HomeMy WebLinkAbout20052574.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 1,2005, and ending
September 30, 2006, 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 31st day of August, A.D., 2005.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST: at, �" ,/I LaV
William H. ke, Chair
Weld County Clerk to th �eo �.F=��. civ
M. eile, Pro-Tern
BY:
`�_�
Deputy Clerk to the Bob WIC
D 'd . Lon
AP D AS TO F •
Robert D. Masden
ounty Attorney EXCUSED
Glenn Vaad
Date of signature: /V
2005-2574
H L0032
r"� ; FfL o9-/6-0S—
Memorandum
111 I TO: William H. Jerke, Chair
OBoard of County Commissioners
• From: Mark E. Wallace,MD, MPH, Director
COLORADO Department of Public Health and
Environment
DATE: August 26, 2005 / V'1
SUBJECT: MCH Program Task Order
Enclosed for Board review and approval is a task order for the Maternal and Child Health
Program (MCH) program which now includes funding for 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$193,082. 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 $850 per child for
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, 2005 through September 30, 2006 is $334,334. Of this amount $228,139 are pass
through funding from the federal government, and $106,195 are state of Colorado funds.
I recommend your approval of this task order.
Enc.
2005-2574
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
DEPARTMENT OR AGENCY NUMBER
FLA
CONTRACT ROUTING NUMBER
06-00531
TASK ORDER
PSD-MCH
This Task Order is made this 19TH day of AUGUST,2005,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 Coloradol 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 171h
Avenue,Greeley,Colorado 80631, hereinafter referred to as"the Contractor".
FACTUAL RECITALS
Pursuant to section 25-1.5-101 0)(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 1 of 10
S eves_ 075 O4/
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)MCH-MC6-HHS 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)
06GFNDMATCH and MCH-MC6-HHS for Health Care Program for Children with Special Needs(HCP)services
under Contract encumbrance number PO FLA MCH0600531.
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 Number
100,Organizational Unit Code 6810,Appropriation Code 609 and Object Code 5120 under Contract encumbrance
number PO FLA HCP06000001 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 1,2005. 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 September30,2006,unless sooner terminated by the parties pursuant to the terms and 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.
Page 2 of 10
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,($0.00)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 NINETY-THREE THOUSAND,
EIGHTY-TWO DOLLARS,($193,082.00). Of the HCP financial obligation, Eighty-Six
Thousand, Eight Hundred Eighty-Seven Dollars,($86,887.00)are identified as attributable to a
funding source of the federal government and,One Hundred Six Thousand,One Hundred
Ninety-Five Dollars,($106,195.00)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 THIRTY-FOUR THOUSAND,THREE HUNDRED
THIRTY-FOUR DOLLARS,($334,334.00). Of the total financial obligation, Two Hundred
Twenty-Eight Thousand,One Hundred Thirty-Nine Dollars,($228,139.00)are identified as
attributable to a funding source of the federal government and, One Hundred Six Thousand,
One Hundred Ninety-Five Dollars,($106,195.00)are identified as attributable to a funding
source of the state of Colorado.
4. In addition to the budget referenced in paragraphs 1. and 2. above,the Contractor shall be
reimbursed for the initial term of this Contract, for TBI services for a sum not to exceed Eight
Hundred Fifty Dollars($850.00)per child upon receipt of an invoice.
Page 3 of 10
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 FIFTY-TWO THOUSAND,
THREE HUNDRED FIFTY-THREE DOLLARS($152,353.00) Statewide for TBI services for
federal fiscal year 2005-2006(October 1,2005 through and including September 30,2006). Of
this total financial obligation,ZERO DOLLARS,($0.00)are identified as attributable to a
funding source of the federal government and,ONE HUNDRED FIFTY-TWO THOUSAND,
THREE HUNDRED FIFTY-THREE DOLLARS($152,353.00)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 D". 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
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(11)months.
The final payment for the twelfth(12th)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
E". 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.
Page 4 of 10
8. Reimbursement for the HCP 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(II)months or one fourth(1/4)for the first three(3)quarters.
The final payment for the twelfth (12th)month or fourth (4'h)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 F". 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.
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.
Page 5 of 10
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 G". 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 paragraph number(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;
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.
Page 6 of 10
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.
1. 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.
5. Contractor shall retain and use all revenues generated by the individual MCH Programs for
services in those programs.
Page 7 of 10
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 IS, 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 8of10
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 (1)(B)and Section 505 (5)(D). The 100 percent of poverty gross income guideline for farm
or non-farm families is currently at$9 570 for a family of 1, $12 830 for a family of 2;$16,090 for
a family of 3; $19350 for a family of 4;$22610 for a family of 5; $25,870 for a family of 6;
$29,130 for a family of 7;and$32390 for a family of 8. For families of more than eight,add
$3 260 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: I, eseVi By: 7 '-u*s C .c-y-f t'
Name: Wi 11 i am 14 .Terke For the Execu ve Director
Title: BOCC Chair DEPARTME T OF PUBLIC HEALTH
FEIN: 84-6000813 AND ENVIRONMENT
Date: 08/31/2005 Date:
!J ` ATTE§ )d4a ROGRAM APPROVAL:
1861
�2i9!`�//
�h y�. _ i � ., � By:
,�� an County,County, c—
t41 '•rS�i' District,or Town Clerk or lent
APPROVALS:
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
PUBICW DEPARTME T IF ����- 4-�
AAL
IC HE `0��
Mark E. Wallace, MD, MPH-Director
C
Date: tu 1": 31
Revised:11/5/04
Page 10 of 10
Exhibit A
STATEMENT OF WORK
To Task Order Dated 08/19/2005-Contract Routing Number 06 FLA 00531
This Statement of Work is for the three maternal and child health (MCH)populations, which covers 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)
I. 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-1, "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 Actual Budget Allocations for Federal Fiscal Year 2004-2005. On or before
December 1,2005,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.,perinatal,child and adolescent,and children
and youth with special health care needs(CYSHCN),for the federal fiscal year 2004-2005
(October 1,2004,through September 30,2005). 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:
Sally Merrow at: sallv.merrowstate.co.us
3. Submission of Final Expenditure Reports for Federal Fiscal Year 2004-2005: On or before
December 1,2005,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.,perinatal,
child and adolescent,and children and youth with special health care needs, for federal fiscal year
2004-2005 (October 1,2004,through September 30,2005),utilizing the sample form previously
set forth in the Task Order as"Exhibit E".
Page I of 8
The Contractor shall report actual expenditures and the match separately for the perinatal,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 1,2004,
through September 30,2005 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
4. Submission of Numbers Served Report for Federal Fiscal Year 2004-2005. On or before January
15,2006,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 2004-2005 (October 1,2004,through September 30,2005). 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:
Jan Reimer at:jan.reimerAstate.co.us
state.co.us
5. Submission of Estimated Funding Allocations for Federal Fiscal Year 2006-2007. 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 2006-2007 (October 1,2006,through September 30,2007).
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:
Sally Merrow at: sally.merrowAstate.co.us
6. Submission of Detailed Line Item Application Budget and Detailed Budget Narrative for Federal
Fiscal Year 2006-2007. On or before May 1,2006,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.perinatal,child and adolescent,and CYSHCN for the federal fiscal year
2006-2007(October 1,2006,through September 30,2007). A sample form"Application Budget
and Final Expenditure Report",which the Contractor shall use, is set forth in Exhibit E of the
Task Order.
Page 2 of 8
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
B. Prenatal,and Child/Adolescent
1. 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 2005-2006 and for the development of the Contractor's Local Prenatal and
Child/Adolescent Plan for the federal fiscal year 2006-2007.
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 perinatal, 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
Colorado Child Health Plan Plus+(CCHP);
Page 3 of 8
e. Refer families participating in any and all programs in its agency such as WIC, 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.
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 2005-2006(October 1,2005,through September 30,2006). 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 2005-2006 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 I,2005,through September 30,2006".
3. Submission of Prenatal and Child/Adolescent Final Report for Federal Fiscal Year 2004-2005: On
or before January 15,2006,the Contractor shall submit a Prenatal and Child/Adolescent Final
Report for the contractor's federal fiscal year 2004-2005 (October 1,2004,through September 30,
2005)activities. Instructions for submitting the Prenatal and Child/Adolescent Final Report are
set forth in Section I of 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
2005-2006: On or before May I,2006,the Contractor shall submit a Prenatal and Child/Adolescent
6-Month Progress Report for the first six months(October 1,2005—March 31,2006)of the
Contractor's federal fiscal year 2005-2006 activities. Instructions for submitting the Prenatal and
Child/Adolescent 6-Month Progress Report are set forth in Section I of 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 2006-2007:
On or before May 1,2006,the Contractor shall submit a Prenatal and Child/Adolescent Local
Plan for federal fiscal year 2006-2007(October 1,2006 through September 30,2007). The
Prenatal and Child/Adolescent Local Plan shall consist of three(3)sections, I.)Organizational
Chart, 2.)Statement of Need,utilizing the Performance Measure Checklist—Part II-FY07,
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-l0".
Instructions for completing and submitting the Local Prenatal and Child/Adolescent Plan are set
forth in Section B of Steps I through 5 of Attachment A-11, incorporated herein by this
reference,made a part hereof, and attached hereto.
Page 4 of 8
C. Health Care Program for Children with Special Needs(HCP)
The Contractor shall provide leadership, in coordination with public and private community
partners, in the development of the Contractor's Local Children and Youth with Special Health
Care Needs(CYSHCN)Plan and the implementation of the Contractor's CYSHCN Operational
Plan.
The State HCP staff shall provide guidance and technical assistance to the Contractor to support
the implementation of the Contractor's CYSHCN Operational Plan for federal fiscal year
2005-2006 and for the development of the Contractor's Local CYSHCN Plan for the federal fiscal
year 2006-2007.
The CYSHCN Operational Plan and the Local CYSHCN Plan are to be based on an assessment of
the health status needs of the children and youth with special health care needs population and of
the health system resources of a community. These plans are further designed to:
a. 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",previously set forth in this Exhibit;
b. 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
children and youth with special health care needs, 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;
c. Facilitate outreach and enrollment efforts, including having information and applications
on site,to increase enrollment of eligible children and youth with special health care
needs, in Medicaid (Colorado Baby Care/Kid's Care Program)or Colorado Child Health
Plan Plus+(CCHP);
d. 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 children and youth with special health care needs in the
community.
2. Contractor shall engage in defined core public health activities designed to enhance the health
status of children and youth with special health care needs. The"Suggested Children with Special
Health Care Need Activities", attached hereto as"Attachment A-12",which is incorporated
herein by this reference and made a part hereof, shall be used, if appropriate,as guidance. These
activities shall include direct or enabling services, population-based activities and infrastructure
building activities as described in "Attachment A-1", "Core Public Health Services Delivered by
MCH Agencies".
Page 5 of 8
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 2005-2006(October 1,2005,through September 30,2006). The
CYSHCN Operational Plan previously developed by the Contractor, in consultation with the State,
based on an assessment of the health status needs of its CYSHCN population and of the health
system resources of its community,and shall utilize in full or in part the best-practice model plans
developed for specific performance measures by the State staff. The federal fiscal year 2005-2006
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,2005, through September 30,2006".
The CYSHCN Operational Plan is designed to: contribute to the accomplishment of the National
MCH CSHCN 6 Core Outcomes and Performance Measures,as identified in"Attachment A-l4
which is incorporated herein by this reference and made a part hereof.
4. Contractor shall perform in accordance with the HCP Contract Performance Measures, located in
Section A.1. of the HERMAN Document.
5. Contractor shall ensure that all IRIS users attend IRIS and security training and meet the"HCP
Regional Office Standards for Usage of IRIS II",and any subsequent amendments thereof,
attached hereto as"Attachment A-15", incorporated herein,by this reference,made a part hereof.
6. Contractor shall implement the"IRIS II Security Policy and Procedures",and any subsequent
amendments thereof, attached hereto as"Attachment A-16", incorporated herein by this
reference,made a part hereof.
7. Submission of the HCP Contract Performance Measure Annual Report: On or before January 15,
2006,the Contractor shall submit,to the Contractor's State HCP Program Consultant,the HCP
Contract Performance Measure Annual Report by completing Section A.1.of the HERMAN
Document.
8. Submission of CYSHCN Final Report for Federal Fiscal Year 2004-2005: On or before January
15,2006,the Contractor shall submit the CYSHCN Final Report for the Contractor's federal fiscal
year 2004-2005 (October 1,2004,through September 30,2005)activities. Instructions for
submitting the CYSHCN Final Report are set forth in Section II of Attachment A-7.
9. Submission of CYSHCN 6-Month Progress Report for Federal Fiscal Year 2005-2006: On or
before May 1,2006,the Contractor shall submit a CYSHCN 6-Month Progress Report,pertaining
to the CYSHCN Operational Plan for the first six months(October 1,2005—March 31,2006)of
the Contractor's federal fiscal year 2005-2006 activities. Instructions for submitting the CYSHCN
6-Month Progress Report are set forth in Section II of Attachment A-8.
