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Home My WebLink About20062560.tiff RESOLUTION RE: APPROVE COMBINED TASK ORDER FOR MATERNAL AND CHILD HEALTH PROGRAM AND HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS 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 a Combined Task Order for the Maternal and Child Health Program and the Health Care Program for Children with Special Needs between the County of Weld,State of Colorado,by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and the Colorado Department of Public Health and Environment,commencing October 1,2006, and ending September 30, 2007, with further terms and conditions being as stated in said task order, and WHEREAS,after review, the Board deems it advisable to approve said task order, 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 Combined Task Order for the Maternal and Child Health Program and the Health Care Program for Children with Special Needs between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County 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 task order. The above and foregoing Resolution was,on motion duly made and seconded,adopted by the following vote on the 13th day of September, A.D., 2006. Elsa BOARD OF COUNTY COMMISSIONERS I WELD COW COLORADO ATTEST: gay 1 •� ' r112 . V' . J. .-ile, Chair Weld County Clerk to the tq1 ,°IIIBY:C 61 i ( G ZQ David E. Long, Pro-rem De ty Cler to the Board - Wi � m H. Jerke \\\\R3 �n _ O D AS TO � & U \R3 Rober��t��D. Ma en n orney it<% tr1 o/ -) Glenn Va j.-.-:------- 2006-2560 Date of signature: I p HL0033 nn ! l Col_ o-uq) D9---15--Uit" Memorandum ' TO: M.J. Geile, Chair OBoard of County Commissioners • From: Mark E. Wallace, MD, MPH, Director COLORADO Department of Public Health an \ Environment DATE: September 7, 2006 SUBJECT: MCH Program Task Order Enclosed for Board review and approval is a task order for the Maternal and Child Health Program (MCH) Program and the Health Care Program for Children with Special Needs (HCP). This task order is between the Colorado Department of Public Health and Environment and Weld County. Funding in the amount of$141,252 for the MCH program will be used to provide prenatal and postpartum care, including education and counseling to increase early entry into prenatal care, and to assist women with enrollment in Medicaid by maintaining the Health Department's status as a Presumptive Eligibility Site. Nursing staff will provide education for parents and providers in the community regarding the school immunization law and the benefits of immunizations. The task order will also provide funding for the HCP program in the amount of$180,773. These funds will be used to provide core public health services for children with special health care needs and case management for children with traumatic brain injuries. Some of the services provided will be case finding, community involvement, and interagency collaboration to children and their families who are determined eligible for such services. Eligible children are those who have or are at risk for a chronic physical, developmental, behavioral, or emotional condition. In addition to the above mentioned funding, Weld County will be reimbursed a sum not to exceed $900 per child for 12 months of services provided to children with traumatic brain injuries (TBI). The combined total reimbursement for the MCH and HCP programs for the time period October 1, 2006 through September 30, 2007 is $322,025. Of this amount $223,150 are pass through funding from the federal government, and $98,875 are state of Colorado funds. I recommend your approval of this task order. Enc. 2006-2560 DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT DEPARTMENT OR AGENCY NUMBER FLA CONTRACT ROUTING NUMBER 07-00394 TASK ORDER PSD-MCH This Task Order is made this 25TH day of AUGUST, 2006, by and between: the state of Colorado,acting by and through the COLORADO 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, the 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 17'" Avenue,Greeley,Colorado 80631, hereinafter referred to as"the Contractor", FACTUAL RECITALS Pursuant to section 25-1.5-101 (j)(I),C.R.S., as amended, the General Assembly of the state of Colorado has declared that the state"has, in addition to all other powers and duties imposed upon it by law,the powers and duties to disseminate public health information." Section 25-1.5-101 (r), C.R.S., as amended, states that the state can, "operate and maintain a program for children with disabilities to provide and expedite provision of health care services to children who have congenital birth defects or who are the victims of burns or trauma or children who have acquired disabilities". Section 25-1-709(I)(a), C.R.S., as amended, further states that"[t]he program and services of regional health departments shall include to the greatest extent possible, but not be limited to personal health services, including: maternal and child health services; program for children with disabilities". To accomplish its statutory duties, the State has determined that public health services are desirable in the Contractor's region. The United State Department of Health and Human Services ("HHS"),through the Maternal and Child Health Services Block Grant(MCH)has awarded the State Title V federal funds under Notice of Grant Award("NGA) number B04MC04248(See,Catalog of Federal Domestic Assistance("CFDA") number 93.994). The State's Prevention Services Division(PSD) is charged with the administration of funds from the Title V MCH Block Grant to improve the health and well being of the maternal and child/adolescent populations through assessing population needs, influencing health policy, engaging in strategic planning and coordinating/implementing best practices and evidenced-based programs. The authority for the administration of the Title V MCH Block Grant, including the maternal, child and children with special health care needs resides in Title V of the Social Security Act, §§ 501-509. Each state that receives MCH funds from the HHS must demonstrate to the HHS that it has served three(3)distinct population groups with the MCH funds. These three(3)distinct population groups are: "the perinatal population", which is defined to include women of childbearing age, pregnant women,and mothers;the"child and youth population", which is defined to include infants,children,and adolescents from birth through age twenty(20); and, the "children with special health care needs population"(CSHCN),which is defined as those children who have,or are at increased risk for a chronic physical,developmental, behavioral,or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. Page I of 10 • The State has formulated a comprehensive statewide plan to carry out a Maternal and Child Health Program, funded by Title V MCH dollars. As part of the comprehensive plan, it is the express intent of the state to support local public health agencies in contributing to a coordinated, efficient statewide program which focuses on specific MCH performance measures set by the MCH state and Federal agencies. Local public health agencies, working in partnership with other community organizations, facilitate the development and enhancement of community-based systems of care for the maternal, and child population.The goal of these systems is to ensure that all families have access to direct care services, as well as,enabling and population-based services that address the issues and health problems delineated in the MCH performance measures. Section 29-1-201, C.R.S. as amended, encourages governments to make the most efficient and effective use of their powers and responsibilities by cooperating and contracting with each other to the fullest extent possible to provide any function, service, or facility lawfully authorized to each of the cooperating or contracting entities. Section 29-1- 201,C.R.S.,as amended, further states that all state of Colorado contracts with its political subdivisions are exempt from the state of Colorado's personnel rules and procurement code. The Contractor is a political subdivision of the state of Colorado. The State and the Contractor mutually agree that the most efficient and effective way to provide the above-described services is at the local level. The State and the Contractor previously entered into a Master Contract with contract routing number 05 FAA 00054. This Task Order is issued pursuant to the terms and conditions of that Master Contract. As to the State, authority exists in the Law and Funds have been budgeted, appropriated,and otherwise made available, and a sufficient uncommitted balance thereof remains available for subsequent encumbering and payment in Fund Code(s) 100, Organizational Unit Code 6520, Appropriation Code 581, Program Code(s)9017, Function Code(s)ONST, Object Code(s) 5120,and Grant Budget Line Code(s)MC7A and MC7B for Prenatal and Child/ Adolescent services and Fund Code(s) 100,Organizational Unit Code 6810,Appropriation Code 606 and 611, Program Code(s)9017, Function Code(s) FLWT, Object Code(s)5120, and Grant Budget Line Code(s) MC7* and MC7C for Health Care Program for Children with Special Needs(HCP)services and Fund Code(s) 100, Organizational Unit Code(s)6810, Appropriation Code(s)731, Program Code(s)9017, Function Code(s)FLWT, Object Code(s)5120,and Grant Budget Line Code(s) LF7C for the Traumatic Brain Injury(TBI)survey services under Contract encumbrance number PO FLA MCH0700394. And, authority exists in the Law and Funds have been budgeted, appropriated, and otherwise made available, and a sufficient uncommitted balance thereof remains available for subsequent encumbering and payment in Fund Code(s) 100, Organizational Unit Code(s)6810,Appropriation Code(s)609, Program Code(s)9017, Function Code(s) FLWT, Object Code 5120, and Grant Budget Line Code(s)OF6P under Contract encumbrance number PO FLA HCP07000001 for Traumatic Brain Injury(TBI)services. All required approvals,clearances, and coordination have been accomplished from and with all appropriate agencies. NOW,THEREFORE, in consideration of their mutual promises to each other, stated below,the parties hereto agree as follows: A. PERIOD OF PERFORMANCE AND TERMINATION. The proposed effective date of this Task Order is October 1,2006. However, in accordance with section 24-30-202(1),C.R.S., as amended,this Task Order is not valid until it has been approved by the State Controller,or an authorized designee thereof. The Contractor is not authorized to, and shall not,commence performance under this Task Order until this Task Order has been approved by the State Controller. The State shall have no financial obligation to the Contractor whatsoever for any work or services or,any costs or expenses, incurred by the Contractor prior to the effective date of this Task Order. If the State Controller approves this Task Order on or before its proposed effective date,then the Contractor shall commence performance under this Task Order on the proposed effective date. If the State Controller approves this Task Order after its proposed effective date, then the Contractor shall only commence performance under this Task Order on that later date. The initial term of this Task Order shall commence on the effective date of this Task Order and continue through and including September 30,2007, unless sooner terminated by the parties pursuant to the terms and Page 2 of 10 conditions of this Task Order. In accordance with section 24-103-503,C.R.S., as amended, and Colorado Procurement Rule R-24-103-503,the total term of this Contract, including any renewals or extensions hereof, may not exceed five(5)years. B. DUTIES AND OBLIGATIONS OF THE CONTRACTOR. The Contractor, in accordance with the terms and conditions of the Master Contract and this Task Order, shall perform and complete, in a timely and satisfactory manner, all work items described in the Statement of Work, which is incorporated herein by this reference, made a part hereof and attached hereto as"Exhibit A". 2. The State and the Contractor have determined that the Contractor is a business associate under HIPAA in regards to the TBI services in this Task Order. Contractor hereby agrees to, and has an affirmative duty to, execute the State's current HIPAA Business Associate Agreement, which is attached hereto as "Exhibit B", and incorporated herein by this reference. This Business Associate Agreement shall be fully and properly executed by the Contractor and returned to the State at the time the Contractor signs the primary task order of which this exhibit is a part. C. DUTIES AND OBLIGATIONS OF THE STATE. In consideration of those Prenatal and Child/Adolescent services, set forth in Exhibit A, satisfactorily and timely performed by the Contractor under this Task Order,the State shall cause to be paid to the Contractor a sum not to exceed ONE HUNDRED FORTY-ONE THOUSAND, TWO HUNDRED FIFTY-TWO DOLLARS,($141,252.00). Of the financial obligation for the Prenatal and Child/Adolescent services,One Hundred Forty-One Thousand,Two Hundred Fifty-Two Dollars,($141,252.00)are identified as attributable to a funding source of the federal government and, Zero Dollars,($0.001 are identified as attributable to a funding source of the state of Colorado. 2. The Contractor shall be reimbursed for the HCP services in accordance with the Budget, which is incorporated herein by this reference, made a part of hereof attached hereto as"Exhibit C" for the initial term of this Task Order. In consideration for those HCP services timely and satisfactory performed by the Contractor under this Task Order,the State shall cause to be paid to the Contractor an amount not to exceed ONE HUNDRED EIGHTY THOUSAND,SEVEN HUNDRED SEVENTY-THREE DOLLARS,($180,773.00). Of the HCP financial obligation, Eighty-One Thousand,Eight Hundred Ninety-Eight Dollars,($81,898.00)are identified as attributable to a funding source of the federal government and, Ninety-Eight Thousand, Eight Hundred Seventy-Five Dollars,($98,875.00)are identified as attributable to a funding source of the state of Colorado. 3. The total financial obligation, Prenatal and Child/Adolescent and HCP financial obligations combined, is THREE HUNDRED TWENTY-TWO THOUSAND,TWENTY-FIVE DOLLARS,($322,025.00). Of the total financial obligation, Two Hundred Twenty-Three Thousand,One Hundred Fifty Dollars,($223,150.00)are identified as attributable to a funding source of the federal government and, Ninety-Eight Thousand, Eight Hundred Seventy-Five Dollars,($98,875.00)are identified as attributable to a funding source of the state of Colorado. Page 3 of 10 4. In addition to the budget referenced in paragraphs Cl. and C2. above,the Contractor shall be reimbursed for the initial term of this Task Order, for TBI services for a sum not to exceed Nine Hundred Dollars($900.00)per child for 12 months of services. Upon receipt of a TBI Care Coordination Invoice, incorporated herein by this reference, made a part hereof,and attached hereto as "Exhibit D",payments shall be made in twelve monthly increments as follows: $240 for the month in which the family signs the Care Coordination Plan and$60 for each of the eleven succeeding months as long as the client is in active status. Contractor shall only be reimbursed for months for which the client's status in the HCP/Clinical Health Information Record of Patients (CHIRP)database is"Active" Payment pursuant to this Contract shall be made as earned, in whole or in part, from available funds encumbered in an amount not to exceed ONE HUNDRED NINE THOUSAND, EIGHT HUNDRED DOLLARS($109,800.001 Statewide for TBI services for federal fiscal year 2006- 2007(October 1, 2006 through and including September 30,2007). Of this total financial obligation,ZERO DOLLARS,($0.00)are identified as attributable to a funding source of the federal government and,ONE HUNDRED NINE THOUSAND,EIGHT HUNDRED DOLLARS($109,800.00) are identified as attributable to a funding source of the state of Colorado. The liability of the State,at any time, for such payments shall be limited to the unencumbered remaining balance of such funds. If there is a reduction in the total funds appropriated for the purposes of this Contract, then the State, in its sole discretion, may proportionately reduce the funding for this Contract or terminate this Contract in its entirety. 5. The Contractor shall be compensation for the Prenatal and Child/Adolescent services under this Task Order through the State's Electronic Fund Transfer. 6. To receive compensation for the HCP services under this Task Order, the Contractor shall submit a signed, monthly or quarterly Cost Reimbursement Statement within sixty(60)calendar days of the end of the billing period for which services were rendered. A sample Task Order Reimbursement Statement is incorporated herein by reference, made a part hereof, and attached hereto as"Exhibit E". Expenditures shall be in accordance with those items identified in Exhibit C. These items may include, but are not limited to: the Contractor's salaries, fringe benefits, supplies,travel, operating, and indirect costs which are allowable and allocable expenses related to its performance under this Task Order. Each Cost Reimbursement Statement shall reference the related Master Contract by its contract routing number and this Task Order by their respective contract routing numbers. The Task Order contract routing number is located on page one and the Master Contract contract routing number is located on page two of these documents. Each Cost Reimbursement Statement shall also indicate the applicable performance dates,the names of payees;a brief description of the services performed during the relevant performance dates;all expenditures incurred; and,the total reimbursement requested. Reimbursement during the initial,or any renewal,term of this Task Order shall be conditioned upon affirmation by the State that all services were rendered by the Contractor in accordance with the terms of this Task Order. Each Cost Reimbursement Statement shall be sent to: Aida Diaz Prevention Services Division Colorado Department of Public Health and Environment PSD-HCP-A4 4300 Cherry Creek Drive South Denver,CO 80246 Page 4 of 10 7. Reimbursement for the Prenatal and Child/Adolescent services under this Task Order,and any renewal or extension hereof, shall be made to the Contractor on a monthly. Accordingly,the Contractor shall be paid one twelfth(1/12)of the State's financial obligation for the Prenatal and Child/Adolescent services under this Task Order each month for the first eleven(I I)months. The final payment for the twelfth(12h)month for the initial term of this Task Order,and any renewal or extension hereof, is contingent upon the State's timely receipt of a Final Expenditure Report from the Contractor by utilizing the"Application Budget and Final Expenditure Report" form incorporated herein by this reference, made a part hereof,and attached hereto as "Exhibit F". The Contractor shall submit two(2) Final Expenditure Reports using the"Application Budget and Final Expenditure Report"form, one report for the prenatal population and one report the child/adolescent population. 8. Reimbursement for the FICP services under this Task Order,and any renewal or extension hereof, shall be made to the Contractor on a monthly or quarterly basis. Accordingly, the Contractor shall be paid one twelfth(1/12)of the State's financial obligation under this Task Order each month for the first eleven(11) months or one fourth(1/4) for the first three(3)quarters. The final payment for the twelfth(12th)month or fourth(4th)quarter for the initial term of this Task Order, and any renewal or extension hereof, is contingent upon the State's timely receipt of the a Final Expenditure Report from the Contractor by utilizing the"Application Budget and Final Expenditure Report" form set forth in "Exhibit E"hereto, for the children with special health care needs population. 9. The State shall reimburse the Contractor for actual indirect costs up to the Prevention Services Division's maximum of twenty-five percent(25%) when the Contractor's indirect rate is based on Direct Costs,twenty-seven percent(27%)when the Contractor's indirect rate is based on Salary Only,or thirty percent(30%)when the Contractor's indirect rate is based on Salary and Fringe where no other direct costs are charged. 