HomeMy WebLinkAbout20051717.tiff RESOLUTION
RE: APPROVE TASK ORDER FOR NURSE HOME VISITOR PROGRAM 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 Task Order for the Nurse Home Visitor
Program 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 July 1,
2005, and ending June 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 Task Order for the Nurse Home Visitor Program between the County
of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County,
on behalf of the Weld County Department of Public Health and Environment, and the Colorado
Department of Public Health and Environment be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said task order.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 13th day of June, A.D., 2005.
BOARD OF COUNTY COMMISSIONERS
Etta WELD COUNTY, COLORADO
g A ' � : f !, e/t G,% , J Jerk
jha t
1861 h William H. Jerk Chair
4 +' 'aunty Clerk to the Board
•
Deputy Clerk to the Board
Davi E. ongg
AP ED RM: � & $,
Robe . Masden
ount orney
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Glenn Vaad
Date of signature: 25—
2005-1717
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Memorandum
TO: William H. Jerke, Chair
Board of County Commissioners
I C FROM: Mark E. Wallace, MD, MPH Director, Department of Public Health
and Environment Oa/We CS
COLORADO DATE: June 9,2005 Wt""" -5
SUBJECT: Task Order for the Nurse Home Visitor
Program
Enclosed for Board review and approval is a task order between the Weld County Board of
Commissioners on behalf of the Department of Public Health and Environment (WCDPHE) and
the State of Colorado through the Colorado Department of Public Health and Environment for
the Nurse Home Visitor Program.
Under the provisions of this task order, WCDPHE will provide countywide nurse home visitor
services to low-income, first-time mothers. The funding from this task order is to be used to
support health, education, and other resources for new young mothers during pregnancy and the
first years of their infants' lives.
For providing the services described above during the time period of Julyl, 2005 through
June 30, 2006, the State will pay Weld County an amount not to exceed $468,023; and it is
anticipated Medicaid will pay approximately $182,513.
I recommend your approval of this task order.
Enclosure
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
PSD-CASH-NHVP
DEPARTMENT OR AGENCY NUMBER
FLA
CONTRACT ROUTING NUMBER
06-00093
TASK ORDER
PSD-CASH-NHVP
This Task Order is made this 10TH day of JUNE,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 Colorado) whose address or principal place of business is 915 10th Street,3rd
Floor,Greeley,Colorado 80631 for the use and benefit of the Weld County Department of Public Health and
Environment,whose address or principal place of business is 1555 North 17th Avenue,Greeley,Colorado
8�hereinafter referred to as"the Contractor".
FACTUAL RECITALS
The State has received funds pursuant to a Master Settlement Agreement between several states,including the state
of Colorado,and certain tobacco companies. Section 24-75-1101,et seg.,C.R.S.,as amended,describes how the
state of Colorado shall apportion moneys it has received,and will receive,under that Master Settlement Agreement.
Section 24-75-1104.5(a),C.R.S.,as amended,allocates part of these moneys to the"Colorado Nurse Home Visitor
Program". Section 25-31-101,et seq.,C.R.S.,as amended,creates the"Colorado Nurse Home Visitor Program"
(the Program)to provide nurse home visitor services to low-income,first-time mothers in the state of Colorado.
Pursuant to section 25-31-106,C.R.S.,as amended,the Contractor has submitted a grant application which has been
reviewed by the University of Colorado Health Sciences Center in accordance with section 25-31-105,C.R.S.,as
amended,and approved by the State in accordance with section 25-31-107,C.R.S.,as amended.
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)13M,Organizational Unit Code(s)6250,Appropriation Code(s)593,Program Code(s)9017,
Function Code(s)XMPT,Object Code(s)5420,and Grant Budget Line Code(s)8B6C under Contract encumbrance
number PO FLA NHV0600093. All required approvals,clearances,and coordination have been accomplished from
and with all appropriate agencies.
Page 1 of 8
ateo.5—/7/7
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 July I.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 June 30,2006,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.
B. DUTIES AND OBLIGATIONS OF THE CONTRACTOR.
I. 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 Contractor shall provide the nurse home visitor services in accordance with the terms and
conditions contained in the"REVISED Progress Report and Budgets for FY2005-06 Continuation
Funding Requests,"which is incorporated herein by this reference,made a part hereof,and
attached hereto as Exhibit B
3. This Contract is governed by those rules that were adopted by the state of Colorado's Board of
Health pursuant to section 25-31-104,C.R.S.,as amended,set forth in Attachment H of Exhibit
B hereto.
C. DUTIES AND OBLIGATIONS OF THE STATE.
1. The Contractor may only request reimbursement from the State in accordance with the categories
and line items set forth in the Budget,which is incorporated herein by this reference,made a part
hereof,and attached hereto as"Exhibit C',that may include,but not limited to,the Contractor's
salaries,fringe benefits,supplies,travel,operating,indirect costs which are allowable,and other
allocable expenses related to its performance under this Task Order.
2. The Contractor shall be compensated in accordance with the rates set forth in Exhibit C hereto. In
consideration of those Continuation services 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 FOUR
HUNDRED SIXTY-EIGHT THOUSAND.TWENTY-THREE DOLLARS,($468,023.00)for
the initial term of this Task Order. For a total financial obligation of the State of FOUR
HUNDRED SIXTY-EIGHT THOUSAND.TWENTY-THREE DOLLARS,($468,023.00).
Of the total financial obligation of the State referenced above,Zero Dollars,($0.00)are identified
as attributable to a funding source of the United States government and,FOUR HUNDRED
SIXTY-EIGHT THOUSAND,TWENTY-THREE DOLLARS ($468,023.00)are identified as
attributable to a funding source of the state of Colorado.
Page 2 of 8
3. To receive compensation under this Task Order,the Contractor shall submit a signed monthly
billing statement A billing statement must be submitted within sixty(60)calendar days of the end
of the billing period for which services were rendered. A sample billing statement titled"Task
Order Reimbursement Statement"is attached hereto as Exhibit D and incorporated herein by this
reference. The Contractor shall use the billing statement provided by the State or a similar format
as provided by the Contractor and approved by the State.
Each billing statement shall reference the related Master Contract and this Task Order by their
respective contract routing numbers. The contract routing numbers are located on page one of
these documents. .Each billing 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 if reimbursement is allowed;and,the total reimbursement
requested. Reimbursement during the initial,or any renewal or extension,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 billing statement shall be sent
to:
Lee Joseph
Prevention Services Division
Office of Maternal and Child Health
Colorado Department of Public Health and Environment
PSD-MCH-A4
4300 Cherry Creek Drive South
Denver,CO 80246-1530
Final billing under this Contract must be received by the State within a reasonable time after the
expiration or termination of this Task Order,but in no event no later than sixty(60)calendar days
from the effective expiration or termination date of this Contract.
Unless otherwise provided for in this Contract,"Local Match"shall be included on all billing
statements,in the column provided therefore,as required by the funding source.
The Contractor shall not use federal funds to satisfy federal cost sharing and matching
requirements unless approved in writing by the appropriate federal agency.
4. 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 E". 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 fmancial obligation;
D. A provision stating that the Task Order Change Order Letter is effective upon approval
by the State Controller,or designee,or its proposed effective date,whichever is later.
Page 3 of 8
Upon proper execution and approval,a Task Order Change Order Letter shall become an
amendment to this Task Order. Except for the General and Special Provisions of the Master
Contract,and the Additional Provisions of the Task Order,if any,the Task Order Change Order
Letter shall supersede this Task Order in the event of a conflict between the two. It is expressly
understood and agreed to by the parties that the task order change order letter process may be used
only for increased or decreased levels of funding,corresponding adjustments to service or program
levels,and any related budget line items. Any other changes to this Task Order,other than those
authorized by the task order option to renew letter process described below,shall be made by a
formal amendment to this Task Order executed in accordance with the Fiscal Rules of the state of
Colorado.
If the Contractor agrees to and accepts a proposed Task Order Change Order Letter,then the
Contractor shall execute and return that Task Order Change Order Letter to the State by the date
indicated in that Task Order Change Order Letter. If the Contractor does not agree to and accept a
proposed Task Order Change Order Letter,or fails to timely return a partially executed Task Order
Change Order Letter by the date indicated in that Task Order Change Order Letter,then the State
may,upon written notice to the Contractor,terminate this Task Order no sooner than thirty(30)
calendar days after the return date indicated in the Task Order Change Order Letter has passed.
This written notice shall specify the effective date of termination of that Task Order. If a Task
Order is terminated under this clause,then the parties shall not be relieved of their respective
duties and obligations under that Task Order until the effective date of termination has passed.
Increases or decreases in the level of contractual funding made through the task order change
order letter process during the initial,or renewal,term of a Task Order may only be made under
the following circumstances:
E. If necessary to fully utilize appropriations of the state of Colorado and/or non-
appropriated federal grant awards;
F. Adjustments to reflect current year expenditures;
G. Supplemental appropriations,or non-appropriated federal funding changes resulting in an
increase or decrease in the amounts originally budgeted and available for the purposes of
a Task Order;
H. Closure of programs and/or termination of related contracts or task orders;
I. Delay or difficulty in implementing new programs or services;and,
J. Other special circumstances as deemed appropriate by the State.
5. 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 F". 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;
Page 4 of 8
entity. By signing this Contract,the Contractor certifies that the Contractor shall comply with the
requirements of the Act and shall not allow smoking within any portion of any indoor facility used
for the provision of services for children as defined by the Act. The Contractor agrees that it shall
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.
3. The Contractor certifies,to the best of its knowledge and belief,that no federally appropriated
fiords have been paid or shall 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 Contract,and the extension,continuation,renewal,
amendment,or modification of this Contract,or any grant,loan,or other cooperative agreement
that utilizes Federal funds. If any funds other than federally appropriated fiords have been paid or
shall 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
Contract,or any other grant,loan,or other cooperative agreement,then the Contractor shall •
complete and submit Standard Fonn-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.
4. The Contractor shall protect the confidentiality of all applicant or recipient records and other
materials that are maintained in accordance with this Contract. Except for purposes directly
connected with the administration of this Contract,no information about or obtained from,any
applicant or recipient shall be disclosed in a form identifiable with the applicant or recipient
without the prior written consent of the applicant or recipient,or the parent or legal guardian of a
minor applicant or recipient with the exception of information protected by Colorado statute as it
applies to confidentiality for adolescent services in which case the adolescent minor and not the
parent or legal guardian must provide consent or,as otherwise properly ordered by a court of
competent jurisdiction. 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.
5. The Contractor shall not charge for services those individuals of families at or below two hundred
percent(200%)of 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)(I)). 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;$22,610 for a
family of 5;$25,870 for a family of 6;$29,130 for a family of 7;and$32,390 for a family of 8.
For families of more than eight,add$3 260 for each additional member.
6. Under this contract,the Contractor shall 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.
Page 6 of 8
D. A provision stating that the Task Order Option to Renew Letter is effective upon
approval by the State Controller,or designee,or its proposed effective date,whichever is
later.
Upon proper execution and approval,a Task Order Option to Renew Letter shall become an
amendment to this Task Order. Except for the General and Special Provisions of the Master
Contract,and the Additional Provisions,if any of that Task Order,a Task Order Option to Renew
Letter shall supersede that Task Order in the event of a conflict between the two. It is expressly
understood and agreed to by the parties that the task order option to renew letter process may be
used only to:renew a Task Order;increase or decrease levels of funding related to that renewal;
make corresponding adjustments to service or program levels,and,adjust any related budget line
items. Any other changes to a Task Order,other than those authorized by the task order change
order letter process described above,shall be made by a formal amendment to a Task Order
executed in accordance with the Fiscal Rules of the state of Colorado.
If the Contractor agrees to and accepts a proposed Task Order Option to Renew Letter,then the
Contractor shall execute and return that Task Order Option to Renew Letter to the State by the
date indicated in that Task Order Option to Renew Letter. If the Contractor does not agree to and
accept the proposed renewal term,or fails to timely return a partially executed Task Order Option
to Renew Letter by the date indicated in that Task Order Option to Renew Letter,then the State
may,upon written notice to the Contractor,terminate this Task Order no sooner than thirty(30)
calendar days after the return date indicated in the Task Order Option to Renew Letter has passed.
This written notice shall specify the effective date of termination of that Task Order. If a Task
Order is terminated under this clause,then the parties shall not be relieved of their respective
duties and obligations under that Task Order until the effective date of termination has passed.
6. 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.
IX ADDITIONAL PROVISIONS
1. The Contractor is authorized to make limited transfers of funds from one line item in its Budget to
another line item in its Budget without the prior,expressed,written consent of the State. A
transfer from one line item to another line item may not exceed ten percent(10%)of the total
amount of the line item from which the transfer is made. If the Contractor desires to transfer more
than ten percent(10%)from one line item in its Budget to another line item in its Budget,then the
Contractor shall prior to the transfer,enter into an amendment to the Original Contract with the
State,which requires State Controller or delegate approval,before the transfer can be made.
2. The Contractor agrees to provide services to all Program participants and employees in a
smoke-free environment in accordance with Public Law 103-227,also known as"the Pro-Children
Act of 1994",(Act). Public Law 103-227 requires that smoking not be permitted in any portion of
any indoor facility owned or leased or contracted for by an entity and used routinely or regularly
for the provision of health,day care,early childhood development services,education or library
services to children under the age of 18,if the services are funded by Federal programs either
directly or through State or local governments,by Federal grant,contract,loan,or loan guarantee.