10. Submission of the Local CYSHCN Plan for Federal Fiscal Year 2006-2007: On or before May 1,
2006 the Contractor shall submit to the State HCP Program Consultant, a"Local CYSHCN Plan
for federal fiscal year 2006-2007(October I,2006 through September 30, 2007). The Local
CYSHCN Plan shall consist of three(3)sections, 1.)Organizational Chart,2.) Statement of Need,
utilizing the Performance Measure Checklist—Part I-FY07,which is incorporated herein by this
reference,made a part hereof,and attached hereto as"Attachment A-9"; and 3.)CYSHCN
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 CYSHCN Plan are set forth in Section A of
Steps 1 through 5 of Attachment A-11, incorporated herein by this reference,made a part hereof,
and attached hereto.
Page 6 of 8
11. The Contractor shall serve the population of children and their families who fall within the MCH
definition of children with special health care needs(CSHCN): "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.
13. The HCP Discipline Regional Coordinators funded through this Task Order shall serve the
CSHCN as defined below:
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) through the TBI Trust Fund Pilot Project, in
accordance with the following process:
A. Upon receiving a referral packet of information from the state office,the HCP RO shall
"register"the child into IRIS and assign a Care Coordinator. The Care Coordinator shall
provide care coordination for up to one(1)year 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 one(1)year. The Care
Coordinator shall develop the care coordination plan by reviewing the needs described on
the TIM Trust Fund application, 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 an
invoice, in the amount of Eight Hundred Fifty Dollars($850.00)per child,to:
Rasa Eglite
Prevention Services Division
Colorado Department of Public Health and Environment
PSD-HCP-A4
4300 Cherry Creek Drive South
Denver,CO 80246
Page 7 of 8
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 IRIS Database to document care coordination plan,
activities, and outcomes.
F. The Care Coordinator shall have care coordination plans available for audit purposes.
G. The Care Coordinator shall provide the state family satisfaction survey to the families
that received care coordination at the end of the one-year period and encourage them to
respond.
H. The HCP RO multi-disciplinary team shall provide technical assistance to the Care
Coordinator, as needed.
I. 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",
incorporated herein,by this reference,attached hereto as"Attachment A-17", for
documentation of services on the IRIS database and maintaining client records.
J. 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-18" and
any subsequent amendments thereto,attached hereto, incorporated herein by this reference, made a
part hereof.
Page 8 of 8
Attachment A-1
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/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, 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 CRCSN Notification program
• Gap filling screening-Newborn Hearing,Early Vision
• Medical Home training, awareness campaign
• Medicaid/CHP+/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-IRIS, HERMAN, State and National data.
• Interagency& inter-organizational agreements-Part C,Respite programs, other
• Participate in development of local/state Data Systems-IRIS,NEST
• Participate in state/local standard development and dissemination-NB 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 5 of 5
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-1 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.
I Budget Expenditure Report:
Due Date: December 1,2005(For The Period Of October 1,2004 through September 30,2005)
Please provide actual numbers for how the funds were used in the period of October 1, 2004 through September 30, 2005.
n Budget Application:
Due Date: May 1,2006(For The Period of October 1,2006 through September 30,2007)
Based on your county plan,please estimate the following based on your MCH funding formula contract amounts for the
period of October 1,2006 through September 30,2007.
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.
Page 1 of 1
Attachment A-3
MATERNAL AND CHILD HEALTH
INSTRUCTIONS FOR COMPLETING AND SUBMITTING THE NUMBERS SERVED REPORT(Tables I & II)
For the period of October 1, 2004 through September 30, 2005
Due Date: January 15, 2006
Estimates are acceptable and are preferable to no data. Please estimate to the best of your ability. Columns 2-6 must equal Column 1 and the table is
designed to add your input automatically. If a person can be counted in more than one category in a year, select one class only in which to report
them. If you cannot provide any information in health insurance coverage, put your total number of clients in column (6), Number Unknown.
These data are compiled at the state level and submitted to the Maternal and Child Health Bureau for Form 7 in the MCH Block grant application.
If you need assistance in filling out this form, call Sue Ricketts, Prevention Services Division, Colorado Department of Public
Health and Environment, 303-692-2316, or email her at sue.ricketts@state.co.us.
Submit the Numbers Served Report, via e-mail, no later than 5:00 P.M. on January 15, 2006, to: Jan Reimer at: jan.reime
r@state.co.us
j r@state.co.us
Page 1 of 3
Attachment A-3
County: , `�- �. Prepared by _ -r 7Fst • . �o , s
Program: a of s�'_.. ..,' __. _..: Telephone. fa_ s .. $ ��. ..
r . P fliK' �r €
� 3�
Email: . .. '�:.;:a .. .. .
Table I
Number of Individuals Served (Unduplicated) Under Title V
By Class of Individuals and Health Coverage, FY 2005
October 1,2004 through September 30,2005
Column(1)will automatically total across columns(2)through(6).
Columns(1)to(6)will automatically total for Total MCH Population. nput=' 1 n yellowshar .,:.
(1) (2) (3) (4) (5) (6)
)—vg a-, ar n, . �, � 5 ii .
Unduplicated Count byr ..- "�' '� ,X r ;y • Itr ,,.
Class of Individual Served - ... ,t ,,.. ,_. w .�a ., .„ r -. � ,,.,.� .P_..
, start here
Pregnant women receiving prenatal care _ v 91` b , �, ,' " ' ";7714-- EitieH"At'Infants under age one(not elsewhere) -` `1 tl -,� ��ks �' _
Children age 1-22(not elsewhere) a1 ': , �.r,r i. = .. s... .
*`- ':mot . .
Children with special health care needs ^_, ..ti _ -.. #. m.�- -
*s - ..
Other individuals(not elsewhere)' -s p) r+ ,» asz,
L'Asha .1,, ... ,� x- - m _
Total MCH Population(automatic) "*' ,� Ef"._.'� F* 6 * a e3 ' t ,szLrh B1
Please take the Total Number shown in Column 1 for Children age 1-22:
k ,_:• " ,v , DOR NOT REMOVE CELL PROTECTION IN
and estimate the number in each of these age groups: GRAY AREAS!l
Age 1-4
Age 5-9
Age 10.14 ''
Age 15-19 n;,
Age 20-22
Unknown
Total of ages: S :" '` .
Total shown above for children age 1-22: Plit,iwa' " `-''(
Difference: jet
u g `.;
The totals should match and the difference should be zero.
Page 2 of 3
Attachment A-3
*Fill out Table /l if you serve pregnant women
Q [PersttA1T11]
Table II
Number of Deliveries Served by Title V
Unduplicated Count by Race and Ethnicity, FY20O5
October 1,2004 through September 30,2005
� More cells»>
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
Total Oth.
Asian or Other Non- and
American Pacific and Total Total Hisp- Un-
Total All Races White'* Black Indian Islander Unknown Ethnicities Hispanic anic kn.
Pregnant women start he start here:
n:
receiving pnc . ,..�G::-_ .: :ay., .z:
Count Hispanics in the White column,unless they belong to one of the other racial groups.
Total in Table I for Pregnant women: `V 1 'tilt
Total in Table II for Pregnant women: 9'
beceDifference: , „s' $;
These totals should match and the difference should be zero.
al
Total All Races Col.(1): - -teal
Total Ethnicities Col.(7): ricail_ � .,
Difference:
These totals should match and the difference should be zero.
Page 3 of 3
Attachment A-4
MATERNAL AND CHILD HEALTH
PRIORITIES,PERFORMANCE MEASURES,AND OUTCOME MEASURES
As of October 1,2005
Colorado MCH Priorities
I. 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 Statesponsored newbom
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, Polo, 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 both
10. The rate of deaths to children aged 14 and younger caused by motor vehicle crashes per 100,000 children
11. Percentage of mothers who breast feed their infants at hospital discharge
12. Percentage of newborns who have been screened for hearingimpairment 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 dl 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 highrisk 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
1. 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
1. 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
1. 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 acces 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
Attachment A-6
Weld County Department of Public Health and Environment
Prenatal and Child/Adolescent Operational Plan
for
October 1, 2005 — September 30, 2006
Page 1 of 6
Immunizations
Goal: Achieve and maintain effective vaccination coverage levels for universally recommended vaccines among children
Immunization Rates (HP 2010)
Sample long-term objective: Outcome Evaluation: Outcome/Progress:
By September 2010,increase to 90%the proportion of young children 19- Data source not available at this time
35 months in Weld County who receive all vaccines that have been Utilize future state/county data sources
recommended for universal administration. when available
Sample short-term objective:
By September 30,2006,85%of immunization providers in Weld County County-wide assessment of immunization
will utilize and demonstrate compliance with the recommended strategies providers utilization of strategies to
to improve immunization coverage from the Revised Standards for Child improve vaccination coverage from the
and Adolescent Immunization Practices developed by the National Revised Standards for Child and
Vaccine Advisory Committee(NVAC)and published by the National Adolescent Immunization Practices
Immunization Program(NIP) developed by the National Vaccine
Advisory Committee(NVAC)and
published by the National
Immunization Program(NIP)
completed as both a pre and post
measure
Sample short-term objective:
By September 30,2005,the Weld County Department of Public Health
and Environment will collect baseline information regarding childhood Immunization data compiled and bathers
vaccination rates in Weld County,and identify barriers to obtaining identified, including the immunization rate
immunizations from the agency clinics,community health centers,schools for 19-35 month olds in Weld County.
when appropriate and private providers in the community
Page 2 of 6
Activities Process Evaluation Outcome/Progress
1.1 Assessment of current community provider activities and planning
• Assess which agencies/coalitions are addressing child and Document assessment activities.
adolescent immunizations
• Assess which providers are providing vaccinations Community stakeholder group has met,
• Conduct meetings with stakeholders/coalition(physicians, membership is documented,and a plan of
midlevel providers, school nurses,childcare centers, faith based action with defined roles for each member
settings) is completed
• Use/adapt existing CDPHE assessment tool to gather information Identify/implement assessment tool,
from health care clinics, schools,day care providers to establish a gather and compile data to document
baseline for immunization rates and also identify perceived immunization rates and perceived barriers
barriers to getting immunizations to getting immunizations
1.2 Make available the Revised Standards for Child and Adolescent Number of trainings and copies of the
Immunization Practices developed by the National Vaccine Advisory Revised Standards for Child and
Committee(NVAC)and published by the National Immunization Program Adolescent Immunization Practices
(NIP)to all immunization providers and community stakeholders/coalition developed by the National Vaccine
Advisory Committee(NVAC)that were
disseminated—percentage of providers
reached.
1.3 Implementation of strategies to improve vaccination coverage Number and proportion of reminder
• Systems are used to remind parents/guardians,patients,and systems utilized by immunization
healthcare professionals when vaccinations are due and to recall providers in the county
those who are overdue
• Office or clinic-based patient records reviews and vaccination Number of Immunization providers
coverage assessments are performed annually patient record reviews and vaccination
• Healthcare professionals practice community-based approaches coverage assessments completed annually
Document activities of community
stakeholder group/coalition to improve
immunization rates in the community.
Page 3 of 6
Resources
Primary MCH Contact—Cathy White,RN,MSN School Age and Youth Child Health Nurse consultant,303-692-2375,cathy.white@state.co.us
For More Information Contact:
• Joni Reynolds,Immunization Nurse Consultant at ioni.revnolds@state.co.us/phone 303 692-2363
On-line Resources:
• Copy of the Revised Standards for Child and Adolescent Immunization Practices go online at http://www.cdc.gov/nip/recs/rev-immz-stds.htm
• Standards for Child and Adolescent Immunization Practices article published in Pediatrics go online at http://www.cdc.gov/nip/recs/rev-immz-
stds.htm
Local health department contact for this goal area:
Name:Trish McClain,RN
Phone:970/304-6420,ext.2302 Email: pmcclain@co.weld.co.us
Page 4 of 6
MCH Performance Indicator(NPM 18): The percentage of infants born to pregnant women receiving prenatal care beginning in the first
trimester.
Contact Person: Julie Davis,Women's Health Section,iulie.davis(&)state.co.us or(303)692-2497.
Goal 1: Increase first trimester enrollment into prenatal care.
Objective 1 (Long-term) Outcome Evaluation Outcome/Progress
Increase the first trimester enrollment from a baseline of 73.8%in FY First trimester enrollment rate in Weld County as
2002 to 77%by 2008 in Weld County. measured by birth certificate data.
Activity Process Evaluation
1.1 Analyze first trimester enrollment data—Cohid,vital statistics—to Data analyzed and high-risk groups identified. Completed FY05
determine the groups of women at highest risk for not accessing prenatal
care in Weld County.
Short-Term Objective#1: Maintain Provider Capacity Outcome Evaluation Outcome/Progress
By September 30,2006,maintain the number of prenatal clients served
at Sunrise Community Health Center and Weld County Department of Number of clients:
Public Health and Environment prenatal clinic sites. Sunrise Community Health Center--400
Weld County Department of Public health and
Environment-- 200
Activity Process Evaluation
1.1 Provide infrastructure support to Sunrise Community Health Center 1.1 Infrastructure support provided and capacity
to maintain their capacity to provide prenatal care to Medicaid and maintained.
uninsured low-income women. To include providing clinic space, Space
support staff,program supervision,and supplies. Staff by FTE:
3 FTE Sunrise
1.4 FTE WCDPHE
(Supervision,medical care,eligibility)
1.2 Collaborate with Sunrise Community Health Center to develop and 1.2 All parts of the safety net system remain available.
provide a single point of entry into a continuum of Prenatal&infant Any gaps are identified and described. (target groups
care. and resources)
Page 5 of 6
1.3. Refer pregnant clients who access Weld County Department of 1.3. Pregnant clients referred for prenatal care services.
