HomeMy WebLinkAbout20041510.tiff RESOLUTION
RE: APPROVE TASK ORDER AMENDMENT #1 FOR NURSE 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 Amendment#1 for 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, 2004, and ending June 30, 2005,with further terms and conditions being as
stated in said amendment, and
WHEREAS,after review,the Board deems it advisable to approve said amendment,a copy
of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Task Order Amendment#1 for 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 amendment.
The above and foregoing Resolution was,on motion duly made and seconded,adopted by
the following vote on the 26th day of May, A.D., 2004.
BOARD OF COUNTY COMMISSIONERS
fa La WEtIUNTY, COLORADO
I •ail' �� �(�{,�(�(,. 410
l 1861 y ?; :4CP tj` 47)44471Robert D. Masden, Chair
k to the Board
t U I�1 William H. e, Pro-Tem
Deputy Clerk to the Board i
M. J . ei e
APPR AS TO FORM:
EXCUSED
David Long
untyAtt rneypllG��
Glenn Vaad
Date of signature: lo
2004-1510
H L0031
( � ', AIL c3 0 n- I le,-0 C-f
Memorandum
TO: Rob Masden, Chair
Board of County Commissioners
IFROM: Mark E. Wallace, MD, MPH
O Director, Department of Public Healthi
and Environment
COLORADO DATE: May 21, 2004 q�
SUBJECT: Task Order Amendment#1
Enclosed for Board review and approval is Task Order Amendment#1 between the Colorado
Department of Public Health and Environment and Weld County for the Nurse Home Visitor
Program.
Under the provisions of the original task order, WCDPHE will implement and 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.
Through this amendment, the State will pay up to $278,210 to provide continued nurse home
visitor services to the current clients and up to $148,899 to provide services to an additional 50
clients. With the beginning of this amendment on July 1, 2004, WCDPHE will be able to bill
Medicaid for the nurse home visits for both the mother and the newborn. It is anticipated
Medicaid will pay approximately $112,884 for current client visits and $56,422 for new client
visits. If this amendment is approved, it will add funding for two additional nurses, a .25 FTE
office technician, and .25 FTE of nurse supervisor.
For the time period, July 1, 2004 through June 30, 2005, Weld County will be reimbursed by
CDPHE an amount not to exceed $427,109 for the Nurse Home Visitor Program. I recommend
your approval of this task order amendment.
Enclosure
2004-1510
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
DEPARTMENT OR AGENCY NUMBER
FLA
CONTRACT ROUTING NUMBER
05-00051
TASK ORDER AMENDMENT#1
Nurse Home Visitor Program
This Amendment is made this 12TH day of MAY, 2004,by and between: the state of Colorado, acting by and
through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT,whose address or principal place
of business is 4300 Cherry Creek Drive South,Denver,Colorado 80246,hereinafter referred to as"the State";
and,Board of County Commissioners of Weld County (a political subdivision of the state of
Colorado),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 80631,hereinafter referred to as"the
Contractor".
WHEREAS,the State has received funds pursuant to a Master Settlement Agreement between several states,
including the state of Colorado, and certain tobacco companies;
WHEREAS, section 24-75-1101, et seq., C.RS., as amended,describes how the state of Colorado shall apportion
moneys it has received, and will receive,under that Master Settlement Agreement;
WHEREAS, Section 24-75-1104(a), C.R.S., as amended, allocates part of the Master Settlement Agreement
moneys to the"Colorado Nurse Home Visitor Program";
WHEREAS, section 25-31-101,et seq., C.R.S., as amended, creates the"Colorado Nurse Home Visitor Program"
("Program");
WHEREAS,pursuant to section 25-31-106, C.R.S.,as amended,the Contractor had previously submitted a grant
application that was reviewed by the University of Colorado Health Sciences Center in accordance with sections 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;
WHEREAS,the parties previously entered into a Master Contract with contact routing number 00 FAA 00008;
WHEREAS,the parties entered into a Task Order,hereinafter referred to as the"Original Task Order", dated
December 29,2000,with contract encumbrance number PO FAA FH50100942, and contract routing number 01
FAA 00942,whereby the Contractor was to provide to the State 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;
WHEREAS, as of the made date of this Amendment,the State has a currently valid Group H purchasing delegation
agreement with the division of finance and procurement within the Colorado Department of Personnel and
Administration;
WHEREAS,the State promises to provide an additional$278,210.00 to the Contractor for the period between July
1,2004, and June 30, 2005, in exchange for the promise of the Contractor to provide continued nurse home visitor
services to the current clients,hereinafter referred to as"Continuation Services";
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WHEREAS,the State also promises to provide an additional$148,899.00 to the Contractor for the period between
July 1, 2004, and June 30,2005,in exchange for the separate promise of the Contractor to provide nurse home
visitor services to an additional fifty(50)low-income,first-time mothers,hereinafter referred to as"Expansion
Services";
WHEREAS, 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 Number 13M, Organization Code 6250, and Appropriation Code 593,under Contract
Encumbrance Number PO FLA NHV0500051; and,
WHEREAS, all required approvals, clearances, and coordination have been accomplished from and with all
appropriate agencies.
NOW THEREFORE,in consideration of their mutual promises to each other, stated below,the parties hereto agree
as follows:
1. Consideration for this Amendment to the Original Task Order, contract encumbrance number PO FAA
FHS0100942 and contact routing number 01 FAA 00942,consists of the payments and services which
shall be made pursuant to this Amendment, and the promises and agreements herein set forth.
2. It is expressly agreed to by the parties that this Amendment is supplemental to the Original Task Order.
The Original Task Order has been amended by Task Order Renewal Letter 01,contract routing number 02
FAA 00183,Task Order Renewal Letter 02,contract routing number 03 FAA 00290,Task Order Change
Order Letter 01,contract routing number 03 FAA 00865, and Task Order Option To Renew Letter 03,
contract routing number 04 FAA 00065 collectively referred to herein as the Original Task Order. The
Original Task Order, as amended,is incorporated herein by this reference,made a part hereof, and attached
hereto as"Attachment A". All terms, conditions,and provisions of the Original Task Order,unless
specifically modified herein,are to apply to this Amendment as if those terms, conditions, and provisions
were expressly rewritten,incorporated, and included herein.
3. It is expressly agreed to by the parties that the Original Task Order is, and shall be,modified, altered, and
changed in the following respects only:
A. In accordance with paragraph D.2.of the amended Original Task Order,the amended Original
Task Order is renewed for the period of July 1, 2004,through and including June 30, 2005.
B. Part B. of the amended Original Task Order, "DUTIES AND OBLIGATIONS OF THE
CONTRACTOR",is modified to add new paragraphs 3,4,5, 6,7, 8, 9, 10, and 11. These new
paragraphs read as follows:
3. The Contractor shall provide Continuation Services to the original low-income, first-time
mothers in those communities served by the Contractor for the period of July 1, 2004,
through June 30,2005. The Contractor shall coordinate its efforts with the State's
Program Manager,the State's Program Nursing Consultant and the National Center for
Children, Families and Communities("National Center"). The Contractor shall provide
these services in accordance with the terms and conditions of the Colorado Nurse Home
Visitor Program's"REVISED Progress Report and Budgets for FY2004-05 Continuation
Funding Requests",which are incorporated herein by this reference,made a part hereof,
and attached hereto as"Attachment B",and the Contractor's 2004-2005 Budget
Narrative for the Continuation Services,which are incorporated herein by this reference,
made a part hereof, and attached hereto as"Attachment C".
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4. The Contractor shall implement and provide Expansion Services to an additional fifty
(50)low-income, first-time mothers for the period of July 1,2004,through June 30,
2005. The Contractor shall coordinate its efforts with the State's Program Manager,the
State's Program Nursing Consultant and the National Center. The Contractor shall
provide these services in accordance with the terms and conditions of the Colorado Nurse
Home Visitor Program's 2004-2005 New and Expansion Grant Application,which is
incorporated herein by this reference,made a part hereof, and attached hereto as
"Attachment 0", and the Contractor's Budget Narrative for the Expansion Services,
which is incorporated herein by this reference,made a part hereof, and attached hereto as
"Attachment E".
5. 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, express,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 Task Order with the State,which requires
State Controller or delegate approval,before the transfer can be made.
6. On or before August 31,2004,the Contractor shall submit to the State a detailed final
Expenditure Report for the Continuation Services provided during the term of July 1,
2003,through June 30,2004,in the format attached hereto as"Attachment F" of this
Amendment,which is incorporated herein by this reference and made a part hereof
7. On or before August 31,2004,the Contractor shall submit to the State a detailed final
Expenditure Report for the Expansion Services provided during the term of July 1, 2003,
through June 30,2004,in the format previously referenced as"Attachment F".
8. Contractor shall submit reimbursement requests to Medicaid for all eligible clients in
accordance with the Medicaid Reimbursement Guidelines for the Continuation Services,
which is incorporated herein by this reference,made a part hereof, and attached hereto as
"Attachment G".
9. Contractor shall submit reimbursement requests to Medicaid for all eligible clients in
accordance with the Medicaid Reimbursement Guidelines for the Expansion Services,
which is incorporated herein by this reference,made a part hereof, and attached hereto as
"Attachment H".
10. Contractor shall obtain the required training to implement the Nurse-Family Partnership
Program(Program),which is administered through the University of Colorado Health
Sciences Center School of Nursing, (UCHSC).
11. In addition to obtaining the required Program training,the contractor shall:
a. Implement the Nurse-family Partnership in accordance with the implementation
guidelines developed by UCHSC.
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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;
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 both the Continuation and Expansion 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. Assume all costs for training of nurses,including travel and materials.
e. Assure the availability of appropriate computer systems and software at the
Program site for the recording and transfer of evaluation data to UCHSC.
f. Collect data for evaluation purposes,using forms developed by UCHSC. Enter
the data collected into the Clinical Information System(CIS)program,
developed by UCHSC, 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.
i. Assume all costs for training of subsequent replacement and expansion nurses
consistent with the per nurse training cost.
j. Provide the recommended equipment and supplies needed for Program
implementation.
C. In consideration for the Contractor's timely and satisfactory completion of the Continuation
Services for the renewal term of July 1, 2004 through June 30, 2005,the"not to exceed amount"
in the Original Task Order is hereby increased by Two Hundred Seventy-Eight Thousand,Two
Hundred Ten Dollars($278,210.00)for an amended total financial obligation of the State of
ONE MILLION FOUR HUNDRED TWENTY-NINE THOUSAND,THREE HUNDRED
SEVENTY DOLLARS,($1,429,370.00). Of this increased amount for the Continuation
Services, Two Hundred Seventy-Eight Thousand, Two Hundred Ten Dollars ($278,210.00)
are identified as attributable to a funding source of the state of Colorado. Expenditures for the
Continuation Services shall be in accordance with those items identified in "Attachment I"of this
Amendment.
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D. In consideration for the Contractor's timely and satisfactory completion of the Expansion Services
for the renewal term of July 1, 2004 through June 30, 2005,the"not to exceed amount"identified
in Part 3. C. above is hereby increased by One Hundred Forty-Eight Thousand, Eight Hundred
Ninety-Nine Dollars($148,899.00)for an amended total financial obligation of the State of ONE
MILLION FIVE HUNDRED SEVENTY-EIGHT THOUSAND, TWO HUNDRED SIXTY-
NINE DOLLARS AND SEVEN CENTS,($1,578,269.07). Of the increased amount for the
Expansion Services, One Hundred Forty-Eight Thousand,Eight Hundred Ninety-Nine
Dollars($148,899.00)are identified as attributable to a funding source of the state of Colorado.
Expenditures for the Expansion Services shall be in accordance with those items identified in
"Attachment J" of this Amendment.
4. The effective date of this Amendment is July 1,2004,or upon approval of the State Controller,whichever
is later
5. Except for the General Provisions and Special Provisions of the Original Task Order, in the event of any
conflict,inconsistency,variance,or contradiction between the terms and provisions of this Amendment and
any of the terms and provisions of the Original Task Order,the terms and provisions of this Amendment
shall in all respects supersede,govern, and control. The Special Provisions shall always control over other
provisions of the Original Task Order or any subsequent amendments thereto. The representations in the
Special Provisions to the Original Task Order concerning the absence of bribery or corrupt influences and
personal interest of State employees are presently reaffirmed.