10. The State may prospectively increase or decrease the amount payable under this Task Order through a"Task Order Change Order Letter"that is substantially similar to the sample Task Order Change Order Letter that is incorporated herein by this reference, made a part hereof,and attached hereto as"Exhibit G". To be effective, a Task Order Change Order Letter must be: signed by the State and the Contractor;and, approved by the State Controller or an authorized designee thereof. Additionally,a Task Order Change Order Letter shall include the following information: A. Identification of the related Master Contract and this Task Order by their respective contract routing numbers and affected paragraph number(s); B. The type(s)of service(s)or program(s) increased or decreased and the new level of each service or program; C. The amount of the increase or decrease in the level of funding for each service or program and the new total financial obligation; D. A provision stating that the Task Order Change Order Letter is effective upon approval by the State Controller,or designee,or its proposed effective date,whichever is later. Page 5 of 10 Upon proper execution and approval, a Task Order Change Order Letter shall become an amendment to this Task Order. Except for the General and Special Provisions of the Master Contract, and the Additional Provisions of the Task Order, if any,the Task Order Change Order Letter shall supersede this Task Order in the event of a conflict between the two. It is expressly understood and agreed to by the parties that the task order change order letter process may be used only for increased or decreased levels of funding,corresponding adjustments to service or program levels,and any related budget line items. Any other changes to this Task Order,other than those authorized by the task order option to renew letter process described below,shall be made by a formal amendment to this Task Order executed in accordance with the Fiscal Rules of the state of Colorado. If the Contractor agrees to and accepts a proposed Task Order Change Order Letter,then the Contractor shall execute and return that Task Order Change Order Letter to the State by the date indicated in that Task Order Change Order Letter. If the Contractor does not agree to and accept a proposed Task Order Change Order Letter, or fails to timely return a partially executed Task Order Change Order Letter by the date indicated in that Task Order Change Order Letter,then the State may, upon written notice to the Contractor,terminate this Task Order no sooner than thirty(30) calendar days after the return date indicated in the Task Order Change Order Letter has passed. This written notice shall specify the effective date of termination of that Task Order. If a Task Order is terminated under this clause,then the parties shall not be relieved of their respective duties and obligations under that Task Order until the effective date of termination has passed. Increases or decreases in the level of contractual funding made through the task order change order letter process during the initial, or renewal,term of a Task Order may only be made under the following circumstances: E. If necessary to fully utilize appropriations of the state of Colorado and/or non- appropriated federal grant awards; F. Adjustments to reflect current year expenditures; G. Supplemental appropriations, or non-appropriated federal funding changes resulting in an increase or decrease in the amounts originally budgeted and available for the purposes of a Task Order; H. Closure of programs and/or termination of related contracts or task orders; I. Delay or difficulty in implementing new programs or services; and, J. Other special circumstances as deemed appropriate by the State. 11. The State may renew a Task Order through a"Task Order Option to Renew Letter" substantially similar to the sample Task Order Option to Renew Letter that is incorporated herein by this reference, made a part hereof, and attached hereto as"Exhibit H". To be effective, a Task Order Option to Renew Letter must be: signed by the State and the Contractor;and,approved by the State Controller or an authorized designee thereof. Additionally, a Task Order Option to Renew Letter shall include the following information: A. Identification of the related Master Contract and that Task Order by their respective contract routing numbers and affected paragraphnumber(s); B. The type(s)of service(s) or program(s), if any, increased or decreased and the new level of each service or program for the renewal term; C. The amount of the increase or decrease, if any, in the level of funding for each service or program and the new total financial obligation; Page 6 of 10 D. A provision stating that the Task Order Option to Renew Letter is effective upon approval by the State Controller, or designee,or its proposed effective date, whichever is later. Upon proper execution and approval,a Task Order Option to Renew Letter shall become an amendment to this Task Order. Except for the General and Special Provisions of the Master Contract,and the Additional Provisions, if any of that Task Order, a Task Order Option to Renew Letter shall supersede that Task Order in the event of a conflict between the two. It is expressly understood and agreed to by the parties that the task order option to renew letter process may be used only to: renew a Task Order; increase or decrease levels of funding related to that renewal; make corresponding adjustments to service or program levels, and,adjust any related budget line items. Any other changes to a Task Order,other than those authorized by the task order change order letter process described above, shall be made by a formal amendment to a Task Order executed in accordance with the Fiscal Rules of the state of Colorado. If the Contractor agrees to and accepts a proposed Task Order Option to Renew Letter, then the Contractor shall execute and return that Task Order Option to Renew Letter to the State by the date indicated in that Task Order Option to Renew Letter. If the Contractor does not agree to and accept the proposed renewal term, or fails to timely return a partially executed Task Order Option to Renew Letter by the date indicated in that Task Order Option to Renew Letter,then the State may, upon written notice to the Contractor,terminate this Task Order no sooner than thirty(30) calendar days after the return date indicated in the Task Order Option to Renew Letter has passed. This written notice shall specify the effective date of termination of that Task Order. If a Task Order is terminated under this clause,then the parties shall not be relieved of their respective duties and obligations under that Task Order until the effective date of termination has passed. 12. All attachments or exhibits to this Task Order are incorporated herein by this reference and made a part hereof as if fully set forth herein. If a conflict or inconsistency is found to exist between the terms and conditions of this Task Order and those of any attachment or exhibit hereto,then the terms and conditions of this Task Order shall control. D. ADDITIONAL PROVISIONS. Contractor shall assure attendance of at least one local Prenatal and Child/Adolescent services and/or HCP staff representative to state or regional teleconferences, meetings, and/or videoconference meetings that the state may organize to address priority Prenatal and Child/Adolescent services and/or HCP needs, promote learning groups, increase skills as Prenatal and Child/Adolescent services and/or HCP practitioners and/or carry out state and local MCH planning activities. 2. The State is responsible to ensure that the program planning, evaluation,and monitoring requirements as described in this Task Order and the Attachments are met by the Contractor. To fulfill these responsibilities,the State has the right to make site visits and schedule any other meetings at the Contractor's location. 3. Contractor shall cooperate with the State and provide all requested records regarding recipients for whom services were provided under this Task Order. 4. The Contractor shall cooperate with the State to ensure that the program planning, evaluation, and monitoring requirements as described in this Task Order and the Attachments are met. This cooperation includes, but is not limited to participation in mutually agreed upon site visits at the Contractor's location,and any other meetings required by the State. Page 7 of 10 5. Contractor shall retain and use all revenues generated by the individual MCH Programs for services in those programs. 6. The State will not accrue any liability for non-payment of care coordination fees by HMO providers or other third party payers. The State will facilitate negotiations with the Contractor during collection efforts, however timely notification by the Contractor to the State and third parties will be essential. 7. 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). 8. The 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,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 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, the Contractor certifies that the Contractor will comply with the requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision of services for children as defined by the Act. The Contractor agrees that it will require that the language of the Act be included in any subcontracts which contain provisions for children's services and that all contractors shall sign and agree accordingly. 9. The Contractor certifies,to the best of its knowledge and belief,that no federally appropriated funds have been paid or will be paid by or on behalf of the Contractor,to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of this Task Order, and the extension, continuation,renewal, amendment, or modification of this Task Order, or any grant, loan,or other cooperative agreement that utilizes Federal funds. If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency,Member of Congress, an officer or employee of Congress in connection with this Task Order,or any other grant, loan,or other cooperative agreement,then the Contractor shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying" in accordance with its instructions. The Contractor shall require that the language of this certification be included in the award documents for subawards at all tiers(including subcontracts, subgrants, and contracts under grants, loans,and cooperative agreements)and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. This certification is a prerequisite for making or entering into this transaction imposed by section 1352,title 31,U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than$10,000 and not more than$100,000 for each such failure. Page 8 of 10 10. 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 (I)(B) and Section 505 (5)(D). The 100 percent of poverty gross income guideline for farm or non-farm families is currently at$9 800 for a family of 1,$13200 for a family of 2; $16 600 for a family of 3;$20,000 for a family of 4;$23400 for a family of 5; $26 800 for a family of 6; $30,200 for a family of 7; and$33600 for a family of S. For families of more than eight, add $3 400 for each additional member. 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. 11. The Contractor shall protect the confidentiality of all applicant or recipient records and other materials that are maintained in accordance with this Task Order. Except for purposes directly connected with the administration of this Task Order, 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. The Contractor shall have written policies governing the access to, and duplication and dissemination of, all such information. The Contractor shall advise its employees, agents, servants, and subcontractors, if any,that they are subject to these confidentiality requirements. 12. Contractor shall ensure that the provisions of Section 601 of Title VI of the Civil Rights Act of 1964 are carried out. That Act states that "no person in the United States shall on the ground of race, color, or national origin,be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance." The Office of Civil Rights has concluded that it is the responsibility of any program which is a recipient of funds from the Department of Health and Human Services to ensure that clients who do not speak or understand English well, be provided interpretation services to ensure that the service provider and the client can communicate effectively. The Contractor shall have policies and procedures to ensure that interpretation services are available for clients with Limited English Proficiency and will advise such clients that an interpreter will be provided for them. If a client has their own interpreter,they shall be advised that the Contractor will provide an interpreter if the client so chooses. 13. The services or activities under this Task Order may be carried out by the Contractor itself, or through subcontracts with other providers or,through collaborative partnerships with other community partners. The State authorizes the Contractor to subcontract some,or all, of the services that are to be performed under this Task Order. However,a subcontractor is subject to all of the terms and conditions of this Task Order. Additionally, the Contractor remains ultimately responsible for the timely and satisfactory completion of all work performed by any subcontractor(s) under this Task Order. If the Contractor desires to subcontract some,or all, of the services that are to be performed under this Task Order,the Contractor shall obtain the prior, express,written consent of the State before entering into any subcontract. Page 9 of 10 IN WITNESS WHEREOF,the parties hereto have executed this Task Order as of the day first above written. CONTRACTOR: STATE: BOARD OF COUNTY COMMISSIONERS STATE OF COLORADO OF WELD COUNTY Bill Owens. Governor (a political subdivision of the state of Colorado) for the use and benefit of the Weld County Department of Public Health and Environment - By: .✓ By: a ly.,./ Name: M. J. Geile For the Executive Director Title: BOCC Chair DEPARTMENT OF PUBLIC HEALTH FEIN: 84-6000813 AND ENVIRONMENT Date: SFP 1 3 2006 Date: . !% ATJZ yMat PROGRAM APPROVAL: • li �, ter if 11 1,11( By: I/lM.liY-1 a � and ,ounty,County, 'hie/ i.e, 1 t istrict,or Town Clerk or Equivalent.ipAPPROVALS: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts.This contract is not valid until the State Controller,or such assistant as he may delegate,has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below,the State of Colorado may not be obligated to pay for the goods and/or services provided. STATE CONTROLLER: Leslie M. Shenefelt By: 4)i.A.....a.—a\c.—.,—...... Date: l oft 101,O Revised: 11/5/04 WELD BOUNTY DEPARTMENT OF Ptk LiC HEA TM rr�'D E ON ENT BY: &U� ,' Page 10 of 10 Mark E. Wallace, MD, MPH•Director Exhibit A STATEMENT OF WORK To Task Order Dated 08/25/2006-Contract Routing Number 07 FLA 00394 This Statement of Work is for the three maternal and child health(MCH)populations, which cover prenatal, child and adolescent, and children and youth with special health care needs. Because there are some tasks pertaining to all three MCH populations, some tasks pertaining only to the prenatal and child/adolescent populations and other tasks pertaining only to the children and youth with special health care needs population this Statement of Work has been set up in three Sections; A. Maternal and Child Health(MCH), B. Prenatal and Child/Adolescent, and C. Health Care Program for Children with Special Needs(HCP). It is important to note that when the Contractor is requested to submit a report in an item in Section A the information provided is to be for all three MCH populations. A. Maternal and Child Health(MCH) 1. Under this Task Order, a local public health agency, such as the Contractor, shall provide the core public health services of assessment, policy development,and assurance on behalf of the prenatal, child and adolescent, and children and youth with special health care needs(CYSHCN) populations as described and defined in"Attachment A-I","Core Public Health Services Delivered by MCH Agencies",which is incorporated herein by this reference, made a part hereof, and attached hereto. 2. Submission of Final Expenditure Reports for Federal Fiscal Year 2005-2006: On or before December I,2006,the Contractor shall submit to the State for review and approval three(3) Final Expenditure Reports; one for each of the three(3)maternal and child populations, i.e., prenatal, child and adolescent, and children and youth with special health care needs, for federal fiscal year 2005-2006(October I,2005,through September 30, 2006), utilizing the sample form previously set forth in the Task Order as"Exhibit F". The Contractor shall report actual expenditures and the match separately for the prenatal, child and adolescent, and children and youth with special health care needs programs showing both the funds received from the State via this Task Order and other sources of funding available for match. The agency's Director or Authorized Representative shall sign the final expenditure reports prior to submitting them to the State. The final payment for the term of October I,2005, through September 30,2006 is contingent upon the State's timely receipt of the three(3) fully completed and signed Final Expenditure Reports,which shall be mailed to: Sally Merrow Prevention Services Division Colorado Department of Public Health and Environment PSD-MCH-A4 4300 Cherry Creek Drive South Denver,CO 80246 Page I of 9 3. Submission of Actual Budget Allocations for Federal Fiscal Year 2005-2006. On or before December 1,2006,the Contractor shall submit to the State one(1) "Core Public Health Application and/or Expenditure Report" form showing the Contractor's actual budget allocations for the three(3)maternal and child populations, i.e.,prenatal, child and adolescent, and children and youth with special health care needs(CYSHCN), for the federal fiscal year 2005-2006 (October 1,2005,through September 30,2006). A sample form, which the Contractor shall utilize, is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment A-2". The completed report shall be submitted via electronic mail to: cdnhe.usmchreports@ state.co.us 4. Submission of Numbers Served Report for Federal Fiscal Year 2005-2006. On or before January 15, 2007,the Contractor shall submit to the State, for review and approval,a completed"Number of Individuals Served(Unduplicated) Under Title V Report",for those services provided by the Contractor in federal fiscal year 2005-2006(October 1,2005,through September 30,2006). A sample form, which the Contractor shall utilize, is incorporated herein by this reference, made a part hereof,and attached hereto as"Attachment A-3". This report shall be submitted via electronic mail to: Karen Trierweiler at: karen.trierweiler(u state.co.us 5. Submission of Estimated Funding Allocations for Federal Fiscal Year 2007-2008. On or before May 1, 2006,the Contractor shall submit to the State for review and approval one(1)"Core Public Health Application and/or Expenditure Report"form showing the estimated funding allocations for the three(3)maternal and child populations, i.e., prenatal,child and adolescent,and CYSHCN for the federal fiscal year 2007-2008 (October 1,2007,through September 30,2008). A sample form,which the Contractor shall utilize,has previously been set forth is this Attachment as"Attachment A-2",which shall be submitted via electronic mail to: cdohe.psmchreportsAstate.co.us 6. Submission of Detailed Line Item Application Budget and Detailed Budget Narrative for Federal Fiscal Year 2007-2008. On or before May 1,2007,the Contractor shall submit to the State for review and approval three(3)"Application Budget and Final Expenditure Report" forms showing the estimated detailed line item funding allocations to each of the three(3) maternal and child populations, i.e. prenatal,child and adolescent,and CYSHCN for the federal fiscal year 2007-2008 (October 1,2007,through September 30,2008). A sample form"Application Budget and Final Expenditure Report", which the Contractor shall use, has previously been set forth as Exhibit F of the Task Order. The Contractor shall also submit a budget narrative for each of the three(3)budgets. Each budget narrative shall begin on a new page and be no more than two (2)pages. The narratives shall explain and justify the expenses for personal services,operating,equipment, supplies,travel,and contractual services. The narratives shall link each expense with a Local Prenatal and Child/Adolescent or CYSHCN Plan objective. In each narrative provide names and titles of all personnel, as well as the percent of time going to each major objective. Each population's detailed line item application budget and narrative shall be submitted to: Sally Merrow Prevention Services Division Colorado Department of Public Health and Environment PSD-MCH-A4 4300 Cherry Creek Drive South Denver,CO 80246 Page 2 of 9 B. Prenatal,and Child/Adolescent The Contractor shall provide leadership, in coordination with public and private community partners, in the