Description of Item List MCH action plans & objectives this budget Item supports Total Amount Required Other (if applicable) Total Amount Requested from CDPHE Total Contractual $0.00 $0.00 0 SUB -TOTAL BEFORE INDIRECT 13,395 Indirect $16,208.20 $2,812.95 Item Description of Item Indirect Rate 11.98% $1,941.74 $336.99 1,605 Page 7 of 8 EXHIBIT G 87 Colorado D p nmenc of Public Health and Environment Colorado Department of Public Health and Environment PREVENTION SERVICES DIVISION- BUDGET JUSTIFICATION FORM To Task Order Contract Dated 08/14/2012 - Contract Routing Number 13 FLA 48090 - Contract Amendment Routing Number 14 FLA 59156 FY14 Maternal and Child Health Planning Budget Agency Name Weld County Department of Public Health & Environment Budget Period October 1, 2013 -September 30, 2014 Identify the population for this budget CYSHCN - Medical Home Identify all action plans related to this budget Medical Home Indirect Type Negotiated Indirect Rate with CDPHE Total Indirect $1,941.74 $336.99 1,605 TOTAL MATCH OR IN KIND $18,149.94 $3,149.94 TOTAL 15,000 Date Completed: 8/2/2013 Program Contact Name & Amy Antuna, RN, BSN, HCP Supervisor Title Phone g, 970-304-6420 x2322, as ntuna@co.weld.co.us Email Fiscal Contact Name & Tanya Geiser Director, Title Administrative Services Phone & 970-304-6410 ext 2122 tgeiser@co.weld.co.us Email rN f , GCore;`iServices What percentage of funding from the budget total is allocated to work at each level of the MCH pyramid? Direct Services Enabling Services Population -based Approaches Infrastructure Building Approaches 50% 50% Total to equal 100% 100% HCP CARE COORDINATION ONLY What is the estimated number of children/youth with special health care needs who will receive HCP Care Coordination services in FY14? # with an HCP Care Coordination Action Plan: # who will receive information only: CRCSN notifications: Does your agency wish to receive them? Opt -in Opt -out TOTAL BUDGET: $333,886.00 Page 8 of 8 EXHIBIT H GRANT FUNDING CHANGE LETTER I Date: I State Fiscal Year: I Grant Funding Change Letter # [ CMS Routing # J TO: Insert Grantee's name In accordance with Section of the Original Contract routing number , [insert the following language here if previous amendment(s), renewal(s) have been processed] as amended by [include ail previous amendment(s), renewal(s) and their routing numbers], [insert the following word here if previous amendment(s), renewal(s) have been processed] between the State of Colorado, Department of Public Health and Environment and Contractor's Name beginning Insert start date <insert start date of original contract> and ending on Insert ending date <insert ending date of current contract amendment>, the undersigned commits the following funds to the Grant: The amount of grant funds available and specified in Section of <insert,contract,amendment number and routing number> is ❑ increased or Eldecreased by $amount of change to a new total funds available of $ <insert new cumulative total> for the following reason: . Section. is hereby modified accordingly. This Grant Funding Change Letter does not constitute an order for services under this Grant. The effective date of hereof is upon approval of the State Controller or , whichever is later. STATE OF COLORADO John W. Hickenlooper, GOVERNOR Department of Public Health and Environment PROGRAM APPROVAL: BY: By: Lisa Ellis, Purchasing & Contracts Unit Director Date: ALL GRANTS REOUIRE APPROVAL BY THE STATE CONTROLLER CRS §24-30-202 requires the State Controller to approve all State Grants. This Grant is not valid until signed and dated below by the State Controller or delegate. Grantee is not authorized to begin performance until such time. If Grantee begins performing prior thereto, the State of Colorado is not obligated to pay Grantee for such performance or for any goods and/or services provided hereunder. STATE CONTROLLER David J. McDermott, CPA By: Date: STATE OF COLORADO CDPHE-Weld County-MCH-14 FLA 59156 -Notification Moritz - CDPHE, Heather <heather.moritz@state.co.us> To: Tanya Geiser <tgeiser@co.weld.co.us> Cc: Gina Febbraro - CDPHE <gina.febbraro@state.co.us>, Leticia Aguirre - CDPHE <leticia.aguirre@state.co.us> Tue, Sep 10, 2013 at 9:28 AM Dear Tanya, This email serves as notification of your FULLY EXECUTED Colorado Department of Public Health & Environment (CDPHE) Contract Amendment listed below: Contractor Name: Board of County Commissioners of Weld County for the use and benefit of the Weld County Department of Public Health and Environment Contract Amendment Number: 14 FLA 59156 Original Contract Number: 13 FLA 48090 Division: Prevention Services Division/PSD Program Name: Maternal and Child Health Program/MCH Reason for Contract: Renewed Contract Please "Reply to Sender" acknowledging the receipt of this email. The Contract Amendment listed above has been fully executed and you may begin work on October 1, 2013. An original hard copy of the Contract Amendment will be mailed to you soon. Please contact me with questions or concerns. My contact information is listed below. Kind regards, Heather Moritz Contract Administrator Prevention Services Division Colorado Department of Public Health & Environment 4300 Cherry Creek Drive South Denver, CO 80246-1530 Phone: (303) 692-6271 heather.moritz@state.co.us Hello