The law also applies to children's services that are provided in indoor facilities that are
constructed,operated,or maintained with such Federal funds. The law does not apply to
children's services provided in private residences;portions of facilities used for inpatient drug or
alcohol treatment;service providers whose sole source of applicable Federal funds is Medicare or
Medicaid;or facilities where WIC coupons are redeemed. Failure to comply with the provision of
Public Law 103-227 may result in the imposition of a civil monetary penalty of up to$1,000 for
each violation and/or the imposition of an administrative compliance order on the responsible
Page 5 of 8
7. 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 actively 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 shall advise such clients that an interpreter shall be provided for them. If a client
has their own interpreter,they shall be advised that the Contractor shall provide an interpreter if
the client so chooses.
Page 7 of 8
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: 4.--11/I1-1- By:
Name: William H. Jerke or Ex cutive ire
Title: Chair DEPAR ENT OF PUBLIC HEALTH
13 AND ENVIRONMENT
Date:
1861 r \^. .,
i. a
Se01) I ATTEST: g,,, ,I ROGRAM APPROVAL:
B � V�� __.... By: �((/ __
Itv, t•t.;�.. ,,,,,t ,nnis rr.ittE1,
§pfsgantanccgcnimorasicomfaumuenix
Deputy Clerk to the Board
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:
slie M.Shenefelt
WELD COUNTY DEPARTMENT OF
PU IC - HEALTH AND ENVIRONMENT
BY; , 4AM>4,%y: I!
Mark E. Wallace, MD, MPH-Director
ate: 6 c),
Revised:11/5/04
Page 8 of 8
c9z9c' —/7/7
Exhibit A
STATEMENT OF WORK
To Task Order Dated 06/10/2005-Contract Routing Number 06 FLA 00093
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order specified above.
1. The Contractor shall implement and provide nurse home visitor services through nurses licensed to practice
in the state of Colorado to low-income,first-time mothers in those communities served by the Contractor.
2. The Contractor shall coordinate its efforts in providing the services with the State's Nurse Home Visitor
Program(NHVP)Director,the National Center for Children,Families and Communities(National Center),
and/or subcontractors of the National Center.
3. The Contractor shall provide the nurse home visitor services in accordance with the terms and conditions
contained in the Contractor's Progress Report and Budget Narrative for FY2005-2006,which are
incorporated herein by this reference,made a part hereof,and attached hereto as Attachment A-1 and
Attachment A-2.
4. On or before September 30,2005,the Contractor shall submit to the State two(2)detailed Final
Expenditure Reports;one(I)for the Continuation Services and one(I)for the Expansion services provided
during the term of July 1,2004,through June 30,2005,in the format attached hereto as Attachment A-3,
which is incorporated herein by this reference and made a part hereof,or in a similar format as provided by
the Contractor.
5. Contractor shall submit reimbursement requests to Medicaid for all eligible clients in accordance with the
Medicaid Reimbursement Guidelines for Continuation Services,which is incorporated herein by this
reference,made a part hereof,and attached hereto as Attachment A-4.
6. Contractor shall obtain the required training to implement the Nurse-Family Partnership Program
(Program),which is administered through the National Center or its subcontractors.
7. In addition to obtaining the required Program training,the contractor shall:
a. Implement the Nurse-family Partnership in accordance with the implementation guidelines set
forth by the National Center and/or its subcontractors.
b. Conduct the Program in accordance with the home visit guidelines including:
1. Ensure a minimum enrollment of at least 100 first time mothers for the Continuation
Services,unless otherwise approved;
2. Ensure a minimum enrollment of at least 25,50,75 or 100 additional first time mothers
for the Expansion Services;
3. Ensure that each staff nurse carries a caseload of not more than 25 active families for the
Continuation,Expansion and New Services;
4. Maintain the established visit schedule;and
5. Ensure that the essential Program content is covered.
c. Arrange and provide Nursing Child Assessment Satellite Training(NCAST)for your agency's
staff. The Keys to Caregiving portion must be completed prior to attending initial core training
(Training I). The Feeding Scale portion must be completed prior to attending Training II,and the
Teaching Scale portion must be completed prior to attending Training III.
d. Assure that all Program nurses attend the required trainings and that all training related costs are
covered.
Page 1 of 2
Exhibit A
e. Assure the availability of appropriate computer systems and software at the Program site for the
recording and transfer of evaluation data to the National Center.
f. Collect data for evaluation purposes,using forms developed by the National Center and/or its
subcontractors. Enter the data collected into the Clinical Information System(CIS)program,on a
monthly basis;taking 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. Contractor's failure to comply with any applicable provision
of HIPAA will constitute a breach of this agreement.
g. Prohibit distribution of,or access to,Program guidelines and the CIS to any individual or
organization not party to the administration and operation of the Program. Contractor agrees to
make no changes or alterations to the CIS software,and to allow only trained,authorized users to
access the web-based CIS.
h. Provide the recommended equipment and supplies needed for Program implementation.
i. Ensure that program eligibility is based on the client's income and should not be restricted by age
or length of gestation and that all program brochures and referral materials are stated as such.
j. Utilize a standard program application in which clients document their income or attest that they
receive no income as a means of verifying each client's eligibility for the program.
Page 2 of 2
Attachment A-1
NBV/NFP Progress Report
Page 1 of 7
cnik
Colorado Nurse Home Visitor Program(NHVP)
2005-06 PROGRESS REPORT COVER SHEET
1. Name of Agency: Weld County Department of Public Health and Environment
2. Name of person completing Progress Report Nancy Weber RN, KPH
Nursing Supervisor
Position/Title:
Telephone: 970 304 6420 - FAX: 970 304 6416
E-Mail: nveber@ co.weld.co.us
3. Name of Authorized Signer: Dr. Hark Wallace
(Must be an individual with authority to sign a grant application_)
Position/Title: Executive Director
Telephone: 970 304 6410 FAX: 970 304 6412
E-Mail: awallace@coamid.co-us
Signature:X . V k/ '0"`Si\--, •
�J
4. Total request for July 1,2005 through June 30,2006: (9 67 7 l�( l
5. List county(ies)to be served: Weld County
6. Total number of families to be served: 150
7. Total FTE to be funded with NHVP dollars: 7.5 FTE
8. Total number of nurse home visitors to be funded with NHVP dollars: 7
Page 2 of 7
•
Weld County Nurse Family Partnership _
Progress Report
March 1, 2004 —February 28, 2005
A. Funding Level and Fiscal Management -
At this time the Weld County Nurse Family Partnership (NFP) program has
received $262,284, through December 2004, from the CDPHE NHVP contract,
an average of $43,714 per month. For the months from July 2004 through
January 2005, the Weld County NFP has received a total of $ 48,842.85
in Medicaid reimbursement for Targeted Case Management Services
provided to clients and children. The total funds received for the
program through January 2005 is $311,127. The total expenditures of
the program for this same time period-are $ 260,571.88. The. 2004-05
budgets of the Weld County NFP Continuation program and the Weld County
Expansion Plan were written and approved to provide a renewal program
award of $ 398,654 and $215,243 in funds for expansion of the program.
Due to the loss. of Presumptive Eligibility (PE) , and the fact that
three of our six nurses are currently in the process of training in the
NFP program, we are not able to match the CDPHE projections of Medicaid
reimbursement income for 2004-05 contract period. Working with
Administration Division, we have been successful in developing a system
to process Medicaid bills and track reimbursement.
Through the remainder of the Progress Report, all activities and
descriptions will reflect the total Weld County NFP program. We will
not differentiate between continuation or expansion programs.
B. Client Information
As of February 18, 2005 he have 91 active NFP clients, and 10 open
referrals. The client demographics indicate an average client age of
17.72 years old, 47% of current clients are enrolled in school, clients
report their race as: 77% Hispanic, 19% White - Non Hispanic, and 4%
Multiracial. 53% of our current clients enrolled in the NFP program by
16 weeks of gestation, and 86% of the clients were enrolled by 28 weeks
of their gestation.
C. Program Evaluation
1. Referral and Resources
The Weld County NFP program received 108 referrals from March 1, 2004
to February 18, 2005. Our majority referral sources are:
Agency / Program . # Referrals Sent
Weld County Medicaid application process 35
Sunrise Community Health Center - 38
Weld County School Districts (4) 13
North Colorado Family Medicine 11
Other - - 11
These referral sources and cooperating agencies have been very
consistent in the three year history of our local NFP program. The
relationships with these agencies, their understanding of the NFP
program and goals, and the NFP quick response to their referrals has
enhanced our ability to enroll clients at an early gestational age.
Many clients live in drastic poverty. They frequently lack access to
food, housing, transportation, safety, and have limited personal or
situational support. Clients are often faced with situations such as:
Page3of7
• A need for safe housing away from drugs, yet are not 18. years
old, and are unable to apply for housing assistance.
• Enrolled in school, but lack transportation to attend the face to
face interview to apply for childcare assistance.
• Out of necessity, household members utilize the monthly WIC or
other food provisions, before the next supply visit.
The greatest need of our clients is adequate resources.
The NFP RNs facilitate the use--of community resources, educate clients
to use resources appropriately, and convey the client situations to
other agencies when necessary.
Since the September 1, 2004 loss of Medicaid PE, we have reorganized
and are working directly with the Medicaid application staff .at the
Health Department. They screen applicants for eligibility and interest
in NFP, and with permission, client information is forwarded to the NFP
Supervisor as a program referral.
2. Enrolling and Retaining Clients
In.June 2004, we experienced the resignation of one 'RN. This decreased
our caseload to 75 active clients. In mid-July 2004, we hired 1
replacement RN, and 2 expansion RNs. Thus, three new RNs joined the
program, and started the extensive schedule of training, and are
initiating their own caseloads. They are expected to reach the client
to RN ratio of 25:1, by July 1, 2005.
The total Weld County NFP program enrollment as of 2-28-05, is 91
active clients, and ten open client referrals being followed by the
assigned RN. It is always necessary for the visiting RNs to assess the
willingness of the clients to continue their participation. Two
strategies that our program staff utilize to encourage clients to
remain active in NFP are:
• Offer the client some flexibility of visit times or location to
suit the client's schedule
• Demonstrate their eligibility to earn High School credit for
continued NFP participation.
Occasionally clientsare unable to continue program participation due
to their school and/or work schedules. In these situations, the RN
offers a varied visit schedule. This is sometimes successful, but
often not. The supervisor and RN then process the client's situation.
At times the client is using skills learned in the NFP program to meet
their goals to work and be independent.
Our RN staff includes two fluent Spanish speakers, and one RN with
Spanish language skills that enable her to communicate effectively with
bilingual clients. We have not denied client enrollment on the basis of
language limits.
3. Nurse Home Visitor Support, Retention and Recruitment
Reflection is an important part of the NFP program. Nurses often
discuss with their supervisor, their interactions with clients and co-
workers. As part of supervision, we have weekly scheduled Team
Meetings, and daily informal gatherings to solve issues, present
resource information, discuss caseconferences -and "touch base" with
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the team members. One on one meetings with RN and supervisor are
designed to discuss a particular RN need, or review visit activity
data.
One RN resigned' in June 2004 to pursue her career goals in the clinical
setting. We were able to hire 3 RNs in July 2004 to fill our vacancy,
and 2 expansion positions. We only had 4 applicants, for the 3
positions. Staff members feel this is due to the limited pay scale of
the agency, and the demands of the position. Since we had the unique
situation of hiring all 3 positions in July 2004, we only had a small
amount of salary cost savings. (approximately 20 days). In November
2004,. one RN position was transitioned from 1.0 FT$ to 0.5 FTE; so from
November 16, 2004 to present, we have decreased salary expenses in our
program.
The greatest challenge that all the NFP RNs face is to gain access to
• the resources needed by the clients. It is difficult for the clients
to receive the assistance they need to mange themselves and their baby,
in their given situations.
• Clients need safe housing - but are too young to apply for
assistance
• Clients may need a modified school schedule - but are not able to
meet with school officials
• Clients need childcare support - but are not able to attend face
to face appointments at the Dept. of Social Services as scheduled
• Clients need mental health services - but are not able to pay for
appointments, are not requiring emergency room admission or
suicide. intervention. •
• Clients need transportation - but do not live near bus route
access
• Clients need legal advice on custody, violence - but do not have
funds
• Clients need food - Parents won't cooperate with the Food Stamp
• application requirements
• Clients need Medicaid - but the application is lost, denied, or
the employer won't produce an income letter
We schedule community agencies to attend Team meetings to educate us on
access and eligibility criteria for clients to use available services.
Nurses regularly share information in our resource files to help other
clients access a resource appropriately.
4. Advisory Board / Supporting Council
The Weld County Perinatal Advisory Committee serves as the NFP Advisory
Board, and meets quarterly at Weld County Department of Public Health
and Environment. Membership has remained quite constant, representing
the Department of. Social Services, the University of Northern Colorado,
Greeley School District #6, North Colorado Medical Center, United Way,
the Weld County Judicial District, and Invest in Kids. A recent
success for Weld NFP, is the authorization of our local school district
to award .5 semester of elective credit to students that complete 70
hours of NFP participation. Two members of the Advisory Board are
school employees that have worked to raise awareness in the district to
acknowledge NFP curriculum for school credit. At this time, 8 Weld
County schools award credit to eligible students. This achievement was
celebrated at our December 2004 Advisory Board meeting.