development of the Contractor's Local Prenatal and Child/Adolescent Plan and the implementation of the Contractor's Prenatal and Child/Adolescent Operational Plan. The State shall provide guidance and technical assistance to the Contractor to support the implementation of the Contractor's Prenatal and Child/Adolescent Operational Plan for federal fiscal year 2006-2007 and for the development of the Contractor's Local Prenatal and Child/Adolescent Plan for the federal fiscal year 2007-2008. The Prenatal and Child/Adolescent Operational Plan and the Local Prenatal and Child/Adolescent Plan are to be based on an assessment of the health status needs of the prenatal, child and adolescent populations and of the health system resources of a community. These plans are further designed to: a. Contribute to the accomplishment of the State's priorities, performance measures,and outcome measures,as identified in"Attachment A-4",which is incorporated herein by this reference, made a part hereof, and attached hereto; b. Provide for the continuation of the core public health services of assessment, policy development,and assurance on behalf of the maternal and child health populations and in implementing the 10 essential services for this population in partnership with the State, as identified in "Attachment A-5",which is incorporated herein by this reference, made a part hereof, and attached hereto; c. Work with public and private community partners to plan for the development and maintenance of resources that assure access to direct care and services for vulnerable women, children,and adolescents,such as those who are low-income, uninsured, underinsured, or who live in rural or underserved areas or who are from ethnic or cultural minority communities and may experience language or cultural barriers to services; d. Facilitate outreach and enrollment efforts, including having information and applications on site, to increase enrollment of eligible children and adolescents, including those with special health care needs, in Medicaid(Colorado Baby Care/Kid's Care Program)or Child Health Plan Plus(CHP+); e. Refer families participating in any and all programs in its agency such as Women, Infants and Children(WIC); Early and Periodic Screening, Diagnosis and Treatment(EPSDT); Immunization Clinics; Family Planning;HCP; etc. to appropriate enabling and direct care service programs in the community. All pregnant women in need of resources for prenatal medical care shall be provided with information about programs such as Prenatal Plus, WIC,etc., as needed. The Contractor shall provide all individuals seeking reproductive health services: with information about pregnancy planning,the consequences of unintended pregnancies,and, referrals to comprehensive family planning services; and f Work with public and private community partners to plan for the development and implementation of population-based approaches for addressing MCH performance measures and priority issues for women,children and adolescents in the community. Page 3 of 9 2. Prenatal and Child/Adolescent Operational Plan Implementation. The Contractor shall implement its "Prenatal and Child/Adolescent Operational Plan" for those services and activities that shall be completed in federal fiscal year 2006-2007(October 1, 2006,through September 30,2007). The Prenatal and Child/Adolescent Operational Plan previously developed by the Contractor, in consultation with the State,based on an assessment of the health status needs of its prenatal and child/adolescent populations and of the health system resources of its community and shall utilize in full or in part the best-practice templates developed for specific performance measures by the State staff. The federal fiscal year 2006-2007 Prenatal and Child/Adolescent Operational Plan is incorporated herein by this reference, made a part hereof, and attached hereto as"Attachment A-6", titled,"Weld County Department of Public Health and Environment Prenatal and Child/Adolescent Operational Plan for October 1,2006,through September 30,2007". 3. Submission of Prenatal and Child/Adolescent Final Report for Federal Fiscal Year 2005-2006: On or before January 15,2007,the Contractor shall submit a Prenatal and Child/Adolescent Final Report for the contractor's federal fiscal year 2005-2006(October 1,2005,through September 30, 2006) activities. Instructions for submitting the Prenatal and Child/Adolescent Final Report are set forth in"Attachment A-7", incorporated herein by this reference, made a part hereof, and attached hereto. 4. Submission of Prenatal and Child/Adolescent 6-Month Progress Report for Federal Fiscal Year 2006-2007: On or before May 1,2007,the Contractor shall submit a Prenatal and Child/Adolescent 6-Month Progress Report for the first six months(October I,2006—March 31, 2007)of the Contractor's federal fiscal year 2006-2007 activities. Instructions for submitting the Prenatal and Child/Adolescent 6-Month Progress Report are set forth in"Attachment A-8", incorporated herein by this reference, made a part hereof,and attached hereto. 5. Submission of Local Prenatal and Child/Adolescent Plan for Federal Fiscal Year 2007-2008: On or before May 1, 2007,the Contractor shall submit a Prenatal and Child/Adolescent Local Plan for federal fiscal year 2007-2008 (October 1,2007 through September 30,2008). The Prenatal and Child/Adolescent Local Plan shall consist of three(3)sections, 1.)Organizational Chart,2.) Statement of Need, utilizing the Performance Measure Checklist—Part II-FY08, which is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment A-9"; and 3.) Prenatal and Child/Adolescent Operational Plan, utilizing a standard table format, which is incorporated herein by this reference, made a part hereof,and attached hereto as, "Attachment A-10". Instructions for completing and submitting the Local Prenatal and Child/Adolescent Plan are set forth in"Attachment A-11", incorporated herein by this reference, made a part hereof, and attached hereto. C. Health Care Program for Children with Special Needs(HCP) The Contractor shall develop an Annual Plan for Children and Youth with Special Health Care Needs in collaboration with community partners in the region. The purpose of the Annual Plan is to assure that the Contractor systematically addresses the Six Core Outcomes and Performance Measures for children with special health care needs, which is incorporated herein by this reference, made a part hereof, and attached hereto as,"Attachment A-12", according to identified community health needs and local capacity to effect improvement on the status of the Outcomes. The elements of the Annual Plan shall include: a. Organizational Chart b. CYSHCN Statement of Need c. CYSHCN Operational Plan d. MCI-I Fiscal Statement e. Detailed Line Item Application Budget and Detailed Budget Narrative f. Core Public Health Application and/or Expenditure Report Page 4 of 9 The State HCP staff shall provide consultation and technical assistance to the Contractor for implementation of the Contractor's CYSHCN Operational Plan for federal fiscal year 2007 and for the development of the Contractor's Annual Plan for the federal fiscal year 2008. The Contractor's Annual Plan is to be based on an assessment of the health status of children and youth with special health care needs in the Contractor's region and of the health system's capacity to address these needs, The Annual Plan is designed to: a. Support the Core Public Health functions of assessment,policy development,and assurance and the 10 Essential Services of Public Health on behalf of the MCH populations and in partnership with the department, as identified in"Attachment A-5", previously set forth in this Exhibit; b. Encourage Contractor collaboration with public and private community partners in the region,to develop and maintain resources that assure access to direct care and services for vulnerable children and youth with special health care needs. Vulnerable children may be defined as those who are low-income, uninsured, underinsured, or who live in rural or underserved areas or who are from ethnic or cultural minority groups who may experience language or cultural barriers to services; c. Facilitate Contractor outreach and enrollment efforts including client technical assistance and applications on site, as capacity allows,to increase enrollment of eligible children and youth with special health care needs, in Medicaid,Child Health Plan Plus(CHP+), and Supplemental Security Income(SSI); d. Encourage Contractor to work with public and private community partners in the region to develop and implement population-based approaches to addressing the Six Core Outcomes and Performance Measures and priority issues for children and youth with special health care needs in the Contractor's region. 2. Contractor shall engage in public health activities designed to enhance the health status of children and youth with special health care needs. These activities shall include direct services, enabling services,population-based activities and infrastructure building as described in the,"Core Public Health Services Delivered by MCH Agencies", previously references as"Attachment A-I". 3. Children and Youth with Special Health Care Needs(CYSHCN)Operational Plan Implementation: The Contractor shall implement its"Children and Youth with Special Health Care Needs(CYSHCN)Operational Plan" for those services and activities which shall be completed in federal fiscal year 2006-2007(October 1,2006,through September 30, 2007). The federal fiscal year 2006-2007 CYSHCN Operational Plan is incorporated herein by this reference, made a part hereof,and attached hereto as"Attachment A-13",titled, "Weld County Department of Public Health and Environment CYSHCN Operational Plan for October I, 2006,through September 30,2007". The CYSHCN Operational Plan is designed to:contribute to the accomplishment of the Six Core Outcomes and Performance Measures,as identified in"Attachment A-l2, which has previously been referenced in this Exhibit. 4. Contractor shall perform in accordance with the HCP Contract Performance Measures, located in the January Reporting section of the HERMAN Application. Page 5 of 9 5. Contractor shall work collaboratively with the State's delegated staff for consultation, technical assistance,oversight and training on documentation in the Health Care Program for Children with Special Needs/Clinical Health Information Record of Patients(HCP/CHIRP)database and to ensure that all HCP/CHIRP database users follow the HCP/CHIRP database policies and procedures as outlined in the HCP Policy and Procedure Manual and CHIRP User Guide. 6. Contractor shall follow the HCP/CHIRP Security policy and procedures outlined in the CHIRP User Guide and HCP Policy and Procedure Manual 7. Submission of the HCP Contract Performance Measure Annual Report: On or before January 15, 2007,the Contractor shall submit the HCP Contract Performance Measure Annual Report by completing the January Reporting section of the HERMAN Application. The report is to be submitted by electronic mail to: cdphe.psmchreports(a state.co.us 8. Submission of CYSHCN Operational Plan Final Report for Federal Fiscal Year 2005-2006: On or before January 15, 2007,the Contractor shall submit the CYSHCN Operational Plan Final Report for the Contractor's federal fiscal year 2005-2006(October 1,2005,through September 30,2006) by completing the January Reporting section of the HERMAN Application. The report is to be submitted by electronic mail to: cdphe.psmchreportsstate.co.us 9. Submission of CYSHCN Operational Plan 6-Month Progress Report for Federal Fiscal Year 2006-2007: On or before May I,2007, the Contractor shall submit to the Contractor's State HCP Program Consultant the CYSHCN Operational Plan 6-Month Progress Report, pertaining to the CYSHCN Operational Plan for the first six months(October I,2006—March 31,2007)of the Contractor's federal fiscal year 2006-2007 activities by completing the May Reporting section of the HERMAN Application. The report is to be submitted by electronic mail to: cdphe.psmch reports(n�state.co.us 10. Submission of the Local CYSHCN Annual Plan for Federal Fiscal Year 2007-2008: On or before May 1,2007 the Contractor shall submit a"Local CYSHCN Annual Plan for federal fiscal year 2007-2008 (October 1,2007 through September 30,2008). Instructions for completing submitting the CYSHCN Annual Plan are set forth in the May Reporting section of the HERMAN Application. The Annual Plan is to be submitted by electronic mail to: cdphe.psmchreports(7a state.co.us I I. The Contractor shall serve the population of children and their families who are determined to fall under the MCH definition of children with special health care needs(CSHCN), which is: "Children with special health care needs are those who have or are at risk for a chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children generally." (Developed by the Federal Bureau of Maternal Child Health in 1995.) Recipients served shall be children residing or whose families have residence in Weld County. 12. The Weld HCP Regional Office staff shall work cooperatively with the public health nurses (PHNs) from Weld County. Page 6 of 9 13. The HCP Discipline Regional Coordinators funded through this Task Order shall serve the CYSHCN population in the following functional roles: a. The Audiology Regional Coordinator shall serve Weld County. b. The Nutrition Regional Coordinator shall serve Weld County. c. The OT/PT Regional Coordinator shall serve Weld County. d. Speech Regional Coordinator shall serve Weld County. e. The Family Regional Coordinator shall serve Weld County. f. The Vision Regional Coordinator shall serve Weld County. g. The Nursing Regional Coordinator shall serve Weld County h. The Social Work Regional Coordinator shall serve Weld County. 14. The Weld HCP Regional Office (HCP RO) shall provide care coordination for families who have children with Traumatic Brain Injury(TBI)who are enrolled with the TBI Trust Fund Program in their region, in accordance with the following process: a. Upon receiving a referral packet of information from the state office, the HCP RO shall enter the child into the HCP/CHIRP database and assign a Care Coordinator. The Care Coordinator shall provide care coordination for up to twelve(12) months for each child. b. The Care Coordinator shall contact the family to set up an appointment to develop a care coordination plan that is reasonable to accomplish within twelve(12) months. The Care Coordinator shall develop the care coordination plan by reviewing the needs described on the TBI Trust Fund Program application, completing a standardized assessment of client and family,asking the family to describe their priority wants or needs, and consulting the HCP RO multi-disciplinary team and/or community providers/agencies. The Care Coordinator shall complete the HCP care coordination plan form, sign the plan, and obtain a signature from the family. c. Upon obtaining a signed care coordination plan,the Care Coordinator shall send a TBI Care Coordination Invoice,utilizing the form previously set forth in the Task Order as "Exhibit D"; the form shall be sent to: Rasa Eglite Prevention Services Division Colorado Department of Public Health and Environment PSD-HCP-A4 4300 Cherry Creek Drive South Denver,CO 80246 d. The Care Coordinator shall implement the care coordination plan. e. The Care Coordinator shall enter demographic information, registration, status, referrals, concerns, and encounters into the HCP/CHIRP database to document the care coordination plan, progress of activities, and outcomes. f. The Care Coordinator shall assure that the care coordination plan is documented in the HCP/CHIRP database and shall be completed for goal statement(s), activities and outcomes per HCP policies and procedures. Page 7 of 9 g. The Care Coordinator shall have care coordination plans available for audit purposes. h. The Care Coordinator shall inform families that received care coordination that they will be sent a state family satisfaction survey at the end of the twelve-month period and encourage them to respond. The HCP RO multi-disciplinary team shall provide technical assistance to the Care Coordinator,as needed. j. The HCP RO and Care Coordinator shall use the"HCP Policy and Procedures for Care Coordination Services for Children and Youth with Traumatic Brain Injury", which is made available on the HCP web site: www.hcpcolorado.org for implementation and documentation of TBI Program services. k. The Contractor, HCP RO,and Care Coordinator shall comply with any and all local agency HIPAA regulations;take all appropriate steps to maintain client confidentiality; and obtain any necessary written permissions or agreements for data analysis or disclosure of protected health information, in accordance with the Health Insurance Portability and Accountability Act of 1996(HIPAA)regulations, including, but not limited to,authorizations, data use agreements, business associate agreements, as necessary. Failure to comply with any applicable provision of HIPAA shall constitute a breach of this Task Order. 15. The Contractor agrees that any charges for attendance and services at specialty clinics sponsored by HCP must conform to the "Clinic Support Fee Schedule" for HCP clinics, "Attachment A-14" and any subsequent amendments thereto, attached hereto, incorporated herein by this reference, made a part hereof. 16. The Contractor shall retain and use all HCP Specialty Clinic revenues generated by the Contractor to support the HCP clinic activities such as clinic supplies,clinic equipment,clinic furniture,or parent professional stipends. 17. HCP designated staff and Care Coordinators shall follow the policies and procedures in the"HCP Policies and Procedures Manual". 18. The Contractor shall collaborate with HCP to plan and test the pilot outreach to families with children who have been hospitalized with traumatic brain injury through July 31, 2007 by completing the following: a. Attend 6-8 telephone conference calls with the State and other pilot sites as needed - b. Contact families by following a protocol that the pilot sites develop c. Provide information on traumatic brain injury,the potential effects of TBI,both medical and later signs/symptoms once the child returns to school,and on the TBI trust fund, d. Provide information on major relevant services, including insurance and Child Health Plan Plus,and help connect families with a medical home and with services and supports in the community e. Enter information into the HCP/CHIRP Database to track clients and document activities and outcomes,such as a successful contact and the result of the contact f. Provide written feedback on the pilot outreach and indicate any changes, adjustments to protocols,and possible improvements g. Attend specified training as needed Page 8 of 9 The State anticipates that the final planning meetings will be in late 2006 and the pilot outreach will begin in the spring of 2007. For this pilot outreach project,the State expects to provide the Weld HCP Regional Office,through the HCP/CHIRP database, contact information on 35-40 children with traumatic brain injury residing in Weld county. Page 9 of 9 Attachment A-I CORE PUBLIC HEALTH SERVICES DELIVERED BY MCH AGENCIES DIRECT HEALTH CARE SERVICES: (GAP FILLING) Examples: Basic Health Services, and Health Services for CSHCN ENABLING SERVICES: Examples: Transportation,Translation,Outreach, Respite Care,Health Education, Family Support Services,Purchase of Health Insurance, Case Management,Coordination with Medicaid, WIC,and Education POPULATION-BASED SERVICES: Examples: Newborn Screening,Lead Screening,Immunization, Sudden Infant Death Syndrome Counseling,Oral Health, Injury Prevention,Nutrition and Outreach/Public Education INFRASTRUCTURE BUILDING SERVICES: Examples: Needs Assessment,Evaluation,Planning, Policy Development, Coordination,Quality Assurance, Standards Development,Monitoring, Training,Applied Research, Systems of Care, and Information Systems MCHB/DSCH 10/20/97 Page 1 of 5 DEFINITIONS OF THE FOUR TYPES OF SERVICES BY WHICH THE CORE PUBLIC HEALTH SERVICES ARE PROVIDED BY MATERNAL AND CHILD HEALTH PROGRAMS AS DEFINED BY THE MATERNAL AND CHILD HEALTH BUREAU As of October 1,2003 1. Direct Health Care Services Direct health care services are defined as basic health services. Such services are generally delivered"one on one" between a health professional and a patient in an office,clinic or emergency room. Basic services include what most consider to be ordinary medical care, inpatient and outpatient medical services, allied health services, drugs, laboratory testing, x-ray services,dental care, and pharmaceutical products and services. State Title V programs may support services such as prenatal care, child health, school health and family planning by directly operating programs or by funding local providers. Direct health care services also include health care services for children with special needs. 