6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR
ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED,
AND OTHERWISE MADE AVAILABLE.
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IN WITNESS WHEREOF,the parties hereto have executed this Amendment on 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)
By: `-•-4` % By:
Name: Robert D. Masden or t e Ex utive Director
Title: Chair 05/26 iv � DEPART ENT OF PUBLIC HEALTH
FEIN: 84-6000813 j`: la ; % AND ENVIRONMENT
wAz
, / 0�1
(Se AT ST: ;;� r I GRAM APPROVAL:
VNC N
By: �Y, �y .� •,S !� , By: o
con ty, Cala J
COMMEEDDSOCIDEXCa Deputy Clerk to the Board
LEGAL REVIEW:
OFFICE OF THE ATTORNEY GENERAL
WELD COUNTY DEPARTMENT OF Ken Salazar,Attorney General
PUBLIC HCM-y ;NV�'R/pjN/b�ENT
BY: MVO�tJC��
Mark E. Wallace, MD, MPH•Director By:
Date:
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 goods and/or services provided.
STATE CONTROLLER
Arthur L.Barnhart
1
By: yr
Date: 1/4,5479
Page 6 of 6
Attachment A
Department or Agency Name
COLORADO DEPARTMENT OF PUBLIC
HEALTH AND ENVIRONMENT
Department or Agency Number
FAA
Contract Routing Number
01-00942
TASK ORDER
This TASK ORDER is made this 29TH day of DECEMBER,20O0 by and between:the State of Colorado,for the
use and benefit of 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 17'"Avenue,Greeley, Colorado
80631,hereinafter referred to as"the Contractor".
FACTUAL RECITALS
Section 29-1-201,8 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. All
State contracts with its political subdivisions are exempt from the state of Colorado' State's personnel rules under
section 24-50-101 et seq.,and the State procurement code under section 24-101-101,et seq.,C.R.S.,as amended.
The State has formulated a comprehensive State plan,with associated budgets,relative to the State's programs and
services which allocates funds to local health agencies in order to provide certain purchased services to the people
of the state of Colorado. This funding is to be allocated through task orders with local health agencies.
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 sue, 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(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)
Pursuant to section 25-31-106,C.R.S.,as amended,the Contractor has submitted a grant application which has been
reviewed the University of Colorado Health Sciences Center in accordance with sections 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
Finally,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 Number 13M,Organizational Unit Code 6250,Appropriation Code 593,under Master Contract
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Routing Number 00-FAA 00008. All required approvals,clearances,and coordination have been accomplished
from and with all appropriate agencies.
NOW THEREFORE,in consideration of their mutual promises to each other, stated below,the parties hereto
agree as follows:
A. PERIOD OF PERFORMANCE. In accordance with section 24-30-202(1), C.R.S., as amended,the
effective date of this Task Order is the date the State Controller approves this Task Order. The initial term
of this Task Order shall commence on the effective date of this Task Order and continue through and
including June 30,2001 unless sooner terminated by the parties pursuant to the terms and conditions of
this Task Order and the Master Contract. The Contractor may only commence performance under this
Task Order as of its effective date. The State shall have no fmancial obligation to the Contractor for any
work or services or,any costs or expenses, incurred by Contractor prior to the effective date of this Task
Order. The total term of this Task Order, including any renewals or extensions hereof,may not exceed five
(5)years.
B. DUTIES AND OBLIGATIONS OF THE CONTRACTOR. The Contractor, in accordance with the
terms and conditions of the Master Contract and this Task Order, shall perform and complete in a timely
and satisfactory manner all work in accordance with the following:
1. This Contract is governed by those rules which were adopted by the state Board of Health
pursuant to section 25-31-104,C.R.S.,as amended. Those rules,as amended,are incorporated
herein by reference,made a part hereof,and attached hereto as "Attachment A".
2. 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. The Contractor shall coordinate its efforts with the State's Program Manager,
the State's Program Nursing Consultant and the National Center for Children,Families and
Communities(National Center). The Contractor shall provide these services in accordance with
the terms and conditions contained in the Colorado Nurse Home Visitor Act Grant Application
Materials,which are incorporated herein by this reference,made a part hereof,and attached hereto
as"Attachment B", and the Contractor's grant application,which is incorporated herein by this
reference,made a part hereof,and attached hereto as "Attachment C".
C. DUTIES AND OBLIGATIONS OF THE STATE. The State,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 in accordance with the following:
I. Compensation. In consideration of those services timely and satisfactorily performed by the
Contractor under this Task Order,the State shall cause to be paid to the Contractor an amount not
to exceed ONE HUNDRED SEVENTY FIVE THOUSAND EIGHT HUNDRED THIRTY
ONE DOLLARS,($175,831.00)for the initial term of this Task Order. Of this total financial
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obligation of the State to the Contractor under this Task Order,$0.00 are identified as attributable
to a funding source of the United States and$175,831.00 are identified as attributable to a funding
source of the state of Colorado. Payments under this Task Order are subject to verification by the
State that the Contractor has fully and satisfactorily complied with the terms and conditions of this
Task Order. The Contractor shall maintain original documentation for all costs related to the
Contractor's performance under this Task Order for a period of six(6)years following the date of
termination of this Task Order.
2. Payment Mechanism. The Contractor may only request reimbursement from the State in
accordance with the categories and line items of the budget,which is incorporated herein by this
reference,made a part hereof, and attached hereto as "Attachment D". These expense items may
include,but are not limited to:the Contractor's salaries,fringe benefits,supplies,travel,operating,
and indirect costs which are allowable and allocable expenses related to its performance under this
Task Order.
To receive compensation under this Task Order,the Contractor shall submit a signed,monthly
billing statement, submitted in duplicate. A sample billing statement is incorporated herein by this
reference,made a part hereof,and attached hereto as "Attachment E". Billing statements shall:
reference this Task Order by its Task Order routing number,and Master Contract routing number,
which number is located on page one of this document;state the applicable performance dates,the
names of payees;a brief description of the services performed during the relevant performance
dates;expenditures incurred; and,the total reimbursement requested. Reimbursement 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. Billing statements shall be sent to:
Colorado Department of Public Health and Environment
Attn: Lee Joseph,Fiscal Officer-PISCY-A4
4300 Cherry Creek Drive South
Denver CO 80246-1530
D. ADDITIONAL PROVISIONS.
Change Order Letter Process. The State may prospectively increase or decrease the amount
payable under this Task Order through a"Task Order Change Order Letter". A sample Task
Order Change Order Letter is incorporated herein by this reference,made a part hereof,and
attached hereto as"Attachment F". To be effective,the 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,the Task Order Change Order Letter shall include the following
information:
A. Identification of the related Master Contract by its contract routing number and this Task
Order by its contract number,and the affected Task Order paragraph number(s);
B. The type(s)of service(s)or program(s)increased or decreased and the new level of each
service or program;
C. The amount of the increase or decrease in the level of funding for each service or
program and the new total financial obligation;
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D. The intended effective date of the funding change;and,
E. A provision stating that the Task Order Change Order Letter shall not be valid until
approved by the State Controller or such assistant as he may designate.
Increases or decreases in the level of contractual funding made through this task order change
order letter process during the initial or renewal terms of this Task Order may be made under the
following circumstances:
F. If necessary to fully utilize appropriations of the state of Colorado and/or non-
appropriated federal grant awards;
G. Adjustments to reflect current year expenditures;
H. 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
this Task Order;
I. Closure of programs and/or termination of related contracts or task orders;
J. Delay or difficulty in implementing new programs or services;and,
K. Other special circumstances as deemed appropriate by the State.
Upon proper execution and approval,the Task Order Change Order Letter shall become an
amendment to this Task Order. Except for the General and Special Provisions of the Master
Contract,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 renewal 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 the proposed change,then the Contractor shall execute and
return the Task Order Change Order Letter to the State by the date indicated in the Task Order
Change Order Letter. If the Contractor does not agree to and accept the proposed change,or fails
to timely return the partially executed Task Order Change Order Letter by the date indicated in the
Task Order Change Order Letter,then the State may,upon written notice to the Contractor,
terminate this Task Order twenty(20)calendar days after the return date indicated in the Task
Order Change Order Letter has passed. The written notice shall specify the effective date of
termination of this Task Order. In the event of termination under this clause,the parties shall not
be relieved of their respective duties and obligations under this Task Order until the effective date
of termination has occurred.
2. The State may renew this Task Order through a"Task Order Renewal Letter",a sample of which
is incorporated herein by this reference,made a part hereof,and attached hereto as"Attachment
G". To be effective,the Task Order Renewal Letter must be: signed by the State and the
Contractor;and,approved by the State Controller or an authorized designee thereof. Additionally,
the Task Order Renewal Letter shall include the following information:
A. Identification of this Task Order by its contract routing number and affected paragraph
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number(s);
B. The type(s)of service(s)or program(s), if any,increased or decreased and the new level
of each service or program for the renewal term;
C. The amount of the increase or decrease, if any, in the level of funding for each service or
program and the new total financial obligation;
D. The intended effective date of the renewal;and,
E. A provision stating that the Task Order Renewal Letter shall not be valid until approved
by the State Controller or such assistant as he may designate.
Upon proper execution and approval,the Task Order Renewal Letter shall become an amendment
to this Task Order. Except for the General and Special Provisions of the Master Contract,the
Task Order Renewal 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 renewal letter
process may be used only to: renew this 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 this Task Order,other than those authorized by
the task order change order letter process described above, 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 the proposed renewal term,then the Contractor shall
execute and return the Task Order Renewal Letter to the State by the date indicated in the Task
Order Renewal Letter. If the Contractor does not agree to and accept the proposed renewal term,
or fails to timely return the partially executed Task Order Renewal Letter by the date indicated in
the Task Order Renewal Letter,then the State may,upon written notice to the Contractor,
terminate this Task Order twenty(20)calendar days after the return date indicated in the Task
Order Renewal Letter has passed. This written notice shall specify the effective date of
termination of this Task Order. If the Task Order is terminated under this clause,then the parties
shall not be relieved of their respective duties and obligations under this Task Order until the
effective date of termination has passed.
E. ATTACHMENTS. All attachments to this Task Order are incorporated herein by this reference and made
a part hereof as if fully set forth herein. In the event of any conflict or inconsistency between the terms and
conditions of this Task Order and those of any attachment hereto,the terms and conditions of this Task
Order shall control.
Page 5 of 6
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
For the use and benefit of the
WELD COUNTY DEPARTMENT OF
PUBLIC HEALTH AND ENVIRONMENT
(a political subdivision of the state of Colorado)
By: 2% C.
. i e BY: V
Fo e Executiv i ector
Chair (01/08/2001) Colorado Department
FEIN: 84-6000813 Public Health and Environment
If Corporation,Town/City/County,or Equivalent: PROGRAM APPROVAL:
L B
6 '1By: i III �rr �N C ��..
7CJi>3E�IdL13EvfiLS.. .: r ? � �7,`t�„u',J3
Deputy Clerk to lsF, ,� •#
APPROVALS:
COLORADO DEPARTMENT OF LAW COLORADO DEPARTMENT OF PERSONNEL
OFFICE OF Tilt A RNEY GENERAL OFFICE OF THE STATE CONTROLLER
Ken Salazar,Attor y eneral Arthur L.Barnhart,State Controller
By: By: J CL c s
WELD COUNTY DEPARTMENT OF
PUBLIC HEALTH AND ENVIRONMENT
BY: d Page 6 of 6
Mark E. Wallace, MD, MPH•Direct() B
ATTACHMENT A
Rules Concerning the 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(1)(a), C.R.S., as
one whose accreditation may be accepted in lieu of board approval(12) "Nurse Home Visitor Program"or"Program"means a program that is described
in §25-31-104(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.
(I) 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(I);
(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 costs include but
are not limited to, travel costs and training materials;
(C) Costs to purchase and maintain the management
information system and related technical assistance;
(I)) Operating costs, including but not limited to, office and
program supplies, postage, telephones, computer(s) with
intemet access, liability insurance, medical supplies,
2
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 gram;
(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§1.2 (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;
3
(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§1.2 (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§1.2(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;
(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 describing the implementing entity's strategy to recruit and
train sufficient qualified nurses to implement and expand the
program; and
4
(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
(1) 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 close 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.