Page 5a7 of 7
5. Broad _- Based Community Support
In the Weld County community, our NFP program enjoys a favorable
atmosphere. NFP nursing staff and the supervisor, participate on many
community committees. This provides positive relationships with other
community agencies. Recently we have had a few high risk births, which
have necessitated that the NFP RNs work close with the labor and
delivery staff, nursery staff, and local physicians. These events,
although not optimal, have reinforced our visibility with hospital
staff, and renewed understanding of the supportive nature of NFP.
In our home agency, we have experienced constant support during our
four years of program implementation. Our agency administrators support
program activities and staff needs. Our County Commission board has
repeatedly supported our renewal process and CDPHE contract.
6. Existing Visitation Programs
At this time the Weld County NFP program staff have cooperative
relationships with other visiting agencies, such as: First Steps (a
Prenatal Plus model) , Family Connects, Bright Beginnings, C.A.R.E. ;
United Way, Promises For Children, and Catholic Charities. Much of the
success in these relationships is that we work closely with the agency
staff through the Promises For Children Committee, and that NFP RNs
complete Warm Welcome visits and Moving On visits for the United Way
Bright Beginnings program.
7. Integration of CIS
Our weekly NFP team meetings are the format used to share quarterly
summary reports and phase reports with team members. When new
information is provided, or a particular topic is being discussed
(i.e. client age, education level, birth weights) we regularly share
report information with the Advisory Committee. All reports are shared
with agency administration when requested.
The RN visitors are interested in how their data compares to the
national NFP standards, and how our program compares to other Colorado
programs. When areas for improvement are identified, such as number ofactive clients, we generate activities and priority to address that
topic. At the time of our NFP Expansion, and hiring 3 new RNs, we
experience aneed to make client enrollment a priority. At a team
meeting we identified 3 strategies to increase client referrals '-
1) Contact long time program partner, Sunrise Community Health
Center, to send additional referrals for the next few months.
2) Select and assign staff to visit the Windsor Family Physician •
office, to encourage the office to make referrals to our NFP program.
3) Visit with the staff of the Johnstown Family Physician office
to encourage referrals of client receiving prenatal care at their .
office.
B. General Program Implementation
Our program Data manager is excellent in her role. She is accurate and
fast. Support is provided to her as a full member of the NFP team.
Our team meetings and celebrations include all team members. The Data
Manager is often scheduled on the agenda to present data form needs,
Page 6 of 7
ordering preferences and inquiries, and operation suggestions for team
projects. The NFP staff members do a great- job-supporting their clients
and families, even through difficult times. It is important that as a
team we recognize and celebrate the highlights and challenges that each
team member deals with.
The most significant challenge for the NFP program this year is the
continued:struggle to meet all NFP criteria; adapt to new expectations
such as Medicaid billing, schedule and attendance of new staff at
mandatory trainings, adopting-new materials, purchasing adequate
materials, and operating with budget cuts and limitations. We would
like to emphasize that there is a positive value of statewide or
regional recognition. Functions that celebrate and encourage the local
teams are a necessary strategy to promote a strong Colorado Nurse
• Family Partnership.
Page 7 of 7
Attachment A-2
Weld County Nit Budget Narrative for 2005-06
Personnel Costs:
The amounts in this section reflect the salaries and benefits of seven
staff members in the position of Community Health Nurse II, a .75 FTE
Office Technician III staff position as Data Manager, and a .75 FTE
Nursing Supervisor. The personnel involved in these positions are all
currently active and employed in these positions, with the exception of
one 0.5 FTE RN position which will be added after 7-1-05. The fringe
benefit formula is assigned by the Weld County Government Personnel
Division. All projected salaries include service step increases and
anticipated cost of living increases.
Operating Expense
• General office supplies are used by the 9 staff members housed at
the Weld County Department of Public Health and Environment.
Large 3 ring notebooks are provided for each client to store
their program materials. A variety of office supplies are used
by staff to complete learning activities and client projects.
Other materials are necessary for program organization, storage,
and as replacement items.
• Client support materials are provided to clients at age
appropriate intervals to foster child development and promote
parenting skills. It is anticipated that in year 2005-06, 40% of
the $145 will be utilized on families, based on the stages of our
client caseload. 308 is designated in year 2006-07 and 30% in
year 2007-08.
• Copy costs for the 2005-06 year are anticipated to be at $2000
for the year. Our entire agency is expected to use the county
print shop for all printing needs. The established priced are
$.06 per page, and $.09 for double sided printing. A caseload of
150 clients required nearly 30,000 printed forms in their visit
materials.
• An emergency fund of $500 is in place for client emergencies that
the visitors need to respond to, such as: food, bottled water,
heat, medicine• Postage is for client and program contacts• Office phone equipment and service is provided for all program
staff.
• Computer network fees provide access to the internet system.
• Eight cell phone service package contracts each cost $40 per
month times 12 months.
• Health and program supplies will include scale batteries, tape,
gloves, models, sanitizer and paper towels.
• Staff development is available to provide team or individual
training in program related fields for all nine staff members.
This is figured w $300 per person for the 9 staff members.
• Advisory Board meetings are held quarterly, with and expense
approximately $200 per meeting.
Page 1 of 2
NCCFC/UCHSC Training, Technical Assistance and Materials Costs
• $6000.00 is anticipated to be the cost of Technical Assistance
from NFP. $1000 is the expected expense for CIS system support
• NFP materials for one new visiting RN will be $1750.00
• Clinical Training for one new RN will cost $2500.00
• PIPE materials for new staff will cost $170.00
• Indirect expenses paid to the NCCFC/UCHSC are based on 26% of the
total cost of Training and Technical Assistance
NCAST Training and Materials
One staff member will be required to attend the entire NCAST training
series: A small amount of NCAST materials will be necessary to
complete client assessments. It is required to purchase the screening
materials and educational tools from the NCAST program directly.
Travel Costs• Program visits are calculated for 25 clients per 1.0 FTE of RN
• staff. Three nurses have a 10 mile round trip average, and 3-
nurses have a 30 mile round trip average.
o SO visits x 10 miles x 12 months x $ 0.385 = $2310 x 3 RN =
$6,930
o 50 visits x 30 miles x 12 months x $0.385 = $6,930 x 3 RN =
$20,790
Supervisor visit mileage and meeting attendance is expected to
approximately $100 / month. Total visit travel expenses will be
$28,920 for 2005-06.
• The reimbursement rate of $.385/mile is determined by the Weld
County Government. A 1% increase is projected in the
reimbursement rate for the years 2006-07, and 2007-08.
• Travel related to training is calculated to include 1 new RN that
will be required to attend 12 days of NCCFC training and 6 days
of NCAST training.
o 18 nights of lodging ® $100.00 /night o 6 trips to the Denver metro area for training ® 100 miles
per trip
Equipment
• One additional computer with agency programs and network software
will be purchased to be available to the new RN visitor hired
after 7-1-05.
• Two replacement baby scale sets willbe purchased to maintain a
current working inventory for all visiting staff.
• One additional cell phone will need to be purchased.
Page 2 of 2
Attachment A-3
•
PREVENTION SERVICES DIVISION
NURSE HOME VISITOR PROGRAM
APPLICATION BUDGET and/or FINAL EXPENDITURE REPORT FORM
CONTRACTOR: FOR THE PERIOD:
PROJECT:
CHECK WHICH TYPE OF REPORT IS BEING SUBMITTED: BUDGET FINAL EXPENDITURE REPORT
Annual #of Total SOURCE OF FUNDS
Salary months Amount Received
Rate Budget FTE Required OTHER* from CDPHE
PERSONAL SERVICES:
......
Contractual/Fee for Service •Supervising •
Personnel —...
Fringe Benefits: Rate=
Total Personal Services $ $ $
OPERATING EXPENSES(which are not part of indirect):
Total Operating $ — $
TRAVEL(In-state/Out-stale)
Total Travel
Contractual
Total Contractual $ $ $
Total Direct Costs(Personal Services+OperatinlT+Travel+Contractual) $ 3
INDIRECT COST
Total Indirect Costs
TOTAL PROJECT COST $ _ $
'Source of funding for"Other"(Match or In-kind)I.e.Maternal and Child Health programs
Local/county funding $
State per capita funding $
Medicaid(w al not be used to match) $
Patient fees $
Other(list) $
TOTAL $
May the NON FEDERAL funds be used as match? YES NO
Signature of Agency's Director or Authorized Representative Date
•
Page lof 1
Attachment A-4
Colorado Department of Public Health and Environment
State Fiscal Year 2005-2006
Colorado Nurse Home Visitor Program
MEDICAID REIMBURSEMENT GUIDELINES
FOR CONTINUATION SERVICES
Agencies receiving funding through the Colorado Nurse Home Visitor Program (NHVP) are required to bill the Colorado
Department of Health Care Policy and Financing (HCPF) for Targeted Case Management (TCM) services provided to
Medicaid eligible mothers and children receiving services through the NHVP. Below is the information pertaining to the
NHVP Medicaid reimbursement.process.
•
Contractor Name: Weld County Department of Public Health and Environment
Reimbursement Period: July I,2005 To June 30,2006
Definition of Reimbursable Services: Colorado Nurse Home Visitors will provide Targeted Case Management (TCM)
services to first-time (defined as no previous live births), pregnant women or whose first child is less than one month old and
who are at or below 200%of the Federal Poverty Level. Program enrollment occurs during pregnancy, or within one month
postpartum,and services are designed to continue through the child's second birthday. TCM services include: Assessment of
the needs for health, mental health, social services, education, housing, child care, and related services for the women and
children; Development of care plans to obtain the needed services; Referral to resources to obtain the needed services,
including to medical providers who provide care to Medicaid-eligible pregnant women and children; Routine monitoring and
follow-up visits with the women in which the progress in obtaining the needed services is monitored, problem-solving
assistance is provided,and the care plans are revised to reflect the women and children's current needs.
Medicaid Billing Information:
NHVP providers will submit bills through the Medicaid Management
Billing Cycle Information System(MMIS)at the end of the month for each mother/child
receiving a visit.
Medicaid Reimbursement Rate 5190.04
Claim Form CO-1500
Claim Type E(practitioner/physician)
40(clinic)
Category of Service Includes provider types 16(clinic),32(Family Qualified Health Center),and 45
(Rural Health Center).
G9006,HD(For services rendered to the mother)
Procedure Code Modifiers
T1017,HD(For services rendered to the child)
Page 1 of 2
For the Mother-Services to the mother shall be limited to 3 units per month
with a lifetime maximum of 30 units,or 3 units per month for 10 months. One
(1)unit equals 15 minutes of service. Each unit will equal$63.35($190.04
divided by 3). Full Medicaid reimbursement will be earned with a minimum of
45 minutes of service per month.
Service Limits
For the Child-Services to the child shall be limited to 3 units per month with
a lifetime maximum of 75 units,or 3 units per month for 25 months. One(1)
unit equals 15 minutes of service. Each unit will equal$63.35($190.04 divided
by 3). Full Medicaid reimbursement will be earned with a minimum of 45
minutes of service per month.
Affiliated Computer Services(ACS),the Medicaid fiscal agent,has a 120-day
Billing Requirements "timely filing"policy(invoices must be submitted to ACS within 120 days
from the date of service). Claims are usually paid/denied/adjusted within two
weeks of receipt—the maximum ACS response time is set at 30 days.
For information related to Medicaid billing and training,please contact
Affiliated Computer Services(ACS)at http://coloradomedicaid.acs-inc.com or
Provider Services Unit at 1-800-237-0757 or(303)534-0146 Monday through
Friday,8:00 a.m.to 5:00 p.m.
Medicaid Contractor
You may also contact Dolores Archuleta,Colorado Department of Health Care
Policy and Financing,at 303-866-6010 or dolores.archuleta@state.co.us if you
have questions on the Medicaid enrollment or billing process.
FY 2005-2006 Funding Structure:
Medicaid Reimbursement Rate $190.04
Estimated Medicaid Clients by Site 74
Estimated Monthly Medicaid Revenue $14,063
Estimated Annual Medicaid Revenue $168,756
CDPHE Tobacco Funding $478,819
TOTAL FY05-06 NHVP FUNDING $647,575
$467,668
Total FY05-06 Contract Amount
($478,819 minus$11,151 for training and technical assistance costs that CDPHE will
pay directly to NCC FC)
Page 2 of 2
•
EXHIBIT B
STATE OF COLORADO
Bib Owens,Governor
Douglas H.Benevento,Executive Director .e of c.,
Dedicated to protecting and improving the health and environment of the people of Colorado •
Nc _
4300 Cherry Creek Dr.S. Laboratory Services Division *4,Q?)**
Denver,Colorado 80246-1530 8100 Lowry Blvd.