2. Enabling Services Enabling services are defined as services that allow or provide for access to and the derivation of benefits from the array of basic health care services. Enabling services include transportation,translation, outreach, respite care, health education, family support services, purchase of health insurance, case management, and coordination of care. These kinds of services are especially necessary for the low-income population which is disadvantaged, geographically or culturally isolated,and for those with special and complicated health needs. 3. Population-Based Services Population-based services are defined as services which are intended and available for the entire population, rather than for a selected group of individuals. Disease, prevention, health promotion and statewide outreach come under this heading. Oral health, injury prevention, nutrition and outreach and public education are topics which also belong in this category. Population-based services are generally available for women and children regardless of whether they receive care in the public or private sector or whether or not they have health insurance. 4 Infrastructure Building Services Infrastructure building services are defined as those services that are directed at improving and maintaining the health status of a population. Included among those services are development and maintenance of health systems, standards, and guidelines,training,data,and planning. Needs assessment,evaluation, policy development, quality assurance, information systems, and applied research are all contained within the infrastructure umbrella. Page 2 of 5 Core Public Health Services Local Activities for Prenatal Care Direct Services • Provision of prenatal care/family planning services Enabling Services • PN+program services/Nurse Family Partnership Services • Medicaid/Child Health Plan Plus(CHP+) information/enrollment • Translation services • Transportation • Prenatal care/resource referrals and/or care coordination • Client health education regarding breastfeeding, seat belts, immunization,smoking cessation, etc. Population-Based Services • Prenatal Weight Gain Campaign • Unintended Pregnancy Prevention projects • Breastfeeding Promotion campaign • Medicaid/CHP+countywide outreach Infrastructure Building • MCH community needs assessment • Perinatal Periods of Risk Analysis • Local MCH Plans,progress reports and evaluations • Local Prenatal/Prenatal Plus/PRAMS data collection and analysis Page 3 of 5 Core Public Health Services Local Activities for Children and Adolescents Direct Services • Well Child Care for Undocumented Kids • Primary care in School-Based Health Centers • Immunization Clinics Enabling Services • Health education regarding breastfeeding, seatbelts, immunization, smoking cessation, etc. • CHP+& Medicaid Outreach& Enrollment • Translation Services • Plans for Locating a Clinic in a School to Increase Access • Client Health • Education re: pregnancy prevention, fitness, nutrition, motor vehicle safety, immunizations, substance abuse, etc. Population Based Services • Breastfeeding Promotion campaign • Medicaid/CHP+county-wide outreach • Public education/social marketing related to child abuse prevention, injury prevention, importance of immunizations, etc. • Car seat safety checks • Working with schools to improve nutrition, fitness, health education Infrastructure Services • Community Needs Assessment; Planning and Evaluation • Policy Development • Quality Assurance(e.g. working with private immunization providers&child care providers) • Coalition Participation • Working with School Health Team and Early Childhood Specialists to Identify and Plan to Address Unmet Needs • Monitoring;Training Staff, Parents, Community Professionals Page 4 of 5 • Core Public Health Services Local Activities for Children and Youth with Special Health Care Needs Direct Services • Provision of multi-disciplinary clinical services at HCP Specialty Clinics, Diagnosis and Evaluation (D&E) clinics Enabling Services • Intensive Individual Care Coordination services-Colorado Traumatic Brain Injury Trust Fund Program, HCP Clinics, Contracted Managed Care Organizations, families with no other source for care coordination • Information, resource and referral to all families, providers, organizations • Family Advocacy Population Based Services • Tracking and follow-up of Newborn Metabolic Screening • Tracking and follow-up of Newborn Hearing Screening • Tracking and monitoring for Colorado Resources for Children with Special Needs (CRCSN)Notification program • Gap filling screening-Newborn Hearing, Early Vision • Medical Home training,awareness campaign • Medicaid/CHP+/Supplemental Security Income(SSI)outreach • Public Education-Newborn Hearing Screening, Early Vision, Developmental Screening(including mental and emotional), Infrastructure Services • Administration of Specialty and D&E Clinics • Needs assessment, Planning, &Evaluation and reporting- HERMAN, other • Data Collection/analysis-HCP/CHIRP database, HERMAN, State and National data. • Interagency& inter-organizational agreements-Part C, Respite programs, other • Participate in development of local/state Data Systems-HCP/CHIRP database, NEST • Participate in state/local standard development and dissemination-Newborn Hearing Screening and Follow Up, Early Vision Screening and Follow Up, Care Coordination • Participate in interagency workgroups to provide leadership for priority setting, planning & policy development Page 5of5 Attachment A-2 MATERNAL AND CHILD HEALTH CORE PUBLIC HEALTH SERVICES BUDGET APPLICATION AND EXPENDITURE REPORT CONTRACTOR: INSTRUCTIONS: When completing this form consider the Local Activities guidance in Attachment A-I and allocate the associated costs and percentages for your agency. Please indicate which report this form is being submitted for by placing a check mark in the box located in front of the report's name. Budget Expenditure Report: Due Date: December 1,2006(For The Period Of October 1, 2005 through September 30, 2006) Please provide actual numbers for how the funds were used in the period of October I,2005 through September 30, 2006. n Budget Application: Due Date: May 1,2007(For The Period of October 1,2007 through September 30,2008) Based on your county plan,please estimate the following based on your MCH funding formula contract amounts for the period of October I,2007 through September 30,2008. MATERNAL AND CHILD HEALTH REPORTING FOR THE CORE PUBLIC HEALTH SERVICES SECTION I AMOUNT AND PERCENTAGE ALLOCATED TO: DOLLARS PERCENTAGE CHILD AND ADOLESCENT HEALTH PRENATAL HEALTH TOTAL 100% CHILD AND ADOLESCENT PERCENTAGE ALLOCATED TO EACH SERVICE TYPE BELOW: DIRECT SERVICES ENABLING SERVICES POPULATION-BASED SERVICES INFRASTRUCTURE BUILDING SERVICES TOTAL 100% PRENATAL HEALTH PERCENTAGE ALLOCATED TO EACH SERVICE TYPE BELOW: DIRECT SERVICES ENABLING SERVICES POPULATION-BASED SERVICES INFRASTRUCTURE BUILDING SERVICES TOTAL 100% SECTION II AMOUNT OF FUNDS ALLOCATED TO: DOLLARS CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS PERCENTAGE ALLOCATED TO EACH SERVICE TYPE BELOW: DIRECT SERVICES ENABLING SERVICES POPULATION-BASED SERVICES INFRASTRUCTURE BUILDING SERVICES TOTAL 100% NOTE: Administrative costs can be allocated to each of the above categories as appropriate. 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M (C ?J+ 3 w V"iii r .0 •I.• ≥ y CU Z a a m o 0 4• J ° m o U d W 9 c _ c _ _ c 3 • C 2 D 0 0 0 0 • 0 • • .� 0 a) a) a. n m 3 a t E y E E J co o • m $ x CO CO (0 �.. • c O m q y. Z Z O L d m • • Ii 2• • • 3 `o m `o ` o c ? c• C • 'u F ` D a m@ n n 0. a y 3 G t' u 1 • a`� o $_ > yo `e EE E • c 3 , C • 'S „ S C 3 C c c U a _ . • 03 a E • E 0 0 O O e c W 6 c a s` m n • 2 O • t •.c L L 0 O O 2 0 S •. = 0 0 0 H ' M Q }q 4F! C C - 4.4 m E .c v - 9 c Y' E6 c L 7 V Q In u a a z° x as P''s N A u m 3 a v m H w o N 0. ro:rz Mz h O) - FeA 3 u , tO es r sy V W CO a a o s • LL U c4,, r' 5. Gs. F- •- o ¢ 0 Si r `�6. m co 0 m CD 111 E Q a w 0le (o N C . 0) d ta — Nd � c 0 CO O = c C) CO a ,; u c d m art o e e 'O H • T o E a d n m Q d f0 O 3 "_ G b 0 " 2o to . u y . O 0 CD d O o m M1j v e 7 3 t k JE V •$1 N N o H 1p • 9 1;.xo Cu, 7 m i Z G V G •_ ri. d 2s € m a o yd„ G C ; c v a a 3 N t s.O b u 1 w 0 J o �,, d E E E = a ce E ]� Q x �if�+e ; 3 0 o O p cu 4 t :-' O ti b V V N 2 _" a. I-- • . 0 - e .01c sn y t d ++ rA Cu L d F- u 4. 13 w O a A': 3 a w m u C 'c u ' C) ED H r c _ 6 c _ R C C c !0 Q W e0 C C N co Y o a G o a G i*i t * ...... d m F F H H Attachment A-4 MATERNAL AND CHILD HEALTH PRIORITIES, PERFORMANCE MEASURES,AND OUTCOME MEASURES As of October I,2005 Colorado MCH Priorities 1. Reduce teen pregnancy and unintended pregnancy in women of all ages 2. Improve perinatal outcomes 3. Reduce child and adolescent morbidity and increase health and safety in child-care settings 4. Reduce overweight among children and adolescents, addressing physical activity and nutritional habits 5. Improve efforts to reduce unintentional and intentional injury, addressing motor vehicle crashes, suicide, child abuse and other violence 6. Improve immunization rates for all children 7. Increase access to health care(including behavioral health care) 8. Improve state and local infrastructure by increasing capacity to analyze data, carry out evaluations,develop quality standards,and assure availability of services to all children, including children with special health care needs 9. Reduce substance abuse(alcohol, tobacco, and drugs) 10. Improve oral health and access to oral health care National Performance Measures 1. The percent of infants who are screened for conditions mandated by their State-sponsored newborn screening programs(e.g. phenylketonuria and hemoglobinopathies)and receive appropriate follow-up and referral as defined by their state 2. The percent of children with special health care needs age 0 to 18 years whose families partner in decision making at all levels and are satisfied with the services they receive 3. The percent of children with special health care needs age 0 to18 who receive coordinated, ongoing comprehensive care within a medical home 4. The percent of children with special health care needs age 0 to 18 whose families have adequate private and/or public insurance to pay for the services they need 5. The percent of children with special health care needs age 0 to 18 whose families report the community- based service systems are organized so they can use them easily 6. The percent of youth with special health care needs who received the services necessary to make a transition to all aspects of adult life Page 1 of 3 7. The percent of children of 19 to 35 month olds who have received full schedule of age appropriate immunizations against Measles,Mumps, Rubella, Polio,Diphtheria,Tetanus,Pertussis, Hemophilus Influenza,and Hepatitis B 8. The rate of birth(per 1,000)for teenagers aged 15 through 17 years 9. Percent of third grade children who have received protective sealants on at least one permanent molar tooth 10. The rate of deaths to children aged 14 and younger caused by motor vehicle crashes per 100,000 children I I. Percentage of mothers who breast-feed their infants at hospital discharge 12. Percentage of newborns that have been screened for hearing impairment before hospital discharge 13. Percent of children without health insurance 14. Percent of potentially Medicaid-eligible children who have received a service paid by the Medicaid program 15. The percent of very low birth weight infants among all live births 16. The rate(per 100,000)of suicide deaths among youths 15 through 19 17. Percent of very low birth weight infants delivered at facilities for high-risk deliveries and neonates 18. Percent of infants born to pregnant women receiving prenatal care beginning in the first trimester State Performance Measures 1. The proportion of children and adolescents attending SBHCs 2. The percent of Medicaid-eligible children who receive dental services 3. The percent of women with inadequate weight gain during pregnancy 4. The rate of birth(per 1,000)for Latinal teenagers age 15-17 5. Motor vehicle death rate 15-19 6. Percent of mothers smoking during the 3 months before pregnancy 7. Percent of children ages 2-14 whose BMI>85%of normal weight for height 8. The percent of children who have difficulty with emotions,concentration,or behavior 9. Percentage of center-based child care programs using a child care nurse consultant 10. The proportion of high school students reporting binge drinking in the past month Page 2 of 3 1. Nationally Chosen Outcome Measures The infant mortality rate per 1,000 live births 2. The ratio of the black infant mortality rate to the white infant mortality rate 3. The neonatal mortality rate per 1,000 live births 4. The postneonatal mortality rate per 1,000 live births 5. The perinatal mortality rate per 1,000 live births State Chosen Outcome Measure I. The low birth weight rate per 1,000 live births Revised June 23,2005 Page 3 of 3 Attachment A-5 MATERNAL AND CHILD HEALTH TEN ESSENTIAL PUBLIC HEALTH SERVICES TO PROMOTE MATERNAL AND CHILD HEALTH I. Assess and monitor maternal and child health status to identify and address problems. 2. Diagnose and investigate health problems and health hazards affecting women, children,and youth. 3. Inform and educate the public and families about maternal and child health issues. 4. Mobilize community partnerships between policymakers, health care providers, families,the general public, and others to identify and solve maternal and child health problems. 5. Provide leadership for priority-setting,planning, and policy development to support community efforts to assure the health of women, children, youth and their families. 6. Promote and enforce legal requirements that protect the health and safety of women, children, and youth, and ensure public accountability for their well-being. 7. Link women,children, and youth to health and other community and family services, and assure access to comprehensive,quality systems of care. 8. Assure the capacity and competency of the public health and personal health workforce to effectively address maternal and child health needs. 9. Evaluate the effectiveness, accessibility,and quality of personal health and population-based maternal and child health services. 10. Support research and demonstrations to gain new insights and innovative solutions to maternal and child health-related problems. Page 1 of 1 E r u E .�i O C W CK N "C O C •.. N ct O _ M CC O � Z E .Vi d galV t • d Lr G) © w u MI• Ft a. E CI ^0 A C1 o t aCTI O O• �. Va II 00, WI In i` bE al s i6. Er. c y oa EE M E u E C G O d O — G u E uvs -5 - a tit O U O ¢ .0 _ a.. 5 Ct ea en O In 0 0 Col v N a z 4" a o 04 o. c o w Y 0 0 ea. ° IN) U •GOZ (A C13 Ile G ,� .b eu I LC L. G' 2 e au)• O. C ' .0 a)+ ia U n. L V� )- vj .E ct 0 0 7 y oU N G 7 'O P. 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E., a - a 00 a0i 's ;o '� 0 U 0. .a Oa U OCD R o E Lo 4 a Ct o .'..'r U y � U a U aN) o y rF� CU N V V) MI CI vl N XI � 0 tu cn } \ 0 \ o « \ { cn ) % kj ) } \ / - a ° P. ; k . ] z + £ ) , ` § ° ` \f) ne .. \ ) C � m � 6 - � 44.) lath \ ( � ) � .— .— an Cd \ + \ ) ) / 1.4 . - 32 § ± Comt ) § n § 4- ■ {\ . , o 1 \ vl\ ) ) t &a j \ . ) } ) 7 ) 0 \ } Cet -c �G C71 \ > a eal .2 ae } / / ) ze> e - k t - - - j 2 2 • Attachment A-7 MATERNAL AND CHILD HEALTH Instructions for submitting the Prenatal and Child/Adolescent Final Report for FY06 DUE DATE: On or Before January 15,2007 The Contractor is requested to submit a report for the period of October 1, 2005 through September 30, 2006;the report is for the Maternal and Children Health(MCH)prenatal and child/adolescent populations. The information in this document provides guidance for submitting the final report. A. Create a cover page that contains the following information: 1. Title the Report: "Prenatal and Child/Adolescent Final Report for FY06" 2. Agency name 3. Contact person, and 4. Contact's telephone number B. Provide a response to each of the following items pertaining to the implementation of your Prenatal and Child/Adolescent Operational Plan for the period of October 1, 2005 through September 30, 2006. Each response must begin with the respective title: 1. Important Administrative or Organizational Changes: Describe any important administrative or organizational changes that affected the implementation of the Prenatal and Child/Adolescent Operational Plan during the twelve-months this fiscal year. 2. Significant Problems or Accomplishments: Summarize any significant problems or accomplishments in this same 6-month period. 3. Emerging Issues: Describe any emerging issues regarding the prenatal and child/adolescent population in your community. C. Attach the templates used for the Prenatal and Child/Adolescent Operational Plan for FY06. Provide a brief description of the progress made on each activity, in the corresponding box, in the Outcomes/Progress column. D. Submit your Prenatal and Child/Adolescent Final Report for FY06, via e-mail, no later than 5:00 P.M. on January 15,2007 to: cdphe.psmchreportsAstate.co.us Note: A complete Prenatal and Child/Adolescent Final Report shall contain the following, in this order: a. Cover Page b. Responses to Implementation Items c. Prenatal and Child/Adolescent Operational Plan for FY06 templates with a brief description, in the Outcome/Progress column,of the progress made on each activity. Page 1 of 1 Attachment A-8 MATERNAL AND CHILD HEALTH Instructions for submitting the Prenatal and Child/Adolescent Fiscal Year 07 6-Month Progress Report DUE DATE: On or Before May 1,2007. The Contractor is requested to submit a report for the period of October 1,2006 through March 30, 2007;the report is to cover the Maternal and Child Health(MCH)prenatal and child/adolescent populations. The information in this document provides guidance for submitting the 6-month progress report. Please follow the instructions below to create the Prenatal and Child/Adolescent 6-Month Progress Report for FY07: A. Create a cover page that contains the following information: 1. Title the Report:"Prenatal and Child/Adolescent 6-Month Progress Report for FY07" 2. Agency name 3. Contact person, and 4. Contact's telephone number B. Provide a response to each of the following items pertaining to the implementation of your Prenatal and Child/Adolescent Operational Plan for the period of October I, 2006 through March 30, 2007. Each response must begin with the respective title: I. Important Administrative or Organizational Changes: Describe any important administrative or organizational changes that affected the implementation of the Prenatal and Child/Adolescent Operational. 2. Significant Problems or Accomplishments: Summarize any significant problems or accomplishments. 3. Emerging Issues: Describe any emerging issues regarding the prenatal and child/adolescent population in your community. C. Attach the templates used for the Prenatal and Child/Adolescent Operational Plan for FY06. In the Outcome/Progress column provide a brief description of the progress made on each activity, in the corresponding"6-Month Progress Report"box. D. Submit your Prenatal and Child/Adolescent 6-Month Progress Report For FY 07, via e-mail, no later than 5:00 P.M. on Mav 1,2007 to: cdphe.usmchreDortsAstate.co.us state.co.us Note: A complete Prenatal and Child/Adolescent 6-Month Progress Report shall contain the following, in this order: a. Cover Page b. Responses to Implementation Items c. Prenatal and Child/Adolescent Operational Plan for FY07 templates with a brief description, in the Outcome/Progress column,of the progress made on each activity. 