Public Health and Environment's(WCDPHE)for prenatal care. Number of referrals to:
PN+
NFP
High risk prenatal care
Residency program for delivery
Family Planning
Post Partum care
Monfort Children's Clinic
Children with Special Health Care Needs
1.4 Maintain first trimester enrollment community outreach campaign. 1.4 Community outreach campaign maintained.
To include the 2 FTE eligibility technicians, .25 FTE Prenatal The number of clients educated and enrolled into
Community Coordinator Medicaid.
The number of radio interviews,community
presentations,news articles(describe activities,articles,
etc.
1.5 Maintain involvement with the Promises Coalition of Weld County. 1.5 Involvement with Promises Coalition maintained.
(List any other committees or population based activities)Design a Report on the number of brochures printed,distributed
brochure that educates on the importance of early prenatal care, and agencies contacted.
Medicaid application,and health promotion for pregnancy.
Page 6 of 6
Attachment A-7
MATERNAL AND CHILD HEALTH
FINAL REPORTS
Instructions for submitting the Prenatal and Child/Adolescent Final Report and the Children and Youth with
Special Health Care Needs(CYSHCN)Final Report for FY05 for the period of October 1,2004 through
September 30,2005
DUE DATE: On or Before January 15,2006
The Contractor is requested to submit two(2)separate reports for the three(3) Maternal and Child Health
populations for the period of October 1,2004 through September 30,2005: one report to cover the prenatal and
child/adolescent populations and one report to cover the CYSHCN population. The information in this document
provides guidance for submitting each final report.
1. PRENATAL AND CHILD/ADOLESCENT FINAL REPORT FOR FY05
A. Create a cover page that contains the following information:
1. Title the Report: "Prenatal and Child/Adolescent Final Report for FY05"
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,2004 through
September 30,2005. 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 FY05.
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 FY05,via e-mail, no later than 5:00
P.M. on January 15,2006 to:
Jan Reimer at:jan.reimerAstate.co.us
state.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 FY05 templates with a brief
description, in the Outcome/Progress column, of the progress made on each
activity.
Page 1 of 3
II. CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS(CYSHCN)FINAL
REPORT FOR FY05
The CYSHCN Final Report for FY 05 is completed using the CYSHCN Operational Plan for FY05.
A. Create a cover page that contains the following information:
1. Title the Report: "CYSHCN Final Report for FY 05"
2. Agency Name
3. Contact person,and
4. Contact's telephone number
B. Attach your agency's CYSHCN Operational Plan for FY05; in the Outcomes/Progress column,
provide a brief description of the progress made on each activity for the period of October I,2004
through September 30,2005 include the following in your description of progress:
1. State if objective was fully met, partially met,or not met.
2. Describe any important administrative or organizational changes.
3. Summarize any significant problems or accomplishments, including completed activities.
4. Describe any emerging issues.
C. Submit your CYSHCN Final Report FY 05,via e-mail,to your State HCP Consultant. (See page 3
for name&e-mail address of your HCP consultant.)
Note: A complete CYSHCN Final Report shall contain the following,in this order:
a. Cover Page
b. CYSHCN Operational Plan for FY05 templates with a brief description of the
progress made on each activity.
Page 2 of 3
HCP PROGRAM CONSULTANTS
AND REGIONAL OFFICE ASSIGNMENTS
Effective: June 1, 2005
REGIONAL OFFICES CONSULTANT E-MAIL ADDRESS PHONE NUMBER
Boulder HCP Regional Office Vickie Thomson vickie.thomson(Wstate.co.us 303-692-2458
Denver HCP Regional Office Eileen Forlenza eileen.forlenza(&state.co.us 303-692-2794
El Paso HCP Regional Office Steve Holloway steve.hollowav(a,state.co.us 303-692-2327
Jefferson HCP Regional Office Steve Holloway steve.hollowav(astate.co.us 303-692-2327
-Broomfield Health Dept.
Larimer HCP Regional Office Shirley Babler shirlev.bablerAstate.co.us 303-692-2455
Northeast HCP Regional Office Barb Deloian barbara.deloian(a�state.co.us 303-692-2303
Northwest HCP Regional Office Anne-Marie Braga anne-marie.braea(a�state.co.us 303-692-2362
Pueblo HCP Regional Office Shirley Babler shirlev.babler@,state.co.us 303-692-2455
South Central HCP Regional Office Anne-Marie Braga anne-marie.braea(a)state.co.us 303-692-2362
-Las Animas-Huerfano Health Dept.
Southeast HCP Regional Office Eileen Forlenza eileen.forlenzaAstate.co.us 303-692-2794
Southwest HCP Regional Office Barb Deloian barbara.deloianAstate.co.us 303-692-2303
Tri-County HCP Regional Office Tim Hershey tim.hershev(aistate.co.us 303-692-2413
Weld HCP Regional Office Lynn Bindel Ivnn.bindek&state.co.us 303-692-2392
Western Slope HCP Regional Office Karen Fehringer karen.fehrineer(&,state.co.us 303-692-2399
-Delta Health Dept.
Page 3 of 3
Attachment A-8
MATERNAL AND CHILD HEALTH
6-MONTH PROGRESS REPORTS
Instructions for submitting the Prenatal and Child/Adolescent 6-Month Progress Report and the Children
and Youth with Special Health Care Needs(CYSHCN)6-Month Progress Report For FY06 for the period
of October 1,2005 through March 30,2006.
DUE DATE: On or Before May 1,2006.
The Contractor is requested to submit two(2)separate reports for the three(3)Maternal and Child Health
populations for the period of October I,2005 through March 30,2006: one report to cover the prenatal and
child/adolescent populations and one report to cover the CYSHCN population. The information in this document
provides guidance for submitting each 6-month progress report.
I. PRENATAL AND CHILD/ADOLESCENT 6-MONTH PROGRESS REPORT FOR FY06
Please follow the instructions below to create the Prenatal and Child/Adolescent 6-Month Progress Report
for FY06:
A. Create a cover page that contains the following information:
1. Title the Report: "Prenatal and Child/Adolescent 6-Month Progress 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 March
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.
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 06,via e-mail, no
later than 5:00 P.M. on May 1,2006 to:
Jan Reimer at: ian.reimerna,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 FY06 templates with a brief
description, in the Outcome/Progress column,of the progress made on each
activity.
Page 1 of 3
II. THE CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS(CYSHCN)6-MONTH
PROGRESS REPORT FOR FY06
Providing information in the Outcomes/Progress column of the CYSHCN Operational Plan for FY 06
completes the CYSHCN 6-Month Progress Report. Please follow the instructions below:
A. Create a cover page that contains the following information on the top of the first page of the
Operational Plan
I. Title the Report: "CYSHCN 6-Month Progress Report for FY 06"
2. Agency Name
3. Contact Person, and
4. Contact's telephone number
B. Attach the templates used for the CYSHCN 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. Include changes that affected implementation of plan,such as:
I. Describe any important administrative or organizational changes.
2. Summarize any significant problems or accomplishments, including completed activities.
3. Describe any emerging issues.
C. Submit your CYSHCN 6-Month Progress Report,via e-mail,no later than 5:00 P.M. on May I
2006,to your State HCP Program Consultant. (See page 3 for name& e-mail address of your
consultant.)
Note: A complete CYSHCN 6-Month Progress Report shall contain the following,in this
order:
a. Cover Page
b. CYSHCN Operational Plan for FY06 templates with a brief description, in the
Outcome/Progress column,of the progress made in all of the activities.
Page 2 of 3
HCP PROGRAM CONSULTANTS
AND REGIONAL OFFICE ASSIGNMENTS
Effective: June 1, 2005
REGIONAL OFFICES CONSULTANT E-MAIL ADDRESS PHONE NUMBER
Boulder HCP Regional Office Vickie Thomson vickie.thomsonAstate.co.us 303-692-2458
Denver HCP Regional Office Eileen Forlenza eileen.forlenzaAstate.co.us 303-692-2794
El Paso HCP Regional Office Steve Holloway steve.hollowavi&state.co.us 303-692-2327
Jefferson HCP Regional Office Steve Holloway steve.hollowav(&state.co.us 303-692-2327
-Broomfield Health Dept.
Larimer HCP Regional Office Shirley Babler shirlev.bablera,state.co.us 303-692-2455
Northeast HCP Regional Office Barb Deloian barbara.deloianAstate.co.us 303-692-2303
Northwest HCP Regional Office Anne-Marie Braga anne-marie.braga@state.co.us 303-692-2362
Pueblo HCP Regional Office Shirley Babler shirley.babler(&state.co.us 303-692-2455
South Central HCP Regional Office Anne-Marie Braga anne-marie.bra2a(&,state.co.us 303-692-2362
-Las Animas-Huerfano Health Dept.
Southeast HCP Regional Office Eileen Forlenza eileen.forlenza(state.co.us 303-692-2794
Southwest HCP Regional Office Barb Deloian barbara.deloian(a?state.co.us 303-692-2303
Tri-County HCP Regional Office Tim Hershey tim.hersheystate.co.us 303-692-2413
Weld HCP Regional Office Lynn Bindel Ivnn.bindelna,state.co.us 303-692-2392
Western Slope HCP Regional Office Karen Fehringer karen.fehringer(a,state.co.us 303-692-2399
-Delta Health Dept.
Page 3 of 3
Attachment A-9
PERFORMANCE MEASURE CHECKLIST-PART I-FY 07
CYSHCN OUTCOMES & NATIONAL PERFORMANCE MEASURES
3 How Need is Being Addressed•ei
Oll
°L °L o _ m SI 44 3 o Explanation or Description
ri y y V C fQ y W L L
ow y1° m d r o Ug rc L co .5W y For
U g i S V e � £ c s 1 L ggft Ps f 9 y .. Checked Boxes
v eo `j ° 4 4 pd9 0o du
as Z
Reported
CYSHCN Outcome 1: by HCP
Families of CYSHCN will region 15 18
partner in decision-making
at all levels=Family
Participation degree(score)
NPM 2: Percent of families
of children with special N/A
needs who participate in 57.4 55.0 N/A
decision-making and are
satisfied with services
CYSHCN Outcome 2: All
children with special needs
will receive regular,
ongoing comprehensive
care within a medical home
NPM 3:Percent of children N/A 51.7 50.0 N/A
with special needs with a
medical home
Page I of 10
Attachment A-9
PERFORMANCE MEASURE CHECKLIST-PART I-FY 07
CYSHCN OUTCOMES & NATIONAL PERFORMANCE MEASURES
3 How Need is Being Addressed o
s
v w is c 9 e ° o �
e y r h V o m z d _ d IN) z ew� w V L Explanation or Description
7 W � W N O �y t.. L i C L y y v
a G C F y For
U .� sl ct) CaLeo — e z .2 I? v t Checked Boxes
Pr o� CW ` a. 0dc � o tic.) a
a Qa zz z
CYSHCN Outcome 3: All
families of children with
special health care needs
(CYSHCN)will have
adequate private and/or
public insurance to pay for
the services they need
NPM 4: Percent of children
and youth with special N/A 58.2 55.0 N/A
needs with adequate
insurance
CSHCN Outcome 4: All
children will be screened
early and continuously for
special health care needs
NPM 1: Percent of infants
receiving newborn N/A 98.0 98.0 All
screening
NPM 12: Percent of
newborns receiving 96.2 95.0 N/A
newborn hearing screening
before discharge
Page 2 of 10
Attachment A-9
PERFORMANCE MEASURE CHECKLIST-PART I-FY 07
CYSHCN OUTCOMES & NATIONAL PERFORMANCE MEASURES
3 How Need is Being Addressed
d o 0 7„,CC c 70'
z 9l S d L m `-� U Explanation or Description
14
p W `° r .. tJ o "�' v U e t o t a e a 00. c For
o ( x C7 ` sl m C .