Phone(303)692-2000 Denver,Colorado 80230-6928 `rays
TDD Line(303)691-7700 (303)692-3090
Located in Glendale,Colorado Colorado Department
htp://www.cdphe.state.to.us of Public Health
and Environment
Date January 20,2005
To: Nurse Home Visitor Program/Nurse-Family Partnership Grantees
From: Esperanza Y.Zachman,Nurse Home Visitor Program Director
Re: REVISED Progress Report and Budgets for FY2005-06 Continuation Funding Requests
Attached please find the instructions to complete the revised Progress Report and Budgets for FY05-06,
FY06-07 and FY07-08. The state fiscal year (FY) is defined as July la through June 30th The enclosed
documents must to be submitted by current Nurse Home Visitor Program (NHVP) grantees and
received at the Colorado Department of Public Health and Environment (CDPHE) on or before 5:00
PM on Thursday, March 3, 2005 for consideration of continued funding for FY05-06. The Progress
Reports and Budgets will be reviewed by the National Center for Children, Families and Communities
(the National Center) of the University of Colorado Health Sciences Center and/or the National Nurse-
Family Partnership. The National Center is the facility designated in the NHVP legislation to make
recommendations to the Colorado Board of Health regarding the granting of NHVP funds to local
entities to deliver the Nurse-Family Partnership(NFP)services at the community level.
The budget you submit for FY05-06 is the budget that will be used for your FY05-06 contract, should
you receive continuation funding. The budgets you submit for FY06-07 and FY07-08 are prospective
budgets that will be used for planning purposes and to estimate the future costs of the program. You
will find a sample site budget and detailed narrative to use as guidance in preparing your budgets. It
is important that the budget requests are as realistic and accurate as possible so that the awards made
to grantees will be cost-effective.
As you know, we are in the midst of our first year of Targeted Case Management (TCM) Medicaid
claims. We know that the Medicaid integration has not been without its challenges, especially with the
elimination of Presumptive Eligibility. Our department will be working with all NHVP grantees to
revise the Medicaid revenue estimates for FY05-06 in attempts to more accurately reflect the number of
Medicaid clients in your NFP program. Please keep in mind that every agency selected to receive
2005-06 NHVP funds will be expected to certify that it is currently a Medicaid provider and must bill
Medicaid, in a timely fashion, for TCM services provided through the NHVP (see Attachment G).
Funding for all NHVP sites is now intended to be a combination of state Tobacco Master Settlement
dollars and Medicaid revenue generated from TCM claims. All continuation sites will be required to
support local NHVP services, in some part, with Medicaid reimbursements. Medicaid revenue
Page 1 of 29
estimates for new and expansion sites will be established in a different manner,meaning far less than
that for continuation sites,as it takes at least 6-8 months to establish a new or growing NHVP site:
Lastly, our intent is to make this application available electronically unless otherwise requested. This
grant application will be available on-line at www.cdphe.state.co.us and search for Nurse Home Visitor
Program. If you would like to have a hard copy of this grant application, you may request one by
responding to this email or feel free to call me.
Please note that the Progress Report and Budget have been revised and you are required to submit this
new format. As always, please feel free to call me with your questions, needs or concerns. I can be
reached at ey.zachman@state.co.us or 303-692-2943.
Thank you.
H:\W PDO6\NH VP\APPibtioin0506PropnsitePorts\0506Connatter.doc
Page 2 of 29
Colorado Department of Public Health and Environment(CDPHE)
Prevention Services Division
Child,Adolescent and School Health Section
W. 4300 Cherry Creek Drive South,PSD-A4
Denver,Colorado 80246
300492-293
ey.zachman@stateco,us
COLORADO NURSE HOME VISITOR PROGRAM(NHVP)
APPLICATION TIME LINE
January 2005 •
January 20,2005 Grant Application Packets available.
January 20-February 4,2005 Question and Answer Period open.
February 14,2005 Answers to questions available on the CDPHE website.
March 3,2005(5:00 PM) Deadline for Progress Report and Budgets for current grant
recipients requesting NHVP continuation funds. Materials must
be received by this date.
March 3,2005(5.00 PM) Deadline for New and Expansion Grant Applications. Materials
must be received by this date.
March 4-8,2005 Application Qualification Screening by CDPHE.
March 9-30,2005 Review and Evaluation of Qualified Applications by the National
Center for Children,Families and Communities,University of
Colorado Health Sciences Center.
April 6,2005 Funding Recommendations of the National Center for Children,
Families and Communities forwarded to the State Board of
Health.
April 2005 State Board of Health Deliberation and Action on Funding
Recommendations.
April—June 30, 2005 Contracting Process between CDPHE and selected applicants for
July 1,2005 through June 30, 2006.
Page 3 of 29
Colorado Department of Public Health and Environment(CDPHE)
COLORADO NURSE HOME VISITOR PROGRAM(NHVP)
(Nurse-Family Partnership or NFP)
FY 2004-05 PROGRESS REPORT
and
FY 2005-06,FY 2006-07 and FY 2007-08 BUDGETS
In order to be considered for continuation funding,CDPHE requires the following documents from programs
currently receiving a grant from the Colorado Nurse Home Visitor Program, which is funded through the
state's Tobacco Settlement Agreement. Your Progress Report and FY05-06,FY06-07 and FY07-08 Budgets and
Narratives must be received by CDPHE on or before March 3, 2005 by 5pm and must be stapled or binder
clipped only. Please submit one(1)original and four(4)copies for a total of five(5)Progress Reports to:
Esperanza Y. Zachman,NHVP Program Director
CDPHE
4300 Cherry Creek Drive South,PSD-A4
Denver,CO 80246-1530
Progress Reports and Budgets will not be accepted/considered if they are
> Late including received on March 3, 2005 but after 5:00 p.m. or postmarked on or before March 3,2005 but
not received by CDPHE until after March 3,2005 5:00 p.m.
> Incomplete. All required sections and attachments must be complete and included in each of the 5
copies.
> Received without required number of copies.
> Faxed or Emailed
The Progress Report and Budgets will be reviewed by the National Center for Children, Families and
Communities (National Center) of the University of Colorado Health Sciences Center and/or the National
Nurse-Family Partnership. The budget requests for FY05-06 will be compared to the actual spending from last
year and this year. The National Center is responsible for monitoring the contract performance of each agency
funded with NHVP including the number of clients served and the quality implementation of the NW as
measured by, but not limited to, client enrollment, client attrition, staffing and submission of data as
determined by benchmarks from the NFP's clinical research trials and from experience implementing the NW
nationally. The National Center has a process for agencies that are not implementing the program in a quality
manner as determined by the criteria referenced above whereby a negotiated Improvement Plan is put in place
which is time-framed and which specifies the appropriate consequence, including but not necessarily limited
to, reduction or cessation of funding. The recommendations of the National Center will be presented to the
State Board of Health at the April 2005 Board of Health meeting.
All application questions must be submitted by email to Esperanza Y. Zachman, NHVP Program Director at
ey.zachman@sstate.co.us between January 20th and February 4th. Responses are expected to be posted by
February 14th on the Colorado Department of Public Health . and Environment website at
www.cdphe.state.co.us and search for Nurse Home Visitor Program.
Page 4 of 29
COLORADO NURSE HOME VISITOR PROGRAM(NHVP)
PROGRESS REPORT CONTENTS
➢ FY04-05 Progress Report questions for the time period of March 1,2004 through February 28,2005.
> Attachment A: Progress Report Cover Sheet
> Attachment B: Progress Report Checklist
> Attachment C: Grantee Response to Site Review
> Attachment D: Budget Page(Excel spreadsheet)to be used for—
FY05-06-July 1,2005 through June 30,2006
FY06-07-July 1,2006 through June 30,2007
FY07-08-July 1,2007 through June 30,2008
> Attachment E.1 and Attachment E.2: NFP Sample Budget and Detailed Narrative
> Attachment F: Assurance of Intention to Meet Program Requirements
> Attachment G: Assurance of Intention to be an Active Medicaid Provider
> Attachment H: NHVP Rules
> Attachment I: Estimates of First-Time and Low-Income Mothers
Page 5 of 29
FY 2004-05 NHVP/NFP PROGRESS REPORT
THIS PROGRESS REPORT HAS BEEN REVISED. SITES ARE REQUIRED TO USE THIS NEW FORMAT.
Please respond to each of the following items pertaining to your current NHVP/NFP program for the time
period of March 1,2004—February 28,2005. Each response must begin with the respective title. Please use
Courier font,10 pt,with 1"margins per page.
NOTE: At minimum,applicants are required to utilize their OS data,and site consultation reports and site
reviews in preparing this Progress Report. NHVP application reviewers will be using this same information as
well as financial and contract performance histories to judge your funding request. It is imperative that this
Progress Report is consistent with information used by the application reviewers. Inconsistencies could result in
a lower review score and in a weaker funding recommendation to the State Board of Health,or possibly a
recommendation of no funding.
A. FUNDING LEVEL and FISCAL MANAGEMENT:
1. What is the total cost of the program for FY04-05(July 1,2004 through June 30,2005)?
2. How much FY04-05 NHVP funding did the program receive? How much revenue is expected from Medicaid
claims?(The combination of these two sources is expected to cover the total cost of the program.)
3. Describe your current spending of NHVP funds,including whether or not you expect any NHVP funds to remain
unexpended at the end of the contract period(June 30,2005)and,if so,why.
4. Describe your current rate of generating Medicaid revenue, including whether or not you are on target to make
the contract estimated revenue and, if not, why. Who in the organization is responsible for tracking NHVP
Medicaid revenue?
B. CLIENT INFORMATION: The actual number of clients enrolled and number of clients who are active as
of February 28,2005.
C. PROGRAM EVALUATION: An evaluation of program progress, which includes the effectiveness of the
program in achieving its stated outcomes. To report on the effectiveness of the program,please share with
us, in seven (7) single-spaced pages or less, how your site has addressed the issues critical to sustaining
the Nurse Home Visitor Program in your community. Use bullet points or tables when applicable.
Comment on the successes and challenges you encountered March 1, 2004 through February 28, 2005 in
each of the following eight(8)areas:
1. Referral and Resources
a. How many referrals have you received and from which organizations?
b. Are the number and sources of referrals consistent with what you outlined in your original application? If not,
why not and what steps are you taking to re-engage those referral sources?
c. Describe your process for assuring that referrals are received early in gestational age.
d. What strategies have you implemented to facilitate the flow of referrals into the program?
e. What are your clients' greatest needs? Please give specific examples of how you have worked with the
community to connect your clients with needed resources.
f. Describe how the loss of Presumptive Eligibility has impacted referrals to the program as well as the ability of
clients to receive medical care. How have you addressed this issue with your community?
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` �°"�"°"
2. Enrolling and Retaining Clients
a. If you have not consistently met your contractual active enrollment goal of 100 families(50 families for programs
with waivers),please explain why. In addition,detail your strategies for reaching and maintaining your
contractual enrollment requirements,including who is responsible for implementing the strategies and a timeline
for implementation to assure compliance with your NHVP contract.
b. How do you monitor client attrition,in addition to using the CIS?
c. Provide two strategies that you and your nurses have successfully used to re-engage clients who appear to be
losing interest in the program or who have indicated a desire to dropout.
d. Other than relocating or fetal/infant loss,what reasons do clients give for dropping out of the program? What
specific measures have been taken through supervision and other means to respond to these reasons? What
impact have these steps had on reducing your site's attrition?
e. How do you assure that non-English speaking clients are successfully participating in the program? If
interpreters are used,describe your supervision of these staff to assure they are comfortable with competent in
their role.
•
3. Nurse Home Visitor Support,Retention and Recruitment
a. Give examples of how you integrate reflection into your supervision.
b. Describe your schedule fort-on-1 meetings with nurses,team meetings including case conferences,and for home
visit observations with the home visitors. Attach one team meeting agenda that included a case conference.
c. Which forms do you use to record your supervision with home visitors and your home visit observations? Attach
a completed supervision form(remove client identifiers)used with your home visitors.
d. In addition to the required supervision and case conferencing, what activities have taken place to ensure the
nurses feel supported and receive the professional development they need to thrive in their positions?
e. What have the nurses found to be their greatest challenges? Greatest needs? How have you helped meet these
needs?
f. If applicable,how many nurses have left in the last year and what reasons have they given for leaving?
g. If applicable,what challenges have you faced in hiring nurses? Have you had vacancy savings? How long does
it take to fill a nurse home visitor position?
h. Attach your latest Transition Plan to prevent client attrition in the event of nurse turnover or extended absence.
4. Advisory Board/Supporting Council
a. How are the participants on your board/council remaining actively engaged in the program? What have been the
strategies for keeping them involved? If they are not engaged,what is your strategy to increase participation and
support?
b. Give an example of what your board/council has done to support the Nurse Home Visitor Program.
c. Has there been turnover among your board membership? Why? Who has been added?
d. Attach two samples of coalition meeting minutes from the last year.
' 5. Broad-Based Community Support
a. Beyond support from your board,describe your overall community support over the last year?
b. What actions have you taken to develop new community support and maintain existing community support for
the program?
c. Provide specific examples of how, in the past year, the Implementing Agency administration has supported this
program and explain its impact on program implementation.
d. How would you characterize support for the program—improved, same, less? Who have been the supporters?
What is planned for the future?
6. Existing Visitation Programs
a. Describe your current relationships with other visitation programs in your community including what makes
some relationships more successful and,if applicable, what you are doing to improve coordination with others.
Page 7 of 29
F - NM?Application
7. Integration of CIS
a. Describe your team process and schedule for reviewing data from 1)CIS,2)Quarterly Summary Reports and,3)
annual Phase Reports from the National Nurse-Family Partnership.
b. Describe how your team integrates/applies the National Performance Standards to the program.
c. Describe how available data and reports are used to address performance concerns with nurses (i.e., failure to
make visits according to the schedule,failure to address all domains,failure to meet required caseload).
d. Based on your data and reports, describe the specific action your team has taken over the past year to address
areas that need improvement? State the needed area of improvement and detail progress that has been made.
e. What challenges and/or needs do you have in effectively using the available data and reports?