1.5 Awarding of Program Grants.
(I) The board shall award grants to the selected entities specifying the amount of the
grant.
(2) The grant awards may, at a minimum, include monies to fund:
5
(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 costs 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;
(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:
(1) 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 protocols shall, at a minimum, address:
6
(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 and 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. 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 shall, at a minimum, have the following staff:
7
(a) Four full time equivalent("FTE„)nurses;
(b) One half FIE 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.
1.8 Eligibility of Clients.
(I) 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 §I.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 I, 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;
8
(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.
(3) 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
9
member, the person shall publicly disclose 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 §1.8, except as provided in §I.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.
to
I ATTACHMENT B
•
COLORADO NURSE HOME VISITOR ACT
GRANT APPLICATION MATERIALS
Issued October, 2000
APPLICANTS MAY APPLY FOR FUNDS FOR A PROGRAM WHICH
PROVIDES SERVICES TO LOW-INCOME, FIRST-TIME MOTHERS
THROUGH HOME VISITS BY NURSES AS EITHER:
CATEGORY A APPLICANTS: A NURSE HOME "VISITOR"
PROGRAM, which means a program that provides home visits by nurses to
low-income, first-time mothers which utilizes the program training
requirements, program protocols, program management information
systems, and program evaluation requirements established by rule of the
state board of health.
CATEGORY B APPLICANTS: A NURSE HOME "VISITATION"
PROGRAM, which means a program that provides home visits by nurses to
low-income first-time mothers but does not utilize the program training
requirements, program protocols, program management information
systems, and program evaluation requirements established by rule of the
state board of health and which can show that the program:
1. Has been in operation in the state as of July 1, 1999 for a
minimum of five years; and
2. Has achieved a significant reduction in each of the following:
A. Infant behavioral impairments due to use of alcohol and
other drugs, including nicotine;
B. The number of reported incidents of child abuse and
neglect among families receiving services;
C. The number of subsequent pregnancies by mothers
receiving services;
D. The receipt of public assistance by mothers receiving
services; and
E. Criminal activity engaged in by mothers receiving
services and their children.
ENCLOSURES:
I. A description of the Background, Overview and Goals of the Colorado
Nurse Home Visitor Act
II. Definitions
III. A description of Eligible Applicants
IV. The Statement of Work for Nurse Home "Visitor" Program Applicants and
for the Nurse Home "Visitation" Program Applicants
V. Instructions for Grant Application Narrative for Nurse Home "Visitor"
Program Applicants and for Nurse Home "Visitation" Program Applicants
VI. Grant Narrative
ATTACHMENTS:
Attachment A Rules Concerning the Nurse Home Visitor Program
Attachment B Cover Sheet to Accompany Grant Application
Attachment C Assurance Sheet for Nurse Home "Visitor" Program
Applicants (Category A Applicants)
Attachment D Sample Budget Request Form
Attachment E Sample Site Budget for Category A Applicants
Attachment F Program Clinical Management Information System
Materials
Attachment G Provisions of Contracting with the State
Attachment H Time Line and Checklist for the Submission and Review
of the Grant Applications
DEADLINE: Completed applications are due by 3:00 P.M., Wednesday,
November 1, 2000. Please submit 5 copies to:
Jan Reimer, NHVP Program Coordinator
FCHSD - A4
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver, CO 80246-1530
Late applications or those sent by fax or e-mail will not be considered.
Completed applications which are received by the Colorado Department of
Public Health and Environment after 3:00 P.M. on Wednesday, November
1, 2000 will non be accepted.
Completed applications which are sent by facsimile of electronic
transmission will not be accepted.
Completed applications which are postmarked on or before November 1,
2000, but not received by the Colorado Department of Public Health and
Environment until after 3:00 P.M. on November 1, 2000, will not be
accepted.
GRANT APPLICATION
THE NURSE HOME VISITOR PROGRAM
Colorado Department of Public Health and Environment (CDPHE)
BACKGROUND OVERVIEW AND GOALS
A. The Colorado Department of Public Health and Environment
(CDPHE) is administering the Nurse Home Visitor Program
(NHVP), as provided for in the Nurse Home Visitor Program Act,
section 25-31-101, et.seq., C.R.S., as amended, (the "Act"), which is
funded-through the state's Master Tobacco Settlement Agreement.
The NHVP, which provides educational, health and other resources
for new young mothers during pregnancy and the first years of their
infants' lives, has been proven to significantly reduce the amount of
drug, including nicotine and alcohol use and abuse by mothers, the
occurrence of criminal activity committed by mothers and their
children under fifteen years of age, and the number of substantiated
incidents of child abuse and neglect. Such a NHVP has also been
proven to reduce the number of subsequent births, increase the length
of time between subsequent births, and reduce a mother's need for
other forms of public assistance.
B. The overall goals of the NHVP are:
1. Improve pregnancy outcomes by helping women practice sound
health-related behaviors, including decreasing the use of
cigarettes, alcohol, and illegal drugs and by improving their
nutrition.
2. Improve child health and development by helping parents
provide more responsible and competent care for their children;
and
3. Improve the economic self-sufficiency of families by helping
parents develop a vision for their own future, continue their
education, and find jobs.
C. The NHVP is limited to low-income, first-time mothers, beginning
in pregnancy. Enrollment is restricted to women whose income is
at or below 200% of the federal poverty guidelines, and who have
not had any previous live births.
D. As required in the Act, the National Center for Children, Families
"Health Sciences Facility" by the President of the University of
Colorado. Under the Act, as the designated Health Sciences
Facility, the National Center is responsible for monitoring the
administration of the NHVP to ensure that the NHVP is
implemented according to the program training requirements,
program visit protocols, program clinical information systems, and
program evaluation requirements established by the Rules.
Consequently, successful applicants will be required to strictly
adhere to the visit protocols, procedures and data collection
requirements detailed in the Rules unless they apply and are
contracted with as an Other Nurse Home "Visitation" Program.
Each Nurse Home Visitor Program Applicant will be required to
enter into a contract with the organization that will provide the
required training, technical assistance and materials to such
Applicant.
II. DEFINITIONS
"Board" means the State Board of Health
"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.
"Department" means the Department of Public Health and Environment.
"Entity" means any nonprofit, not-for-profit, or for-profit corporation,
religious or charitable organization, institution or 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.
"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.
2
"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.
"Low-income" means an annual income that does not exceed two
hundred percent of the federal poverty level.
"New Entity" means any entity that has not previously received funding
for the program pursuant to these rules.
"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(1)(a), C.R.S., as one whose accreditation may be accepted
in lieu of board approval.
"Nurse Home Visitor Program" or "Program" means a program
established pursuant to §25-31-101, C.R.S. et seq. and meets the
requirements of these rules.
"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.
"Other 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 as an exception program as defined in §25-31-
104(4), C.R.S. and section 1.10 of these rules.
"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.
III.ELIGIBLE APPLICANTS
Any entity or combinations of entities located in the state of Colorado are
eligible to apply. Applicants must strictly adhere to all applicable federal
and state laws, rules and regulations that have been or may hereafter be
established.
3
IV.STATEMENT OF WORK for Nurse Home "Visitor" Programs (Category A
Applicants) and for Other Nurse Home "Visitation" Programs (Category B
Applicants)
A. Overview of NHVP. (Applies to both categories.) The NHVP is a
voluntary program in which nurses visit the homes of low-income,
first-time mothers starting during pregnancy and continuing through
the child's second birthday. Visits take place on a weekly or bi-
weekly basis and cover topics like: improving pregnancy outcomes
through better health care, improving parenting skills, and
empowering mothers to take charge of their own lives. Nurses shall
use comprehensive visit protocols to assist them in counseling their
clients.
B. Eligibility of Clients. (Applies to both categories.) The Applicant
shall enroll only low-income women who have had no previous live
births. Enrollment preference is given to women enrolled prior to the
28th week of pregnancy, but mothers and their babies may be enrolled
up to the end of the first month of the baby's life.
C. Number of Clients. (Applies to both categories.) Each Applicant shall
be expected to provide services to a minimum of one-hundred, low-
income, first-time mothers in the community, except when waivers
are granted by the State Board, because the population base of the
community does not have the capacity to enroll one-hundred eligible
women.
D. Caseloads. (Applies to both categories.) Each nurse will carry a
caseload of no more than 25 families at one time.
E. Staffing Requirements. (Applies to both categories.) Every one
hundred families will be served by at least 4 FTE Nurses, '/: FTE
Nurse Supervisor, and a ''/2 FTE data entry clerk/office support person.
The Applicant shall use its best efforts to hire nurses with flexible
work hours and who are bilingual, where necessary.
F. Training. (Applies only to Category A Applicants.) Nurses shall
attend the trainings required by the National Center or any other
trainings that meet the requirements of Section 1.6(1) of the Rules
Concerning a Nurse Home Visitor Program. (Please see Attachment
A.)
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G. Program Guidelines. (Applies only to Category A Applicants.)
Nurses shall use home visit guidelines produced by the National
Center or any other guidelines that meet or exceed the requirements
detailed in Section 1.6(2) of the Rules.
H. Program Clinical Management Information System. (Applies only to
Category A Applicants.) Applicants shall use a clinical information
system that is required by the National Center, or any other clinical
information system which complies with the requirements in Section
1.6(3) of the Rules.
I. Program Evaluation and Reporting.
1. Data. (Applies only to Category A Applicants.) Applicants shall
submit data required by the clinical information system to the
National Center on a monthly basis.
2. Program Reports. (Applies to both Category A and B Applicants.)
No later than 60 days after the end of each fiscal year for which
funding was received from the Nurse Home Visitor Fund, each
Applicant shall submit an annual report to both the National
Center, the CDPHE and the community in which the Applicant
runs the NHVP that reports on the effectiveness of the NHVP
within the community. The annual report shall be written in a
manner that is understandable for both the National Center and the
members of the community. Such report shall include, at a
minimum, the following information:
(a) The amount of moneys received by the Applicant for the
preceding fiscal year;
(b) A description of the program, including 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.
J. Record Keeping. (Applies to both Categories.) Each Applicant must
retain any direct pertinent documents, papers and bookkeeping
records involving transactions related to the Contract. These records
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shall be maintained for a period of three years after the end of each
Contract period and shall be made available to the State or its auditors
upon request.
K. Billing. (Applies to both Categories.) Contracts shall be on a cost-
based reimbursement system. Applicants will be required to submit
detailed monthly or quarterly billings (at their discretion) with a brief
description stating their prior month's or quarter's expenditures. This
should include the match according to the categories of the line item
budget as approved and attached to the Contract. CDPHE shall
provide a standard billing form to all Applicants.
L. Budgets for Subsequent Years. (Applies to both Categories.) Budgets
for fiscal years two and three shall be submitted to the CDPHE no less
than 90 days prior to the end of the current year, and shall be
approved upon renewal of Applicant's Contract.
V. INSTRUCTIONS FOR GRANT APPLICATION:
A. All applicants should begin their application with a Cover Page,
following the Sample Cover Page Format found as Attachment B.
B. Applicants must specify how the NHVP will be implemented in their
communities. The following topics should be included:
1. Assurance of Intention to Meet the Requirements for Nurse Home
"Visitor" Programs (Applies to Category A Applicants only.)
2. Qualifying Information for Other Nurse Home "Visitation"
Programs (Applies to Category B Applicants only.)
3. Needs of Population Served (Applies to Both Categories.)
4. Capability of Applicant (Applies to Both Category A and Category
B Applicants.)
a) Organizational structure and commitment
b) Broad Based Community Support
c) Referral Sources
d) Referral Linkages
e) Coordination with Existing Visitation Programs
5. Recruitment and Retention of Nurses (Applies to Both.)
6. Clinical Management Information System (Applies to Category A
Applicants only.)
7. Collaborative Implementation (Applies to Both Categories.)
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8. Request for Waiver (Applies to Both Categories, if needed.)
9. Geographical Placement (Applies to Both Categories.)
10. Budget and Budget Narrative (Applies to Both Categories.)
VI.GRANT NARRATIVE:
A. Please provide information for each of the topics as described in the
following instructions, completing the appropriate sections for
Category A or Category B Applicants, as indicated.