°etc i g ' . — Checked Boxes
o_
a p0 a` � .C . ° d � Et° o du c4
G > > Q a z z z
CYSHCN Outcome 5:
Community based service
systems for CYSHCN and
their families will be
organized for easy use
NPM 5: Percent of families
of children and youth with
special needs reporting N/A 77.4 75.0 N/A
service systems organized
for easy use
CYSHCN Outcome 6: All
youth with special health
care needs will receive
services to transition to
adult life
NPM 6: Percent of children
and youth with special N/A 5.8 6.0 N/A
needs who received services
to transition to adult life
Page 3 of 10
Attachment A-9
PERFORMANCE MEASURE CHECKLIST-PART II-FY 07
PRENATAL,AND CHILD AND ADOLESCENT MEASURES-MARCH 2005
9 ; How Need is Being Addressed c
d
o44 o m Z 9� x L ;, Explanation or Description
o W s v rr o m U r . L 4° c o W For
U '9 ° Lo_ s' a .2 O ° s ' 3 vea Checked Boxes
VJ L a C_ a C a of,
9 C G E
by ' W N ci Z
�a •> > Q a Z
ADOLESCENT HEALTH
MEASURES
NPM 8: Teen(ages 15
through 17)birth rate 25.2 28.0 43.0
NPM 16: Rate of suicide
deaths among youths age
15-19 11.7 12.0 5.0
Old SPM 5: Rate of motor
vehicles deaths, ages 15-19 29.3 19.1 9.2
SPM 4(Old SPM 6): The
percent of high school
students using tobacco N/A 34.4 26.3 21.0
regularly
SPM 1: The percent of high
school students who report
drinking in previous month N/A 50.9 48.0 11.0
Page 4 of 10
Attachment A-9
PERFORMANCE MEASURE CHECKLIST-PART II-FY 07
PRENATAL,AND CHILD AND ADOLESCENT MEASURES-MARCH 2005
•
3 How Need is Being Addressed
63 y m d r0 C
L. o z ;, e Explanation or Description
a �, •• �, G, o w >, w U ea c s oo m = o For
n w aQ N C L
v C7 a sl tang a s w * 2U Checked Boxes
(!) 1: OA C 7 Q C -O ,
'� a � � �' aQ zz z
SPM 7(Old SPM 10)Rate
of homicide among teens
ages 15-19 6.8 5.0 3.0
CHILD HEALTH
MEASURES
NPM 7:Percent of children
through age two with
completed immunizations N/A 67.5o 90.0 90.0
(4:3:1:3:3)
SPM 8(Old SPM 12):
Percent of children on WIC
who are obese 9.4 8.5 5.0
SPM 3:The incidence of
maltreatment of children
less than 18(physical,
sexual or emotional abuse
and/or neglect) 9.0 5.8 10.3
Page 5 of 10
Attachment A-9
PERFORMANCE MEASURE CHECKLIST-PART II-FY 07
PRENATAL,AND CHILD AND ADOLESCENT MEASURES-MARCH 2005
How Need is Being Addressed c
� � ° c o ° al `o
e r o Z fl m d �`- Explanation or Description
o W .W, m eu ri o t y�� U e 'o a .. t° C v a c "t For
n - y `o_ -= ea m 2 z ° U Checked Boxes
aG 4. .7G O etg Zz 2:
a
SPM 10:Rate of injury
hospitalization among
children less than 19 years 308.6 251.0 N/A
NPM 10:Rate of death for
0-14 year olds due to motor
vehicle crashes 5.5 3.0 9.2
National Outcome Measure
6:Child Death Rate(ages 1-
14) 21.3 20.3 N/A
SPM 5: The percent of
children in public schools
with access to health
education and to care
through school based health 11.0 8.75 N/A
centers
NPM 13: Percent of
children without insurance N/A 14.3 15.0 0.0
Page 6 of 10
Attachment A-9
PERFORMANCE MEASURE CHECKLIST-PART II-FY 07
PRENATAL, AND CHILD AND ADOLESCENT MEASURES-MARCH 2005
How Need is Being Addressed e
w a� o c dal a o
e y ,w h o
c S W Explanation or Description
• W W .d on s m W6. N W N O _ C a �. y • 9 d For
U yW `y V o -9 m= tee s ti w' , Checked Boxes
� •L. eo cue a � O w9 e c d �
a as z z
NPM 14:Percent of
Medicaid-eligible children
receiving a Medicaid-paid N/A 84.7 93.0 N/A
service
INFANT HEALTH
MEASURES
NPM 15: Percent of Very
Low Birth Weight live
births 1.3 1.0 0.9
NPM 17:Percent of very
low birth weight infants
delivered at Level III
hospitals 73.7 75.0 90.0
State Outcome Measure 1:
Low Birth Weight Rate 8.9 7.5 5.0
National Outcome Measure
1: Infant mortality rate 6.1 5.7 4.5
Page 7 of 10
Attachment A-9
PERFORMANCE MEASURE CHECKLIST-PART 1I-FY 07
PRENATAL,AND CHILD AND ADOLESCENT MEASURES-MARCH 2005
How Need is Being Addressed c
0
a> 4J a .a� c o
O Z x o L ` „ �, Explanation or Description
s y a as o � JI U c .2 = L h � � c � W For
x C7 0 e_ ee y = ' ; U Checked Boxes
or hcz •yam p dog O 0 d �
EI QQ zz z
National Outcome Measure
3:Neonatal Mortality rate 4.2 3.9 2.9
National Outcome Measure
2: Black/White infant
mortality ratio 3.2 1.9 N/A
National Outcome Measure
4: Post neonatal Mortality
rate 1.9 1.8 1.2
ORAL HEALTH
MEASURES
1S`New Oral Health
Measure: Percent with
caries experience 57.0 N/A 42.0
NPM 9: Percent of third
graders with protective
sealants 34.9 35.0 50.0
Page 8 of 10
Attachment A-9
•
PERFORMANCE MEASURE CHECKLIST-PART II-FY 07
PRENATAL,AND CHILD AND ADOLESCENT MEASURES-MARCH 2005
3 How Need is Being Addressedcu C
d 9 C
a o m Z � L ow eW Explanation or Description
!Jr: N o j�'. W CJ s CG 6 C o G For
o d 0. C7 .r. g O o z = a 8 Checked Boxes
U � rn T. Lon a °e c o O ° 9 �' N v "
46' � w 31 la' ea zz z
2°d New Oral Health
Measure: Percent with 25.9 N/A 21.0
untreated decay
SPM 6(Old SPM 8):
Percent of Medicaid-
eligible children receiving
dental care 31.1 27.0 57.0
PRENATAL HEALTH
MEASURES
SPM 2: The percent of
births that are unintended
39.4 36.0 30.0
NPM 18: Percent of infants
whose mothers received
first trimester prenatal care 79.3 85.0 90.0
SPM 9(Old SPM 13:
women with inadequate
weight gain during
pregnancy 23.3 20.0 N/A
Page 9 of 10
Attachment A-9
PERFORMANCE MEASURE CHECKLIST-PART II-FY 07
PRENATAL,AND CHILD AND ADOLESCENT MEASURES-MARCH 2005
How Need is Being Addressed 9
o •••
-�
L L O O � C 4p
a y o z �, Explanation or Description
O y .+ y a C �"� V = O a "VI 41
c n For
t7 0 = r •� i V Checked Boxes
OE, d
a 1 •; zw � QQ )Zz
z �
NPM 11: Percent of
mothers breastfeeding at
hospital discharge 84.3 87.0 75.0
National Outcome Measure
5: Perinatal Mortality rate 6.5 8.0 4.5
The Performance Measures for which MCH funds will be used are:
Page 10 of 10
Attachment A-10
SAMPLE STANDARD TABLE FORMAT
For use in creating the Prenatal and Child/Adolescent and CYSHCN Operational Plans for FY07
Goal 1:
Objective 1: Outcome Evaluation: Outcome/Progress:
Activities: Process Evaluation:
1.1 Six-Month Progress Report
Year End Progress Report
1.2 Six-Month Progress Report
Year End Progress Report
1.3 Six-Month Progress Report
Year End Progress Report
1.4 Six-Month Progress Report
Year End Progress Report
Page 1 of 1
Attachment A-11
MATERNAL AND CHILD HEALTH
LOCAL PLANS
Instructions for Submitting the Local Prenatal And Child/Adolescent Plan and the Local Children and Youth
with Special Health Care Needs Plan For FY07 for the period of October 1,2006 through September 30,2007
DUE DATE: On or Before May 1,2006
The Contractor is to submit two(2)separate local plans for the three MCH populations;one called the Local
Prenatal and Child/Adolescent Plan,which will cover the prenatal and child/adolescent populations and one called
the Local CYSHCN Plan,which will cover the children and youth with special health care needs population.
Both Local Plans are 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 Plans due on or
before May I,2006.
In each of the Local Plans the Contractor is asked to assess and prioritize the health status needs for each of the
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 two local plans.
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 and/or HCP 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 and HCP 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 1 of 9
The Local Prenatal and Child/Adolescent Plan and the Local CYSHCN Plan will each consist of three sections,the
Agency's Organizational Chart,the Statement of Need,and the Operational Plan.
Section 1-Organizational Chart: For the Organizational Chart Section of the Local Plans the Contractor shall
provide two organizational charts,the first organizational chart is for your Local Prenatal and Child/Adolescent Plan
and needs to contain the names of supervisors, staff under each supervisor,and the percentage of FTE for each staff
receiving MCH funds for performing prenatal and child/adolescent tasks within the agency;the second chart is for
your Local CYSHCN Plan and needs to contain the names of supervisors, staff under each supervisor, and the
percentage of FTE for each staff receiving HCP funds for performing CYSHCN tasks.
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-FY07 to assess and present the priority needs for which
your agency will use the MCH funding for the prenatal and child/adolescent populations.
For the Statement of Need Section of your Local CYSHCN Plan, complete the appropriate sections of the
HERMAN document and the Performance Measure Checklist-Part I-FY07 to assess and present the priority needs
for which your agency will use the HCP funding for the children and youth with special health care needs
population.
Section 3-Operational Plan: For the Operational Plan Section of the Contractor's Local Plans,there should be
goals, objectives, activities and measures for each of the Performance Measures for which your agency will be using
MCH or HCP funds,as indicated in the Statement of Need Section of each 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 Plans or may develop their own plans 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
each of the Operational Plans. The Operational Plans will become an attachment to the FY07 MCH Contract.
Each 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 Plans 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.
Page 2 of 9
STEP-BY-STEP INSTRUCTIONS:
STEP 1. Creating the Organizational Charts
A. Children and Youth with Special Health Care Needs(CYSHCN)Organizational Chart
The Contractor shall provide an organizational chart that contains the names of supervisors
receiving HCP funds for supervising CYSHCN staff,names of supervised CYSHCN staff
under each supervisor,and the percentage of FTE for each CYSHCN staff listed in the
organizational chart.
B. Prenatal and Child/Adolescent 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 organizational Chart.
STEP 2. Completing the Statement Of Need Section of the Local Prenatal and Child/Adolescent Plan and
the Local CYSHCN Plan:
There are two parts to the Performance Measure Checklist for each agency to use to complete the
Statement of Need Sections of the Local Prenatal and Child/Adolescent Plan and the Local CYSHCN
Plan: Part I is for the children and youth with special health care needs population,and Part II is for
the prenatal and child/adolescent populations. The Checklists are 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.
A. Instructions for completing the Statement of Need for the Local CYSHCN Plan
The Statement of Need Section of the Local CYSHCN Plan has two(2)parts:
Part 1 - Surveillance of Need for Performance Outcomes 1-7 in the HERMAN document
Part 2- The Performance Measure Checklist-Part 1-FY07
1. Complete the Surveillance of Need for Performance Outcomes 1-7 in the HERMAN
document. Refer to and use the HCP data report,which shall be provided by the
State HCP office in March 2006. The Surveillance of Need will give you qualitative
and quantitative data on indicators for each of the seven outcomes.
2. Complete the Performance Measure Checklist-Part l-FY07:
a. Decide for each of the six CYSHCN measures if the measure is a low,
medium,or high priority. Fill in the appropriate designation(L, M,H)
under the"Priority Need figh/Med/Low)"column. If the regional or
county measure given meets the Healthy People 2010 goal,mark an"L" for
low in the column. If the regional or county measure is near the Healthy
People 2010 goal,mark an"M"for medium. If the regional or county
measure is far from the Healthy People 2010 goal, mark an"H" for high.
There is not regional or county outcome measure data for all six(6)
CYSHCN Measures, Refer to all available indicator data in the HCP Data
Report and HERMAN to make your judgment of priority level for those
measures.
Page 3 of 9
b. Check one or more of the boxes under the"How Need Is Being Addressed"
heading to show whether you will be using HCP funds to address that need;
other funds to address that need;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 of addressing that need.
It may be appropriate to check more than one box.
c. If the measure is not a high priority need,but your agency has determined
that you need to continue to use HCP funds in order to maintain the good
status that the measure reflects,place a check in the"Need to Maintain
Current Effort"for that measure.
d. In the"Rank for Goals 1-6"column,place numbers I through 6,to indicate
the relative priority that you are giving each measure, I being the highest.
e. In the Explanation or Description for Checked Boxes column, provide a
BRIEF explanation of the situation to explain the checked boxes.
B. Instructions for completing the Statement of Need for the Local Prenatal and
Child/Adolescent Plan:
The Contractor is to complete the Performance Measure Checklist-Part 11-FY07, 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.
Page 4 of 9
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-FY07. These are the measures that you will use to write your
agency's Prenatal and Child/Adolescent Operational Plan
STEP 3. Writing the Operational Plans:
When creating the Prenatal and Child/Adolescent Operational Plan and the CYSHCN Operational Plan
your agency may select state-prepared Model Plans(composed of goals, objectives, activities,process
evaluation methods and outcome evaluation methods),choosing only as many as are appropriate for
the amount of MCH or HCP funds you will be receiving;your agency may write your own plans or
may use a combination of state-prepared Model Plans and agency-developed plans. Please note that
not all performance measures have state-prepared Model Plans developed.