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C.: 0 Q — - - Attachment A-11 MATERNAL AND CHILD HEALTH Instructions for submitting the Local Prenatal And Child/Adolescent Plan For FY08 DUE DATE: On or Before May 1,2007 The Contractor is to submit a local plan called the Local Prenatal and Child/Adolescent Plan, which will cover the prenatal and child/adolescent populations. The Local Prenatal and Child/Adolescent Plan is part of a planning, implementation and evaluation process that is associated with the receipt of State and Federal funds for Maternal and Child Health(MCH)activities in local health departments. The information in this document provides guidance for the development and submission of the Local Plan due on or before May 1,2007. In the Local Plan the Contractor is asked to assess and prioritize the health status needs for the Prenatal and Child/Adolescent populations addressed in the plan and to identify how the MCH funds will be used to address the priority needs. Quantitative and qualitative data gathered at the state and local levels should be used in assessing health status needs. The resources available in the community,to meet these needs, should also be assessed and considered in establishing the priorities to be addressed with MCH funding. Local public health agencies are expected to collaborate with public and private partners in the development of the Local Prenatal and Child/Adolescent Plan. Health issues should be addressed using multi-faceted systematic approaches, which improve health status indicators at a population level. It is the intention of MCH federal and state funding agencies to decrease,over time,the provision of direct patient care services to individuals using MCH monies and to increase enabling, population- based and infrastructure building activities. Local decisions about how to use MCH funds must also take into account whether the activities to be implemented are likely to improve the MCH Performance Measures in the entire county or district and not just within a small group of individuals enrolled in a program within the agency. The contractor's decision to utilize MCH funds to provide direct patient care services must have the approval of the State. Colorado has identified ten MCH priorities to be addressed with MCH Block Grant funding. The services or activities provided under the MCH funding should be responsive to one or more of the priorities, which are as follows: • Improve healthy birth outcomes for pregnant women • Improve access to health care for MCH populations • Improve immunization rates for all children • Reduce the adolescent fertility rate • Reduce the rates of child and adolescents motor vehicle injury and death • Improve preconceptual health among women • Reduce the incidence of overweight and obesity among children and teens • Improve the mental health of MCH populations • Improve the health of children • Reduce the use of tobacco, alcohol and other drugs among the MCH population Page I of 4 The Local Prenatal and Child/Adolescent Plan shall consist of three sections,the Agency's Organizational Chart,the Statement of Need,and the Operational Plan. Section 1-Organizational Chart: The Contractor shall provide an organizational chart that contains the names of supervisors receiving MCH funds for supervising Prenatal and Child/Adolescent staff, names of supervised Prenatal and Child/Adolescent staff under each supervisor,and the percentage of FTE for each Prenatal and Child/Adolescent staff listed in the organizational chart. Section 2-Statement of Need: For the Statement of Need Section of your Local Prenatal and Child/Adolescent Plan,complete the Performance Measure Checklist-Part II-FY08 to assess and present the priority needs for which your agency will use the MCH funding for the prenatal and child/adolescent populations. Section 3-Operational Plan: For the Operational Plan Section of the Contractor's Local Prenatal and Child/Adolescent Plan,there should be goals,objectives,activities and measures for each of the Performance Measures for which your agency will be using MCH funds, as indicated in the Statement of Need Section of the local plan. For certain Performance Measures, the State has developed Model Plans with sample goals,objectives, activities and measures. The Contractor can use these Model Plans for their Operational Plan or may develop their own plan using the same format. The Contractor may also"mix and match"the Model Plans with plans of your own. The Contractor is asked to include a population-based methodology for the activities for at least one(I)of the objectives included in the Operational Plan. The Operational Plan will become an attachment to the FY08 MCH Contract. The Operational Plan shall describe the activities or services to be carried out under the funding provided by this contractual agreement. The activities and services shall be designed to address one or more of the MCH Priorities and associated Performance Measures based on unmet or emerging public health needs of the community. Using the MCH"Core Public Health Services" Pyramid as a guide, local agencies are encouraged to implement infrastructure building, population-based, and enabling services over direct patient care services. Objectives and activities should be developed that are aimed at affecting the outcomes of a large number of people versus a small group. The infrastructure building activities may include the creation of a community planning structure to develop needed health care resources or carrying out further needs assessment. Population-based activities may include injury or disease prevention activities and health promotion activities. Enabling services and activities may include the provision of direct health care information and referral services, follow-up services, and case management services. The services or activities chosen by the Contractor shall be"Best Practice"or"Evidence-Based" approaches or a promising approach,as identified by a review of the applicable literature and consultation with experts. The Operational Plan shall present goals; reasonable, measurable and time-framed objectives;activities that will accomplish the objectives; methods to measure progress in completing the activities(process evaluation); and, methods to evaluate if the objectives are met(outcome evaluation). The Contractor may select from the Model Plans prepared by the State, if such prepared Model Plans address the needs identified as priorities for the Contractor's community in the Statement of Need Section. The objectives and activities of the Model Plans shall be adapted to be reasonable and appropriate for the needs and capacity of the agency. STEP-BY-STEP INSTRUCTIONS: 1. Creating the Organizational Chart 2. Instructions for completing the Statement Of Need Section of the Local Prenatal and Child/Adolescent Plan: Use the Performance Measure Checklist to use to complete the Statement of Need Sections of the Local Prenatal and Child/Adolescent Plan: The Checklist is made up of the performance and outcome measures by which the State MCH program reports to the federal Maternal and Child Health Bureau each year. Each agency will receive a checklist from the State that has been prepared specifically for the counties in its jurisdiction, with the most current data available for each measure for each county. Page 2 of 4 The Contractor is to complete the Performance Measure Checklist-Part II-FY08, which has been pre- populated with the data that is provided in the county profile, beginning with the teen fertility data. You will want to refer to the 2005 County Profiles for your county or counties,which will be provided by the state. The Contractor can also obtain a description of the source of information from the 2005 County Profiles for the data and how the rates reported were determined. The"Trends in MCH Performance Measures"document, released in early 2005, for each county will also be provided by the state. The trend analyses analyzes each agency's performance for each measure for which county-level data are available, relative to the state as a whole,to the state goal for 2005 and to the Healthy People 2010 goal, if applicable. To complete the next section of the checklist: 1. Decide if this measure is a priority need. Refer to the"Trends in MCH Performance Measures" document for the county or counties in your jurisdiction. It will tell you which measures are "close to the goal","far from the goal"or"at some distance from the goal". If the county measure meets the Healthy People 2010 goal, mark an"L" for Low in the"Priority Need (High/Med/Low)"column. If the county measure is near the Healthy People 2010 goal,mark an "M" for medium. If the county measure is at some distance or far from the Healthy People 2010 goal, mark an"H" for high. 2. Under the"How Need Is Being Addressed"Section,check one or more of the boxes to show if you will be using MCH funds to address that need; if you are using other funds to address that need; if other agencies in your community are addressing the need;or, if you are not addressing it because there are no funds or there is no agency or community support for addressing that need. It may be appropriate to check more than one box. 3. If the measure does not show a high need, but your agency has determined that you need to continue to use MCH funds in order to maintain the good status that the measure reflects, place a check in the"Need to Maintain Current Effort"column for that measure. 4. In the Explanation or Description for Checked Boxes column, provide a BRIEF explanation or description of the situation to explain the checked boxes. 5. Summary Statement of Need: List the Performance Measures that have a check mark under the column"Using MCH Funding" on the Performance Measure Checklist-Part II-FY08. These are the measures that you will use to write your agency's Prenatal and Child/Adolescent Operational Plan 3. Writing the Operational Plans: 1. When creating the Prenatal and Child/Adolescent Operational Plan choose state-prepared Model Plans composed of goals,objective,activities, process evaluation methods and outcome evaluation methods)or develop your own agency plans that address priority needs and for which you checked that you will use MCH funding. Choose or write at least one plan that uses a population- based methodology. 2. For state-prepared Model Plans: a. Fill in the appropriate target(the percent or rate to be achieved)that is realistic for your agency and community. b. Follow the sequence of the activities as presented in the Model Plan. Select only what is realistic for your agency for the year. For example, if analyzing the need is all that can be accomplished on that objective in a year's time,then select only those activities. Fill in the level of activities, i.e.the number of meetings or number of individuals to be served, etc.,adapting the level to what will be needed to accomplish the objective that you have set. You may also want to add or adapt an activity that is determined to be more appropriate for your community based on past results or best and/or promising practice literature/research. Page 3 of 4 Note: It is likely that you will use the same objectives for a number of years,but the activities or level of activities to address the objectives are likely to change annually. 3. For Agency-developed Plans: a. You may choose to develop other plans to address one or more of the selected needs. If you choose to do this,you should explain: • what priority need the plan is addressing, • what data or information you used to determine that this is a priority need,and • what information or experience you used to choose the activities or approach to accomplish the objective. This information may be presented in a paragraph or two preceding the agency-developed plan. b. Use the same standard table format as that used for the state-prepared Model Plans. A blank copy of the standard table format is found at the end of the prepared Model Plans. The objectives should be measurable and time-framed;the activities should be ones that will accomplish the objective;there should be process measures that are the ways you will check to see if you are completing the activities;and,there should be outcome evaluation measures that describe how you will evaluate whether the objective has been accomplished. 4: Completing the Cover Page for the Local Prenatal,and Child and Adolescent Plan Create a cover page for the Local Prenatal and Child/Adolescent Plan with the following information: a. Title the Report: "Local Prenatal and Child/Adolescent Plan for FY08" b. Agency Name c. Contact Person d. Contact's Telephone Number e. A Listing of the Topical Areas for which the Goals and Objectives are Written for example: • "Reduce Low Birth Weight—Adequate Weight Gain" • "Reduce Child Injury—Car Seats and Booster Seats" • "Improved Prenatal Outcomes—First Trimester Care" • "Increase Breastfeeding Continuation" 5: Submitting the Local Prenatal and Child&Adolescent Plan Submit the Local Prenatal and Child/Adolescent Plan for FY 07,via e-mail,no later than 5:00 P.M. on May 1,2007 to: cdphe.DsmchrenortsAstate.co.us Note: A complete Local Prenatal and Child/Adolescent Plan shall contain the following,in this order: a. Cover Page b. Section 1 - Prenatal and Child/Adolescent Organizational Chart c. Section 2 - Prenatal and Child/Adolescent Statement of Need(completed Performance Measure Checklist-Part II-FY08), d. Section 3 - Prenatal and Child/Adolescent Operational Plan(state-prepared Model Plans with local adaptations and/or agency-developed plans) Page 4 of 4 Attachment A-12 HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS(HCP) SIX CORE OUTCOMES AND PERFORMANCE MEASURES As of October I,2003 Outcome#1: Families of children with special health care needs(CSHCN)will partner in decision making at all levels, and will be satisfied with the services they receive. 1. Percent of families of CSHCN reporting satisfaction with the quality of: regular source of primary care, getting referrals and appointments for needed services,coordination between primary and specialty care overall services. 2. Percent of parents of CSHCN who report satisfaction with their level of involvement/input in setting concerns and priorities to make decisions about their child's care plan. 3. Percent of parents of CSHCN who report knowing the steps to take when they are not satisfied with the services their child/family receives. 4. Number of parents of CSHCN who are supported financially for their involvement in state and local activities. 5. Number of parents of CSHCN who report that they are effective partners in policymaking at the state and local levels. Outcome#2: All children with special health care needs(CSHCN) will receive coordinated ongoing comprehensive care within a medical home. 1. Percent of CSHCN with a regular source of primary medical care through a primary care provider. 2. Percent of CSHCN whose regular source of care communicates in a way that is clear and understandable to the family. 3. Percent of parents whose regular source of primary medical care identifies,discusses,and addresses the comprehensive needs of their child and family. 4. Percent of CSHCN whose regular source of primary medical care ensures age-appropriate well-child checks, including: vision, hearing, developmental, behavioral/mental health,oral health, newborn screening, immunizations. 5. Percent of parents of CSHCN who receive referrals and assistance from their regular source of primary medical care in accessing needed/desired services. Outcome#3: All families of children with special health care needs(CSHCN)will have adequate private and/or public insurance to pay for the services they need. I. Percent of CSHCN with insurance that covers costs of needed services, including: mental health,dental care, age-appropriate well-child checks,durable medical equipment,ancillary services,non-durable medical supplies,care coordination, prescriptions, specialty care, related therapies(e.g., physical therapy (PT),occupational therapy(OT),speech/language,audiology), in-home nursing. Page 1 of3 2. Amount of out-of-pocket costs paid by families of CSHCN, including costs of: mental health,dental care, age-appropriate well-child checks,durable medical equipment, ancillary services, non-durable medical supplies,respite care,transportation,care coordination, prescriptions, specialty care, related therapies(e.g., PT,OT,speech/language,audiology), in-home nursing,home modifications, car/van modifications. 3. Percent of CSHCN who can choose the providers of their choice. 4. Percent of CSHCN whose insurance provides: timely approval for needed care,overall parental satisfaction,clear information, about coverage resources,and complaint procedures to providers and parents. Outcome#4: All children will be screened early and continuously for special health care needs. I. Percent of infants whose mothers began prenatal screening in the first trimester of pregnancy, for smoking, alcohol,drugs, tests for birth defects, HW,physical abuse. 2. Percent of infants and families being tracked for special health care needs and developmental delays. 3. Percent of children receiving age-appropriate well-child checks including: vision, hearing,developmental, behavioral, mental health, oral health, metabolic, and Early and Periodic Screening, Diagnosis and Treatment(EPSDT)(if implemented in state). 4. Percent of children receiving needed follow-up due to failed screening or risk factors: vision, hearing, developmental, behavioral, mental health,oral health,and metabolic. Outcome#5: Services for children with special health care needs and their families will be organized in ways that families can use them easily. 1. Percent of parents of CSHCN who have a single coordinated service plan that involves all providers and a lead service coordinator who communicates with the family. 2. Percent of parents of CSHCN who report that they are able to access comprehensive services for their child and family. 3. Percent of parents of CSHCN who have specialty care available in their region of the state. 4. The degree to which the state service system has an enrollment/eligibility process that links families of CSHCN(and their medical home) with a wide variety of public and private services and resources. 5. Number of private/public partnerships to provide community-based,comprehensive medical services for CSHCN,e.g., data sharing,contracts, memorandum of agreements(MOAs). Outcome#6: All youth with special health care needs(SHCN)will receive the services necessary to make appropriate transitions to adult health care,work and independence. 1. Percent of youth with SHCN who by age 14 have a transition plan that addresses employment, transportation, housing, independent living,physical and mental health and necessary accommodations; and percent of youth with SHCN by age 16 have a transition plan that includes appropriate agencies as part of the transition planning team. 2. Percent of youth with SHCN whose regular source of primary medical care facilitates the transition from pediatric to adult providers. Page 2 of 3 3. Percent of adult health care providers who are prepared to serve youth with SHCN. 4. Percent of youth who report satisfaction with the information and training they received to make informed decisions about their health care and other services. 5. Percent of youth with SHCN who receive necessary services/supports by age 21: health insurance, post- secondary education,employment,transportation, housing,personal care attendant, Supplemental Security Income(SSI), Social Security Act(SSA)-related work incentives,e.g. PASS, 1619 a& b. Last Revised June 17,2003 Page 3 of 3 Attachment A-13 Health Care Pmgram O►+ Ca Im ith Special Needs r«.n.wa And•Ate wiry Weld County Department of Public Health and Environment CYSHCN Operational Plan for October 1, 2006, through September 30 2007 National Outcome 1: Families of CSHCN will partner in decision-making at all levels and will be satisfied with the services they receive. Objective Outcome Evaluation Continue to encourage family awareness of resources, 1.Documentation of family participation in support support services and opportunities to participate in decision- groups. coalitions.systems building activities. A. making in Weld County during FY 2007. CHIRP community encounters B.Anecdotal reporting C Minutes horn various meetings 2. Documentation of HCP efforts to notify Tamil Activity Process Evaluation Continue quarterly distribution of HCP Family 1. Document number of newsletters distributed Connections(in English and Spanish)to HCP 2 Maintain list of recipients families receiving level 2 and 3 care coordination, providers.community agencies,support groups.. trainings.etc. Activity Process Evaluation Continue support of Spanish Speakers Support 1.Documentation of contacts/related activities Group as evidenced by: in CHIRP Community Encounters, 1.Continue to promote community awareness of 2.Maintain list of publications,announcements and this articles about the group during FY 07 group through HCP Family Connections, 3.Documentation of financial and staff support community provided by HCP program announcements.fliers,P2P list sery etc. 2 Otter support for mailings(printing and postage) and other activities as allowed by HCP financial and staff constraints Activity Process Evaluation Continue collaboration with New Start to implement 1.Documentation of participation in grant related peer mentoring program for children with acquired activities in CHIRP community encounters or brain injuries and their families. communications in charts of participating clients. Activity Process Evaluation Continue collaboration with Envision(CCB)to host 1.Document staff support in CHIRP community caregiver's appreciation event in November 2006. encounters. 