8. General Program Implementation
a. Because of their integral part in the program,describe how administrative staff(clerks)are recognized,supported
and actively engaged in the implementation and success of the program.
b. Describe the most significant challenges experienced.by the program including what unexpected or unusual
circumstances have impacted the continuing operation? (Example:staff turnover among nurses or implementing
agency staff changes)
c Share other successes your site has had in the past year.
FY 05-06, FY 06-07 and FY 07-08 Budget
The state fiscal year(FY)is defined as July 1^M through June 30th.
Please submit a separate 12-month budget (Attachment D) for FY05-06, FY06-07 and FY07-08 and a detailed
narrative explaining the projected program expenses for each year as instructed in the Budget and Budget
Justification section which follows. Please utilize the attached Sample Site Budget and the Detailed Narrative
for Sample Site Budget (Attachments El and E.2) for guidance in what should be included in your budget.
We recognize that the structure of your site may be different than the .5 FTE Supervisor, four 1.0 FTE Nurses
and .5 FIE Data Entry Clerk used to create this sample budget;we will take that into account when reviewing
the budgets.
Funding for all NHVP sites must be a combination of state Tobacco Master Settlement dollars and Medicaid
revenue generated from Targeted Case Management Medicaid claims submitted for Medicaid eligible clients.
Each NHVP grant application budget should be created based on the total expected cost of the program for
that particular year, minus costs related to Medicaid billing. Our department will work with NHVP sites to
establish Medicaid revenue estimates, which will then, in part, determine how much Tobacco Master
Settlement funds are recommended to the State Board of Health as NHVP awards. Every agency selected to
receive NHVP funds will be expected to certify that it is a current Medicaid provider and must bill Medicaid,
in a timely fashion, for TCM services provided through the NHVP (see Attachment G). Medicaid revenue
estimates for new and expansion sites will be established in a different manner, meaning far less than that for
continuation sites, as it takes at least 6-8 months to establish a new or growing NHVP site. Contingent upon
the FY05-06 NHVP appropriation, our department will consider providing an additional funding amount to
cover some of the costs related to Medicaid billing. Should it occur,this process will only take place following
confirmation of our FY05-06 NHVP appropriation and will be added during the contracting process.
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M5-06 NNW Application
The purpose of the budget justification narrative is to better understand how sites plan to use the funds
allocated for the Nurse Home Visitor Program. When writing the narrative, be as detailed as possible in
defining how you calculated the dollar figures you have submitted. If there are any variances in line items or
additional line item requests not included in the sample FY 05-06 budget, please justify those in each budget
narrative. Please include documentation to support any requests over 5 percent for any given item in the
sample budget. If supporting documentation is not included, the increased amount will not be approved.
There is no guarantee that requests for increased funding will be granted.
Within the sample budget the allocations for some items vary from year to year. For sites reaching the end of
their first three-year cycle,please review the following line items carefully:
Client Support Materials: The total amount allocated for this cost over a client's three year period in the
program is$145-$85 in the.first year and $30 in the both the second and third years. Estimate the number of
clients graduating in the FY05-06 and then budget$85 per client to fill those spots. Budget an additional $30
for each on-going client. Do not budget for clients that may be lost due to attrition. Explain how you arrived
at your estimates.
Copies of Forms/Facilitators: Estimate the cost of copies that need to be made in FY05-06 and for each of the
following two years'budgets. Explain how you arrived at your estimates.
Medical and Program Supplies: Estimate only what is needed for replacement equipment. Maximum
allowance for the third year and every year thereafter is$300.00.
Please prepare your budget requests as realistically and accurately as possible. The closer we are to budgeting
the actual costs that will be needed to fund the programs, the more effectively we will be able to distribute
grant funds and the greater the number of families that will be served. Please follow the instructions for the
Budget and Budget Justification Narrative.
Budget and Budget Justification Narrative Instructions
1.) Budget pages: Provide an actual budget for FY05-06 and prospective budgets for FY06-07, and FY07-08 for
implementation of the NHVP. Applicants may use the Budget Request Form(Attachment D)or another spreadsheet
format that provides all the requested information. The budget provided for fiscal year 05-06, as approved by the
Board of Health upon the recommendation of the National Center, will be the budget for the contract for FY05-06 if
the Applicant is approved for funding. The budgets for fiscal years 06-07 and 07-08 will be used for planning
purposes.
2.) Budget Narrative: Provide a detailed narrative description justifying each item listed on the budget pages, so the
reader can discern the source of funds, how the funds will be used, and how Applicant arrived at the amounts.
Include the descriptive justification for the following:
a. Personnel Costs: Salaries and fringe benefits for the staff.
b. Operating Costs: Office supplies, client support materials, copies of forms/facilitators and outreach materials,
postage, telephone, computer network fees, cellular phone usage, medical and program supplies, professional
development.
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FY 506 WHY?Appfotlm
c. Equipment Cons: Funding for equipment,including computers and software.
d. NCCFC/UCHSC Training,Technical Assistance and Materials Costs:
NCCFC/UCHSC clinical training and support,NCCFC/UCHSC materials,purchase of clinical information system
(CIS), NCCFC/UCHSC technical assistance, indirect rate costs paid to NCCFC/UCHSC and purchase of PIPE
materials. Applicants should include funding to cover the costs of each of the trainings (including training
materials) required by Section 1.6(1) of the Rules for each of the Nurses and Nurse Supervisor to attend such
trainings.
e. Travel Costs:
Travel costs in the course of carrying out the work of the program through visits to clients and outreach in the
community,travel to attend the NCCFC/UCHSC trainings and travel to attend NCAST training.
I NCAST Training and Materials Costs: Costs of NCAST training and materials.
g. Indirect Costs:
Implementing agency indirect costs are permitted in the budget but shall be capped at 25%of total direct tusk.,
27% of total direct salary and fringe benefits,or 30%of total direct salary and fringe where no other direct costs
are charged,depending on which method has been previously approved and utilized by Applicant in contracting
with CDPHE. If the applicant's organization does not have an approved indirect rate, the applicant's proposed
budget may include a flat indirect rate of 10% of salary cost, excluding fringe benefits, requested from the
CDPHE. If the applicant's organization does not have an approved indirect rate but wants reimbursement for
overhead costs in excess of 10% of funds requested, they may go through the approval process with the State.
Please note that this process takes several weeks and may not be the best option for agencies that do not have
multiple State contracts. Once a contract is received, a contractor can submit an indirect cost proposal to the
CDPHE for review and approval. Such indirect rates are valid for one year and must be approved prior to
payment for indirect costs.
Please Note: Care should be taken to assure that those costs budgeted as direct costs are not also included as
indirect costs. For example, rent for program staff may be budgeted as a direct cost,but then those costs should
not also be part of the agency's indirect costs allocation pool.
Estimating Administrative Costs:
The state is expected by the Legislature to carefully track and monitor the administrative costs of local
grants. (C.R.S. 24-75-1105) In addition, the 2002 State Performance Audit conducted by the Office of
the State Auditor recommended that the State ensure that the administrative costs for the Nurse Home
Visitor Program are reasonable and necessary by improving its methods for tracking and evaluating
the administrative costs portion of site budgets.
Administrative costs are generally defined as those costs necessary for the proper administration of the
program,but not linked directly to the provision of services. Applicants are asked to assist the state in
estimating the portion of their costs that are administrative costs as opposed to programmatic costs.
The costs of the items presented in the Sample Budget will be considered to be programmatic costs as all
of these costs are incurred in the direct support of the activities of the program.However, agencies vary
in their cost allocation methodologies so that some of these items might be in the agency's indirect costs
allocation pool rather than budgeted as direct costs. Rent for the program staff, which would be
considered a programmatic cost, also is often budgeted in the agency's indirect costs pool.If any of the
items that are on the Sample Budget or other programmatic costs such as rent, are found in the
agency's indirect costs pool, the applicant is asked to list those programmatic costs,estimate the
Page 10 of 29
Ft0506 NHVP Application
•
percent of the indirect costs pool that is for these programmatic costs, and describe how you arrived at
the estimate. The balance of the indirect costs would be considered to be the agency's administrative
costs.
h. In-Kind Contributions:
In order to have all true costs of the program reported, as recommended in the 2002 Performance
Audit,all in-kind contributions need to be presented. These in-kind contributions need to be limited to
those that support the basic program budget as presented in the Sample Budget. They may include the
• contribution of program administrators' time, i.e. an Executive Director, Nursing Director or Program
Manager's time,not to exceed a total of.1 FTE. In-kind contributions also may include all or part of the
agency's indirect costs. If the agency's negotiated indirect rate is higher than the amount allowed
under the CDPHE indirect rate cap,the difference should be reported as an in-kind contribution.
i. Other funds:
If Applicant currently operates the NHVP using funding other than from the Nurse Home Visitor
Fund,Applicant shall:
1. State whether Applicant exyen.(s to continue to receive funding from such alternative-funding
source.
2. State whether the funds received pursuant to a Contract will be used to increase the number of
clients served or merely to replace that funding.
j. In-Kind Contributions and Other Community Contributions:
Community contributions are important indicators of a community's commitment to the program and
we encourage you to solicit in-kind or monetary contributions from your community. Be sure to list
any in-kind contributions or financial donations in your budget and/or in the narrative that will
accompany it. Those contributions that are for the basic program costs presented in the Sample Site
Budget should be reported as In-Kind Contributions on the Budget Form, as directed in #8 of the
Budget and Budget Justification Instructions. If your site needs office space, you may include it in the
budget request. However, office space and/or furniture is often a good in-kind contribution that can be
made by the Implementing Agency, the county or others in the community. If you do offer office space
as an in-kind donation, indicate if this includes any furniture the staff may need (examples: desks,
chairs,file cabinets).
k. Narrative should also address:
1. The sustainability of any other funding sources;and
2. Unique circumstances that cause any budget items in Applicant's Proposal to deviate by more that
five(5)percent from the model site budget.
Page 11 of 29
Attachment A
5.0
Colorado Nurse Home Visitor Program(NHVP)
2005-06 PROGRESS REPORT COVER SHEET
1. Name of Agency:
•
Address/City/Zip
2. Name of person completing Progress Report
Position/Title:
Telephone: FAX:
E-Mail:
3. Name of Authorized Signer:
(Must be an individual with authority to sign a grant application.)
Position/Title:
Telephone: FAX:
E-Mail:
Signature:X
4. Total request for July 1,2005 through June 30, 2006:$
5. List county(ies) to be served:
6. Total number of families to be served:
7. Total FTE to be funded with NHVP dollars:
8. Total number of nurse home visitors to be funded with NHVP dollars:
Page 12 of 29
Attachment B
Colorado Nurse Home Visitor Program(NHVP)
PROGRESS REPORT CHECKLIST
❑ A Progress Report for the time period of March 1,2004 through February 28,2005
❑ Attachment A: Progress Report Cover Sheet
❑ Attachment B: Progress Report Checklist
❑ Attachment C: Grantee Response to Site Review
Attachment D(A separate Excel spreadsheet for each year)
❑ FY05-06-July 1,2005 through June 30,2006
❑ FY06-07-July 1,2006 through June 30,2007
❑ FY07-08-July 1,2007 through June 30,2008
❑ A detailed Budget Narrative to justify projected expenses for each of the corresponding budgets
submitted.
❑ Attachment F: Assurance of Intention to Meet Program Requirements
❑ Attachment G: Assurance of Intention to be an Active Medicaid Provider
❑ One team meeting agenda that included a case conference. (Question 3.b.,Page 5)
o A completed supervision form(remove client identifiers). (Question 3.c.,Page 5)
o Latest Transition Plan to prevent client attrition. (Question an.,Page 5)
❑ Attach two samples of coalition meeting minutes from the last year. (Question td.,Page 5)
❑ One(1) original and Four(4) copies of the completed Progress Report and Budgets
for a total of Five (5)Progress Reports. (Must be stapled or binder dipped only.)
Page 13 of 29
Attachment C
Colorado Nurse Home Visitor Program (NHVP)
(Nu se-Family Partnership)
GRANTEE RESPONSE to SITE REVIEW
Dated January 2005,Matt Buhr-Vogl of the National Nurse-Family Partnership office sent out site review letters to
each of our FY04-05 NHVP grantees. In two (2)single-spaced pages or less using Courier font,10 pt,with 1"
margins per page,please respond to each of the issues stated in your letter emphasizing your progress-to-date
where applicable. If you do not have a copy of the site review letter,please contact Esperanza Y.Zachman,NHVP
Director,at 303.692.2943 or ey.zachman@state.co.us to request a copy of the letter for your site. Thank you.