A. Children and Youth with Special Health Care Needs(CYSHCN)Operational Plan
Instructions
I. For the CYSHCN 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 HCP 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. Choose from the listed activities and 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.
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 use the HCP funds for agency-developed plans as long
as they address priority needs of the children and youth with special health
care needs population in your community as presented in the Statement of
Need section of the Local CYSHCN Plan. You may also choose to use
other approaches than those outlined in the prepared Model Plans by writing
objectives and activities of your own.
Page 5 of 9
b. Use the same standard table format as that used for the prepared Model
Plans. A blank copy of the standard table format can be 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 explaining how your agency 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.
B. Prenatal,and Child and Adolescent Operational Plan Instructions
1. For 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.
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.
Page 6 of 9
STEP 4: Completing the Cover Pages for the Local Plans
A. Local Children and Youth with Special Health Care Needs(CYSHCN)Plan
1. Download the current HERMAN document from the HCP website at
www.cdphe.state.co.us/ps/hcp/hcphom.asp by:
a. Clicking on"Useful Forms."
b. Selecting appropriate form under"Annual HCP Reporting,"
2. Complete the cover page for the HERMAN document with the following
information:
a. Agency Name
b. Date of Report
c. Contact person for report
d. Contact's telephone number, and
e. Contact person's email
3. Save your HERMAN document to your hard drive or a floppy disk;title document:
HERMAN for FY07.
B. Local Prenatal, and Child and Adolescent Plan
1. 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 FY07"
b. Agency Name
c. Contact Person
d. Contact's Telephone Number
a. 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"
STEP 5: Submitting the Local Plans
A. Local Children and Youth with Special Health Care Needs(CYSHCN)Plan
Submit your Local CYSHCN Plan for FY07 via e-mail,no later than 5:00 PM May 1,2006
to your State HCP Program Consultant(see page 9 for a list of the HCP Program Consultants
and their e-mail addresses).
Note: A complete Local CYSHCN Plan shall contain the following, in this order:
a. Cover Page of the HERMAN document
b. Section 1 - CYSHCN Organizational Chart
c. Section 2 - CYSHCN Statement of Need(completed Surveillance of Need
for Performance Outcomes 1-7 in the HERMAN document
and Performance Measure Checklist—Part I-FY07),
d. Section 3 - CYSHCN Operational Plan(state-prepared Model Plans with
local adaptations and/or agency-developed plans)
Page 7 of 9
B. 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 1,2006 to:
Jan Reimer at:jan.reimerAstate.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 -FY07),
d. Section 3 - Prenatal and Child/Adolescent Operational Plan (state-
prepared Model Plans with local adaptations and/or agency-
developed plans)
Page 8 of 9
HCP PROGRAM CONSULTANTS
AND REGIONAL OFFICE ASSIGNMENTS
Effective: June 1, 2005
REGIONAL OFFICES CONSULTANT E-MAIL ADDRESS PHONE NUMBER
Boulder HCP Regional Office Vickie Thomson vickie.thomsonnstate.co.us 303-692-2458
Denver HCP Regional Office Eileen Forlenza eileen.forlenza(aistate.co.us 303-692-2794
El Paso HCP Regional Office Steve Holloway steve.holloway(astate.co.us 303-692-2327
Jefferson HCP Regional Office Steve Holloway steve.hollowayAstate.co.us 303-692-2327
-Broomfield Health Dept.
Larimer HCP Regional Office Shirley Babler shirley.bablerAstate.co.us 303-692-2455
Northeast HCP Regional Office Barb Deloian barbara.deloian(a�state.co.us 303-692-2303
Northwest HCP Regional Office Anne-Marie Braga anne-marie.bragaAstate.co.us 303-692-2362
Pueblo HCP Regional Office Shirley Babler shirley.bablerAstate.co.us 303-692-2455
South Central HCP Regional Office Anne-Marie Braga anne-marie.braga(a�state.co.us 303-692-2362
-Las Animas-Huerfano Health Dept.
Southeast HCP Regional Office Eileen Forlenza eileen.forlenza(aistate.co.us 303-692-2794
Southwest HCP Regional Office Barb Deloian barbara.deloian(aistate.co.us 303-692-2303
Tri-County HCP Regional Office Tim Hershey tim.hersheyAstate.co.us 303-692-2413
Weld HCP Regional Office Lynn Bindel Ivnn.bindelAstate.co.us 303-692-2392
Western Slope HCP Regional Office Karen Fehringer karen.fehringer(u),state.co.us 303-692-2399
-Delta Health Dept.
Page 9 of 9
•
Attachment A-12
HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS(HCP)
SUGGESTED CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEED ACTIVITIES
As of October 1, 2003
The following suggested strategies are offered as guidance to local public health agencies in defining how current or
new services fit within the core public health functions. The Maternal and Child Health contract between local
agencies and Colorado Department of Public Health and Environment(CDPHE)requires needs assessment of local
communities. Local public health staff are currently doing many of the following activities. The CDPHE Health
Care Program for Children with Special Needs(HCP)and Public Health Nursing consultant staff will provide
technical assistance, as needed in assisting local public health agencies to define which of these—or other activities—
are most appropriate for addressing the needs of children with chronic illnesses and disabilities.
1. Direct Services
1.1 Seek out funding resources and work with specialty provders to establish alternative funding
sources for families.
1.2 Work with health providers so that they appropriately refer families to state and local resources
that can fund or discount specialty medical care services.
1.3 Offer access to SELECT specialty care through HCP Specialty Clinic program. However no direct
payment for services is available through HCP.
2. Enabling Services
2.1. Conduct an initial interview with a defined population(NICU, SSI, etc.)of new families to help
them determine their need for information,referral and/or care coordination using a standard tool
such as the "Family Status Profile"form.
2.2. Assist families who have insurance coverage, including private insurance, CHP+and Medicaid and
those in managed care plans,to understand their benefits and their disenrollment and grievance
procedures.
2.3. Refer families to agencies and services for which they are eligible and assist them with the
registration or application process, e.g.,WIC,CHP+, Baby Care/Kids Care,Medicaid, SSI, Part C,
Voc Rehab, Mental Health, etc. Follow-up with the family to assure the family was able to make
the suggested contacts.
2.4. Determine the status of primary care and immunizations and make appropriate referrals. Work in
collaboration with the EPSDT outreach worker if the child is on Medicaid to assure that EPSDT
benefits have been explained and an EPSDT screen has been completed and billed.
2.5. Initiate or participate in the development of a Care Plan, IFSP(Individual Family Service Plan),or
IEP(Individual Educational Plan)with the family and medical home when it has been determined
that a family would benefit from care coordination. This includes a statement of the family's
strengths and needs as identified by the family and strategiesfor enhancing the child's
Page 1 of 5
development. Include a statement of major outcomes to be achieved by the child and family. State
the criteria, procedures and time lines. Document periodic statements of progress towards meeting
family goals and the need for modifications or revisions. The process for the development of a
care plan, IFSP,or IEP should include all the disciplines involved with the child's care, i.e.,
medical home, audiologist,CHIP therapist,social worker,family advocate,OT/PT, dietitian,
speech therapist, etc.
2.6. Follow-up with family according to plans written on care plan, IFSP,or IEP. Should MCP staff
have no direct role in the IFSP or IEP,or are not doing care coordination,assure that a contact
with each family is made at leak once a year to assure that the child and family are receiving
necessary services and that the family is aware of community resources available to them.
2.7. Make home visits when appropriate. (Situations might include complex medical or surgical
conditions or when resources or help can be provided relating to the home environment.)
2.8. Work in concert with the EPSDT outreach worker to review monthly listing of SSI recipients and
Contact SSI families to assure that health care needs are being met. If there are needs which HCP
can meet,assure that children are enrolled in the program.
2.9. Meet periodically with staff from local agencies such as social services,representatives from the
Community Centered Board, mental health and special educationservices from local schools to
collaborate around services to individual children and their families.
2.10. Work with the older children and their families to facilitate transition from pediatric services to
adult health care services. (To begin at about age 12 years.)
2.11. Work with NICU Consortium contacts in hospitals to identify needs of newborns as the child
prepares to leave the hospital to return to the community. Make contact with other community
resources as needed.
2.12. Design and maintain a clinic structure including identifying and scheduling clinic providers,
facilities,and equipment. Set clinic dates. Seek referrals by contacting local doctors,Child Find,
interagency councils,and Community Center Boards to inform them of the cynics. Distribute the
local HCP clinic schedule to appropriate agencies and individuals.
2.13. Organize,schedule and staff each clinic using guidelines provided in the HCP Procedure Manual.
Obtains a HCP application on each child scheduled for clinic and a consent for service signed by
the parent or legal guardian. Provide the clinician with Medicaid and private insurance billing
information and collect clinic support fees.
2.14. Complete a Clinic Encounter Form for each clinic patient. After each cinic submit Encounter
Forms,a copy of the attendance list(schedule)and the dictation to the assigned Regional Office.
2.15. Assure that families have transportation to each clinic and that appropriate and competent
interpretation services are available.
2.16. Depending on the complexity of the child's condition and the needs of the family, appropriate team
members shall attend,when available,and participate in the HCP Specialty clinics.
2.17. Evaluate the clinic caseload,waiting list and summaries yearly to determine the number and type
of specialty clinics needed. Report findings to the Regional Office Team Leader and State Nursing
Consultant.
Page 2 of 5
2.18. Identify existing primary health care and specialty providers and support resources includiig
translation,transportation and respite care.
3. Population-based Services
3.1. Promote public health services available to children, i.e., HCP, WIC,EPSDT,and Immunization,
by using local media, posters and attendance at health fairs, etc.
3.2. Develop and maintain liaisons with the local community resources to maintain open
communication,to promote the services of HCP and other services available to children with
special needs, and to establish a network for working together to eliminate gaps a duplication of
services and supports.
3.3. Assure that HCP staff is knowledgeable in Early Childhood Connections(Part C of IDEA), IFSPs,
Service Coordination, Procedural Safeguards and eligibility criteria.
3.4. Assure that HCP staff is knowledgeable in the eligibility criteria and referral procedures for
Medicaid, SSI,Children's Medical Waiver 200, Children's Home Care Based Services Waiver
(Katie Beckett-Model 200 Waiver), and EPSDT. Assure that EPSDT case managers are
knowledgeable about HCP services.
3.5. Assure that training opportunities are provided to staff on cultural competency and familycentered
care.
3.6. Establish or maintain interagency collaboration through periodic meetings with representatives of
the local human services agencies,the Community Center Board,the mental health agency and
special education services from the school district to understand their services,to learn about their
eligibility criteria,and to provide them with information about HCP and other resources within the
local community.
3.7. Participate in the community's early child identification process as an active member of the
community team. This participation could include assigning staff time to directly participate in a
community sponsored identification process or coordinating the agency's services such as EPSDT,
HCP and WIC,with other efforts so as to provide on-going systems of early identification for
children 0-21 years.
4. Infrastructure-building Services
4.1. Know the numbers of children in the counties served by the agency and be able to estimate the
number of children with special health care needs. Know the target population of children who
could potentially benefit from HCP services and the actual number of children currently registeed
with HCP. Analyze large discrepancies between target and actual caseloads.
4.2. Know and analyze the numbers of children enrolled on HCP for care coordination only.
Page 3 of 5
4.3. Coordinate and/or participate in conducting a community needs assessment wih public and private
agencies, organizations,providers and parents which identifies problems or voids within the
service delivery system for children with special health care needs,defines the problems and
determines the services or changes necessary to meet the identified needs. Elements involved in
this process include:
4.3.1. Involvement in tracking and data collection efforts of the community concerning the
number of children with special health needs,the types of services needed,the types of
services available,the accessibility of services,the quality of the services,whether the
services are culturally competent and family centered,and a method to receive customer
feedback about the services.
4.3.2. Awareness of and collaboration with other community agencies and projects regarding
data that is being collected and use of the data to most effectively enhance the community
service system for children with special needs.
4.3.3. Establishment of mechanisms to include strong family participatbn in the development of
all assessments.
4.3.4. Coordination with other agencies and organizations to jointly survey the community
including families, providers and human service agencies and development of a process to
provide feedback to those who participated in the answering of the surveys.
4.4. Provide assessment reports to the community.
4.5. Coordinate and/or participate in the community planning process to develop policies goals and
objectives based on the community needs assessment.
4.6. Develop local networks and partnerships with other community resource agencies to determine
policies to support the development of comprehensive, community-based systems of care including
identification, assessment, intervention and referral services for children with special health care
needs.
4.7. Develop referral and follow-up care systems using available resources such as Colorado Responds
To Children With Special Needs(CRCSN),NICU Consortium,Universal Newborn Hearing
Screening Programs,and hospital discharge planners,to identify children who may need support,
care coordination and/or referral to community resources.
4.8. Establish a mechanism for including input from parents regarding current services, planning,
policy development, implementatbn and evaluation of HCP paid service benefits as well as
community/health services for all children with special health care needs. The process should
include a means to provide feedback to families about decisions made in these areas.