1. Assurance of Intention to Meet Program Requirements for Nurse
Home "Visitor" Programs (Category A Applicants only.) Please
complete the Assurance Form which is found as Attachment C,
assuring that the Applicant will meet the Program Requirements
for Training, Visit Protocols, Program Clinical Management
Information System, and Reporting and Evaluation Systems found
in Section 1.6 of the Rules Concerning the Nurse Home Visitor
Program, which is Attachment A.
2. Qualifying Information for Other Nurse Home "Visitation"
Programs (Category B Applicants Only.)
(a) Provide information which establishes that the applicant's
nurse home visitation program has:
(1.) Been in operation in the state for a minimum of five years,
prior to July 1, 1999, and
(2.) Achieved a significant reduction in each of the following:
(aa) Infant behavioral impairments due to use of alcohol and
other drugs, including nicotine;
(bb) The number of reported incidents of child abuse and
neglect among families receiving services;
(cc) The number of subsequent pregnancies by mothers
receiving services;
(dd) The receipt of public assistance by mothers receiving
services; and
(ee) Criminal activity engaged in by mothers receiving
services and their children.
(b) Describe the reporting and evaluation system that the Nurse
Home Visitation Program will use to submit an annual report
to the Department, no later than sixty days after the end of the
contract period, providing the following information:
(1.) The amount of tobacco settlement moneys received by the
program for the preceding fiscal year;
(2.) 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
(3.) An evaluation of the operation of the program, which
includes the effectiveness of the program in achieving its
stated goals.
3. Needs of Population Served(10 points possible) (Applies to both
Categories A and B.
Describe in detail the specific needs of the population to be served
(including socio-demographic and health characteristics that justify
the need for the NHVP, including the number of first-time, low-
income mothers eligible for the NHVP). Include an estimate of the
number of families that the Applicant will serve who are Medicaid
eligible. (No points will be assigned based on the estimated
Medicaid population eligible to be served. Because there is a
possibility that this will become a Medicaid reimbursable service,
the information is needed for planning purposes only.)
4. Capability of Applicant(Applies to both Categories A and B.)
(a) Organizational Structure and commitment. (15 Points
Possible)
(1) Describe the level of commitment to implement the
NHVP through the administrative levels of the
Applicant' organization. Describe where in the
Applicant's organization the NHVP will be placed and
how that will or will not logically support its
development and management. Applicant shall include
an organizational chart displaying the location of the
NHVP in relationship to existing programs.
s
(2) Describe the history and experience of the Applicant in
providing maternal and child health and related services.
(3) Describe the Applicant's experience with home visiting
as a service delivery strategy.
(4) Summarize the major strengths of the Applicant and the
community that will lead to successful implementation of
the NHVP at this site.
(b) Broad Based Community Support (10 Points Possible)
(Applies to both Categories A and B.)
(1) Describe the breadth of community support for the NHVP
itself and for the Applicant as the lead organization in its
implementation. Include detailed information about the
people and organizations that make up the community
coalition that is supporting the NHVP's implementation.
Breadth of community support shall be judged by the
diversity and depth of involvement of those involved in the
coalition supporting the NHVP's implementation.
(c) Referral Sources (10 points possible) (Applies to both
Categories A and B.)
(1) Describe the Applicant's relationship with the schools,
prenatal clinics, health care providers, social services, or
other referral sources for the Low-income, first-time
mothers that will be served by the NHVP. Describe the
nature of those relationships including how long the
relationships have been in place, how formal they are, and
prior referral links already established from each
relationship. Evidence these referral sources with letters of
support specifically describing how the possible referral
source will work with the Applicant in recruiting NHVP
participants. Explain Applicant's plan for recruiting at
least one-hundred participants.
(d) Referral Linkages (5 points possible) (Applies to both
Categories A and B.)
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(1) Describe the referral linkages that exist between the lead
implementing organization and other service providers
such as workforce preparation, job training, legal, housing
organizations, health care, mental health, and childcare.
Describe the nature of those relationships including how
long a relationship has been in place, how formal it is, and
the degree to which staff within the
(2) Applicant organizations have historically used the services
of the linked providers described. Evidence these referral
linkages with letters of support of specifically describing
how the possible referral linkages will work with the
Applicant in providing support services to clients enrolled
in the NHVP.
(e) Coordination with Existing Visitation Programs (10 points
possible) (Applies to both Categories A and B.)
(1) Describe the Applicant's coordination with other existing
home visitation programs serving young families.
Describe how the NHVP will fit in with and complement
the community's current efforts to meet the needs of the
target population. Include the specific coordination plan
agreed to by all Entities implementing home visiting
services for young families, including any other Entities
already delivering the NHVP.
5. Recruitment and Retention of Nurses (10 points possible) (Applies
to both Categories A and B.)
Describe the Applicant's plan for hiring and retaining the staff
necessary to implement the NHVP. Include:
(a) A recruitment plan to hire a half-time Master's prepared
clinical nurse supervisor, a team of four Bachelor's prepared
Registered Nurses to staff the NHVP, and a half time data
entry clerk. Explain whether or not Applicant anticipates
having to overcome a nursing shortage in Applicant's
community. If a Master's prepared clinical nurse supervisor is
not to be hired, demonstrate that such a person is either
unavailable within the community or an appropriately
to
qualified nurse without a master's degree is available.
Describe plans for recruiting bilingual nurses where
necessary.
(b) Describe where the Nurses will be housed.
(c) Describe plans for promoting a stable operating environment
for the NHVP and preventing staff turnover.
6. Management Information System (5 Points Possible) (Applies to
Category A Applicants only.)
Describe the Applicant's capacity to keep records in a
computerized clinical information system on participating families
and their needs, services provided, progress, and outcomes.
Describe what steps would need to be taken by Applicant to make
its current computer system compatible with the requirements
listed on Attachment D. Describe what quality assurance activities
are planned to monitor the implementation of the NHVP.
7. Collaborative Implementation (10 Points Possible) (Applies to
both Categories A and B.)
Describe Applicant's plan, if any, to work collaboratively with
other Entities in either administering the NHVP directly or through
an advisory or oversight board. If the collaboration will be in
administering the NHVP, please describe the responsibilities of
each Entity, and who will have final decision-making authority
when issues arise. Please detail whether the other Entities are
counties, municipalities, agencies or organizations. Describe how
the Applicant will assure effective collaboration/oversight.
8. Request for Waiver (No Points) (Applies to Both.)
If Applicant plans to seek a waiver from the State Board from the
requirement that it serve at least one hundred, Low-income, first-
time mothers, describe the need for such waiver.
9. Geographical Placement of Applicant — (Applies to Both) (Up to
two Additional Points)
it
Up to two additional points will be awarded to Applicants that are
geographically placed in an area of the State that will advance
implementation of the NHVP in communities throughout the State.
10. Budget and Budget Justification (15 Points Possible) (Applies to
both categories.)
(a) Budget pages: Provide a budget for fiscal year 1 (January 1,
2001 through June 30 2001) for the implementation of the
NHVP. The Budget Request Form found as Attachment D
may be used or the applicant may use another spreadsheet
format that provides all the requested information. The costs
of trainings, including the travel to trainings and the materials
for the trainings should be listed under the travel section.
Category A Applicants should refer to the Sample Budget
(Attachment E) for estimated costs of many of the requested
line items.
(b) 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 you arrived at the amounts. Include the descriptive
justification for the following:
(1) Personnel Costs: Salaries and fringe benefits for the
staff.
(2) Direct Costs/Operating Expenses: Office and program
supplies, postage, telephones, liability insurance, and
medical supplies.
(3) Direct Costs/ Travel: Travel costs in the course of
carrying out the work of the program should be included.
Category A 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, as well
as the travel costs for each of the Nurses and Nurse
Supervisor to attend such trainings.
(4) Direct Costs/Equipment: Funding for equipment,
including computers with Internet access and the clinical
12
management information system and related technical
assistance.
(5) Indirect costs are permitted in the budget but shall be
capped at 20% of the entire budget or 22% of salary and
fringe benefits, depending on which method has been
previously approved and utilized by Applicant.
(6) Contributions from other funding sources, including in-
kind contributions, waivers of indirect costs (in part or in
total), contributions from other local agencies or
organizations.
(7) If Applicant currently operates the NHVP using funding
other than from the Nurse Home Visitor Fund, Applicant
shall:
(a) State whether Applicant expects to continue to
receive funding from such alternative-funding
source.
(b) State whether the funds received pursuant to this RFP
will be used to increase the number of clients served
or merely to replace that funding.
(8) Additional Points: (Up to 5 additional points) Additional
points will be awarded to Applicants that provide some
community financial contribution, either through partial
(or total) waiver of indirect costs, or through other
community funding which shall supplement CDPHE
funding, because such contributions evidence the
community's commitment to implementation of the
NHVP. Include a letter of support from each financially
contributing organization that details its level of
commitment.
(9) Narrative should also address:
a) the sustainability of any other funding sources; and
b) (for Category A Applicants only) unique
circumstances that cause any budget items in
13
Applicant's Proposal to deviate from the model site
budget attached hereto as Attachment A.
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Rules Concerning the Nurse Home Visitor Program
1.1 Definitions.
"Board"means the State Board of Health
(2) "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.
(3) "Department"means the Department of Public Health and Environment.
(4) "Entity"means any nonprofit, not-for-profit, or for-profit corporation, religious or
charitable organization, institution err-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.
(5) "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.
(6) "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.
(7) "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.
(8) "Low-income"means an annual income that does not exceed two hundred percent
of the federal poverty level.
(9) "New Entity"means any entity that has not previously received funding for the
program pursuant to these rules.
(10) "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(1)(a),C.R.S., as
one whose accreditation may be accepted in lieu of board approval.
(11) "Nurse Home Visitor Program"or"Program"means a program established
pursuant to §25-31-101, C.R.S. et seq. and meets therequirements of these rules.
(12) "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 conununity or an appropriately qualified nurse without a
master's degree is available.
(13) "Other 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 as an exception program as defined in§25-31-104(4), C.R.S. and
1
section 1.10 of these rules.
(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(4) 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 costs include but are not
limited to,travel costs and training materials;
(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§1.2 (a)
of these rules, applications for new entities shall contain, at a minimum,
2
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 membership of the
community coalition that is supporting the program's
implementation. Breadth of community support shall be judged by
the diversity of those involved in the coalition 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 referral
sources, including, but not limited to, schools, prenatal clinics,
providers of social services, mental health services, workforce
preparation services,job training services, legal services,health
care services and child care services, for the first-time, low-income
mothers who will be served by the program with specific
information about the duration of these relationships;
(v) Except as provided in §1.9, a description of a plan for recruiting at
least one hundred first-time, low- income mothers;
(vi) 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;
(vii) A plan for hiring and retaining qualified staff that represents the
community's racial and cultural diversity;
(viii) A description of the applicant's capacity to comply with and
monitor the implementation of the grant requirements;
(ix) Summary of the major strengths of the applicant and the
community that will lead to successful implementation of the
program; and
(x) 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.
3
(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§1.2 (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§1.2(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;
(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 describing 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.
(a) Grant applications may be solicited up to two times each fiscal year.
(b) For fiscal year 2000-01, grant applications shall be due on November 1,
2000,unless the department authorizes an extension.
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.
4
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, bipartisan community support for the implementing entity;
(b) Existence of a sufficient number of eligible women to support multiple
implementing entities;
(c) Existence of close 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.
1.5 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, include 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 costs 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
5
•
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;
(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 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 protocols shall, at a minimum, address:
(i) the physical and emotional health of the mother and the baby;
(ii) the environmental health issues such as ensuring a safe
environment for the child;
(iii) the life course development for the mother, including employment,
budgeting and financial planning, transportation and housing;
(iv) the parental role and 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
6
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 provide a
quarterly report to the entity evaluating the program's implementation, and
on an appropriate(semi-annual)periodic basis shall also provide reports
on benchmarks of program outcomes.
(c) The implementing entity shall submit an annual report that complies with
the requirements in §1.1 Ito 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. 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 shall, 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 is 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.
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
7
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 Other Nurse Home Visitation Programs.