Page 14 of 29
COLORADO NURSE HOME VISITOR PROGRAM ATTACHMENT D
APPLICATION BUDGET AND/OR EXPENDITURE REPORT FORM
APPLICANT: FOR THE PERIOD:
PROJECT:
Annual No.of Total SOURCE OF FUNDS
Requested/
Salary months Amount Received
Rate Budget FTE Required Other Sources' from CDPHE
Personal Services:
•
ContractuaVFee for Service _...- . _._..--.-•.--•------.__-_
Supervising Personnel _
Fringe Benefits: Rate=
•
TOTAL PERSONAL SERVICES
Operating Expenses(which are not pal of indrectk
TOTAL OPERATING S S -
$
EQuiprnent Expenses
TOTAL EQUIPMENT $ f $
Travel Expenses
TOTAL TRAVEL
NCCFClUCHSC Training 3 Technical Assistance
TOTAL TRAINING&TECH ASSISTANCE S $ S
NCAST Traing 8 Materials
TOTAL NCAST COSTS S $ S
TOTAL DIRECT COSTS Tenons s«rrca.•op.rstlrp•trnr.r.contraWol) $ $ $
indired Costs
TOTAL INDIRECT COSTS S $ $
TOTAL PROJECT COST S S $
OTHER SOURCES of FUNDING(Match or In-kind)
S
S
S
$
$
TOTAL OTHER SOURCES S
Signature of Authorized Representative Date
Page 15 of 29
oy
�/--- Patmaship Attachment E1
L) wh/....n..,r.., NFP SAMPLE SITE BUDGET
100 FAMILIES
Personnel Costs(Estimate)
Base Fringe Total %Effort Program Program Program Total
CycleYear 1 CydeYear 2 CydeYear 3
Salary Benefits
Nurse Supervisor 47,000.00 12,220.00 59,220.00 50% 29,610.00 31,091.00 32,645.00 93,346.00
Nurse 1 36,500.00 9,490.00 45,990.00 100% 45,990.00 48,290.00 50,705.00 144,985.00
Nurse 2 36,500.00 9,490.00 45,990.00 100% 45,990.00 48,290.00 50,705.00 144,985.00
Nurse 3 36,500.00 9,490.00 45,990.00 100% 45,990.00 48,290.00 50,705.00 144,985.00
Nurse 4 36,500.00 9,490.00 45,990.00 100% 45,990.00 48,290.00 50,705.00 144,985.00
Secretary 21,486.00 5,586.00 27,07200 50% 13,537.00 14,213.00 14,924.00 42,674.00
Sub-Total(Personnel) 227,107.00 238,464.00 250,389.00 715,960.00
Administrative Costs(should be adjusted to reflect local differences)
Office Supplies $100/mo 1,200.00 1,200.00 1,200.00 3,600.00
Client Support Materials $85/family 8,500.00 3,000.00 3,000.00 14,500.00
Copies of Forms/Facilitators $1500 per year I I 1,500.00 1,500.00 1,500.00 4,500.00
Postage $50/mo 600.00 600.00 600.00 1,800.00
Telephone $100/mo 1,200.00 1,200.00 1,200.00 3,600.00
2 Computers w/software $3000 3000.00 0.00 0.00 3,000.00
Computer Network Fees $30/mo 360.00 360.00 360.00 1,080.00
4 Cellular Phones $150/phone 600.00 0.00 0.00 600.00
Cellular Phone Usage Fees $75/mo per Nurse 3,600.00 3,600.00 3,600.00 10,800.00
Liability Insurance $100/mo 1,200.00 1,200.00 1,200.00 3,600.00
Medical Supplies $1,500 1st yr.,$250/yr after 1,500.00 250.00 250.00 2,000.00
Professional Development $2,000 1st yr.,$1,500/yr after 2,000.00 1,500.00 1,500.00 5,000.00
Mileage 20 trips/family @ 10 mi RT 0.31/
P Y mi/yr 6,200.00 6,200.00 6,200.00 18,600.00
Sub-Total(Administrative) I 31,460.00 20,610.00 20,610.00 72,680.00
Sub-Total for Personnel&Administrative 258,567.00 259,074.00 270,999.00 788,640.00
Training and Technical Assistance(Provided by NFP)
Clinical Training&Tech.Assistance $2,500 per nurse,$3,000 per supervisor 13,000.00 13,000.00
NFP Materials(Cost includes Pregnancy,Infancy,and Toddler Guidelines) 1,750.00 1,750.00
(Clinical Information System Support
Purchase of System 1,000.00 1,000.00
Technical Assistance from NFP 6,000.00 6,000.00 6,000.00 18,000.00
Sub-Total Training&Technical Assistance 21,750.00 6,000.00 6,000.00 33,750.00
Indirect Costs*(26%of Training&TA Costs) 5,655.00 1,560.00 1,560.00 8,775.00
Total Cost of Training&Technical Assistance 27,405.00 7,560.00 7,560.00 42,525.00
Travel Costs I I
Travel from Site to Training I-(Airfare/Hotel/Meals) 5,000.00 5,000.00
Travel from Site to Trainings II&III-(Airfare/Hotel/Meals) 5,000.00 5,000.00
Total Costs of Travel I I I 10,000.00 10,000.00
NCAST Training(Not payable to NFP-Site arranges for this training directly with NCAST)
IAPPx.$1,800-$2,300 per site 2,300.00 3,500.00
NCAST Materials 1213.00 1213.00
Pipe Training Materials 824.00 824.00
TOTAL ANNUAL BUDGET 300,309.00 266,634.00 278,559.00 845,502.00
'The University of Colorado's indirect cost rate is 26%of training and technical assistance. If the program funding source
requires a lower rate,documentation is required.
Page 16 of 29
D I kuse9 Attachment E.2
vp NFP Detailed Narrative for Sample Site Budget
Please keep in mind that this is a sample,and that budget costs of goods and services in your area may vary. You will
need to tailor your budget to fit your community's needs.Please note that the sample budget is based on a 100 family site
served by four full-time Nurse Home Visitors,a half-time Nurse Supervisor and a half-time Data Entry Clerk. If you
budget a substantially decreased amount in any line item(greater than 20%)induding any omissions of line items,please
submit a written request for a waiver. Additional line items do not require a waiver.
1. Salaries—These line items should reflect the salaries your agency is currently paying for similar work.
From the date they start their positions,Nurse Home Visitors and Nurse Supervisors are expected to work the full
number of hours they are contracted to work. Time not needed for home visitation in the early months of the program
should be spent conducting outreach to increase community awareness of the program and number of referrals into the
program.
2. Client Support Materials — The total amount allocated for this cost over a client's three year period in the
program is$85 in the first year and$30 in the both the second and third years. The$145/family per program cycle is to be
used to purchase additional support materials for families and for Nurse Home Visitors to assist in the work they are
doing with families beyond handouts from program materials and PIPE. Educational or other support materials may
include digital camera and printer, videos, and flipcharts, in addition to a small number of consumables that would be
purchased in subsequent years. Sites are discouraged from purchasing large gifts for clients. Sites are encouraged to
cultivate community groups and business that donate items for clients. Estimate the number of clients graduating in the
FY05-06 and then budget $85 per client to fill those spots. Budget an additional $30 for each on-going client. Do not
budget for clients that may be lost due to attrition. Explain how you arrived at your estimates.
3. Copies of Forms/Facilitators and Outreach Materials—This line item should be used for copying the program
materials(examples:PIPE,program facilitators)and for program brochures.
4. Cellular Phones—This line item includes phones,adaptors and rechargers. Cell phones are essential for ensuring
the safety of home visitors.
5. Medical and Program Supplies—Below is a list of recommended but not required equipment for the NFP. The
Nurses may have access to many of these supplies so there could be no need to purchase new items. If the
Implementing Agency has some or all of these items already,they could be used by the program and considered in-
kind support. Estimate only what is needed for replacement equipment. Maximum allowance for the third year and
every year thereafter is$300.00.
Recommended Equipment
For each Nurse Home Visitor
• Blood pressure cuff
• Stethoscope
• Disposable measuring tapes
• Thermometer(to teach moms how to take temps)with disposable sleeves
• Pregnancy calculator
• Age appropriate toys for different developmental stages
• Bag to carry equipment
For each office:
• Baby scales
• Batteries and disposable pads for scales
• VCR/TV monitor
• Still and video camera
Page 17 of 29
• Luggage carriers to transport large items
• Disposable exam gloves
• Disinfectant surface wipes
• Alcohol wipes
6. Professional Development—This line item is to be used for additional specialized training the individual Nurses
or team of Nurses may need after thorough assessment of team's needs,and may not fully cover necessary additional
training. This line item is calculated at a maximum of$300.00 per one F.T.E.
7. Computer and Software—In order to meet their program responsibilities,the Nurse Supervisor and Data Entry
Clerk should have access to computers for the half time they are employed by this program. The program Nurses should
have reasonable access to a computer to conduct program related activities such as researching specific client issues,
receiving e-mail,and participating in NFP web-based forums. Software is included in this line item.
8. NFP Clinical Training and Support-Includes the following:
• Training One(usually held in Denver,CO-4 days for Nurses,5 for Supervisors)
(Program overview/theory,pregnancy guidelines,evaluation/CIS etc.)
• Training Two(two-day,conducted regionally)
(Infancy guidelines/Partners In Parenting Education(PIPE))
• Training Three(two-day,conducted regionally)
(Toddler guidelines)
• Supervisors also receive additional training and materials.
The tuition fee is billed once for each Nurse Home Visitor and Nurse Supervisor at the time Training One is attended. This money is
not refunded if a Nurse resigns before all the trainings have been attended.
9. NIP Training Materials-Includes the following:
• Set of Prenatal,Infancy and Toddler Guidelines
• Study guides for Guidelines
• Self-Efficacy Theory Study Guide
• Home Visitor Resource Manual
This fee is billed once for each Nurse and Supervisor at a site.
10. Clinical Information System(CIS)-Includes training,implementation and access to the Web-Based CIS system.
This is a one-time fee,charged"per site."
11. NFP Technical Assistance/NFP Products-Includes the following:
• Technical assistance in operating the CIS from evaluation staff
• Access to site-specific evaluation reports on the Web-based CIS
• Clinical Information System User's Guide and CD-ROM Tutorial
• Formal,written and site-specific evaluation reports from the NFP
• Clinical technical assistance from training staff as needed
• Orientation packet for new sites,and assistance in completing orientation
• One copy each of Training Video and Public Awareness Video
• Newsletters and updates from the NFP
• Technical assistance from NFP site development staff
This is an annual fee, billed to each site when the site contract is fully executed and then on the anniversary of the contract initiation
date each year.
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12. Partners In Parenting Education(PIPE)-The PIPE curriculum and activities for parents and babies is an integral
part of the NFP curriculum,and as such,is part of a Nurses'regular practice with her clients. Sites will get trained in the
use of PIPE at Training Two,but need to purchase the PIPE manuals and materials themselves,in advance of coming to
Training Two. The following materials are required:
• PIPE Textbook(one per Nurse(not Supervisor) $170/each Nurse
• PIPE Activity Cards(one set per site) $42/set
• Parent Handbook(English)(one per site) $51/each
• Parent Handbook(Spanish)(one per site) $51/each
Total PIPE materials cost for sample site(4 Nurses,1 Supervisor): $824
It is recommended that Nurses share the PIPE activity cards and English/Spanish handbooks if they are officed in the same building or
in close proximity(Nurse Supervisor does not need these materials unless she is carrying a caseload). Each Nurse should have her
own textbook. If a Nurse is officed in a different county and can not access these materials on a weekly basis,budget a full set of PIPE .
materials for her.
13. Visit/Outreach Mileage—This line item covers both the Nurses'and Nurse Supervisor's travel related to client
visits and community outreach.
Calculating Mileage for Nurses
There are four considerations that may require you to adjust this line item:
• Number of Nurses
• Number of counties and distance to potential clients within the site's catchment area
• County or agency mileage reimbursement rate
During the first several months of program implementation,Nurses will not be using the full 20 visits to visit each of their families,
but rather using the mileage allocated for some of those 20 visits for outreach within their communities.
Calculating Mileage for Nurse Supervisor
The Nurse Supervisor is expected to do weekly one-on-one visits with each Nurse and one staff meeting per month as well as
community outreach. Therefore, the amount budgeted will be adjusted if there are multiple locations within the site which requires
the Nurse Supervisor to travel to any of these meetings.
14. NFP Training Travel-The costs associated with travel for 5 Nurses(4 Nurses and the Nurse Supervisor)to go to
Denver for T1,and a regional location for 12 and T3(for a total of 9 days of training)include travel,meals,and hotel.
Generally,Nurses attend T2 approximately 4 months after TI and T3 approximately 10 months after T1.
15. NCAST Travel—This line item is budgeted to have the NCAST trainer travel to the site for the trainings.
a. $100 per night for 10 nights in hotel @=$1,000
b. $35 per diem for 10 days @ ea=$350
c. 150 miles each way=300 miles RT @.31 per mile=$93 x 4 trainings=$372
d. Total for ten days of NCAST training =$1,722
16. NCAST Training and Materials—Sites arrange this training either directly from NCAST or from a local,NCAST-
certified trainer. The following materials should be purchased directly by the site in advance of scheduling NCAST
training:
• Keys to Caregiving(one per site)
o video series
o study guide
o one of each of the five parent booklets*
o Total: $640
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• Beginning Rhythms
o study guide(one for each Nurse and Supervisor): $33 each
o sleep activity record pad of 100 sheets(one per site): $18 site
o Total: $183
• NCAST Feeding/Teaching Materials for Nurses
o PCI Set
o Feeding and Teaching Manuals
o Scale Pads
o Teaching Kit
o Total: $182 each Nurse
• NCAST Feeding/Teaching Materials for Supervisor.
o Feeding and Teaching Manuals
o Total: $110 Supervisor
• Network Survey:
o Total: $15/100 copies
*If the site will need Spanish versions of these materials,add$18/nurse or$90 to the$640 total.