4.9. Develop and maintain a system of parent support that includes:
4.9.1. Parent to parent support and/or support groups;
4.9.2. Internal practices that support advocacy for family needs and problem solving;
4.9.3. Information and education;
4.9.4. Linkages with community agencies to assure the availability and adequacy of resources to
support the needs of families.
Page 4 of 5
•
4.10, Assure that there is community parent representation from families who have children with special
needs in the community service system effats. (For example,attending meetings,contacting
representatives,providing input into quality and quantity of local services.)
4.11. Participate actively in a community interagency council(ICC)by meeting regularly for the purpose
of planning and policy development. (These can be a formal or informal group of agencies,
providers and parents who are interested in working together to discuss services for children with
special needs,to identify barriers and gaps in the service delivery system,to devebp collaborative
plans for removing the barriers and gaps including writing communitybased grants for
improvement of local systems.
Last Revised June 17,2003
Page 5of5
Attachment A-13
Weld County Department of Public Health and Environment
CYSHCN Operational Plan
for
October 1, 2005 — September 30, 2006
Page 1 of 8
Goal 1: Families of CYSHCN will partner in decision-making at all levels and will be satisfied with the
services they receive.
Objective 1: Outcome Evaluation: Outcome/Progress:
To continue to increase family participation in decision-making 1. Docu mentation(IRIS or anecdotal)of family
and support services in Weld County. participation in systems building activities,
support groups,coalitions,etc.
Activities: Process Evaluation:
1.1 Increase distribution of the HCP Family Newsletter. 1.Number of newsletters mailed directly to HCP Six-Month Progress Report
a. A minimum of three newsletters will be mailed to families during FY 06.
families registered with HCP during FY 06. 2.A distrib ution list of providers and other
b. Newsletters will be available in English and Spanish. community agencies/groups and number of
c. Newsletters will be distributed to providers,community newsletters mailed will be maintained. Year End Progress Report
agencies and other family support groups as funding
allows.
1.2 Continue support of Spanish Speakers Support Group as 1.Nu mber of contacts documented in community Six-Month Progress Report
evidenced by: encounters in IRIS.
a. Increased community awareness of this group through 2. List of publications, announcements,and
HCP newsletter,community announcements in La articles about the support group during FY 06. Year End Progress Report
Tribuna(Spanish newspaper),contact with primary care 3. .Docu mentation of financial support funded for
practices,P2P list serve,etc. group.
b. Offer support for mailings(printing and postage)and
other activities as allowed by HCP financial and staff
constraints.
1.3 Collaborate with New Start: Services for Individuals with 1.Meetin g minutes with New Start Six-Month Progress Report
Brain Injuries to implement grant: 2. Docu mentation of participation in grant related
a. Identify families to participate. activities in IRIS community encounters or
b. Contact families. individual encounters with participating
c. Assist in development of curriculum. families.
d. Participate in training activities. Year End Progress Report:
Page 2 of 8
Objective 2: Outcome Evaluation: Outcome/Progress:
To evaluate family satisfaction with HCP services and continue Comparison of family satisfaction measures with
to improve the delivery of quality HCP services to families. baseline established FY 05 —06 will indicate
increasing number of families expressing
satisfaction with care coordination services.
Activities: Process Evaluation:
1.1 Family satisfaction surveys will be sent to all families 1.By 4/1/06,establish basel ine of family Six-Month Progress Report
renewing HCP care coordination services during FY 2006. satisfaction with HCP care coordination
a. Tabulate data collected during FY 05 to establish services.
baseline satisfaction levels. 2. Summary report of FY 06 survey results with Year End Progress Report
b. Tabulate data collected during FY 06. recommendations
c. Compare to statewide data.
d. Determine strengths and weaknesses of HCP care
coordination services.
Page 3 of 8
Goal 2: All children with special health care needs will receive regular, ongoing comprehensive care within a
medical home.
Objective 1: Outcome Evaluation: Outcome/Progress:
Increase awareness of the concept of medical home among local Increased number of contacts from medical
primary care practices. practitioners requesting assistance in linking
families to services,consultation on medical
issues,or assistance with resources and referrals;
anecdotal stories from families
Activities: Process Evaluation:
1.1 Send letter describing the CO Medical Home Initiative to I. By Marc h 31,2006,all known pediatric and Six-Month Progress Report
every pediatric and family care practice in Weld County. Offer family practices will receive a letter describing
follow-up visit from HCP staff or Jim Ledbetter for more the CO Medical Home Initiative from the Weld
information. County Regional Office. Year End Progress Report
2. Each contact will be documented as a
community encounter in IRIS.
1.2 Meet with local county practices one on one. I. By Septe mber 30,2006,one or more members Six-Month Progress Report:
of the HCP Regional Team will meet with the
staff and medical providers of at least 3 primary
care practices. Year End Progress Report:
2. Each contact will be documented as a
community encounter in IRIS.
Page 4 of 8
Goal 4: All children will be screened early and continuously for special health care needs.
Objective 1: Outcome Evaluation: Outcome/Progress:
Improve the ability of county agencies to perform vision Retrofitted MTI Photo Screener or new Welch-
screening on children ages 12 to 60 months. Allyn Photo Screener will be available to county
agencies that perform vision screening.
Activities: Process Evaluation:
1.1 Write grant to obtain a new Welch-Allyn photo screener. 1. Sub mit grant(s)prior to deadline(s). Six-Month Progress Report:
[Note: This activity anticipated to occur prior to end of FY 2005.]
Year End Progress Report:
1.2 If grant for Welch-Allyn screener not obtained,research 1. Docu mentation of conversations with other
practicality of retrofitting MTI photo screener in conjunction with agencies in county regarding equipment
other community agencies vs.continued search for grant funding. through community encounters in IRIS.
Page 5 of 8
Goal 5: Community based service systems for CYSHCN and their families will be organized for easy use.
Objective 1: Outcome Evaluation: Outcome/Progress:
During FY 2006,HCP will improve collaboration between Network of agencies working together to provide
agencies serving CYSHCN and their families. services will increase. Baseline established 10-1-
04 to 3-31-05 is 3 agencies.
Activities: Process Evaluation:
1.1 Organize a Weld County Disabilities Council with the 1.Create list of Weld Co unty agencies working Six-Month Progress:
purpose of improving services to CYSHCN and their families. with CYSHCN.
a. Identify Weld County agencies serving CYSHCN and their 2. Letter mailed by 1/1/06. Year End Progress Report:
families in any capacity.
b. Draft letter of intent and mail to above agencies to determine
interest in group.
1.2 Convene planning meeting for council. 1. By Marc h 30,2006,at least one meeting of the Six-Month Progress:
council will have taken place.
2. Lis t of participating agencies.
3. Min utes from meetings available for review.
Year End Progress Report:
1.3 By September 30,2006,conduct at least one business 1. By Septe mber 30,2006 at least one business Six-Month Progress Report:
meeting of the council. meeting of the council will have taken place.
2.Group will be working on vision and mission
statements and goals and action plan for 2007.
Year End Progress Report:
Objective 2: Outcome Evaluation: Outcome/Progress:
24/7 Kids—Support for Families, Inc.will become self- 1.Number of respite nights provided will be at
sustaining and serve more families least once/month throughout FY 06.
2.Nu mber of children and families served will
increase over course of year.
Page 6 of 8
Activities: Process Evaluation:
1.1 HCP Team Member will continue to serve on Board of 1.Co mmunity encounter in IRIS will be made for Six-Month Progress Report:
Directors throughout FY 2006. every meeting attended as well as for time Year End Progress Report:
spent in related activities.
1.2 Weld County Regional Office will offer in-kind support for 1. Docu mentation of work done will be kept by Six-Month Progress Report:
24/7 Kids. Team Leader.
a. Weld County Regional Office will offer printing services to 2. Weld hours will be tracked through community
organization. encounters in IRIS. Year End Progress Report:
b. Weld County Regional Office will offer staff time to assist
with program as funding and capacity allow.
Objective 3: Outcome Evaluation: Outcome/Progress:
Maintain collaborative effort with Part C. Increased referrals from Part C for HCP
consultation on IFSPs and general health or
medical needs.
1.1 Establish working agreement of notifications between Part C 1.MOU si gned between agencies by end of FY Six Month Progress Report:
and HCP. 06. Year End Progress Report:
2. IRIS report on number of notifications received
from Part C.
1.2 HCP Care Coordinators will collaborate with Part C Service 1. HCP Care Coordinators will assume primary Six-Month Progress Report:
Coordinators when children are enrolled in both programs. responsibilities for obtaining medical care for
children with complex medical needs.
2. Part C Service Coordinators will assume
responsibilities for assisting families with
developmental delays for children with
Year End Progress Report:
complex medical needs.
3. HCP and Part C personnel will divide other
responsibilities as needed(social,emotional,
etc.)
4. Encou nters will be documented in IRIS.
1.3 HCP Team Leader will determine reporting mechanism for I. Documentation of participation in IFSP or Six-Month Progress Report:
IRIS data with assistance of Kara Ann Donovan. consultation for individual client encounters in Year End Progress Report:
IRIS report.
Page 7 of 8
Goal 6: All youth with special health care needs will receive services to transition to adult life.
Objective 1: Outcome Evaluation: Outcome/Progress:
By September 30,2006,at least 50%of the youth between 14 and N(50%of youth between 14 and 21)will
21 in the Weld HCP caseload will have discussed the shift to an have discussed medical services transition with
adult provider with their pediatric primary care provider and/or their doctors.
specialists
Activities: Process Evaluation:
1.1 Identify youth who are close to or qualify for adult services 1. Su mmary report from transition survey. Six-Month Progress Report:
and have not discussed the shift to adult providers with their
doctors by surveying youth and families. Transition survey Year End Progress Report:
questions.
1.2 Discuss with youth and their families,the need to begin steps 1. Report of the n umber of youth and parents that
toward transition to adult medical services. Offer support and HCP team members have contacted and
information to build confidence and knowledge to empower provided with support and information services.
youth and families to approach their doctors. 2.Report anecdotal experiences of youth and
parents by HCP staff.
1.3 Establish resource library of information to distribute to 1. Docu mentation in IRIS of materials sent to
families at various ages to assist families with transition issues, families
especially those related to medical care.
Page 8 of 8
Attachment A-I4
HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS(HCP)
6 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 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 will have adequate private and/or public
insurance to pay for the services they need.
1. 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., PT,OT,
speech/language,audiology), in-home nursing.
Page 1 of 3
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.
1. 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 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,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, SSI, SSA-related
work incentives,e.g. PASS, 1619 a& b.
Last Revised June 17,2003
Page 3 of 3
• Attachment A-15
HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS (HCP)
HCP Single County Regional Office Standards for Usage of IRIS II
Policy and Procedures and Training
1. Agency will use the HCP IRIS Help Desk for consultation and assistancewith IRIS data entry,
IRIS training, and IRIS users security approval.
2. HCP/IRIS Policies and Procedures will be followed as described in the IRIS Help File, HCP
Policy and Procedure Manual, agency contract and training materials.
3. New HCP employees will complete the HCP Training CDs including security,multidisciplinary
training and program orientation. New IRIS users will complete IRIS training at the State HCP
Office. The Regional HCP Office will provide IRIS training using the IRIS Train tte Trainer
materials when new users are not able to attend state training. New IRIS users will not be given
IRIS access until security forms are signed and both IRIS training and HCP Training CD have
been completed.
4. New HCP Team Leaders and HCP Technicians will attend IRIS training in the State HCP Office
unless local training is negotiated with the State HCP Office.
II. Documentation of Infrastructure and Population Activities
IRIS Community Encounters will be entered to provide documentation of hfrastructure and population
based activities. (Examples: Community meetings,outreach, screening,training, and capacity building
activities)
III. Documentation of Enabling and Direct Care Activities
1. CYSHCN Regional Caseload on IRIS includes all CYSHCN with whom agency staff have had
person encounters and/or provided referrals within previous twelve months of the reporting period.
2. IRIS Person Encounters will be entered to document person contact and person concerns. Care
coordination will be entered when care coordination is being provided for specific concerns.
Assure assessment of concerns/needs is updated as needed or at least yearly, including entering
outcome for concerns.
3. IRIS Person Referrals will be entered to document all referrals. Assure referral outcome is entered
for each referral.
4. HCP Regional Coordinators completing screening, assessment and/or consultation for CYSHCN
and families will document person encounters, concerns, and person referrals in IRIS.
5. IRIS Clinic visits will be entered before clinic data on IRIS Clinic Schedule. Clinic outcome will
be entered after the clinic date for all CYSHCN attending HCP clinics(only for RO providing
clinics).
IV. IRIS Security
The IRIS II Security Policy and Procedures will be followed. All new IRIS users and current staff and
supervisors will sign the IRIS Security form and User Profile Form and submit to the state office as
requested. IRIS passwords will be changed every sixty days along with the CITRIX password. Bah
passwords will be kept confidential and will not be shared.