(1) A nurse home visitation program may qualify for funding under the nurse home
visitor program if the 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 other nurse home visitation program qualifying for funding under this section
shall be exempt from the requirements of§1.6 through §1.8 if it continues to
demonstrate significant reductions in the occurrences specified in §1.10(1) (b).
(3) Any other 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
8
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.
(3) 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 disclose 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 §1.8 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.
1.14 Effective Date. These emergency rules are effective September 30, 2000.
9
GRANT APPLICATION COVER SHEET FOR:
COLORADO NURSE HOME VISITOR PROGRAMS
(may be typed on this form or information may be computerized)
1. Name of applicant entity:
Address:
Name of person completing application:
Position/Title:
Telephone: FAX:
E-Mail:
2. Name of authorized signer:
Position/Title:
Telephone: FAX:
E-Mail:
Signature:
3. Grant proposal is for:
Nurse Home "Visitor" Program (Category A)
Other Nurse Home "Visitation" Program (Category B)
4. Grant amount for Jan. 1, 2001 through June 30, 2001: $
ASSURANCE OF INTENTION TO MEET
THE PROGRAM REQUIREMENTS
FOR NURSE HOME VISITOR PROGRAM
(CATEGORY A) APPLICANTS
Please assure that the applicant entity intends to meet the Program Requirements
for:
Training Requirements
Visit Protocols
Program Management Information systems
Reporting and Evaluating System
as described in Section 1.6 of the Rules Concerning the Nurse Home Visitor
Program (Attachment A) by signing this assurance page.
Name of Authorized Signer:
Signature of Authorized Signer:
Date:
APPLICANT:
PROJECT:
Detailed Budget Source ofof Fd_
For the Period
Annual Number % Total Applicant Requested
to Salary Months FTE Amount and from
Rate Budget Time Required Other CDPHE
DIRECT COST
Personal Services: $ $ $
ii
II
•
•
Contractual/Fee-for-service:
{,
Sub-Total
$ $ $
Supervising Personnel:
•
•
Sub-Total $ $ $
Fringe Benefits: (incl. rate or method) $ $ $
Total Personal Services $ $ $
(Page 2)
APPLICANT:
PROJECT: -
Source of Funds
Total Applicant Requested
Amount and from
Required Other CDPHE
DIRECT COST (Continued)
Operating Expenses: $ $ $
Sub-Total $ $ $
Travel:
Sub-Total $ $ $
• Equipment:
•
•
Sub-Total $ $ $
•
TOTAL DIRECT COST
BUDGET REQUEST
(Page 3)
APPLICANT:
"ROJECT:
Source of Funds
Total Applicant Requested
Amount and from
Required Other CDPHE
INDIRECT COST S S S
(Incl. Indir. Rate) Sub-Total S $ S
TOTAL PROJECT COST S
S S
*
* SOURCE OF FUNDING FOR THE MATCH, i.e. State, Local, in-kind, etc.
In-kind: S
Donated:
Other (Itemize) :
Total $
• May the non-Federal funds be used to match this grant? Yes _ No _
Signature of Director or Authorized Representative
Assumptions for Sample Site Budget for 100 Families
Please keep in mind that the Sample Budget is only a sample. Each site will
need to tailor its budget to fit its community's needs. Listed below are examples of
some of the line items that may need to be adjusted. This list is by no means
exhaustive, however, so please look at each line item to be sure it will meet your
community's needs. Keep in mind that the budget is based on a 100 family site served
by four full-time nurses, a half-time nurse supervisor and a half-time secretary.
1. Salaries —These line items will need to change to reflect the salaries your agency
is currently paying for similar work.
2. The Indirect Cost Line Item will depend on whether your organization receives its
indirect costs based on its salaries and benefits or its direct program costs. If
your organization uses the latter, this line item will not apply to you and you
must include a separate line item based on direct program costs (which should
be no more than 20% of those costs).
3. Cellular Phones and Fees— If you will have more than four nurses, you will need
to adjust these items.
4. Medical Supplies— If you are going to have nurses stationed in different areas of
your community (different agencies or counties), you might want to increase this
amount to cover an additional baby scale, for example, if the place the nurses
will be housed does not have one.
5. Mileage— If you are in a rural part of the state and the nurses will need to drive
long distances to meet their clients, you might want to increase the amount
listed.
6. Training and Materials — If you plan to have more than 4 nurses and the nurse
supervisor (e.g., if you are a rural site that is going to hire eight half-time nurses
instead of four full-time), you should budget in an additional $2,000 for each
nurse for training and an additional $315 per nurse for materials.
Note: These adjustments will change the amount required by the indirect rate of
the University of Colorado Health Sciences Center.
7. Travel —The costs associated with travel for 5 nurses (4 nurses and the nurse
supervisor) to go to Denver to attend trainings 1, 2 and 3 (for a total of 10 days
of training), are based on the following assumptions.
Year One (1/1/01-6/30/01) Assuming nurses will only attend Training 1 in year one
because it will be held in March, 2001
a. $100 per night for 5 nights in hotel X 5 nurses = $2,500 (assuming each
nurse has her own room)
b. $35 per diem for 5 days X 5 nurses = $875
c. 300 miles each way = 600 miles at .31 per mile and 2 cars (for 5 nurses)
= $372
d. Total for year one—Training 1 = $3,747 » $3,750
Year Two (7/1/01-6/30/02) Assuming nurses will attend Trainings 2 and 3 in year
two
a. $100 per night for 5 nights in hotel X 5 nurses = $2,500 (assuming each
has her own room)
b. $35 per diem for 5 days X 5 nurses = $875
c. 300 miles each way = 600 miles at .31 per mile and 2 cars (for 5 nurses)
and 2 round trips (one for each of Trainings 2 and 3) = $744
d. Total for year two—Trainings 2 and 3 = $4,119 >> $4,120
8. NCAST/PIPE Training Materials — For NCAST materials, add $170 per nurse for
each additional nurse and an additional $180 for every two additional nurses for
PIPE materials. Also add $220 for PIPE materials for each additional site where
one or more nurses will be housed if it is outside the lead agency.
NOTE: Office space is not included on the budget. If your site needs office space you
may include it in the budget. However, office space is often a good in-kind contribution
that can be made by the implementing agency, the county or others in the community.
Another option for this is waiver of part or all of the indirect costs the implementing
agency can receive. Because community contributions are important indicators of a
community's commitment to a program, 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 or in the narrative that will accompany it.
SAMPLE SITE BUDGET
BASED
ON 100 FAMILIES
Personnel Costs
(Estimate)
Base Fringe Total %Effort Year 1 ' Year 2 Year 3
Salary Benefits 1/1.6/30 7/1-6/30 7/1-6/30
Nurse Supervisor 47,000.00 12,220.00 59,220.00 50% 14,805.00 31,091.00 32,645.00
Nurse 1 36,500.00 9,490.00 45,990.00 100% 22,995.00 48,290.00 50,705.00
Nurse 2 36,500.00 9,490.00 45,990,00 100% 22,995.00 48,290.00 50,705.00
• Nurse 3 36,500.00 9,490.00 45990.00 100% 22,995.00 48,290.00 50,705.00
Nurse 4 36,500.00 9,490.00 45,990.00 100% 22,995.00 48,290.00 50,705.00
Secretary 21,486.00 5,586.00 27,072.00 50% 6,768.00 14,213.00 14,924.00
Sub-Total 113,553.00 238,484.00 250,389.00
(Personne
I)
Indirect Costs(22%of Salary and 24,981.66 52,462.08 55,085.58
Benefits)
Sub-Total 138,534.66 290,926.08 305,474.58
,(Personne
I and
Indirect
Costs)
Operational Costs
(should be adjusted to
reflect local differences)
Office Supplies 600.00 1,200.00 1,200.00
5100/mo
Program Supplies 6,750.00 7,250.00 500.00
$145/family
Copies—forms $1,500 per 750.00 1,500.00 1,500.00
year
Postage $50/mo 300.00 600.00 600.00
Telephone 600.00 1,200.00 1,200.00
$100/mo
Computer w/modem&MS Office $1850 1,850.00 0.00 0.00
Computer Network Fees $30/mo 180.00 360.00 360.00
4 Cellular Phones 600.00 0.00 0.00
$150/phon
e
Cellular Phone Usage Fees $75/mo •
C1,800.00 3,600.00 3,600.00
per Nurse
Liability Insurance 600.00 1.200.00 1,200.00
$100/mo
Medical Supplies $1,500 750.00 875.00 250.00
1st 12
months,
S250/yr
after
Other Staff Development $2,000 1,000.00 1,750.00 1,500.00
1st 12
months,
31,500/yr
after
Mileage 20 3,100.00 6,200.00 6,200.00
trlps/family
10ml
RT
.31/mi/yr
Sub-Total 18,880.00 25,735.00 18,110.00
(Operation
al)
Sub-Total 157,414.66 316,66t08 323,584.58
for
Personnel
Operation
al
Training and Technical
Assistance( Provided by
National Center for
Children Families and
Communities)
Clinical Training&Tech. 10,000.00
Assistance $2,000 per person
2-1/2-3 yrs.
NCCFC Materials(Cost includes 1.750.00
Perinatal,Infancy,and Toddler
Protocol)
Clinical Information System
Support
Purchase of System 1,000.00
Technical Assistance from 2,600.00 5,200.00 5,200.00
NCCFC
Sub-Total Tranining& 15,350.00 5,200.00 5,200.00
Technical Assistance
Indirect Costs"(26%of Training& 3,991.00 1,547.00 1,547.00
TA Costs)
Total Cost of Training& 19,341.00 6,747.00 6,747.00
Technical Assistance
Travel Costs
Travel From Sites to Trainings 1,2
&3-Mileage/HotelMeals
Wades with Site-Approximate 3,750.00 4,120.00
Cost$1,000 per trainee)
Total Costs of Travel 3,750.00 4,120.00
NCAST Training(Not payable to
NCCFC-Site arranges for this
training directly with NCAST)
Appx. 3,500.00
$2,500-
$3,500 per
site
NCAST and Pipe Training 1,775.00
Materials
TOTAL ANNUAL BUDGET - 185,780.66 327,528.08 330,331.58
`Only 6 months because the
State fiscal year ends on
6/30+A19
"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.
PECNHV Application-October
2000
National Center for Children, Families and Communities
School of Nursing
University of Colorado Health Sciences Center
Clinical Information System
Introduction
Sites selected to participate in our dissemination of the Prenatal and Early Childhood Nurse
Home Visitation Program are required to have program staff use the CIS which we have designed
for the model to keep track of characteristics of families enrolled in the program, their needs,
services provided,and families' progress on selected indicators of maternal and child functioning.
The current version of the CIS was introduced in January 2000.
Computer Requirements
The minimum hardware specifications needed for the Clinical Information System are:
Pentium II processor
24 mg of RAM
1 gigabyte hard drive
200 MHz
The software and other requirements are:
Microsoft Access 97(version 8.0)
Internet Connection
File Back up Plan utilizing either:
• Tape backup or zip drive for the workstation
• Network backup
Installation of CIS Software
Sites are encouraged to involve their local IS department to assist with establishing an Internet
connection and network backup procedures. Please have IS staff contact Gaye Van Buhler(303-
315-5220; vanbuhler.gay@tchden.org)for additional information.
The software will be sent to you after you have contacted Gaye Van Buhler and provided the
following information:
• The path to msaccess.exe.
• The path on the network where the tables will reside if the site is using the network backup
plan.
• Mailing address for the user manual and the installation CD.
The software will arrive on a CD and will be a standard software setup. Just click on Setup and follow
the steps. Everything is done automatically.
There are seven files to be installed:
I. Uphmvst.mde consists of all the forms, queries, macros, and reports.
2. UpgrdtbLmdb is where all the data and table designs are stored.
3. Nonames.mdb imports all the existing data and strips all personal identifiers of
clients, infants and nurser.It then creates the upsend.mdb file that is transferred
to Denver via email.
4. Upgrade.mdw which must be loaded in the Access files and contains all the
security
parameters for the system.
PECNNV Application-April, 2000 19
S. User.mdb creates a copy of the data so the user can manipulate the data, create
queries and reports to meet his/her specific needs.