2.Document attendance of families(number)and anecdotal feedback received. Page 1 of 7 Attachment A-13 Objective Outcome Evaluation Continue to monitor family satisfaction with HCP care Compare and contrast family satisfaction responses to data coordination services to improve the delivery of quality collected in FY 06.identifying strengths as well as areas of services to CYSHCN and their families through the Weld concern in order to develop plan of action for improvement Regional Office. Activity Process Evaluation Continue to send standardized family satisfaction 1.Determine number of completed surveys surveys to all families receiving level 2 and 3 care returned. coordination on an annual basis {Goal is 40%of active caseload 1 Activity Process Evaluation Identify strengths and weaknesses in delivery of 1. Review results of data collected 2nd half FY 06 care coordination as reported by families receiving and services through the Weld Regional Office. 1st half FY 07 as compiled by state HCP Program. 2.Identify and report program strengths 3. Identify and report areas for improvement Activity Process Evaluation Develop improvement plan to address identified 1 Include planned activities in related Outcomes to weaknesses. be addressed during FY 08. National Outcome 2: All children with special health care needs will receive regular, ongoing comprehensive care within a medical home. Objective Outcome Evaluation In conjunction with HCP social marketing,continue to Summarize anecdotal and analytical information collected in introduce the concept of medical home to the Weld County narrative section of HERMAN 6-month and end of year medical community reports. Activity Process Evaluation Complete initial contact with all county primary 1.List of practices contacted. practices(Family Practice and Pediatric)by 2. 100%of identified county primary practices will September 30.2007. have documented community encounter in CHIRP 3.Information provided to practices available for review upon request. 4. 100%provider feedback following initial contact from HCP documented in CHIRP community encounters. Activity Process Evaluation Make formal presentation on medical home and 1.Minimum of one formal presentation to staff and HCP care coordination to minimum of one primary medical providers of primary care practice care practice by September 30,2007. documented in CHIRP community encounters. Activity Process Evaluation Initiate contact with county ancillary medical 1.List of targeted ancillary medical providers providers,{home health care agencies,NCMC available Family Birth Center,NCMC Pediatric Rehab,etc.) for review. by September 30,2007. 2.25%targeted ancillary medical providers will have documented community encounter in CHIRP. Activity Process Evaluation Make formal presentation on medical home and 1.Minimum of one formal presentation to staff of HCP care coordination to minimum of one ancillary ancillary medical provider documented in CHIRP medical provider by September 30,2007. community encounters Page 2 of 7 Attachment A-13 Objective Outcome Evaluation In conjunction with HCP social marketing.introduce concept Documentation in CHIRP community encounters. of medical home to at least one community agency involved with CYSHCN Activity Process Evaluation Make formal presentation on medical home and 1.Minimum of one formal presentation to staff of HCP care coordination to minimum of one community agency documented in CHIRP community agency involved with CYSHCN by community encounters. September 30.2007. Objective Outcome Evaluation Introduce concept of medical home and its components to 1.Anecdotal responses to materials mailed to families 2 all families of CYSHCN receiving level 2 and 3 care Documentation in CHIRP community encounters of coordination classes on Health Awareness Portfolio 3.Results of post- attendance survey following Health Awareness Portfolio classes Activity Process Evaluation Provide written information explaining medical 1.Flier available for review. home concept to all families receiving level 2 and 3 2.Inclusion in mailings to families documented in care coordination in Weld County: CHIRP. 1 Develop flier explaining medical home concept by October 31,2006. 2 Translate flier into Spanish. 3.Include flier with welcome materials sent to new families and with annual review information. Activity Process Evaluation Monitor family perception of medical home using 1. 100%of families enrolled in level 2 and 3 care four questions developed by HCP: coordination will have documentation of 1 Ask questions of all families enrolled in level 2 responses to and 3 four medical home questions in CHIRP. care coordination on an annual basis. 2.Increase in number and percentage of Weld HCP 2 Compare number and percentage of Weld HCP clients with medical home above baseline of 2%. clients with medical homes during FY 07 with 3.Identification of components least available in county and state statistics for current and Weld previous years County. 3. Identify trends around each of the four medical home components. Activity Process Evaluation Instruct families of CYSHCN on use of Health 1.Number of attendees documented in CHIRP Awareness Portfolio: community encounters and individual client 1.Conduct minimum of two classes(one in English, charts. one in Spanish)on use of Health Awareness 2.Results of follow-up survey. Portfolio by September 30.2007. 2.Provide notebook and labeled dividers to attendees. 3.Develop follow-up phone survey to determine if class and notebook helpful to family. 4.Complete survey with all attendees three months after completion of class. Page 3 of 7 Attachment A-13 National Outcome 3: All families of children with special health care needs (CSHCN)will have adequate private and/or public insurance to pay for the services they need. Objective Outcome Evaluation Continue current efforts to support families with insurance 1.Comparison of percentage of Insurance Concerns concerns. marked for care coordination during FY 06 with county and state data. 2.Comparison of number and percentage of clients enrolled in HCP level 2 and 3 care coordination without insura Activity Process Evaluation Continued assistance to uninsured or underinsured 1.#of referrals to Medicaid/CHP+and outcomes families to access resources available to them. documented in CHIRP. such as public insurance programs,SSI or various 2.#of SSI referrals and outcomes documented in charity funds. CHIRP. 3.#of CYSHCN enrolled in Medicaid/CHP+ 4.#of CYSHCN receiving SSI benefits 5.#of CYSHCN without insurance. 6. Documentation in individual charts of assistance provided by HCP related to accessing insurance resources. Activity Process Evaluation Continued assistance offered to families to 1.#referrals to EPSDT and outcomes understand public and private insurance benefits documented in CHIRP. and the 2.CHIRP documentation of collaboration with associated appeal processes. EPSDT in individual client charts. 3.Anecdotal experiences of assistance with public and private insurance provided to families National Outcome 4:All children will be screened early and continuously for special health care needs. Objective Outcome Evaluation Improve the ability of community agencies to perform vision 1. Retrofitted MTI Photo Screener and new Welch-Allyn screening on children ages 12 to 60 months Photo Screener(s)will be available to community agenies that perform vision screening. 2.Increased community awareness of CDE protocol for vision screening as documented in co Activity Process Evaluation In collaboration with North Colorado Health 1.Retrofitting of MTI Photoscreener complete. Alliance.secure grant to fund retrofitting of MTI 2.Purchase of minimum of two Welch-Allyn Photoscreener and purchase minimum of 2 Welch- photoscreeners and supporting equipment Allyn screeners. Activity Process Evaluation Introduce CDE protocol for vision screening to 1.Documented community encounters in CHIRP community agencies not currently using the with at protocol least one community agency g en cY performing vision screening without using the CDE protocol. Page 4 of 7 Attachment A-13 Objective Outcome Evaluation Assist Dr Deanna Meinke with research on new equipment Successful collaboration between Dr.Meinke and the capable of testing hearing in noisy environments. agency in collection of data for research study. Activity Process Evaluation Assist in arrangements to allow collection of data 1 Documentation of dates and times of data at Weld County Department of Public Health and collection Environment. 2. Project report when completed. National Outcome 5: Community based service systems for CSHCN and their families will be organized for easy use. Objective Outcome Evaluation During FY 07.the Weld HCP team will establish a working Working agreement established with written guidelines and agreement with Envision for the coordinated delivery of non- signed supporting documents such as memorandum of duplicative services to children between birth and three understanding or contracts as needed by September 30. years of age 2007. Activity Process Evaluation Participate in and stay informed of decisions made 1.Documentation of participation in conference at the state and local levels related to the change calls in of the lead agency of Part C services by: CHIRP community encounters. 1.Participation in state regional office and 2. Documentation of participation in ICC in CHIRP discipline community encounters. conference calls. 3 Documentation of consultation provided to 2.Participation in local Interagency Coordinating Envision in CHIRP community encounters Council. 3.Provide consultation to Envision as Part C program is developed. Activity Process Evaluation By December 31.2006.determine process for 1.Written procedure for notifications available notifications between Part C and HCP upon request. Activity Process Evaluation By December 31.2006.establish guidelines for 1 Written guidelines for collaboration available collaboration of care and service coordination for upon children dually enrolled in HOP and Part C. request Activity Process Evaluation Actively pursue a collaboration between Envision 1.Memorandum of understanding/contract signed and the Weld County Department of Public Health by and Environment to fund a minimum of 0.5 FTE both agencies. registered nurse to provide nursing consultation 2.Job description for position written. and assistance to 3 Advertising and hiring completed. children eligible for Part C by September 30.2007. Objective Outcome Evaluation 24/7 Kids-Support for Families will become increasingly 1.Number of families served will be larger than number self-sustaining and continue to serve more families. served during FY 06. 2.Additional funding sources(grants. donations and fund-raising activities)will be secured and generate sufficient funds to cover operating expenses. Activity Process Evaluation HCP Team member will continue to serve on 1 Board meetings and related activities will be Board of Directors throughout FY 07 documented in CHIRP community encounters. Page 5 of 7 Attachment A-I3 Activity Process Evaluation Weld Regional Office will offer in-kind support for 1.Documentation of funding provided by HCP 24/7 Kids: program 1.Printing and postage as funding allows. for printing and postage expenses 2.Staff time to assist with program as funding and 2. Documentation of HCP lime spent through capacity allow. CHIRP community encounters Objective Outcome Evaluation Reexamine creation of Weld County Disabilities Council with 1.Focus group convened to determine community the purpose of improving services for CYSHCN and their interest. 2.Plan of action in place by close of FY 07 families. Activity Process Evaluation By October 31,2006 identify community agencies 1.Generate list of such agencies throughout county serving CYSHCN and their families in any capacity. Activity Process Evaluation Convene focus group. 1.Letter will be sent by November 30 2006 List of 1.Draft letter of intent and mail to identified recipients available upon request agencies 2.Initial meeting will be held by March 31.2007 to determine potential interest in project Minutes available upon request 2 Arrange date.time and location for initial 3 Written plan of action completed by September meeting. 30.2007 3 Chair intial meeting to determine interest.needs and next steps. 4 If decision to pursue Disabilities Council is made, work with focus group to develop one year plan of action for FY 08. National Outcome 6:All youth with special health care needs will receive services to transition to adult life. Objective Outcome Evaluation Compile a transition packet for HCP families and develop a 1.Transition packet completed by September 30.2007 2 plan for consistent distribution beginning FY 2008. Written plan for distribution completed by September 30 2007. Activity Process Evaluation Identify community agencies providing transition 1. List of county agencies involved with transition services and determine scope of services available. services. 2.Presentation at Regional Team meeting by at least one community agency involved with transition services. Activity Process Evaluation By March 30,2007,locate transition packets 1.Contact Tim Hershey at state HCP as resource already in use in other places which could be for adapted for local use. available transition information and to keep abreast of developments at state/national level 2.Contact Sue Foster in South Central Region and obtain copy of information used by TIGER team in San Luis Valley. Page 6 of 7 Attachment A-13 Activity Process Evaluation By September 30,2007.establish resource library 1.List of information available in transition of information related to transition and internal library. office procedure to assure consistent delivery of 2.Written local guidelines for topics to cover transition information to adolescents and their with families at specific ages. families. 3.Written procedure for addressing transition issues with adolescents and their families National Outcome 7: The regional model of operation for HCP will provide high quality, efficient services to families, providers,and state and local partners. Objective Outcome Evaluation The Weld Regional Office will attend 100%of all discipline Attendance as reported by state in FY 07 Data Report and office conference calls and meetings. Activity Process Evaluation Regional team leader will assume responsibility 1.Attendance will be documented in CHIRP for attendance at all Regional Office conference community encounters calls.if unable to attend,team leader will designate 2.Attendance record kept by state HCP office. another member of the team to attend Activity Process Evaluation Each Regional Discipline Coordinator will attend all 1 Attendance will be documented in CHIRP discipline conference calls and meetings. If unable community encounters to attend.Team Leader will be notified and will 2.Attendance records kept by state HCP office designate another team member to attend. Objective Outcome Evaluation The Weld Regional Team will stay informed of all HCP 1 Attendance records as requested. 2.Minutes available updates and program changes. for all Regional Team and Office Team meetings Activity Process Evaluation HCP Regional Team will meet at least once every 1.Attendance records will be kept quarter. 2.Minutes for all meetings held. Activity Process Evaluation HCP Office Team will meet twice each month 1.Attendance records will be kept. 2. Minutes available for all meetings. Page 7 of 7 Attachment A-14 HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS(HCP) CLINIC SUPPORT FEE SCHEDULE Effective October 1,2005 The Health Care Program for Children with Special Needs(HCP) is committed to the HCP Sponsored Specialty Clinics. We want to ensure that throughout Colorado families have access to specialty care. To this end,a Clinic Support Fee helps to provide vital support to the local infrastructure necessary to operate the HCP Specialty Clinics. The sliding fee schedule affects families with or without insurance, including CHP+. Medicaid clients do not pay a clinic support fee. This policy does not apply to the statewide Diagnostic and Evaluation(D&E)Clinic System. I. Pediatric Audiology/Otology, Pediatric, Pediatric Orthopedic, Pediatric Cardiology, Pediatric Neurology, and Pediatric Rehabilitation Clinics A. Families, except those on Medicaid, will be assessed a clinic support fee. B. Clients will be charged a clinic support fee according to their Federal Poverty Level(FPL)as follows: I. No charge for families at or below 100%FPL 2. $5 fee per visit for a rating of 101-133%FPL 3. $10 fee per visit for a rating of 134 to 185%FPL 4. $30 fee per visit for a rating of 186 to 211% FPL 5. $50 fee per visit for a rating of 212 to 399% FPL 6. $75 fee per visit for a rating of 400 to 450%FPL 7. $100 fee per visit for a rating greater than 450%FPL C. All clinic patients must be registered with HCP and complete a financial statement included in the HCP application. Families who choose not to complete the financial statement will be charged the maximum fee on the schedule per visit. D. Each child that has an individual appointment time will be charged a clinic support fee; e.g., a family with two children that have two separate appointment slots would be charged two fees. E. The fees collected are to support HCP clinic activities such as: clinic supplies,clinic equipment, clinic furniture or parent/professional stipends. A record of fees collected and how they are dispersed is to be kept by the clinic coordinator and the Team Leader. 11. Pediatric Clinics Children attending an HCP Pediatric Clinic: A. Upon referral from the child's PCP requesting a diagnostic evaluation and/or continuing consultation from the pediatrician,the child may be seen in the HCP Pediatric Clinic. B. Families not on Medicaid will be charged a clinic support fee. (HCP is providing access for these families, but not paying for services to children.) C. Family pays all labs and x-rays ordered out of clinic. Revised April 2005 Page 1 of 1 EXHIBIT B HIPAA BUSINESS ASSOCIATE Memorandum of Understanding The parties to this Business Associate Memorandum of Understanding ("MOU") are the Colorado Department of Public Health and Environment ("State" or"Department") and the Board of County Commissioners of Weld County ("Contractor," or "Associate"). This MOU is effective as of October 1, 2006 or the compliance date of the Privacy Rule (defined below), whichever first occurs (the "MOU Effective Date"). RECITALS A. The Department is a business associate of the Colorado Department of Human Services ("Covered Entity" or "CE") and as such must comply with applicable requirements Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. § 1320d— 3120d- 8 ("HIPAA"), which requires that if the Department subcontracts any covered function and discloses protected health information to a subcontractor, the Department must enter into a business associate agreement with such a subcontractor. B. The Department wishes to disclose certain information to Associate pursuant to the terms of the Contract, some of which may constitute Protected Health Information ("PHI") (defined below). C. Department and Associate intend to protect the privacy and provide for the security of PHI disclosed to Associate pursuant to the Contract in compliance with the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. § 1320d- 1320d-8 ("HIPAA") and its implementing regulations thereunder by the U.S. Department of Health and Human Services (the "Privacy Rule") and other applicable laws, as amended. D. As part of the HIPAA regulations, the Privacy Rule requires the Department to enter into a contract containing specific requirements with Associate prior to the disclosure of PHI, as set forth in, but not limited to, Title 45, Sections 160.103, 164.502(e) and 164.504(e) of the Code of Federal Regulations ("C.F.R.") and contained in this MOU. E. Authority exists in the Law and Funds have been budgeted, appropriated, and otherwise made available, and a sufficient uncommitted balance thereof remains available for subsequent encumbering and payment in Fund Code(s) 100, Organizational Unit Code(s) 6810, Appropriation Code(s) 609, Program Code(s) 9017, Function Code(s) FLWT, Object Code 5120, and Grant Budget Line Code(s) 0F6P under Contract encumbrance number PO FLA HCP07000001 for Traumatic Brain Injury Services. F. Required approval, clearance and coordination have been accomplished from and with appropriate agencies. Colorado MOU-Subcontracting Covered Functions Rev. 3/04 Page Iof10 The parties agree as follows: 1. Definitions. a. Except as otherwise defined herein, capitalized terms in this MOU shall have the definitions set forth in the HIPAA Privacy Rule at 45 C.F.R. Parts 160 and 164, as amended. In the event of any conflict between the mandatory provisions of the Privacy Rule and the provisions of this MOU, the Privacy Rule shall control. Where the provisions of this MOU differ from those mandated by the Privacy Rule, but are nonetheless permitted by the Privacy Rule, the provisions of this MOU shall control. b. "Protected Health Information" or"PHI" means any information, whether oral or recorded in any form or medium: (i)that relates to the past, present or future physical or mental condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; and (ii) that identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual, and shall have the meaning given to such term under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.501. c. "Protected Information" shall mean PHI provided by CE to the Department or to Associate or created or received by Associate on CE's behalf To the extent Associate is a covered entity under HIPAA and creates or obtains its own PHI for treatment, payment and health care operations, Protected Information under this MOU does not include any PHI created or obtained by Associate as a covered entity and Associate shall follow its own policies and procedures for accounting, access and amendment of Associate's PHI. 2. Statement of Work and Responsibilities. The Statement of Work for purposes of this MOU is contained in the Task Order between the Department and Associate dated August 25, 2006. 