Revised June 10,2005
Page I of 1
Attachment A-16
HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS(HCP)
IRIS II Security Policy,Procedures and Guidelines
Security policy and procedures protect personal health information and IRIS data. The following IRIS security
procedures are required for County Nursing Services, Health Departments and HCE Regional Offices:
I. IRIS Users
a. IRIS users including current users, supervisors and new users will sign a Security and Secure Web
User ID Form before a personal ID and password are assigned for access to CITRIX and the IRIS
database. Users will sign a new security form as requested by State HCP Office.
b. IRIS users will have a personal ID and password assigned by the State HCP Office after
completing IRIS training.
c. IRIS users will not allow new agency staff, another agency staff person, staff from another
program or any person to have access or use their CITRIX/IRIS ID and password.
d. New IRIS users will complete IRIS and security training as defined in the IRIS Standards.
2. An agency supervisor will sign the security form for each/IRIS user indicating the access level the staff
person needs. Forms will be sent to the State HCP office to request a new ID and password for new staff or
when duties change for current staff. Anew ID and password will be issued based on the request of the
supervisor and the discretion of the State HCP Office. Agency supervisors will not allow or request access
for any staff that does not have the need to access HCP person specific data on IRIS.
3. Local Health Department, HCP Regional Office and Nursing Service agencies will have agency policies
and procedures for IRIS security and confidentiality. All staff will be trained on the importance of security
and confidentiality.
4. Agency supervisors will contact the State HCP office and request that an ID and password be expired when
an IRIS user leaves the HCP Program or no longer needs IRIS access. IRIS Users will be deactivated if
they have not signed onto IRIS within six months. Agency supervisors will notify the State HCP office to
request a specific person's ID/password be disabled when a security breach is suspected. A new ID and/or
password will be issued based on the request of the supervisor and the discretion of the State HCP Office.
5. Agency supervisors will supervise and monitor access to the IRIS Database. Agency supervisors will not
allow sharing of IDs or passwords.
6. Agency supervisors will monitor/implement HCP policies and procedures for release of information and
consent for clinic services including HIPAA disclosures as defined with local agency HIPAA policy. (The
Health Insurance Portability and Accountability Act of 1996(HIPAA) 164.528 regarding accounting for
disclosures.)
7. Security for IRIS access to Newborn Evaluation, Screening,and Tracking and CRCSN data will be
predefined with business rules and HCP/IRIS Policies and Procedures. The agency will identify staff
members that have a"need to know" for public health information from the IRIS database.
8. The IRIS Security Policy and agency'HIPAA procedures will be followed when providing care coordination
for referrals and requests for follow-up from NEST data.
Page 1 of 2
9. When an IRIS user forgets a personal password,they will call the IRIS Help Line or he State HCP office
for assistance. The IRIS Help Line staff will re-set the personal password to a default password. The IRIS
user will immediately change the default password to a secure personal password as defined in training
material.
10. Agency supervisors will require IRIS users to change their IRIS password every 60 days when the CITRIX
password is changed. Passwords will be changed more frequently if it is suspected that the password has
been compromised.
Revised June 10,2005
Page 2 of 2
Attachment A-17
HEALTH CARE PROGRAM FOR
CHILDREN WITH SPECIAL NEEDS (HCP)
Policy and Procedures
for
Care Coordination Services
for
Children and Youth with Traumatic Brain Injury
October 1, 2005 - September 30, 2006
Page 1 of I 1
•
HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS (HCP)
Policy and Procedures for
Care Coordination Services for
Children and Youth with Traumatic Brain Injury
October 1, 2005 - September 30, 2006
OVERVIEW OF CARE COORDINATION SERVICES FOR CHILDREN AND YOUTH
WITH TRAUMATIC BRAIN INJURY(TBI)
Traumatic Brain Injury Care Coordination is a collaborative process that assesses, plans,
implements, coordinates, monitors and evaluates the options and services required to meet
individuals' needs, using communication and available resources to promote quality, cost
effective outcomes. TBI Care Coordination operates with an underlying premise that when
individuals reach their optimal level of wellness and functional capability, everyone benefits: the
individual and family being served, their community support systems, the healthcare delivery
system, and insurance carriers.
The primary functions of TBI Care Coordination are:
A. To maximize individual and family understanding and participation through education
and support.
B. To advocate for individual wellness and autonomy through advocacy, communication
and identification of service resources.
C. To optimize access to appropriate community services.
D. To integrate and coordinate service delivery by multiple sources and to prevent
fragmentation of services.
HCP Care Coordination Services for Traumatic Brain Injury follow HCP Policies and Procedures
and are applied consistently by Care Coordinators in all HCP Regions of the state.
The term "individual/family" refers to whoever has legal responsibility for the person receiving
program services. This may be the parent of a minor, an emancipated youth, a guardian, a county
department of social services, or another party having legal responsibility for the program
participant.
Page 2 of 11
IL TRAINING HCP STAFF
Regional/County HCP staff/care coordinators attend training before providing care coordination
services and receiving funding for TBI Care Coordination. The State HCP office will keep
records of HCP staff that have completed training for TBI Care Coordination.
HCP staff must participate at required HCP TBI Care Coordination training or if unable to attend
must complete the following steps before providing TBI Care Coordination:
A. Read provided Power Point Presentation and Handouts
B. View HCP Training Video
C. Read the Brainstars Manual
D. Submit a completed Care Coordination Sample Plan to the Regional Office Team Leader
and/or State Nursing Consultant. For review and approval.
E. Discuss Questions/Concerns with the HCP Regional Office Team Leader and/or State
Nursing Consultant.
III. ELIGIBILITY AND REFERRAL PROCESS
A. Eligibility: The Brain Injury Association of Colorado(BIAC)will perform client intake
and determine eligibility for the Colorado Traumatic Brain Injury Program. Once the
family is determined to be eligible the family is approved for a 12-month period of care
coordination funded by the Colorado Traumatic Brain Injury Trust Fund. Eligible dates
for a 12-month period beginning on the date the care coordination plan is signed. B1AC
will refer eligible families/individuals under age 21 to the state HCP Office(CDPHE)for
care coordination services.
Families/individuals seeking program services will contact BIAC directly to begin the
application process through one of the following options:
1. The family/individual contacts the Brain Injury Association of Colorado directly.
2. Families/individuals contacts the state HCP office or the HCP Regional or
County Nursing Agency. The HCP office informs the family/individual that the
Brain Injury Association of Colorado will complete the application process and
determine eligibility for program services. The HCP office provides contact
information for BIAC to the family and family contacts BIAC.
3. Family/individual contacts the state HCP office or the HCP Regional Office or
County Nursing Agency. HCP contacts the Brain Injury Association of Colorado
on behalf of the family/individual, and provides the family/individual's contact
information so that the Brain Injury Association may contact the
family/individual to begin the application process. HCP will notify BIAC within
two(2) business days of its initial contact with the family/individual seeking
services.
Page 3 of 1 I
B. Referral Process
1. The Brain Injury Association of Colorado(BIAC) refers eligible
families/individuals under age 21 to State HCP office (CDPHE)for care
coordination services.
2. State HCP office forwards referrals to the appropriate Regional HCP Office.
3. The Regional HCP Office forwards all referrals to the appropriate HCP County
Nursing Agency.
C. Wait List: Program services are subject to available funding. If the demand and need for
care coordination services exceeds the available funding, state HCP office will maintain a
wait list of eligible persons.
1. Wait list is maintained in order of the date of referral,and individuals shall
receive program services on a first-come, first-served basis.
2. Persons are also put on the waitlist when the demand is too great for an HCP
regional or county nursing office's capacity. The HCP regional or county
nursing office and the state HCP office referral manager determine HCP office
capacity.
3. The HCP office referral manager reviews active caseload and the number of new
referrals received each month to determine if additional new referrals can be
referred to Regional Offices.
D. Referral Packet: The referral packet includes the signed application from the Brain
Injury Association of Colorado, documentation of diagnosis and any supporting
eligibility information, signed informed consents, and signed subrogation form.
L The Brain Injury Association of Colorado(BIAC) sends referral packet for
eligible persons to State HCP office referral manager
2. Referral manager assures completeness of referral packet contents, including
signatures.
3. Referral manager forwards referral packet to the HCP regional or county office.
4. Referral manager documents the referral in the state HCP TBI database.
IV. IMPLEMENTING CARE COORDINATION SERVICES
A. Assignment of Care Coordinators: HCP solicits and considers the family/individual's
preferences when assigning a Care Coordinator within the capacity of the HCP staff.
Factors such as gender, age, culture, language, location, and hours of availability may be
considered as part of this process.
1. The HCP Regional and/or County Office assigns a Care Coordinator to the
family/individual.
2. Care Coordination assignments are documented in IRIS.
B. Developing the Care Coordination Plan:
1. The HCP Care Coordinator and family/individual develop the care coordination
plan together. The plan reflects the family/individual's own identification of
service needs. The care coordination plan is not a clinical treatment plan and
does not reflect clinical treatment goals or objectives.
Page 4 of II
In selecting specific service providers,the Care Coordinator should assist the
family/individual to choose from among available providers, taking into
consideration any preferences the family/individual may have concerning the
service providers. Factors such as gender,age, culture, language, location,
pediatric specialty, experience with children with special needs and hours of
availability may be considered as part of this process.
The care coordination plan identifies financial assistance programs the
family/individual is receiving, or may be eligible to apply for within the
community or at the State or federal level.
2. Document plan on"Health Care Program for Children with Special Needs(HCP)
Care Coordination Child/Family Plan of Care" form provided by state HCP.
Refer to figure#I.
3. Each outcome/goal must have a documented expected date outcome/goal is to be
achieved.
4. Each outcome/goal must state specific actions/interventions in a logical
sequence.
5. For every action/intervention there must be documented an assigned responsible
person.
6. Evaluation of outcome goal status will be documented during and at the end of
the 12-month period of care coordination services.
C. Signing the Care Coordination Plan: The family/individual who receives program
services must agree to the terms of the care coordination plan.
1. Family/individual signs original agreed upon care coordination plan form.
2. HCP Care Coordinator signs and initials original care coordination form and
gives copy of form to family/individual.
3. Any additionally assigned HCP Care Coordinator that is involved in
modifications or evaluation of the plan's status must initial and sign the original
form.
D. Approval of Care Coordination Plans: The Regional HCP Office and/or State HCP
Office reviews and provides consultation for new care coordination plans.
1. Shortly after State HCP sends the referral packet to the HCP regional or county
office, assigned State staff will contact that local office to provide consultation.
2. HCP Regional and county offices keep a hard copy of completed and signed care
coordination plans on file.
3. State HCP office completes a follow up review of a monthly random sample of
25%of new care coordination plans.
4. For ongoing consultation, as needed, local offices can contact State and/or
Regional office personnel.
Page 5 of 11
E. Duration of Care Coordination Services: CDPHE shall provide the care coordination
services included in the care coordination plan for a period of twelve(12) months from
the date of signature on the completed care coordination plan. If DPHE and/or the
family/individual determine that care coordination services are no longer necessary
before the end of the twelve-month period, DPI-IE shall place the client on"inactive"
status. If the family/individual requests and needs additional care coordination services
after being placed on inactive status and before the end of the twelve-month period,
DPHE shall place the client on"active" status and resume services to the
family/individual.
At the conclusion of the twelve-month period,DPHE shall close the individual's case. A
family/individual may submit a new application for care coordination services to the
Brain Injury Association of Colorado at any time.
V. CLIENT RECORDS
A. Upon completion and signing of a care coordination plan,the HCP regional or county
office opens and maintains a client record for the individual receiving services. The
client record includes the following:
I. Application for benefits,documentation of eligibility, and signed client
agreements and consent for release of medical records. (The Brain Injury
Association of Colorado provides these documents,and they are included in the
referral packet sent from the state HCP office.)
2. The signed Care Coordination plan.
3. Progress notes for each contact with the family/individual receiving services.
Progress notes can be either hard copy written notes or can be documented in the
IRIS database as client encounter notes. If the chart is needed for audit purposes,
the IRIS encounters are printed and included in the chart.
4. Completed satisfaction surveys from the client, the client's family, or other
stakeholders.
5. Record of any client appeals and grievances,and responses to these appeals and
grievances from the State HCP Office. Documentation for client appeals and
grievances are entered in progress notes. See above.
6. The client's Social Security Number, which cross-checked for client
identification.
B. Maintenance of Client Records: The Regional, State and County HCP Offices maintain
all client records in a locked and secure area following the HIPAA guidelines on security
and confidentiality of all written or oral communications regarding the family/individual
receiving benefits.
Client records are available, on request,to any State or Federal agency with review and
audit authority, specifically State and Regional HCP agencies and Department of Human
Services(DHS).
All client care coordination records are the property of DHS and shall be surrendered to
DHS upon request.
Page 6 of 1 I
C. Sharing Client Records/Care Coordination Information:
1. Health Insurance Portability and Accountability Act(HIPAA): HCP Regional
and County Agencies shall comply with all applicable provisions of the Health
Insurance Portability and Accountability Act of 1996. HCP staff and care
coordinators follow County HIPAA policies and procedures for security and
confidentiality. HCP staff provides County Privacy Practices during first contact
with families. Disclosures of Personal Health Information are documented on
approved County Disclosure Form.
2. Consent/Authorization: The family/individual receiving care coordination
benefits signs an HCP authorization to allow communication between County,
State and Regional HCP Offices; all service providers listed in the care
coordination plan and the State Department of Human Services(DHS). HCP
Offices use their own agency's current HIPAA consent/authorization forms.