6. Local.mdb which stores the location of the upgrdtbl.mdb
7. Stork.ico which is the icon on the shortcut icons on the desktop
Transition to Web-based CIS
A Web application of the CIS is under development. The current version of the Access
application will be distributed to new sites until the completion of the Web database application,
approximately August, 2000. After completion of the Web application,all new sites beginning
program operations will be trained to use the Web application for data entry(estimate that this
will begin with new sites scheduled for Training I in October, 2000). The only requirement for
new sites,at that point in time, will be an Internet connection with a standard browser(i.e.
Netscape, Internet Explorer etc.). Sites using the Web application for data entry, however,will be
able to download their own files to a local computer for linkage of data with other informational
systems operational at the site or conduct of local analyses. The downloading of data files
requires interface with some type of database software,e.g., Access, Excel. Sites may choose the
specific software they wish to use for this purpose,but it is our experience that those sites which
do not have support staff who are quite facile in use of spreadsheets and conducting data queries
will find Access the easiest for personnel to learn to use.
The first group of existing sites to be converted to the Web application for data entry will be those
new sites that attended the January 2000 Training I and thereafter who already are using the new
version of the recordkeeping forms and CIS software. The plan is to assist these sites to make
the transition to the Web application for data entry by the end of the year(e.g.,December,2000).
Existing sites which are using the earlier version of the recordkeeping forms and CIS software
(available 1997— 1999)will be converted to the Web application for data entry beginning
January,2001. Information about the potential sustainability of the program will be considered
when developing a plan to transition to the Web application for data entry older,more established
sites. Sites which are not likely to be sustained beyond 2001 will not be asked to transition to the
Web application for data entry,but will be maintained on the older version of the CIS until their
contracts are completed.
D. GENERAL PROVISIONS.
1. If this Contract involves the expenditure of federal or state funds,then this Contract is subject to,
and contingent upon,the continued availability of those funds for payment pursuant to the terms
of this Contract. If those funds,or any part thereof,become unavailable as determined by the
State,then the State may immediately terminate this Contract.
2. The parties warrant that each possesses actual,legal authority to enter into this Contract The
parties further warrant that each has taken all actions required by its applicable law,procedures,
rules,or by-laws to exercise that authority,and to lawfully authorize its undersigned signatory to
execute this Contract and bind that party to its terms.The person or persons signing this Contract,
or any attachments or amendments hereto,also warrant(s)that such person(s)possesses actual,
legal authority to execute this Contract,and any attachments or amendments hereto,on behalf of
that party.
3. THE CONTRACTOR SHALL PERFORM ITS DUTIES HEREUNDER AS AN
INDEPENDENT CONTRACTOR AND NOT AS AN EMPLOYEE OF THE STATE.
NEITHER THE CONTRACTOR NOR ANY AGENT OR EMPLOYEE OF THE
CONTRACTOR SHALL BE.OR SHALL BE DEEMED TO BE.AN AGENT OR
EMPLOYEE OF THE STATE. THE CONTRACTOR SHALL PAY WHEN DUE ALL
REOUIRED EMPLOYMENT TAXES AND INCOME TAX AND LOCAL HEAD TAX ON
ANY MONIES PAID PURSUANT TO THIS CONTRACT. THE CONTRACTOR
ACKNOWLEDGES THAT THE CONTRACTOR AND ITS EMPLOYEES ARE NOT
ENTITLED TO UNEMPLOYMENT INSURANCE BENEFITS UNLESS THE
CONTRACTOR OR A THIRD PARTY PROVIDES SUCH COVERAGE AND THAT THE
STATE DOES NOT PAY FOR OR OTHERWISE PROVIDE SUCH COVERAGE. THE
CONTRACTOR SHALL HAVE NO AUTHORIZATION.EXPRESS OR IMPLIED.TO
BIND THE STATE TO ANY AGREEMENTS.LIABILITY.OR UNDERSTANDING
EXCEPT AS EXPRESSLY SET FORTH HEREIN. THE CONTRACTOR SHALL
PROVIDE AND KEEP IN FORCE WORKERS'COMPENSATION(AND SHOW PROOF
OF SUCH INSURANCE)AND UNEMPLOYMENT COMPENSATION INSURANCE IN
AMOUNTS REOUIRED BY LAW.AND SHALL BE SOLELY RESPONSIBLE FOR THE
ACTS OF THE CONTRACTOR.ITS EMPLOYEES AND AGENTS.
4. Except for"public entities",which are described below,during the term of this Contract,and any
renewal or extension thereof,the Contractor shall procure,at its own expense,and keep in force
and effect,the following insurance coverages:
A. As required by State law,standard Workers'Compensation insurance,including
occupational disease;and,Employer Liability insurance,which covers all employees,on
or off the work site,while acting within the course and scope of employment,in the
amounts prescribed by applicable State law.
Page 5 of**
B. Comprehensive General Liability or Commercial General Liability insurance,to include
bodily injury,personal injury,and property damage coverage,in the minimum amount of
$600,000 combined single limit for total injuries or damages arising from any one
incident(for bodily injuries or damages). The Contactor must purchase additional
insurance if claims against the Contractor reduce the available general aggregate amount
below$600,000 during the term of the Contract.
C. Automobile Liability insurance in the minimum amount of$600,000 combined single
limit auto insurance.
D. All insurance policies shall be issued by a company authorized to do business in
Colorado. The State of Colorado is to be named as additional insured on any issued
insurance policy. Each insurance policy shall contain a provision which prevents
cancellation of that insurance policy without sixty(60)days'prior written notice,by
certified mail,return receipt requested,of such cancellation to the State. On or before the
effective date of this Contract,the Contractor shall provide the State with a certificate of
insurance as evidence that such insurance coverages are in effect as of the effective date
of this Contract.
If the Contractor is a"public entity"within the meaning of the Colorado Governmental Immunity
Act,section 24-10-101,et seq.,7 C.R.S.,as amended("CGIA"),then the Contractor shall at all
times during the term of this Contract,and any renewals or extensions hereof,maintain such
liability insurance,by commercial policy or self-insurance,as is necessary to meet its liabilities
under the CGIA. On or before the effective date of this Contract,the Contractor must provide the
State with written proof of such insurance coverage.
5. The Contractor certifies that,as of the effective date of this Contract,it has currently in effect all
necessary licenses,certifications,approvals,insurance,permits,etc.,if any,required to properly
perform the services and/or deliver the supplies specified in this Contract. The Contractor also
warrants that it shall maintain all necessary licenses,certifications,approvals,insurance,permits,
etc.,if any,required to properly perform this Contract,without reimbursement by the State or
other adjustment in the Contract price. Additionally,all employees or subcontractors of the
Contractor performing services under this Contract shall hold,and maintain in effect,all required
licenses,certifications,approvals,insurance,pemtits,etc.,if any,necessary to perform their
duties and obligations under this Contract. The Contractor further certifies that,if a foreign
corporation or other entity,it currently has obtained and shall maintain any applicable certificate
of authority to do business in the State of Colorado and has designated a registered agent in
Colorado to accept service of process. Any revocation,withdrawal or nonrenewal of any
necessary licenses,certifications,approvals,insurance,permits,etc.,if any,required of the
Contractor,or its employees and subcontractors,to properly perform its duties and obligations
under this Contract shall be grounds for termination of this Contract by the State for default
without further liability to the State.
6. If this Contract involves federal funds,or compliance is otherwise federally mandated,then the
Contractor shall comply with the requirements of the following:
A. Office of Management and Budget Circulars A-87,A-21,or A-122,and A-102 or A-110,
as applicable;
• Page6of**
B. the"Hatch Act"(5 U.S.C. 1501-1508)and Public Law 95-454,Section 4728. These
federal statutes declare that federal funds cannot be used for partisan political purposes of
any kind by any person or organization involved in the administration of
federally-assisted programs;
C. the"Davis-Bacon Act"(40 Stat. 1494,Mar.3, 1921,Chap.411,40 U.S.C.
276A-276A-5). This Act requires that all laborers and mechanics employed by
contractors or sub-contractors to work on construction projects financed by federal
assistance must be paid wages not less than those established for the locality of the
project by the Secretary of Labor;
D. 42 U.S.C.6101 et seq,42 U.S.C.2000d,29 U.S.C.794. These Acts mandate that no
person shall,on the grounds of race,color,national origin,age,or handicap,be excluded
from participation in or be subjected to discrimination in any program or activity funded,
in whole or in part,by federal funds;
E. the"Americans with Disabilities Act"(Public Law 101-336;42 U.S.C. 12101, 12102,
12111- 12117, 12131- 12134, 12141-12150, 12161- 12165, 12181-12189, 12201 -
12213 and 47 U.S.C.225 and 47 U.S.C.611);
F. if the Contractor is acquiring an interest in real property and displacing households or
businesses in the performance of this Contract,then the Contractor is in compliance with
the"Uniform Relocation Assistance and Real Property Acquisition Policies Act",as
amended(Public Law 91-646,as amended and Public Law 100-17, 101 Stat.246-256);
and,
G. when applicable,the Contractor is in compliance with the provisions of the"Uniform
Administrative Requirements for Grants and Cooperative Agreements to State and Local
Governments"(Common Rule).
H. Section 2101 of the Federal Acquisition Streamlining Act of 1994,Public Law 103-
355,which prohibits the use of federal money to lobby the legislative body of a political
subdivision of the State.
7. If this Contract involves federal funds,or compliance is otherwise federally mandated,then by
signing and submitting this Contract,the Contractor affirmatively avers that
A. the Contractor is in compliance with the requirements of the"Drug-Free Workplace Act"
(Public Law 100-690 Title V,Subtitle D,41 U.S.C.701 et seq.);and,
B. the Contractor hereby certifies that it is not presently debarred,suspended,proposed for
debarment,declared ineligible,or voluntarily excluded from covered transactions by any
federal department or agency. The Contractor agrees to comply with all applicable
regulations pursuant to Executive Order 12549,including,Debarment and Suspension
and Participants'Responsibilities,29 C.F.R.98.510(1990).
C. the Contractor agrees to comply with all applicable regulations pursuant to Section 319
of Public Law 101-121,Guidance for New Restrictions on Lobbying,including,
Certification and Disclosure,29 C.F.R.93.110(1990).
Page 7of•*
8. To be considered for payment,billings for payments pursuant to this Contract must be received
within a reasonable time after the period for which payment is requested;but in no event no later
than ninety(90)calendar days after the relevant performance period has passed. Final billings
under this Contract must be received by the State within a reasonable time after the expiration or
termination of this Contract;but in no event no later than ninety(90)calendar days from the
effective expiration or termination date of this Contract.
9. Unless otherwise provided for in this Contract, "Local Match"shall be included on all billing
statements, in the column provided therefor,as required by the funding source.
10. The Contractor shall not use federal funds to satisfy federal cost sharing and matching
requirements unless approved in writing by the appropriate federal agency.
11. In accordance with Office of Management and Budget(OMB)Circular A-133(Audits of States,
Local Governments,and Non-Profit Organizations),if the Contractor receives federal funds from
any source,including State pass through money,in an aggregate amotnt in excess of
$300,000.00(June 24, 1997),in a State fiscal year(July 1 through June 30),then the Contractor
shall have an annual audit performed by an independent certified public accountant which meets
the requirements of OMB Circular A-I33. If the Contractor is required to submit an annual
indirect cost proposal to the State for review and approval,then the Contractor's auditor shall audit
the proposal in accordance with the requirements of OMB Circulars A-21 (Cost Principles for
Educational Institutions),A-87(Cost Principles for State,Local and Tribal Governments),or
A-122(Cost Principles for Non-Profit Organizations),whichever is applicable. The Contractor
shall furnish one(1)copy of the audit report(s)to the State's Accounting Office within thirty(30)
calendar days of issuance;but in no event later than nine(9)months after the end of the
Contractor's fiscal year. If(an)instance(s)of noncompliance with federal laws and regulations
occurs,then the Contractor shall take all appropriate corrective action(s)within six(6)months of
the issuance of(a)report(s).
12. The Contractor shall grant to the State,or its authorized agents, access to the Contractor's
relevant records and financial statements. The Contractor shall retain all such records and
financial statements for a period of six(6)years after the date of issuance of a final audit report.
This requirement is in addition to any other audit requirements contained in other paragraphs of
this Contract.