Total NCAST materials cost for sample site(4 Nurses,1 Supervisor): $1,676
Approximate Registration Costs/Participant: Registration Fees
Beginning Rhythms:(1/4 day) $ 30
Keys to Caregiving: (1 day) $ 60
NCAST Feeding Scale:(3 days) $350
NCAST Teaching Scale:(3 days) $350
Total for One Nurse $790
Total for Site $790 x 5 Nurses=$3,950
17. UCHSC Indirect Costs—UCHSC has an indirect cost rate of 26%of total direct costs.
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Attachment F
Colorado Nurse Home Visitor Program(NHVP)
ASSURANCE of INTENTION to MEET PROGRAM REQUIREMENTS
Current Nurse Home Visitor Program grantees seeking continuation funding must assure that they intend to
meet the Program Requirements,as described in Section 1.6 and Section 1.7 of the Rules Concerning the Nurse
Home Visitor Program (Attachment A), by initialing each of the outlined areas below and by signing this
assurance page.
Training Requirements
Visit Protocols
Program Management Information Systems
Reporting and Evaluating System
Staffing Requirements
Name of Applicant Entity:
Name of Authorized Signer:
Signature of Authorized Signer:X
Date:
Page 21 of 29
Attachment G
C. Colorado Nurse Home.Visitor Program(NHVP)
ASSURANCE of INTENTION to be an ACTIVE MEDICAID PROVIDER
The Center for Medicaid and Medicare Services(CMS)has approved Medicaid reimbursement for Targeted
Case Management(TCM)services provided by Colorado Nurse Home Visitor Program sites. Targeted Case
Management is a large part of the activities provided by nurse home visitors. These case management services
are defined by CMS as."services which will assist individuals eligible under the Colorado State Plan in gaining
access to needed medical,social,educational,and other services."Specifically,the approved Colorado
Medicaid State Plan further elaborates:"Nurse home visitors provide targeted case management...through 1)
assessment of the needs for health,mental health,social service,educational,housing,child care and related
services to women and children;2)development of care plans to obtain the needed services;3)referral to
resources to obtain the needed services;and,4)routine monitoring and follow-up visits with the women in
which the progress of obtaining the needed services is monitored."
The Colorado Department of Public Health and Environment and the Colorado Department of Health Care
Policy and Financing have created a Medicaid Management Information System(MMIS)that allows for
electronic billing of TCM services. All Nurse Home Visitor Program sites will be required to become an active
Medicaid provider,if not already,and must bill Medicaid for TCM services as applicable.
Current Nurse Home Visitor Program grantees seeking continuation funding must assure that they intend to
meet the Medicaid requirements by initialing each of the outlined areas below and by signing this assurance
page. The applicant entity:
Will be an active Medicaid Provider on or before July 1,2005.
Will enroll all NHVP nurses in Medicaid as providers.
Will have a Medicaid consulting physician.
Will submit TCM claims as determined by Medicaid billing rules and requirements,
including timely filing of claims.
Name of Applicant Entity:
Name of Authorized Signer:
Signature of Authorized Signer:X
Date:
Page 22 of 29
Attachment H
V Rules Concerning the Colorado Nurse Home Visitor Program
1.1 Definitions.
(1) "Alternative Nurse Home Visitation Program" means a program that provides home visits by nurses but is not the
program described in§25-31-104(1),C.R.S.,but does qualify for funding from the Nurse Home Visitor Fund because
it meets the requirements of§25-31-104(4),C.R.S.and§1.10 of these rules.
(2) "Board"means the State Board of Health.
(3) "Conflict of interest"means a personal or financial interest that could reasonably be perceived as an interest that may
influence an individual in his or her official duties.
(4) "Department"means the Department of Public Health and Environment.
(5) "Entity"means any nonprofit not-for-profit or for-profit corporation,religious or charitable organization,institution
of higher education, visiting nurse association, existing visiting nurse program, local health department county
department of social services, political subdivision of the state, or other governmental agency or any combination
thereof.
(6) "Expansion Site" means a program that is already serving at least one-hundred low-income, first-time mothers,
through a grant received under these rules,in the previous fiscal year,and the implementing entity is applying for
additional funding to enable it to serve additional low-income,first-time mothers.
(7) "Financial Interest"means a substantial interest held by an individual which is an ownership or vested interest in an
entity, or employment or a prospective employment for which negotiations have begun, or a directorship or
officership in an entity.
(8) "Health Sciences Facility" means a facility located at the University of Colorado Health Sciences Center that is
selected by the President of the University of Colorado.
(9) "Low-income"means an annual income that does not exceed two hundred percent of the federal poverty level.
(10) "New Entity"means any entity that has not previously received funding for the program pursuant to these rules.
(11) "Nurse" means a person licensed as a professional nurse pursuant to§12-38-102, C.R.S., et seq., or accredited by
another state or voluntary agency that the state board of nursing has identified by rule pursuant to§12-38-108(1xa),
C.R.S.,as one whose acueditation may be accepted in lieu of board approval. •
(12) "Nurse Home Visitor Program"or"Program"means a program that is described in§25-31-I04(1),C.R.S.,and meets
the requirements of these rules.
(13) "Nurse Supervisor"means a nurse with a master's degree in nursing or public health,unless the implementing entity
can demonstrate that such a person is either unavailable within the community or an appropriately qualified nurse
without a master's degree is available.
(14) "Visit Protocols" mean nurse home visit guidelines addressing, at a minimum, prenatal, infancy and toddler
development and cover topics such as positive birth outcomes,parental life course development and parenting skills.
1.2 Procedures for Grant Application.
(1) Grant Application Contents.
(a) General. All applications shall be submitted to the department by entities as defined in §1.1(5) in
accordance with these rules and shall contain,at a minimum,the following information:
(i) A description of the specific training to be received by each nurse employed by the applicant to
provide home visiting nursing services through the program, which training shall include, at a
minimum,the training required in§1.6(1);
(ii) A description of the protocols to be followed by the applicant in administering the program, which
protocols shall,at a minimum,comply with the requirements of§1.6(2);
(iii) A description of the management information system to be used by the applicant in administering the
program,which system shall,at a minimum,comply with the requirements in§1.6(3);
(iv) A description of the reporting and evaluation system to be used by the applicant in measuring the
effectiveness of the program in assisting low-income, first-time mothers, which shall, at a minimum,
comply with the requirements in§1.6(4);
(v) A budget which includes,at a minimum,each of the following:
(A) Salaries and benefits for the staff required in§1.7;
(B) Costs of the training provided by the Health Sciences Facility,and costs to cover any other training
required by the Health Sciences Facility. Allowable coats include but are not limited to,travel costs
and training materials;
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(C) Costs to purchase and maintain the management information system and related technical
•
assistance;
(D) Operating costs, including but not limited to, office and program supplies, postage, telephones,
computer(s)with intemet access,liability insurance,medical supplies,mileage reimbursement and
other staff development for the required staff;
(E) A description of how the applicant will fund any additional costs not funded by the grant;
(F) Any in-kind contributions the applicant or other stakeholders in the community may donate.
(b) Applications for New Entities In addition to the requirements of§12(a)of these rules,applications for
new entities shall contain,at a minimum,the following information:
(i) A description of the experience the applicant has working with the target population and existing home
visitation programs;
(ii) A description of the community support for the program and for the applicant as the lead organization
in its implementation,including detailed information about the broad based support for the program's
implementation. Breadth of community support shall be judged by the diversity of those involved in
supporting the program's implementation,and can be evidenced through letters of support and more
formal referral relationships among various community organizations and the applicant;
(iii) A description of the specific needs of the population to be served, including but not limited to, the
socio-demographic and health characteristics that justify the need for the program and the number of
first-time,low-income mothers eligible for the program;
(iv) A description of the relationship of the applicant with the schools, prenatal clinics and other referral
sources for the first-time, low-income mothers who will be served by the program, with specific
information about the duration of these relationships;
(v) A description of the nature and duration of the referral linkages that exist between the applicant and
other service providers throughout the community, including but not limited to, providers of social
services, mental health services, workforce preparation services, job training services, legal services,
health care services and child care services;
(vi) Except as provided in§1.9, a description of a plan for recruiting at least one hundred first-time,low-
income mothers;
(vii)A description of the collaboration between the applicant and other entities providing similar services to
the same population,including plans for coordination and a description of how the program will fit in
with and complement the community's efforts to meet the needs of the target population,if applicable;
(viii) A plan for hiring and retaining qualified staff that represents the community's racial and cultural
diversity;
(ix) A description of the applicant's capacity to comply with and monitor the implementation of the grant
requirements;
(x) Summary of the major strengths of the applicant and the community that will lead to successful
implementation of the program;and
(xi) A statement as to whether the applicant plans to work collaboratively with other entities in either
administering the program or through an oversight board, and whether the other entities are other
counties,municipalities,agencies or organizations.
(xi) If an applicant currently provides services in compliance with§§1.6 through 1.9(1)using funding other
than from the Nurse Home Visitor Program Fund,the applicant shall:
(A) State whether the applicant expects to continue to receive funding from such alternative funding
source;and
(B) State whether the funds received pursuant to these rules will be used to increase the number of
clients served.
(c) Applications for Multiple Community Collaboration. If multiple communities with lower birth rates need
to collaborate to meet the one hundred-family requirement the applicant shall provide specific plans that
address the mechanisms and history of the collaboration in addition to complying with the requirements of
§12(a)and(b). The plan shall include,but not be limited to,examples of previous collaborations.
(d) Applications for Expansion Sites. In addition to complying with the requirements of §12(1)(a), each
expansion site shall submit the following in its application:
(i) Confirmation that the entity has implemented the program in compliance with these rules;
Page 24 of 29
(ii) A description of additional community demand for the program that is not being met through the
current funding;
(iii) A specific plan for building additional infrastructure to support the expansion of the program,
including,but not limited to,physical space,staff supervision and computer data entry personnel;
(iv) A description of how the implementing entity has addressed previous specific challenges relating to the
program;
(v) A plan descn'bing the implementing entity's strategy to recruit and train sufficient qualified nurses to
implement and expand the program;and
(vi) A description of community support for the planned expansion of the program.
(2) Timelines for Grant Applications.
Grant applications may be solicited up to two times each fiscal year.
1.3 Review of Applications.
(1) The department shall conduct an initial review of submitted applications.
(2) After the department's initial review of the applications,the health sciences facility shall review the applications and shall
submit to the board a list of entities that the health sciences facility recommends to administer the program in
communities throughout the state.
1.4 Criteria for Selection of Entities.
(1) At a minimum,the following criteria shall be used for selecting potential grantees:
(a) The applicant meets the definition of an^entity"as defined in§1.1;
(b) The entity submits a completed application in accordance with the requirements of§1.2;
(c) The entity demonstrates the capacity and ability to adequately administer and implement the program;
(d) The entity demonstrates that it will comply with the requirements of§§1.6 through 1.8;
(e) The entity's geographic service area and/or the population it serves advances the implementation of the program in
communities throughout the state;and
(f) The entity is selected on a competitive basis.
(2) More than one entity may receive funding in a particular community if it can demonstrate in its application:
(a) Broad community support for the implementing entity;
(b) Existence of a sufficient number of eligible women to support multiple implementing entities;
(c) Existence of dose coordination and mutual support between the entities;and
(d) A specific plan for the coordination by the applying entity and other nurse home visitation programs in the
community.
13 Awarding of Program Grants.
(1) The board shall award grants to the selected entities specifying the amount of the grant.
(2) The grant awards may,at a minimum,indude monies to fund:
(a) Reasonable and necessary salaries and benefits for nurses,nurse supervisors and data entry employees;
(b) Reasonable and necessary operating costs, including but not limited to, medical, program and office supplies,
telephones,computer equipment mileage reimbursement,any required insurance,and staff development;
(c) Reasonable and necessary training,training materials and travel costs associated with obtaining training required by
§1.6(1);
(d) Reasonable and necessary cost for purchasing the management information system, and any related technical
assistance;and
(e) Reasonable and necessary cost, for developing any infrastructure necessary for program administration and
implementation.
1.6 Program Requirements.
(1) Training Requirements. Each nurse employed by an entity to provide home visiting nursing services through the
program shall be required,at a minimum,to attend and complete the following training:
(a) Up to five days preparatory training for prenatal visits which shall include training on the following topics:
(i) program goals and theoretical underpinnings;
(ii) assessment of family strengths and risk factors;
(iii) relationships skills and principles for developing self-efficacy;
(iv) strategies for facilitating change in maternal health behaviors;
Page 25 of 29
(v) orientation to the prenatal visit protocols;and
(vi) orientation to the management information system and clinical recordkeeping.
(b) Up to four days preparatory training for infant visits which shall include training on the following topics:
(i) nurturing parent-infant attachment
(ii) care of the baby;and
(iii)use of infant visit protocols.
(c) Up to four days preparatory training for toddler visits which shall include training on the following topics:
(i) information on parenting issues;
(ii) achieving goals related to family economic self-sufficiency;and
(iii) orientation to the toddler visit protocols.
(2) Visit protocols.