3. Disclosure Tracking: The HCP County and Regional HCP Offices document any
disclosures/sharing of the client's records on the agency's HIPAA disclosure
form.
4. Privacy Practice Policy: The HCP County and Regional HCP Offices provide
the individual/families receiving services the current agency's HIPAA privacy
practice policy.
VI. IRIS DOCUMENTATION
Specific TBI Care Coordination information is documented on IRIS by either the HCP regional or
county office. The procedures are as follows:
A. Enter demographic information from the BIAC Application (Program, Person and
Household screens).
B. Enter time elapsed since injury. This information is available from the BIAC application
and Household screens. This information is entered on the Program screen.
C. Enter"TBI Care Coordination"as the benefit type on benefit calculator. Enter the
approved 12-month date range from the TBI application as eligibility dates. (Benefits
Calculator)
D. IRIS automatically assigns "Active"status when the registration process, encounters
and/or referrals are completed and entered. To change the child's status to"inactive", a
new Benefits Calculator is added for"TBI CC Inactive". The ending date is changed to
the date the status change is entered.
E. A"Welcome Letter for Care Coordination" is mailed to individuaUfamily. IRIS
generates an auto encounter to document the correspondence. (HCP Letter)
F. Enter client encounters to document all contacts with the individual/family.
G. New concerns are added as necessary with each encounter. (Concerns)
H. Progress notes are entered to document progress on the care coordination plan. See also
Section III Client Records. (Client Encounter).
Page 7 of 11
1. Enter all referrals to document the family's being referred to community resources,
medical providers, etc. (Client Referral Screen).
J. Enter services the child is currently receiving when care coordination with HCP begins
and services the family starts during care coordination with HCP. (Client Services
Screen)
K. Change the benefit type and ending eligibility dates on the Benefits Calculator when the
individual/family no longer needs HCP Care Coordination i.e. "Closed - moved from
state".
NOTE: Care Coordination Care Plan will be added to IRIS after July 1, 2004 and documentation
will be entered in IRIS on the Care Plan Tab on the Client Chart. The care plan will be printed
from IRIS as an IRIS Report and then signed by the family and the care coordinator.
VII. REIMBURSEMENT FOR CARE COORDINATION
The fixed price for care coordination services reimbursement is$850 per client per year. The
fixed price per person covers all of the care coordination services the client needs for a period of
twelve (12)consecutive months after the care coordination plan is completed and signed.
Services may be provided to an individual for up to one year. However, services shall be
discontinued and the client placed on"inactive" status if the individual's need for care
coordination services has been met prior to the end of 12 months, or if the individual no longer
qualifies for services(e.g. he/she moves out of state).
Once a care coordination plan is signed,the care coordinator will send the HCP care coordination
invoice(Provider)to the HCP TBI Referral Manager with a check box assuring the plan is
signed. The HCP TBI Referral Manager will log the information and initiate payment process.
VIII. QUALITY ASSURANCE
A. The State HCP Office, in collaboration with HCP regional and county offices, completes
quality improvement activities on a yearly basis. State and Regional HCP ensures that all
Care Coordinators are appropriately and consistently trained, apply the policies and
procedures for care coordination services, and participate in audits of care coordination
care plans, client records, IRIS documentation and family satisfaction surveys.
The State HCP office:
1. Evaluates the outcomes of the care coordination services provided by
determining whether the quality of clients' lives have been maintained or
improved as a result of receiving services.
2. Evaluates administrative processes, such as customer service,and response to
appeals and grievances; and
3. Uses results of quality improvement activities to plan and improve HCP care
coordination services and administrative systems.
State HCP documents its quality improvement efforts and makes information on quality
improvement activities and results available to clients, families and other stakeholders.
Page 8 of 11
B. Customer Satisfaction Surveys: State HCP requests that families/individuals who receive
program services complete a Customer Satisfaction Survey when an individual goes on
"inactive status", and at the end of twelve months when the case is closed. HCP provides
assurances to clients that their responses will be confidential. HCP uses the results of
satisfaction surveys to evaluate the outcomes of the services provided and the
administrative referral and documentation system.
1. HCP Regional or county offices sends family the"Customer Satisfaction Survey"
provided by State HCP office.
2. Survey is sent out when family goes on"inactive status" and/or at end of 12-
month service period.
3. Regional and county office staff instructs family to complete survey and return to
State HCP office.
4. State HCP office compiles and shares survey data and results
C. Annual Quality Improvement Report: State HCP submits an Annual Quality
Improvement Report to Department of Human Services, September 30th each year. The
Report includes:
1. A quality improvement program description outlining the administrative structure
and operation of the quality improvement program;
2. Results of the previous year's quality improvement activities
3. A work plan describing the planned activities on what?
D. Client Appeals and Grievance Process: Regional and County HCP Agencies are familiar
with and follow the HCP Grievance and Appeal process to ensure that families receiving
care coordination for TBI receive fair treatment and, support to enable them to advocate
for appropriate and helpful care coordination services.
Individuals who are eligible for services, and other individuals acting on behalf of
eligible individuals, shall have a right to appeal decisions of HCP to deny, reduce,
suspend or terminate program services. The HCP appeal/grievance process is a formal
mechanism for providing feedback regarding the HCP administrative processes, as well
as assuring consistency and fair treatment in policy implementation. A primary function
of the grievance process is to provide HCP management feedback regarding policies.
The process is an integral part of Quality Assurance and includes annual review of logs
and other records,to identify patterns of dissatisfaction and recommend policy changes.
Appeals and Grievances may address issues including but not limited to:
1. Quality of care coordination services provided by HCP
2. Timeliness of care coordination services
3. Dissatisfaction with a Care Coordinator or HCP staff
4. Accessibility of HCP Care Coordinator or HCP staff
5. Availability of HCP Care Coordinator or HCP staff
The HCP Director has overall responsibility for assuring the HCP Appeal Grievance
Process protects the family and/or individual rights. This activity is administered through
the Quality Assurance Committee. The assigned State HCP staff person is responsible
for the day-to-day operation of this process, including accepting the complaints,
researching and documenting the issues, coordinating follow-up and calling the QA
Committee as needed.
Page 9 of 11
The QA Committee will review the reports for all appeals and grievances during the past
12 months during the yearly quality assurance review.
E. HCP Appeal and Grievance Process
1. Provide to families/individuals the Appeal and Grievance policies and procedures
as part of the care coordination planning process. The care coordinator will
describe the procedures and give the family a copy of the written procedures
when the care coordination plan is signed. The HCP state office will provide
these written procedures to all local HCP offices.
2. Regional, County and/or State HCP Office become aware of families/individuals
and other person's dissatisfaction with a decision to deny, reduce,suspend or
terminate services and/or request to access Appeal and Grievance process.
3. County/Regional HCP offices documents the issues, and follows up with the
appropriate Regional/County HCP staff/Care Coordinator to resolve the problem.
4. The Regional/County HCP office staff then contacts the family and explains how
the issue is being addressed. Within 10 calendar days. The Regional/County
HCP staff provides the family with the written appeal/grievance process and
explains the next steps(See E, F below) if they are not satisfied with the
resolution.
5. Family remains dissatisfied and/or wishes to proceed with Appeal and Grievance
Process. Regional/County HCP Office assists the family to call the State HCP
Office and/or calls the State HCP Office on the family's behalf. State HCP
requires that the family put the complaint in writing within ninety(90)calendar
days from the date of the follow-up call?The State HCP Office staff contacts
both the Regional/County HCP Office staff and the family to discuss possible
solutions to the family's complaint.
6. If the State HCP Office staff assigned to cover all appeal/grievance calls and the
family cannot come to resolution, the Quality Assurance HCP State Committee
meets within thirty(30)calendar days of the family's letter received date. The
committee includes the HCP Director. The decision of the special committee is
final. The care coordinator and family can attend the meeting to testify.
7. The State HCP office will document the process by maintaining the following
information for each complaint:
a. date received
b. complainant name, address, and phone number
c. area coordinator name and agency
d. description of the complaint
e. action taken including documentation of phone calls, meetings, etc.
f. resolution
g. date resolved
This will be documented in the state project referral database.
Page 10 of 11
•
Contact Information
Brain Injury Association of Colorado(BIAC)
Address: 4200 W. Conejos Place, Suite 524
Denver, CO 80204
Phone: 303-355-9969
800-955-2443
FAX: 303-355-9968
Website: www.biacolorado.org
HCP TBI Referral Manager
Name: Rasa Eglite
Address: Health Care Program for Children with Special Needs(HCP)
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
PSD - HCP -A4
Denver, CO 80426-1530
Phone: 303-692-2411
800-886-7689 (ext. 2411)
FAX: 303-753-9249
E-mail: rasa.eglite@state.co.us
Page 11 of 11
Attachment A-18
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:
1. 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.,The
family with two children that have twoseparate 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.
II, 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
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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, 2005 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 Number 100, Organizational Unit Code
6810, Appropriation Code 609 and Object Code 5120 under contract encumbrance
number PO FLA HCP06000001 for Traumatic Brain Injury Services.
F. Required approval, clearance and coordination have been accomplished from and with
appropriate agencies.
Colorado MOU-Subcontracting Covered Functions
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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 1,
2005.
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 1, 2005.
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, 2006.
Colorado MOU-Subcontracting Covered Functions
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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
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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
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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(6)
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
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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
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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.
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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.
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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.
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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 Watters
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: Judy 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.
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Page 10 of 10
•
•
ATTACHMENT B-1
This Attachment sets forth additional terms to the HIPAA Business Associate MOU
dated October 1, 2005, 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 I
��,Q� •
Attachment B-1-1
At
o 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 of 2
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 Auhorization 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, 2005 through SEPTEMBER 30, 2006
Funded
by
CDPHE
HCP Weld County Regional Office:
(1/12 payable monthly October 2005 through August 2006,
September 2006 payment is contingent upon the State's timely
receipt of the Contractor's FY06 Final Expenditure Report) 164,032
Sub-total HCP Regional Office: 164,032
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
Total HCP Weld County Regional Office 193,082
Page 1 of 1
EXHIBIT D
INVOICE NUMBER
COST REIMBURSEMENT STATEMENT
TO: Aida Diaz FROM:
Colorado Department of Public Health and Environment
Prevention Services Division
4300 Cherry Creek Drive South,PSD-HCP-A4
Denver,Colorado 80246-1530
FAX: ( 303 ) 782-5576 DATE OF EXPENDITURE:
TYPE OF FROM: Final
PROGRAM: Bill?
FEDERAL ID TO: O Yes
NUMBER: ❑ No
I I I 1
Reimbursement
Description of Expenditure Local Agency Match Amount Requested Total
GRAND TOTAL
This is to certify that the above expeises were incurred per Contract# and we are requesting reimbursement for same.
SIGNATURE(CONTRACTOR): DATE:
I hereby certify that all contract requirements have been met and the amounts are correct. Payment is authorized.
AUTHORIZED DESIGNEE(STATE): DATE:
Contractor Notified of Reimbursement Amount Change?
0 Yes 0 No Initial:
EXHIBIT E
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:
O CHILDREN AND ADOLESCENT POPULATION
❑PRENATAL POPULATION
❑CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS POPULATION
O FINAL EXPENDITURE REPORT DUE DATE: December 1,2005(For The Period Of:October 1,2004 through September 30,2005)
APPLICATION BUDGET DUE DATE: May 1,2006(For The Period Of:October 1,2006 through September 30,2007)
ANNUAL FULL TOTAL SOURCE OF FUNDS
SALARY TIME AMOUNT RECEIVED
EXPENSE CATEGORIES RATE EQUIVALENT REQUIRED OTHER' FROM CDPHE
PERSONAL SERVICES(Names 8 Ti let_
Contractual/Fee for Service
Supervising Personnel/Team Leader for HCP
Fnnge Benefits: Rate=
TOTAL PERSONAL SERVICES($and FTE) $ $ $
OPERATING EXPENSES(which are not part of indirect):
TOTAL OPERATING EXPENSES $ $ $
TRAVEL EXPENSES jln-state/Out-stateZ_____
TOTAL TRAVEL EXPENSES $ $ $
Contractual
TOTAL CONTRACTUAL EXPENSES $ $ $
Total Direct Costs(Personal Services+Operating+Travel+Contractual) $ $ $
INDIRECT COST: Rate=
TOTAL INDIRECT COST $ $ $
TOTAL PROJECT COST $ $ $
*Source of funding for"Other'(Match or In-kind)I.e.Maternal and Child Health Programs
Local/County Funding $
Medicaid(will not be used to match) $
Patient Fees $
Other(List): $
TOTAL $
May the NON FEDERAL funds be used as match? YES NO
Signature of Authorized Representative Date
Page 1 of 1
EXHIBIT F
TASK ORDER CHANGE ORDER LETTER
]Date]
Task Order Change Order Letter Number**, Contract Routing Number** *** *****
State Fiscal Year 20**-20**, *************** Program
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'LEGAL
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,j$*.**'for an amended total financial obligation of the State of
********** DOLLARS,($*.**). 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 1
EXHIBIT G
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 I of I
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