13. Unless otherwise provided for in this Contract,for all contracts with terms longer than three(3)
months,the Contractor shall submit a written progress report,if required by this Contract,
specifying the progress made for each activity identified in this Contract. These progress reports
shall be in accordance with the procedures developed and prescribed by the State. The
preparation of progress reports in a timely manner is the responsibility of the Contractor. If the
Contractor fails to comply with this provision,then such failure:may result in a delay of payment
of funds;or,termination of this Contract. Progress reports shall be submitted to the State no later
than the end of each calendar quarter,or at such other time as may otherwise be specified.
Page 8 of•"`
14. The Contractor shall maintain a complete file of all records,documents,communications,and
other materials which pertain to this Contract. Such materials shall be sufficient to properly
reflect all direct and indirect costs of labor,materials,equipment,supplies,and services,and other
costs of whatever nature for which a contract payment was made. These records shall be
maintained according to generally accepted accounting principles and shall be easily separable
from other records of the Contractor. Copies of all such records,documents,communications,
and other materials shall be the property of the State and shall be maintained by the Contractor,in
a central location as custodian for the State,on behalf of the State,for a period of six(6)years
from the date of final payment under this Contract,or for such further period as may be necessary
to resolve any pending matters,including,but not limited to,audits performed by the federal
government.
15. The Contractor authorizes the State,or its authorized agents or designees,to perform audits or
make inspections of its records for the purpose of evaluating its performance under this Contract
at any reasonable time during the term of this Contract and for a period of three(3)years
following the termination of this Contract. As such,the Contractor shall permit the State,any
appropriate federal agency or agencies,or any other duly authorized governmental agent or
agency,to monitor all activities conducted by the Contractor pursuanfo the terms of this
Contract. Such monitoring may include,but is not limited to:internal evaluation procedures,
examination of program data,special analyses,on-site checks,formal audit examinations,or any
other reasonable procedures. All monitoring shall be performed by the State in such a manner that
it shall not unduly interfere with the work of the Contractor.
16. If the Contractor obtains access to any records,files,or information of the State in connection
with,or during the performance of,this Contract,then the Contractor shall keep all such records,
files,or information confidential and shall comply with all laws and regulations concerning the
confidentiality of all such records,files,or information to the same extent as such laws and
regulations apply to the State. Any breach of confidentiality by the Contractor or third party
agents of the Contractor shall constitute good cause for the State to cancel this Contract,without
liability to the State. Any State waiver of an alleged breach of confidentiality by the Contractor,
or third party agents of the Contractor,does not constitute a waiver of any subsequent breach by
the Contractor,or third party agents of the Contractor.
17. Unless otherwise agreed to in this Contract,or in a written amendment executed and approved
pursuant to Fiscal Rules of the State of Colorado,the parties agree that all material,information,
data,computer software,documentation,studies,and evaluations produced in the performance of
this Contract for which the State has made a payment under this Contract are the sole property of
the State.
18. If any copyrightable material is produced under this Contract,then the State,and any applicable
federal funding entity,shall have a paid in full,irrevocable,royalty free,and non-exclusive
license to reproduce,publish,or otherwise use,and authorize others to use,the copyrightable
material for any purpose authorized by the Copyright Law of the United States as now or
hereinafter enacted. Upon the written request of the Contractor shall provide the State with three
(3)copies of all such copyrightable material.
Page 9 of**
19. If required by the terms and conditions of a federal or state grant,the Contractor shaft obtain the
prior approval of the State and all necessary third parties prior to publishing any materials
produced under this Contract. If required by the terms and conditions of a federal or state grant,
the Contractor shall also credit the State and all necessary third parties with assisting in the
publication of any materials produced under this Contract.
20. If this Contract is in the nature of personal/purchased services,then the State reserves the right to
inspect services provided under this Contract at all reasonable times and places during the tens of
this Contract. "Services",as used in this clause, includes services performed or written work
performed in the performance of services. If any of the services do not conform with the terms of
this Contract,then the State may require the Contractor to perform the services again in
conformity with the terms of this Contract,with no additional compensation to the Contractor for
the reperformed services. When defects in the quality or quantity of the services cannot be
corrected by reperformance,then the State may:require the Contractor to take all necessary
action(s)to ensure that the future performance conforms to the terms of the Contract;and,
equitably reduce the payments due to the Contractor under this Contract to reflect the reduced
value of the services performed by the Contractor. These remedies in no way limit the other
remedies available to the State as set forth in this Contract.
21. If,through any cause attributable to the Contractor's action(s)or inaction(s),the Contractor: fails
to fulfill,in a timely and proper manner,its duties and obligations under this Contract;or,violates
any of the agreements,covenants,provisions,stipulations,or terms of this Contract,then the State
shall thereupon have the right to terminate this Contract for cause by giving written notice thereof
to the Contractor. Such written notice shall be given at least ten(10)calendar days before the
proposed termination date and shall afford the Contractor the opportunity to cure the default or
state why termination is otherwise inappropriate. If this Contract is terminated for default,then all
finished or unfinished data,documents,drawings,evaluations,hardware,maps,models,negatives,
photographs,reports,software,studies,surveys,or any other material,medium or information,
however constituted,which has been or is to be produced or prepared by the Contractor under this
Contract shall,at the option of the State,become the property of the State. The Contractor shall
be entitled to receive just and equitable compensation for any services or supplies delivered to,
and accepted by,the State. If applicable,the Contractor shall return any unearned advance
payment it received under this Contract to the State. Notwithstanding the above,the Contractor is
not relieved of liability to the State for any damages sustained by the State because of the
Contractor's breach of this Contract The State may withhold any payment due to the Contractor
under this Contract to mitigate the State's damages until such time as the exact amount of the
State's damages from the Contractor's breach of this Contract is determined. If,after terminating
this Contract for default,it is determined for any reason that the Contractor was not in default,or
that the Contractor's action or inaction was excusable,then such termination shall be treated as a
termination for convenience,and the rights and obligations of the parties shall be the same as if
this Contract had been terminated for convenience as described in paragraph 22 below.
Page 10 of**
NURSE HOME VISITOR PROGRAM
GRANT APPLICATION TIME LINEAND CHECKLIST
TIME LINE
October 1, 2000 Grant Application Packets available
October 1 - 10, 2000 Question and Answers Period open
October 13, 2000 Written answers to questions mailed to all
applicants
Nov. 1, 2000 (3:00 PM) Grant Application Submission Deadline
Nov. 1 - 3, 2000 Application Qualification Screening by
CDPHE
Nov. 3 - 9, 2000 Evaluation of Qualified Applications by the
National Center at the University of
Colorado Health Sciences Center
Nov. 10, 2000 Recommendations of National Center
Forwarded to Board of Health
Nov. 15, 2000 Board of Health Deliberation and Action on
Recommendations of National Center
Nov. 15 - Dec. 31, 2000 Preparation of Contracts Between CDPH&E
and Approved ApplicantsContractors
J January 1 - June 30, 2001 Implementation of Nurse Home Visitor
Programs
April, 2001 Grant Application Process for second round
of grant awards begins
CHECKLIST
Cover Sheet (with authorized signature)
Grant Narrative
Budget Narrative
Budget Request Form
Assurance Form (Category A) (with authorized
signature)
Questions and Answers
Regarding Applications for the
Colorado Nurse Home Visitor Program
Question 1: Can new clients be enrolled who are less than 12 weeks pregnant?
Answer: Yes,clients should be enrolled as early in pregnancy as possible.
Question 2: Can the same individual be served and billed for under both Prenatal Plus and the
Nurse Home Visitor Program?
Answer: No, not at the same time. The client should be enrolled in whichever program is
most appropriate for that client. The statute does allow Nurse Home Visitor
Program clients to be enrolled up to the end of the baby's first month of life.
Therefore, technically, the same individual could be served under Prenatal Plus
through the baby's birth,then closed to that program and enrolled in the Nurse
Home Visitor Program before the baby is one month old. However, this practice
is strongly discouraged as the likelihood of good outcomes for first-time mothers
and their babies under the Nurse Home Visitor Program are improved when there
is enrollment early in the pregnancy.
Question 3: To whom should the Letters of Support be addressed?
Answer: Letters of Support may be addressed to the State Board of Health at the Colorado
Department of Public Health and Environment.
Question 4: Is there a difference between"advisory"and"oversight" in describing the
functions of a board for a collaborative effort?
Answer: The intent is that the local initiative has the support of a broad-based community
group. That group may be primarily advisory or may have more of an oversight
role. It is up to the applicant to determine what is appropriate and present
information to show there will be a group in place to assure a collaborative effort
or to provide oversight, whichever is appropriate.
Question 5: What data sources do we need to use to identify"socio-demographic and health
characteristics"that justify the need?
Answer: Socio-demographic data,which includes birth and infant mortality data as well as
racial/ethnicity demographic information is available from the Health Statistics
Section of the Center for Health and Environment Information& Statistics
Section(CHEIS)of the Colorado Department of Public Health and Environment.
This data is also available through local public health agencies for those counties
served by that agency. Local public health agencies also have County Maternal
and Child Health (MCH) Data Sets that were provided from the state to the
counties when regional MCH planning meetings were held around the state in
February, 2000. These County MCH Data Sets have some relevant health status
indicators, as do Prenatal Risk Assessment Monitoring System(PRAMS) reports.
Other socio-demographic data might come from Kids Count.
Question 6: If the proposed program is to serve multiple counties,does the application need to
describe all the linkages with other agencies in all the counties?
Answer: Yes,to an extent. The application should present enough information to show
that the applicant has linkages to agencies from which and to which referrals will
be made in the implementation of the program in each of the counties or
communities in which it will be operating,but it does not need to be a lengthy
description of the relationship with every agency. In many cases it will be
difficult to generalize across multiple counties about the referral linkages that are
in place. Typically, each county will have a few key referral linkages and the
applicant should include information on those linkages within each county. The
applicant should also provide enough information to establish that it has
experience in providing services which make it an appropriate agency to provide
the Nurse Home Visitor Program Services.
Question 7: Who has the most accurate data on the number of first-time, low-income mothers
in a given county?
Answer: An analysis of data from the Prenatal Risk Assessment Monitoring System was
done by the Health Statistics Section to provide estimates by county or
geographical region. Please see the attached document.
Corrections to the Application document:
Correction 1: On page 10 of the Grant Application, a part of a sentence is missing at the end of
the first paragraph. The additional part of the sentence is: ". . . Applicant
organization have historically used the services of the linked providers described."
Correction 2: On page 11, under the instructions for Management Information System(No. 6),
the reader is referred to the requirements described in Attachment"D", which
should be Attachment"F"instead.
Estimates of First-Time and Low-Income Mothers
The attached pages provide estimates of the number of women who were first-time mothers and
low-income who delivered in 1999 by county(or regional grouping of counties) of residence.
This information was developed using data from the 1997 and 1998 Prenatal Risk Assessment
Monitoring System (PRAMS) telephone surveys of women who had live births in those years.
From this data estimates of the percent who were first-time mothers and low-income in the
geographical areas were made. Then the estimated percentages were multiplied against the total
number of live births in the geographical areas in 1999 to get estimates of the numbers of births
to first-time, low-income mothers in each geographical area. This information may be of help in
estimating the number of potentially eligible women to be served in any given area. Please note
that the term"poor" used in the document means the same as "low-income".
You should be aware that:
The actual number of first-time low-income mothers is somewhere within the range of
the numbers provided. In many cases the range is quite wide. A more precise estimate is
not possible at this time.
The PRAMS data used to estimate the number of mothers who were low-income is based
on those who reported incomes under 185%of the Federal Poverty Level and those who
did not know what their income was. The eligibility requirements for women to be
served under the Colorado Nurse Home Visitor Program is set at having incomes up to
200 %FPL. So the number who would qualify potentially could be somewhat higher
than the numbers reported in this document.
There were only two years of PRAMS data to use at this time. Therefore there is a fairly
wide range to the estimates of the percent and the number of first-time and low-income
mothers in each geographical area. The range of the estimated percents and numbers will
become smaller as more years of data become available.
PRAMS data for counties with smaller populations is grouped together in regions.