3. Payment Amount and Billing Procedure. The consideration for Associate performing its obligations under Section 2 above, is set forth in the Task Order between the Department and Contractor dated August 25, 2006. 4. Term. The term of this MOU begins on the MOU Effective Date, as set forth in the opening paragraph of this MOU, and runs through and including September 30, 2007. Colorado MOU—Subcontracting Covered Functions Rev. 3/04 Page 2 of 10 5. Obligations of Associate. a. Permitted Uses. Associate shall not use Protected Information except for the purpose of performing Associate's obligations under and as permitted by the terms of this MOU. Further, Associate shall not use Protected Information in any manner that would constitute a violation of the Privacy Rule if so used by CE, except that Associate may use Protected Information: (i) for the proper management and administration of Associate; (ii) to carry out the legal responsibilities of Associate; or (iii) for Data Aggregation purposes for the Health Care Operations of CE. Additional provisions, if any, governing permitted uses of Protected Information are set forth in Attachment B-1. b. Permitted Disclosures. Associate shall not disclose Protected Information in any manner that would constitute a violation of the Privacy Rule if disclosed by CE, except that Associate may disclose Protected Information: (i) in a manner permitted pursuant to this MOU; (ii) for the proper management and administration of Associate; (iii) as required by law; (iv) for Data Aggregation purposes for the Health Care Operations of CE; or (v) to report violations of law to appropriate federal or state authorities, consistent with 45 C.F.R. Section 164.502(j)(1). To the extent that Associate discloses Protected Information to a third party, Associate must obtain, prior to making any such disclosure:(i) reasonable assurances from such third party that such Protected Information will be held confidential as provided pursuant to this MOU and only disclosed as required by law or for the purposes for which it was disclosed to such third party; and (ii) an agreement from such third party to notify Associate within one business day of any breaches of confidentiality of the Protected Information, to the extent it has obtained knowledge of such breach. Additional provisions, if any, governing permitted disclosures of Protected Information are set forth in Attachment B-1. c. Appropriate Safeguards. Associate shall implement appropriate safeguards as are necessary to prevent the use or disclosure of Protected Information otherwise than as permitted by this MOU. Associate shall maintain a comprehensive written information privacy and security program that includes administrative, technical and physical safeguards appropriate to the size and complexity of the Associate's operations and the nature and scope of its activities. d. Reporting of Improper Use or Disclosure. Associate shall report to the Department in writing any use or disclosure of Protected Information other than as provided for by this MOU within three (3) business days of becoming aware of such use or disclosure. e. Associate's Agents. If Associate uses one or more subcontractors or agents to provide services under this MOU, and such subcontractors or agents receive or have access to Protected Information, each subcontractor or agent shall sign an agreement with Associate containing substantially the same provisions as this MOU and further identifying CE as a third party beneficiary with rights of enforcement and indemnification from such subcontractors or agents in the event of any violation of such subcontractor or agent agreement. Associate shall implement and maintain appropriate sanctions against agents and subcontractors that violate such restrictions and conditions and shall mitigate the effects of any such violation. Colorado MOU—Subcontracting Covered Functions Rev. 3/04 Page 3 of 10 f. Access to Protected Information. Associate shall make Protected Information maintained by Associate or its agents or subcontractors in Designated Record Sets available to the Department for inspection and copying within seven(7) business days of a request by the Department to enable CE to fulfill its obligations to permit individual access to PHI under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.524. g. Amendment of PHI. Within seven (7) business days of receipt of a request from the Department for an amendment of Protected Information or a record about an individual contained in a Designated Record Set, Associate or its agents or subcontractors shall make such Protected Information available to CE for amendment and incorporate any such amendment to enable CE to fulfill its obligations with respect to requests by individuals to amend their PHI under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.526. If any individual requests an amendment of Protected Information directly from Associate or its agents or subcontractors, Associate must notify the Department in writing within three(3) business days of the receipt of the request. Any denial of amendment of Protected Information maintained by Associate or its agents or subcontractors shall be the responsibility of CE. h. Accounting Rights. Within seven (7) business days of notice by the Department of a request for an accounting of disclosures of Protected Information, Associate and its agents or subcontractors shall make available to the Department the information required to provide an accounting of disclosures to enable CE to fulfill its obligations under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.528. As set forth in, and as limited by, 45 C.F.R. Section 164.528, Associate shall not provide an accounting to CE of disclosures: (i) to carry out treatment, payment or health care operations, as set forth in 45 C.F.R. Section 164.506; (ii) to individuals of Protected Information about them as set forth in 45 C.F.R. Section 164.502; (iii) pursuant to an authorization as provided in 45 C.F.R. Section 164.508; (iv) to persons involved in the individual's care or other notification purposes as set forth in 45 C.F.R. Section 164.510; (v) for national security or intelligence purposes as set forth in 45 C.F.R. Section 164.512(k)(2); (vi) to correctional institutions or law enforcement officials as set forth in 45 C.F.R. Section 164.512(k)(5); (vii) incident to a use or disclosure otherwise permitted by the Privacy Rule; (viii) as part of a limited data set under 45 C.F.R. Section 164.514(e); or(ix) disclosures prior to April 14, 2003.. Associate agrees to implement a process that allows for an accounting to be collected and maintained by Associate and its agents or subcontractors for at least six (6) years prior to the request, but not before the compliance date of the Privacy Rule. At a minimum, such information shall include: (i) the date of disclosure; (ii) the name of the entity or person who received Protected Information and, if known, the address of the entity or person; (iii) a brief description of Protected Information disclosed; and (iv) a brief statement of purpose of the disclosure that reasonably informs the individual of the basis for the disclosure, or a copy of the individual's authorization, or a copy of the written request for disclosure. In the event that the request for an accounting is delivered directly to Associate or its agents or subcontractors, Associate shall within five (5) business days of the receipt of the request forward it to the Department in writing. It shall be CE's responsibility to prepare and deliver any such accounting requested. Associate shall not disclose any Protected Information except as set forth in Section 5(b) of this MOU. Colorado MOU-Subcontracting Covered Functions Rev. 3/04 Page 4 of 10 • i. Governmental Access to Records. Associate shall make its internal practices, books and records relating to the use and disclosure of Protected Information available to the Secretary of the U.S. Department of Health and Human Services (the "Secretary"), in a time and manner designated by the Secretary, for purposes of determining CE's compliance with the Privacy Rule. Associate shall provide to the Department a copy of any Protected Information that Associate provides to the Secretary concurrently with providing such Protected Information to the Secretary. j. Minimum Necessary. Associate (and its agents or subcontractors) shall only request, use and disclose the minimum amount of Protected Information necessary to accomplish the purpose of the request, use or disclosure, in accordance with the Minimum Necessary requirements of the Privacy Rule including, but not limited to, 45 C.F.R. Sections 164.502(b) and 164.514(d). k. Data Ownership. Associate acknowledges that Associate has no ownership rights with respect to the Protected Information. 1. Retention of Protected Information. Except as provided in Section 7(e) of this MOU, Associate and its subcontractors or agents shall retain all Protected Information throughout the term of this MOU and shall continue to maintain the information required under Section 5(h) of this MOU for a period of six (6) years after termination of the Contract. m. Notification of Breach. During the term of this MOU, Associate shall notify the Department within two business days of any suspected or actual breach of security, intrusion or unauthorized use or disclosure of PHI and/or any actual or suspected use or disclosure of data in violation of any applicable federal or state laws or regulations. Associate shall take (i) prompt corrective action to cure any such deficiencies and (ii) any action pertaining to such unauthorized disclosure required by applicable federal and state laws and regulations. n. Audits, Inspection and Enforcement. Within seven (7) business days of a written request by the Department, Associate and its agents or subcontractors shall allow the Department to conduct a reasonable inspection of the facilities, systems, books, records, agreements, policies and procedures relating to the use or disclosure of Protected Information pursuant to this MOU for the purpose of determining whether Associate has complied with this MOU; provided, however, that: (i) Associate and the Department shall mutually agree in advance upon the scope, timing and location of such an inspection; (ii) the Department shall protect the confidentiality of all confidential and proprietary information of Associate to which the Department has access during the course of such inspection; and (iii) the Department shall execute a nondisclosure agreement, upon terms mutually agreed upon by the parties, if requested by Associate. The fact that the Department inspects, or fails to inspect, or has the right to inspect, Associate's facilities, systems, books, records, agreements, policies and procedures does not relieve Associate of its responsibility to comply with this MOU, nor does the Department's (i) failure to detect or(ii) detection, but failure to notify Associate or require Associate's remediation of any unsatisfactory practices, constitute acceptance of such practice or a waiver of the Department's enforcement rights under this MOU. Colorado MOU-Subcontracting Covered Functions Rev. 3/04 Page 5 of 10 o. Safeguards During Transmission. Associate shall be responsible for using appropriate safeguards to maintain and ensure the confidentiality, privacy and security of Protected Information transmitted to CE pursuant to this MOU, in accordance with the standards and requirements of the Privacy Rule, until such Protected Information is received by the Department, and in accordance with any specifications set forth in Attachment B-1. p. Restrictions and Confidential Communications. Within seven (7) business days of notice by the Department of a restriction upon uses or disclosures or request for confidential communications pursuant to 45 C.F.R. 164.522, Associate will restrict the use or disclosure of an individual's Protected Information, provided Associate has agreed to such a restriction. Associate will not respond directly to an individual's requests to restrict the use or disclosure of Protected Information or to send all communication of Protected Information to an alternate address. Associate will refer such requests to the Department so that the Department can coordinate with the CE and prepare a timely response to the requesting individual and provide direction to Associate. 6. Obligations of the Department and CE. a. Safeguards During Transmission. The Department and CE shall be responsible for using appropriate safeguards to maintain and ensure the confidentiality, privacy and security of PHI transmitted to Associate pursuant to this MOU, in accordance with the standards and requirements of the Privacy Rule, until such PHI is received by Associate, and in accordance with any specifications set forth in Attachment B-1. b. Notice of Changes. The Department shall provide Associate with a copy of CE's notice of privacy practices produced in accordance with 45 C.F.R. Section 164.520, as well as any subsequent changes or limitation(s) to such notice, to the extent such changes or limitations may effect Associate's use or disclosure of Protected Information. The Department shall provide Associate with any changes in, or revocation of, permission to use or disclose Protected Information, to the extent it may affect Associate's permitted or required uses or disclosures. To the extent that it may affect Associate's permitted use or disclosure of PHI, the Department shall notify Associate of any restriction on the use or disclosure of Protected Information that CE has agreed to in accordance with 45 C.F.R. Section 164.522. CE may effectuate any and all such notices of de-identified information via posting on CE's web site. Associate shall review CE's designated web site for notice of changes to CE's HIPAA privacy policies and practices on the last day of each calendar quarter. 7. Termination. a. Without Cause. Either of the parties shall have the right to terminate this MOU by giving the other party twenty-one (21) calendar days notice. If notice is given, the MOU will terminate at the end of twenty-one (21) calendar days, and the liabilities of the parties hereunder for further performance of the terms of the MOU shall thereupon cease, but the parties shall not be released from duty to perform up to the date of termination. Colorado MOU—Subcontracting Covered Functions Rev. 3/04 Page 6 of 10 • b. Material Breach. Any material breach by Associate of any provision of this MOU, as determined by the Department, shall be grounds for immediate termination of the Contract by the Department. Any dispute concerning the performance of this MOU which cannot be resolved at the divisional level shall be referred to superior departmental management staff designated by each department. Failing resolution at that level, disputes shall be presented to the executive directors of each department for resolution. Failing resolution by the executive directors, the dispute shall be submitted in writing by both parties to the State Controller, whose decision on the dispute shall be final. This dispute resolution mechanism is in addition to, and not in lieu of, any other reporting or other requirement of federal or state law concerning alleged privacy violations. c. Reasonable Steps to Cure Breach. If the Department knows of a pattern of activity or practice of Associate that constitutes a material breach or violation of the Associate's obligations under the provisions of this MOU or another arrangement and does not terminate this MOU pursuant to Section 7(a), then the Department shall take reasonable steps to cure such breach or end such violation, as applicable. If the Department's efforts to cure such breach or end such violation are unsuccessful, the Department shall either (i) terminate this MOU, if feasible or (ii) if termination of this MOU is not feasible, the Department shall report Associate's breach or violation to the CE, the Colorado Attorney General's Office and to the Secretary of the U.S. Department of Health and Human Services. d. Judicial or Administrative Proceedings. Either party may terminate this MOU, effective immediately, if(i) the other party is named as a defendant in a criminal proceeding for a violation of HIPAA, the HIPAA Regulations or other security or privacy laws or (ii) a finding or stipulation that the other party has violated any standard or requirement of HIPAA, the HIPAA Regulations or other security or privacy laws is made in any administrative or civil proceeding in which the party has been joined. e. Effect of Termination. (1) Except as provided in paragraph (2) of this subsection, upon termination of this MOU, for any reason, Associate shall return or destroy all Protected Information that Associate or its agents or subcontractors still maintain in any form, and shall retain no copies of such Protected Information. If Associate elects to destroy the PHI, Associate shall certify in writing to the Department that such PHI has been destroyed. (2) If Associate believes that returning or destroying the Protected Information is not feasible, Associate shall promptly provide the Department notice of the conditions making return or destruction infeasible. Upon mutual agreement of the Department and Associate that return or destruction of Protected Information is infeasible, Associate shall continue to extend the protections of Sections 5(a), 5(b), 5(c), 5(d) and 5(e) of this MOU to such information, and shall limit further use of such PHI to those purposes that make the return or destruction of such PHI infeasible. Colorado MOU-Subcontracting Covered Functions Rev. 3/04 Page 7 of 10 8. No Waiver of Immunity. No term or condition of this MOU shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protection, or other provisions of the Colorado Governmental Immunity Act, CRS 24-10-101 et seq. or the Federal Tort Claims Act, 28 U.S.C. 2671 et seq. as applicable, as now in effect or hereafter amended. 9. Defense. To the extent any legal action against either party is not covered by the Risk Management Fund or other authorized self-insurance fund for tort claims, each party shall defend itself at its own expense in any action by third parties. 