(a) The visit protocols followed by the entity in administering the program shall cover information specific to prenatal,infant
and toddler phases. The visit protowls shall,at a minimum,address:
(i) the physical and emotional health of the mother and the baby, including for the mother information on the
importance of nutrition and avoiding alcohol and drugs,including nicotine;
(ii) the environmental health issues such as ensuring a safe environment for the child;
(iii) the life course development for the mother, including employment, educational achievement, budgeting and
financial planning,transportation and housing;
(iv) the parental role arid responsibilities;and
(v) the role of family and friends in supporting goal attainment.
(3) Program management information systems.
(a) The management information system used by the entity in administering and implementing the program shall, at a
minimum,include the following:
(i) documentation of the services received by clients enrolled in the program;
(ii) information to assist the program staff in tracking the progress of families in attaining program goals;
(iii) information to assist nurse supervisors in providing feedback to individual nurse home visitors on strengths and
areas for improvement in implementing the program;and
(iv) information to assist program staff in planning quality improvements to enhance program implementation and
outcomes.
(4) Reporting and evaluation system.
(a) At least once every month, each implementing entity shall submit the data generated by the management information
system required by§1.6(3)to the health sciences facility;and
(b) The data will be analyzed and the health sciences facility shall make available,on no less than a quarterly basis,a report
to the entity evaluating the program's implementation, and on a semi-annual basis shall also make available reports on
benchmarks of program outcomes.
(c) The implementing entity shall submit an annual report that complies with the requirements in §1.11 to both the health
sciences facility and the community in which the entity implements the program that reports on the effectiveness of the
program within the community.
(d) The annual report shall be submitted on or before March 1,or not later than sixty days after the end of the fiscal year for
which funding was provided if the program has not submitted a request for continuation of funding. The annual report
shall be written in a manner that is understandable for both the health sciences facility and members of the community
that the program serves.
1.7 Staffing Requirements.
(1) For every one hundred low-income,first-time mothers enrolled in the program the program shalt at a minimum,have
the following staff:
(a) Four full time equivalent("FTE")nurses;
(b) One half FTE nurse supervisor,and
(c) One-half FTE data entry/clerical support person.
(2) The data entry/clerical support person shall provide office support to the nursing staff and assure data are submitted as
required by§1.6(3)and(4).
(3) The caseload for any one nurse at one time shall not exceed twenty-five low-income,first-time mothers.
Page 26 of 29
1.8 Eligibility of Clients.
(1) At a minimum,the following is required to be eligible to receive program services:
(a) A woman with an annual income that does not exceed two hundred percent of the federal poverty level;
(b) No previous live births;and
(c) Enrolled in the program during pregnancy or prior to the end of the first month of the baby's life.
(2) Preference will be given to women who enroll in the program prior to the 28th week of pregnancy.
1.9 Number of Clients Served—Waivers.
(1) Except as provided in§1.9(2), each entity shall provide services to a minimum of one hundred low-income, first-time
mothers in the community in which the program is administered and implemented.
(2) (a) If the population base of a community does not have the capacity to enroll one hundred eligible families, an entity
may apply to the board for a waiver from this requirement.
(b) Prior to granting any waivers, the board shall consult with the health sciences facility to ensure that the entity can
implement the program within a smaller community and comply with program requirements.
1.10 Availability of Funding for Alternative Nurse Home Visitation Programs.
(1) An alternative nurse home visitation program may qualify for funding under the nurse home visitor program if the
alternative nurse home visitation program:
(a) Has been in operation in the state as of July 1,1999 for a minimum of five years;
(b) Has achieved a significant reduction in each of the following:
(i) Infant behavioral impairments due to use of alcohol and other drugs,including nicotine;
(ii) The number of reported incidents of child abuse and neglect among families receiving services;
(iii) The number of subsequent pregnancies by mothers receiving services;
(iv) The receipt of public assistance by mothers receiving services;and
(v) Criminal activity engaged in by mothers receiving services and their children.
(2) Any alternative nurse home visitation program qualifying for funding under this section shall be exempt from the
requirements of§1.6 if it continues to demonstrate significant reductions in the occurrences specified in§1.10(1)(b).
(3) Any alternative nurse home visitation program qualifying for funding under this section shall comply with the
requirements of§1.11 of these rules.
1.11 Reporting Requirements for Tobacco Settlement Programs.
(1) All programs shall annually submit to the department a report which,at a minimum,includes the following information:
(a) The amount of tobacco settlement moneys received by the program for the preceding fiscal year;
(b) A description of the program,including the program goals,population served by the program,the actual number of
people served,and the services provided;and
(c) An evaluation of the operation of the program,which includes the effectiveness of the program in achieving its stated
goals.
(2) Reports shall be submitted to the department no later than sixty days after the end of the fiscal year for which funding
was provided.
1.12 Conflicts of Interest
(1) Applicability. Except as provided for in §§25-31-105, C.R.S. through 25-31-108; C.R.S. regarding the health sciences
facility,this section applies to any person involved in:
(a) The review of completed applications;
(b) Making recommendations to the board regarding an entity that may receive a grant and the amount of said
grant or
(c) Members of the board.
(2) Prohibited Behavior. No person who is involved in the activities specified in§1.12 (1)shall have a conflict of interest.
Such conflict of interest includes,but is not limited to,any conflict of interest involving the person and the grantee or the
person and the tobacco industry.
Page 27 of 29
(4) Responsibilities of Persons with a Potential Conflict of Interest A person who believes that he or she may have a
conflict of interest shall disclose such conflict of interest as soon as he or she becomes aware of the conflict of interest. If
the person is a member of the board and acting in the capacity of a board member,the person shall publicly dish the
conflict of interest to the board;other persons shall disclose the conflict of interest in writing to the department If the
board or the department, whichever is appropriate, determines the existence of a conflict of interest the person shall
recuse himself or herself from any of the activities specified in§1.12(1)relating thereto.
1.13 Criteria for Reduction or Cessation of Funding. - -
(1) Upon recommendation from the health sciences facility,the board may reduce or eliminate the funding of a program if
the entity is not operating the program in accordance with the program requirements established in§1.6 through§1A
except as provided in§1.10 of these rules,or is operating the program in such a manner that it does not demonstrate
positive results.
(2) An entity shall receive written notification from the board if the entity's funding is subject to reduction or elimination.
Page 28 of 29
Attachment I
Percent of All Births to First-Time Mothers with Incomes Below 200%of the Federal Poverty Level(Poor*):
Colorado PRAMS,1998-200Z Colorado Vital Statistics,2003
Data from 1/18/05
Region(PMR)** 2003 Number of 1998-2002 Percent 1998-2002 2003 Number
Live Births First-time and Poor 95%Confidence Interval First-time and Poor
First-time and Poor
Colorado 69,304 21.4 20.4-22.4 14,138-15,524
Region(PMR)** 2003 Number of 1998-2002 Percent 1998-2002 2003 Number
Live Births First-time and Poor 95%Confidence Interval First-time and Poor
First-time and Poor
1 1,016 22.7 18.0-27.4 183-278
2 7,380 20.0 17.3-22.7 1,277-1,675
3 40,677 19.5 18.0-21.0 7,322-8,542
4 8,901 24.1 21.7-26.5 1,932-2,359
5 386 22.1 14.9-29.3 58-113
6 673 26.6 20.7-32.5 139-219
7 1,998 30.0 24.8-35.2 496-703
8 671 32.0 26.1-37.9 175-254
9 987 24.8 19.8-29.8 195-294
10 1,090 24.0 19.5-28.5 213-311
11 2,815 26.2 22.2-302 625-850
12 1,726 18.6 15.1-22.1 261-381
13 719 30.6 24.6-36.6 177-263
14 265 26.9 16.7-37.1 44-98
Region(PMR) 2003 Number of 1998-2002 Percent 1998-2002 2003 Number
Live Births First-time and on 95%Confidence Interval First-time and on
Medicaid First-time and on Medicaid Medicaid
Colorado 69,304 12.1 11.3-12.9 7,831-8,940
*Poor is defined as having an income below 200%of the Federal Poverty Level. If income was unknown,women were
also placed in this category if: (1)Medicaid paid for either prenatal care or labor and delivery;(2)They participated in
WIC services during or after pregnancy;or(3)Or they were less than 25 and not married.
"Planning and Management Regions(PMR):
1:Logan,Morgan,Phillips,Sedgwick,Washington,Yuma;2:Larimer,Weld;3:Adams,Arapahoe,Boulder,Clear Creek,
Denver,Douglas,Gilpin,Jefferson;4:El Paso,Park,Teller;5:Cheyenne, Elbert,Kit Carson,Lincoln;6:Baca,Bent,
Crowley,Kiowa,Otero,Prowers;7:Pueblo;8:Alamosa,Conejos, Costilla,Mineral,Rio Grande,Saguache;9:
Archuleta,Dolores, La Plata, Montezuma,San Juan;10:Delta,Gunnison,Hinsdale,Montrose,Ouray,San
Miguel;11:Garfield,Mesa,Moffat,Rio Blanco;12: Eagle, Grand,Jackson,Pitkin, Routt, Summit;13:Chaffee,
Custer,Fremont, Lake;14:Huerfano,Las Animas
For more information about Colorado PRAMS or Colorado Vital Statistics,call the Colorado Department of
Public Health and Environment,Health Statistics Section at(303) 692-2160.
Page 29 of 29
COLORADO NURSE HOME VISITOR PROGRAM EXHIBIT C
APPLICATION BUDGET AND/OR EXPENDITURE REPORT FORM
APPLICANT:WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMEK FOR THE PERIOD: 7/1/05-6130106
PROJECT:NURSE HOME VISITOR PROGRAM Continuation
Annual No.of Total SOURCE OF FUNDS
Requested I
Salary months Amount Received
Rate Budget FTE Required Other Sources' from CDPHE
Personal Services:
Sue Morse-CHN II 45847 12 1 45847 45847
Eva Rodriguez-CHN II 48959 12 1 48959 48959
Mane Rowe-Denning-CHN II 48959 12 1 __. 48959 48959
Vesta Unruh-CHN II 45847 12 1 45847 45847
Gent Holton-CHN II 48403 12 1 48403 48403
Caroline Valdez-CHN II(.50 FTE) 22896 12 0.5 22896 22896
New-CHN II(.50 FTE) 22429 12 0.5 22429 22429
Andrea Snyder-OT III(.75 FTE) 20887 12 0.75 20887 20887
Contractual/Fee for Service
Supervising Personnel
Nancy Weber-CHN Supervisor(.75 FTE) 43254 12 0.75 43254 30192 13062
Fringe Benefits: Rate=33.07% 114912 114912 31881 83031
TOTAL PERSONAL SERVICES 462,393 108 8 462,393 128,285 334,108
Operating Expenses(which are not part of indirect): I I___
Office Supplies 1200 1200 _. . 1200
Ckent Materials 7800 7800 7800
Copies-Forms 1500 __. .. 1500 ___—__ 1500
Emergency Fund - 0 0 0
Postage 600 _. .. 600 312 288
Telephone 1200 _.. 1200 992—
,_ 208
Computer Network Fee 360 360 360.
Cellular Phones Usage Fees 3840 3840 3840
Medical Supples 300 300 300
Other.Staff Development 2700 2700 2700
Meetings 0 0 0
TOTAL OPERATING 19,500 I 19,500 8,504 10,996
Equipment Expenses
Computers with MS software 1,500 1,500 1,500
Baby scales 400 400 400
Cellular Phones 100 100 100
TOTAL EQUIPMENT 2,000 i 2,000 0 2,000
Travel Expenses
Mileage(visits) 28920 28920 28920
Travel to Trainings 2031 2031 2031
TOTAL TRAVEL 30,951 30,951 0 30.951
NCCFC/UCHSC Training 8 Technical Assistance I I
NCCFC Training 2500 2500 2500
CCFC Materials 350 350 350
NCCFC Clinical Info.System Support 0 0 0
NCCFC TA 6000 6000 6000
NCCFC Indirect at 26% 2301 2301 2301
TOTAL TRAINING S.TECH ASSISTANCE 11,151 I 11,151 11,151 0
NCAST Traing 8 Materials
NCAST Training 790 790 ... 790
NCAST Materials 350 350 350
PIPE Material 170 170 170
TOTAL NCAST COSTS 1,310 I 1,310 0 1.310
TOTAL DIRECT COSTS(news 527,305 527.305 147,940 379.365
Indirect Costs @ 23.37% 123,231 123,231 34573 88,658
TOTAL INDIRECT COSTS 123,231 123,231 34,573 - 88,658
TOTAL PROJECT COST 650,536 650,536 162,513 468,023
OTHER SOURCES of FUNDING(Match or In-kind)
CDPHE for NCCFC Training 8 Materials 8 Weld Indirect 13,757.00
Medicaid 168,756.00
f
TOTAL OTHER SOURCES 182,513.00
Signature of Authorized Representative: Judy M.Nero Date: 05/25/2005
Page 1 of 1
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Exhibit E
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 CONTRACTORL. 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**x***-**,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:
Page 1 of 1
Revised:11/5/04
•
Exhibit F
TASK ORDER OPTION TO RENEW LETTER
)Date)
Task Order Option to Renew Letter Number it, Contract Routing Number**********
State Fiscal Year 20**-20** ***************proeram
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 f*.**)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:
Page l of l
Revised:11/5/04
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