10. Disclaimer. The Department makes no warranty or representation that compliance by Associate with this MOU, HIPAA or the HIPAA Regulations will be adequate or satisfactory for Associate's own purposes. Associate is solely responsible for all decisions made by Associate regarding the safeguarding of PHI. 11. Certification. To the extent that the Department determines an examination is necessary in order to comply with CE's legal obligations pursuant to HIPAA relating to certification of its security practices, the Department or its authorized agents or contractors, may, at the Department's expense, examine Associate's facilities, systems, procedures and records as may be necessary for such agents or contractors to certify to the Department the extent to which Associate's security safeguards comply with HIPAA, the HIPAA Regulations or this MOU. 12. Amendment. a. Amendment to Comply with Law. The parties acknowledge that state and federal laws relating to data security and privacy are rapidly evolving and that amendment of this MOU may be required to provide for procedures to ensure compliance with such developments. The parties specifically agree to take such action as is necessary to implement the standards and requirements of HIPAA, the Privacy Rule, the Final HIPAA Security regulations at 68 Fed. Reg. 8334 (Feb. 20, 2003), 45 C.F.R. § 164.314 and other applicable laws relating to the security or privacy of PHI. The parties understand and agree that the Department must receive satisfactory written assurance from Associate that Associate will adequately safeguard all Protected Information. Upon the request of either party, the other party agrees to promptly enter into negotiations concerning the terms of an amendment to this MOU embodying written assurances consistent with the standards and requirements of HIPAA, the Privacy Rule or other applicable laws. The Department may terminate the MOU upon thirty (30) days written notice in the event (i) Associate does not promptly enter into negotiations to amend this MOU when requested by the Department pursuant to this Section or(ii) Associate does not enter into an amendment to this MOU providing assurances regarding the safeguarding of PHI that CE, in its sole discretion, deems sufficient to satisfy the standards and requirements of HIPAA and the Privacy Rule. b. Amendment of Attachment B-1. Attachment B-1 may be modified or amended by mutual agreement of the parties in writing from time to time without formal amendment of this MOU. Colorado MOU—Subcontracting Covered Functions Rev. 3/04 Page 8 of 10 13. Assistance in Litigation or Administrative Proceedings. Associate shall make itself, and any subcontractors, employees or agents assisting Associate in the performance of its obligations under this MOU, available to the Department, at no cost to the Department up to a maximum of 30 hours, to testify as witnesses, or otherwise, in the event of litigation or administrative proceedings being commenced against the Department, CE, its directors, officers or employees based upon a claimed violation of HIPAA, the Privacy Rule or other laws relating to security and privacy of PHI, except where Associate or its subcontractor, employee or agent is a named adverse party. 14. No Third Party Beneficiaries. Nothing express or implied in this MOU is intended to confer, nor shall anything herein confer, upon any person other than the Department, CE, Associate and their respective successors or assigns, any rights, remedies, obligations or liabilities whatsoever. 15. Interpretation. This MOU shall be interpreted as broadly as necessary to implement and comply with HIPAA and the Privacy Rule. The parties agree that any ambiguity in this MOU shall be resolved in favor of a meaning that complies and is consistent with HIPAA and the Privacy Rule. 16. Survival of Certain Terms. Notwithstanding anything herein to the contrary, Associate's obligations under Section 7(d) ("Effect of Termination") and Section 14 ("No Third Party Beneficiaries") shall survive termination of this MOU and shall be enforceable by CE as provided herein in the event of such failure to perform or comply by the Associate. 17. Representatives and Notice. a. Representatives. For the purpose of this MOU, the individuals listed below are hereby designated as the parties' respective representatives. Either party may from time to time designate in writing new or substitute representatives. Colorado MOU—Subcontracting Covered Functions Rev. 3/04 Page 9 of 10 b. Notices. All required notices shall be in writing and shall be hand delivered or given by certified or registered mail to the representatives at the addresses set forth below. State/Department Representative: Name: Kathy Walters Title: HCP Director Department and Division: Colorado Department of Public Health and Environment Prevention Services Division Address: 4300 Cherry Creek Drive South PSD-HCP-A4 Denver, Colorado 80246 Contractor/Business Associate Representative: Name: Judv Nero Title: Business Manager Department and Division: Weld County Department of Public Health and Environment Address: 1555 North 17th Avenue Greeley, CO 80631 18. Availability of Funds. Payment pursuant to this MOU, if in any part federally funded, is subject to and contingent upon the continuing availability of federal funds for the purposes hereof. If any of said federal funds become unavailable, as determined by the Department, either party may immediately terminate or seek to amend this MOU. 19. Audits. In addition to any other audit rights in this MOU, Associate shall permit the Department and any authorized federal agency to monitor and audit records and activities which are or have been undertaken pursuant to this MOU. 20. No Assignment. Except as otherwise provided, the duties and obligations of Associate shall not be assigned, delegated or subcontracted except with the express prior written consent of CE. Any subcontractors or agents used by BA to perform any services in connection with this MOU shall be subject to the requirements of this MOU. Colorado MOU-Subcontracting Covered Functions Rev. 3/04 Page 10 of 10 • Attachment B-1 This Attachment sets forth additional terms to the HIPAA Business Associate MOU dated October 1, 2006, between the Colorado Department of Public Health and Environment (CDPHE) and Board of County Commissioners of Weld County (Associate). This Attachment may be amended from time to time as provided in Section 12(b) of the MOU. 1. Additional Permitted Uses. In addition to those purposes set forth in Section 5(a) of the MOU, Associate may use Protected Information as follows: The Associate may disclose aggregate reports that conform to HIPAA de-identification definitions contained in HIPAA § 164.514 (b) (1) or (2). 2. Additional Permitted Disclosures. In addition to those purposes set forth in Section 5(b) of the MOU, Associate may disclose Protected Information as follows: The Associate may disclose aggregate reports that conform to HIPAA de-identification definitions contained in HIPAA § 164.514 (b) (1) or (2). 3. Subcontractor(s). The parties acknowledge that the following subcontractors or agents of Associate shall receive Protected Information in the course of assisting Associate in the performance of its obligations under the MOU: Associate's Health Care Program for Children with Special Needs discipline coordinator contractors. 4. Receipt. Associate's receipt of Protected Information pursuant to the MOU shall be deemed to occur as follows, and Associate's obligations under the MOU shall commence with respect to such PHI upon such receipt: Delivery of copies of eligibility applications including ICD-9 diagnosis and any other information that can be used in the treatment of the traumatic brain-injured child. This information may be in paper or electronic format. 5. Additional Restrictions on Use of Data. Associate shall comply with the following restrictions on the use and disclosure of Protected Information: N/A 6. Additional Terms. [This section may include specifications for disclosure format, method of transmission, use of an intermediary, use of digital signatures or PKI, authentication, additional security of privacy specifications, de-identification or re- identification of data and other additional terms.] The Associate will secure HIPAA- compliant authorization to allow disclosure of personally identifiable data to the CDPHE TBI Surveillance program. Authorization form to be used is attached as Attachment B- 1-1 to the MOU. Colorado MOU—Subcontracting Covered Functions Rev. 3/04 Page 1 of 1 Attachment B-I-I • 000o��yy000o��0��n0 °aC Health Care Program for Children with Special Needs(HCP) Telephone: (303)692-2370; FAX: (303)782-5576 Colorado Traumatic Brain Injury (TBI) Program AUTHORIZATION TO RELEASE PATIENT INFORMATION OBTAIN FROM: (Who is releasing the information?) RELEASE TO:(Who is receiving the information?) Colorado Department of Public Health and Environment Colorado Department of Public Health and Environment Health Care Program for Children with Special Needs(HCP) Injury Epidemiology Program PSD-HCP-A4 Traumatic Brain Injury Surveillance Project 4300 Cherry Creek Drive South PSD-IE-A4 Denver,CO 80246-1530 4300 Cherry Creek Drive South Denver,CO 80246-1530 SPECIFIC IDENTIFYING INFORMATION BEING REQUESTED: PATIENT NAME: ADDRESS: CITY COUNTY STATE ZIP DATE OF BIRTH: GENDER(Circle): M F RACE(Optional) PERSON AUTHORIZED TO SIGN FOR PATIENT: RELATIONSHIP TO PATIENT: ADDRESS(If different from patient's) DATE OF HOSPITALIZATION FOR TBI: HOSPITAL NAME: PURPOSE FOR DISCLOSURE: (What is the information to be used for?) Public health analysis. The Injury Epidemiology Program will group this information to describe children who received services, compare this group to all children hospitalized with TBI,and estimate the need for TBI services. I understand that signing this authorization is not a condition of receiving services. I understand that a copy or facsimile of this authorization is to be considered as valid as the original and that this authorization will expire 365 days from the date of signature. I also understand that I may revoke this authorization at any time and that I will be asked to sign the Revocation Section on the back of this form. I further understand that any action taken on this authorization prior to the rescinded date is legal and binding. I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes. Patient Signature Date/Time Person authorized to sign for patient Date/Time Address Relationship to Patient Phone City State Zip HCP Staff Signature/Title(if signed in person) Date/Time Page 1 oft REVOCATION SECTION I do hereby request that this authorization to disclose personal information of Name of Patient signed by on Name of person who signed Authorization Date of Signature be rescinded effective . I understand that any action taken on this (Date/Time) authorization prior to the rescinded date is legal and binding. Patient Signature Date/Time Person authorized to sign for patient Date/Time Address Relationship to Patient Phone City State Zip Witness Signature/Title Date/Time Page 2 of 2 EXHIBIT C APPLICANT: Weld County Department of Public Health and Environment PROJECT: Health Care Program for Children with Special Needs (HCP) FOR THE PERIOD: OCTOBER 1, 2006 through SEPTEMBER 30, 2007 Funded by CDPHE HCP Weld County Regional Office: (1/12 payable monthly October 2006 through August 2007, September 2007 payment contingent upon the State's timely receipt of the Contractor's FY 07 Final Expenditure Report) 150,723 Sub-total HCP Regional Office: 150,723 HCP Regional Coordinators: (line item billing) Audiology 2,000 Travel for Colo. Academy of Audiology meeting 250 Nutrition 2,300 Occupational or Physical Therapy 4,500 Parent Consultant 15,000 Regional Coordinator Training and Travel 2,500 Speech 1,500 Vision 1,000 Sub-total Regional Coordinators 29,050 Traumatic Brain Injury Survey Services 1,000 Total HCP Weld County Regional Office 180,773 Page I of I EXHIBIT D Regional Office: Address TBI CARE COORDINATION INVOICE Client Name: Payment TBI Case Number Amount Date Care Plan Signed: 1 — [Insert month care plan signed] $240 2 - $60 3 - $60 4 - $60 5 - $60 6 - $60 7 - $60 8 - $60 9 - $60 10 - $60 11 - $60 12 - $60 Maximum Amount Payable $900 Date: / / Care Coordinator Signature Make Checks Payable to: (If other than HCP RO) Mail or Fax this Invoice to: Rasa Eglite, TBI Project Manager Colorado Department of Public Health and Environment PSD-HCP-A4 4300Cherry Creek Drive South Denver, CO 80246-1530 Phone: 303-692-2411 FAX: 303-753-9249 I certify that I have received&inspected the goods/services invoiced&found them to be satisfactory. Approved for Payment. Date: / / Signature Date: / / Signature Page 1 of 1 . 64 § a � 2 = m 0 E :3 ( Q F - , - § - ) 8La / •-I. \� § \ ; / tzo ID -4.7: \ LT] ; S A / cl @ / cr - 64 ) i et ( � ( \ ) \ CI •4 < 7e cr A y a . et \ } } o k ao \ U, / 0 CO 2 § C U ® § ] t ) k b \ 7 0 ) 2 ! \ 7 % Q. ( / ad . t \ \ a at % _ � O � ) � � al ) ( \ \ '4 \ \ kN E ? 2 E / ; ; � � — C _ © c , � {� / } ) C ^ � U � ° 2e = W a § E) ( \ k § ] § E e k \ \ ; [ ) \ k § \ 0 / / § 0 \ � \ / § § / 2 § a ) tea \ / ) / \ / EXHIBIT F APPLICATION BUDGET AND FINAL EXPENDITURE REPORT CONTRACTOR: Please submit a SEPARATE form for each population group listed below and indicate which group and which report this form is being submitted for: CHILDREN AND ADOLESCENT POPULATION Ei PRENATAL POPULATION CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS POPULATION FINAL EXPENDITURE REPORT DUE DATE: December 1,2006(For The Period Of:October 1,2005 through September 30,2006) O APPLICATION BUDGET DUE DATE: May 1,2007(For The Period Of:October 1,2007 through September 30,2008) ANNUAL FULL TOTAL SOURCE OF FUNDS SALARY TIME AMOUNT • RECEIVED EXPENSE CATEGORIES RATE EQUIVALENT REQUIRED OTHER' FROM CDPHE PERSONAL SERVICES(Names i3 Titles): Contractual/Fee for Service —._...__ Supervising Personnel/Team Leader for HCP Fringe Benefits: Rate= -- TOTAL PERSONAL SERVICES IS and FTE) S $ $ OPERATING EXPENSES1wl'ch are not part of indirect)' TOTAL OPERATING EXPENSES TRAVEL EXPENSES Vin-state/Out-state} - TOTAL TRAVEL EXPENSES S S $ Contractual - TOTAL CONTRACTUAL EXPENSES S S $ Total Direct Costs(Personal Services+Operating+Travel+Contractual) $ .$ $ INDIRECT COST: Rate= TOTAL INDIRECT COST $ S $ TOTAL PROJECT COST S S f 'Source of funding for"Other"(Match or In-kind)I.e.Maternal and Child Health Programs Local/County Funding S Medicaid(will not be used to match) S Patient Fees S Other(List): S a TOTAL $ May the NON FEDERAL funds be used as match? YES NO Signature of Authorized Representative Date Page 1 of 1 EXHIBIT G TASK ORDER CHANGE ORDER LETTER [Date] Task Order Change Order Letter Number**, Contract Routing Number** *** ***** State Fiscal Year 20**-20** *************** Prouram This Task Order Change Order Letter is issued pursuant to paragraph*_*. of the Master Contract identified as contract routing number** *** ***** and paragraph*. *. of the Task Order identified as contract routing number ** *** ***** and contract encumbrance number** *** **********. This Task Order Change Order Letter is between the COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT and JLEGAL NAME OF CONTRACTOR]. The Task Order has been amended by Task Order Option to Renew Letter** contract routing number** *** *****, and/or Task Order Change Order Letter**,contract routing number** *** *****, if any. The Task Order,as amended, if applicable, is referred to as the"Original Task Order". This Task Order Change Order Letter is for the current term of********* ** ****,through ********* **,****. The maximum amount payable by the State for the work to be performed by the Contractor during this current term is increased/decreased by********** Dollars, ($*.**) for an amended total financial obligation of the State of ********** DOLLARS,($*.**). The revised specifications to the original Scope of Work and the revised Budget are incorporated herein by this reference, made a part hereof, and attached hereto as"Attachment *"and "Attachment *". The first sentence in paragraph *_*. of the Original Task Order is modified accordingly. All other terms and conditions of the Original Task Order are reaffirmed, This change to the Task Order shall be effective upon approval by the State controller, or designee,or on ********* **, ****,whichever is later. Please sign,date, and return all ** originals of this Task Order Change Order Letter by********* ** **** to the attention of: ************ ************,Colorado Department of Public Health and Environment,4300 Cherry Creek Drive South, Mail Code ******-**,Denver,Colorado 80246. One original of this Task Order Change Order Letter will be returned to you when fully approved. [LEGAL NAME OF CONTRACTOR] STATE OF COLORADO (a political subdivision of the state of Colorado) Bill Owens,Governor By: By: Name: For the Executive Director Title: DEPARTMENT OF PUBLIC HEALTH FEIN: AND ENVIRONMENT PROGRAM APPROVAL: (Seal-Required) By: ATTEST(required): By: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts.This contract is not valid until the State Controller,or such assistant as he may delegate, has signed it.The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below,the State of Colorado may not be obligated to pay for the goods and/or services provided. STATE CONTROLLER: Leslie M. Shenefelt By: Date: Revised:11/5/04 Page 1 of I EXHIBIT H TASK ORDER OPTION TO RENEW LETTER [Date] Task Order Option to Renew Letter Number**, Contract Routing Number ** *** ***** State Fiscal Year 20**-20** *************** program This Task Order Option to Renew Letter is issued pursuant to paragraph *_*, of the Master Contract identified by contract routing number** *** ***** and paragraph *. *. of the Task Order identified by contract routing number ** *** ***** and contract encumbrance number** *** **********, This Task Order Option to Renew Letter is between the COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT and JLEGAL NAME OF CONTRACTOR(. The Task Order has been amended by Task Order Change Order Letter**, contract routing number** *** *****, and/or Task Order Option to Renew Letter**, contract routing number** *** ***** if any. The Task Order, as amended, if applicable, is referred to as the"Original Task Order". This Task Order Option to Renew Letter is for the renewal term of********* ** ****, through ********* ** **** The maximum amount payable by the State for the work to be performed by the Contractor during this renewal term is ********** Dollars,(*.**)for an amended total financial obligation of the State of********** DOLLARS, This is an increase/decrease of($*.**)of the amount payable from the previous term. The Budget for this renewal term is incorporated herein by this reference, made a part hereof, and attached hereto as"Attachment *". The first sentence in paragraph *_*. of the Original Task Order is modified accordingly. All other terms and conditions of the Original Task Order are reaffirmed. This Task Order Option to Renew Letter is effective upon approval by the State Controller, or designee, or on ********* ** **** whichever is later. Please sign, date,and return all ** originals of this Task Order Option to Renew Letter by ********* ** **** to the attention of: ************ ************,Colorado Department of Public Health and Environment, Mail Code******-**,4300 Cherry Creek Drive South,Denver,Colorado 80246. One original of this Task Order Option to Renew Letter will be returned to you when fully approved. (LEGAL NAME OF CONTRACTOR] STATE OF COLORADO (a political subdivision of the state of Colorado) Bill Owens,Governor By: By: Name: For the Executive Director Title: DEPARTMENT OF PUBLIC HEALTH FEIN: AND ENVIRONMENT PROGRAM APPROVAL: (Seal- required) By: ATTEST(required): By: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts.This contract is not valid until the State Controller,or such assistant as he may delegate, has signed it.The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below,the State of Colorado may not be obligated to pay for the goods and/or services provided. STATE CONTROLLER: Leslie M.Shenefelt By: Date: Revised: 11/5/04 Page 1 of 1 STATE OF COLORADO Bill Owens,Governor Dennis E. Ellis,Executive Director i-.0 co<o\ Dedicated to protecting and improving the health and environment of the people of Colorado 114 4300 Cherry Creek Dr.S. Laboratory Services Division ' ''� Denver,Colorado 80246-1530 8100 Lowry Blvd. r „ Phone(303)692-2000 Denver,Colorado 80230-6928 (876. TDD Line(303)691-7700 (303)692-3090 Colorado Department Located in Glendale,Colorado of Public Health http://www.cdphe.state.co.us and Environment Prevention Services Division Center for Women,Children and Families Telephone:(303)692-2370; FAX:(303)782-5576 October 13,2006 Ms. Judy Nero Business Manager Weld County Health Department 1555 North 17th Avenue Greeley,CO 80631 Re: MCH Task Order Contract Routing Number 07 FLA 00394 Dear Ms.-Nerd:- Enclosed please find a fully executed copy of the above referenced Task Order for your files. This Task Order _ covers the penodfrons6ctober-2, 2006[hfdugh and including Septerr ber3d,-2007: If you have any questions regarding the MCH or Prenatal and Child/Adolescent portions of the Task Order or the attachments please contact Sally Merrow at 303-692-2391 or sally.merrow(cd state.co.us. However, should you have questions regarding the HCP portion of the Task Order or its attachments please contact Charla Low at 303- 692-2423 or charla.lowstate.co.us. Sincerely, 4, ,,,e.„Li_ Peggy Becker MCH Contract Coordinator 303-692-2404 peegy.becker@state.co.us Enclosure Hello