Nevertheless, estimates of the number of first-time and low-income mothers for an
individual county can be derived,starting with the regional data reported here. To do this
take the number of births for that county for 1999 and divide by the total number of 1999
births for that region to get that county's percent of the region's total. Then multiply that
percent against the estimated numbers for that region and you will have the estimated
numbers for that county.
Percent of All Births to First-Time Mothers with Incomes Below 185%of the Federal
Poverty Level (Poor): Colorado PRAMS, 1997-1998; Colorado Vital Statistics, 1999
1999 Number 1997-98 Percent 1999 Number
State of live births first-time and poor first-time and poor
Total 62,142 18.7-22.3 11,637-13,878
1999 Number 1997-98 Percent 1999 Number
County of live births first-time and poor first-time and poor
Adams 5,719 14.0-27.5 801-1,575
Arapahoe 6,779 11.7-24.8 791-1,678
Boulder 3,620 10.2-27.5 370-994
Denver 10,155 18.5-30.0 1,880-3,047
Douglas 3,093 0.9-11.0 26-342
Eagle 717 12.7-29.9 91-215
El Paso 8,196 18.9-27.1 1,546-2,224
Garfield 695 20.4-37.8 142-263
Jefferson 6,597 10.7-22.7 706-1,497
Larimer 3,131 8.7-20.4 272-637
Pueblo 1,934 13.3-29.6 256-573
Weld 2,868 11.7-24.9 336-715
Region 1999 Number 1997-98 Percent 1999 Number
(PMR) of live births first-time and poor first-time and poor
1 1,054 16.6-30.1 175-317
2 5,999 11.9-20.6 713-1,238
3 36,105 16.5-22.0 5,949-7,944
4 8,574 19.0-27.0 1,632-2,314
5 385 not available
6 727 not available
7 1,934 13.3-29.6 256-573
8 667 25.5-43.1 170-288
9 855 11.2-24.4 96-208
10 964 19.7-33.0 " 190-318
11 2,354 21.8-35.6 514-839
12 1,518 15.3-26.5 232-403
13 759 15.3-31.0 116-235
14 246 not available
•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:Bap,Bent,Crowley,Kowa,Otero,Prowers;7:Pueblo
8:Alamosa,Conejos,Costitla,Mineral,Rio Grande,Saguache;9:Archuleta,Dolores,to Plata,Montezuma,San Juan .
10:Delta,Gunnison,Hinsdale,Montrose,Ouray,San Miguel;11:Garfield,Mesa,Moffat,Rio Blanco
12:Eagle,Grand,Jackson,Pitkin,Rout,Summit 13:Chaffee,Custer,Fremont,Lake; 14:Huerfano,Las Animas
5 Sub-State 1999 Number 1997-98 Percent 1999 Number
Regions of live births first-time and poor first-time and poor
1 52,092 17.5-21.7 9,123-11,308
2 5,691 21.2-28.5 1,209-1,622
3 2,166 18.2-27.3 394-591
4 667 25.5-43.1 170-288
5 1,525 20.2-31.4 308-480
**Five Region Sub-State Areas
1 (Front Range):Adams,Arapahoe,Boulder,Denver,Douglas,El Paso,Jefferson,Larimer,Pueblo,Weld
2(Western Slope):Archuleta,Delta,Dolores,Eagle,Garfield,Grand,Gunnison,Hinsdale,Jackson,La Plata, Mesa,Moffat,
Montezuma,Montrose,Ouray,Pitkin,Rio Blanco,Routt,San Juan,San Miguel,Summit
3(Eastern Plains):Baca,Bent,Cheyenne,Crowley,Elbert,Kiowa,Kit Carson,Lincoln,Logan,Morgan,Otero,Phillips,
Prowers,Sedgwick,Washington,Yuma
4(San Luis Valley):Alamosa,Conejos,Costilla,Mineral,Rio Grande,Saguache
5(Eastern Mountains):Chaffee,Clear Creek,Custer,Fremont,Gilpin,Huerfano,Lake,Las Animas,Park,Teller
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.
i
ATTACHMENT C
FAMILY HEALTH SERVIC -.
GRANT APPLICATION COVER SHEET FOR:
COLORADO NURSE HOME VISITOR PROGRAMS NOV 01 2000
1. Name of applicant entity: Weld County Department of Public Health and Environment
Address: 1555 N. 17th Avenue,Greeley. Colorado 80631
Name of person completing application: Mark E. Wallace, MD, MPH
Position/Title: Director
Telephone: (970) 304-6410 FAX: (970)304-6412
E-mail: mwallace@co.weld.co.us
2. Name of authorized signer: Barbara J. Kirkmeyer
Position/Title: Chair, Board of Commissioners, Weld County
Telephone: (970) 336-7204, ext. 4200 FAX: (970) 352-0242
E-mail: bkir ever@co.weld.co.us [[
Signature: A-GtUL`i , JASULJZiL.
(11/01/2000)
3. Grant proposal is for:
XX Nurse Home"Visitor"Program (Category A)
Other Nurse Home"Visitation"Program (Category B)
4. Grant amount for Jan. 1,2001 through June 30, 2001: $175,831
,/coc) --27.22,
ASSURANCE OF INTENTION TO MEET
THE PROGRAM REQUIREMENTS
FOR NURSE HOME VISITOR PROGRAM
(CATEGORY A) APPLICANTS
Please assure that the applicant entity intends to meet the Program Requirements
for:
Training Requirements
Visit Protocols
Program Management Information systems
Reporting and Evaluating System
as described in Section 1.6 of the Rules Concerning the Nurse Home Visitor
Program(Attachment A)by signing this assurance page.
Name of Authorized Signer.Mark E. Wallace, MD, MPH
Signature of Authorized Signer. JL ` L)
lo'3e
Date: 111
r -
Table of Contents
Executive Summary Page 1
Needs of Population Served Page 2
Capability of Applicant Page 3
Organizational Chart Page 5
Evidence of Broad-Based Community Support Page 8
Key Agencies Page 11
Referral Sources Page 28
Referral Linkages Page 31
Coordination with Existing Visitation Programs Page 32
Plan for Recruitment and Retention of Nurses Page 32
Management Information System Capabilities Page 35
Collaborative Implementation Plan Page 36
Request for Waivers Page 37
Geographical Placement of Applicant Page 37
Budget and Budget Justification Page 37
Community Support of Program Page 39
Appendix A: Budget Page 40
Appendix B: Letters of Suppor Page 41
Reference Data Sources Page 42
ii
Executive Summary
The Weld County Department of Public Health & Environment, in collaboration with
other county departments and community agencies, is submitting a proposal to implement
a county-wide Nurse Home Visitor Program as provided for in the Nurse Home Visitor
Program Act, section 25-31-101, et.seq., C.R.S.,as amended,and administered by the
Colorado Department of Public Health and Environment. The department is seeking
funding of$175,831 from January 1,2001 through June 30,2001 to support the
educational,health and other resources to be provided to new young mothers during
pregnancy and the first years of their infants' lives under program guidelines.
The department is uniquely qualified in the county to serve as the lead agency to
implement and successfully carry out this home visitor program directed at improving
outcomes for new mothers and their infants. With over sixty years of experience
providing nursing and home visitation services to residents of Weld County,the
department has considerable experience in establishing its credibility and likelihood for
success in administering the proposed program. The department will integrate program
staff consisting of 0.5 FTE of Master's prepared nursing supervisor,4.0 FTE of
Baccalaureate prepared registered nurse visitors, and 0.5 FTE of data entry/support
personnel into the Division of Public Health Education and Nursing. The new program
staff will join a stable division workforce composed of Baccalaureate prepared public
health nurses already experienced in home visitation and other maternal and child health
services.
The department proposes to collaborate with the Department of Social Services,the
Department of Human Services, United Way of Weld County, Sunrise Community
Health Center, Salud Family Health Centers, Monfort Children's Clinic,North Colorado
Medical Center,North Colorado Family Medicine,First Steps of Weld County,Bright
Beginnings,Weld County School District 6 and The Greeley Dream Team, Inc., in
implementing this program. Three of the four visiting nurses will be outstationed at
Sunrise Community Health Center,Monfort Children's Clinic,and at a county facility in
southern Weld County. One visiting nurse,and all other program staff,will operate out
the department's main office in Greeley. A Community Advisory Board consisting of
eight to ten community representatives will provide advisory oversight to the program
and the department's executive director. Accountability will rest with the Department of
Public Health & Environment. An existing community agency staffing model will be
expanded to incorporate this new program to ensure that services are not duplicated and
that clients are referred into the most appropriate program to meet their unique needs.
Community in-kind support for the program will include donated office space and
supplies,telephone access, staff time to make and receive referrals and coordinate
interagency meetings,meeting space, and staff time to participate on the Community
Advisory Board. Weld County Department of Public Health and Environment will
donate indirect costs of$22,682 during fiscal year one.
1
Needs of Population Served
Weld County is a primarily agricultural county covering 4,002 square miles in north
central Colorado. There are 31 incorporated towns in Weld County. Greeley is the
county seat and principal city in the county with an estimated 1999 population of 84,245'
in the greater Greeley area'. In 1998,a total county population of 162,253"' was
estimated with 36,930'living in unincorporated areas. The ethnic distribution in Weld
County is 73.3%White,24.8%Hispanic,and 1.9%African-American and other groups".
The median age in Weld County in 1999 was 33.1 years with 68.3%of the population
being less than 45 years of age"'. The median household income estimated in 1999 for
Weld County was$35,240 and for Greeley was $31,721". These estimates compare to a
median family income for Colorado of$35,930'. Weld County is ranked 5th in the
nation and lsr in the state in the value of agricultural products sold and 6%of the
workforce is employed in agriculture.
Family economic data from the 1990 census indicates that the median income of female-
headed households in Weld County was only$13,609'compared to $17,505"statewide.
The poverty rate for all ages in Colorado is 10.4%compared to 13.3% in Weld County"'.
Of children under age 18 in Weld County 18.9%are living in poverty. Two-thirds of
Hispanic and African-American youths in Colorado come from low-income households.
Weld County Medicaid data for fiscal year 1999/00 demonstrates a monthly average of
11,530 eligible clients".
Weld County had a fertility rate of 16.5 per 1,000 among females 10-17 (1994-1998
annual average)while Colorado's rate was 12.2 per 1,000. The fertility rate in 1998 for
youth ages 10-14 was 1.4 per 1,000 in Weld County compared to 0.8 per 1,000 in
Colorado. Live births in Weld County totaled 2,868 in 1999""'. Of Weld County women
giving birth in 1999 only 66.2%received prenatal care beginning in the first trimester"'"
In comparison, 81.7%of Colorado women giving birth in 1999 initiated prenatal care
during the first trimester"". In addition to a relatively low rate of initiation of prenatal care
in the first trimester, 12.5%of births in Weld County had at least three pregnancy risk
factors identified'''. In 1999,42.3%of Colorado births were to women having their first
child""'. At North Colorado Medical Center, Weld County's only acute inpatient medical
facility providing obstetrical services, 766 births(37.8%) were to first time mothers out
of a total of 2,028 births in 1999"""'.
Data from one of the county's main providers of prenatal and delivery services
(accounting for 31.5%of all births in Weld County)to women indicates that 374 patients
out of 903 served in 1999(41.4%)were covered by Medicaid or Colorado Access"'
Another 306 women(33.9%)were uninsured'. Applying the North Colorado Medical
Center rate for births to primigravidas(37.8%)to this clinic's financial data(0.378 x 680
low-income mothers)yields a conservative minimum estimate (representing the
experience of only one clinic)of 257 births to first time, low-income mothers in 1999 in
Weld County. Of these 257 first time, low-income pregnancies it would be estimated that
106(0.414 x 257 first-time mothers)might be eligible for Medicaid coverage under
existing regulations.
2 .
Teenage pregnancy is a significant problem in Weld County. It carries substantial social
and economic costs (both direct and indirect)to government, business, non-profit
agencies and the community. The direct costs given to mother and child by doctors,
clinics,North Colorado Medical Center and the community agencies for a one year
period in 1996 totaled $3.6 million"''. The indirect costs (those that divert jobs,taxes,
wages and salaries, and personal income) over the same period were $16.6 million and
137 jobs?". In 1997,births to teens in Weld County represented 16%of all births
(compared to 11.8% statewide)""'.The Weld County teen birth rate in 1997 was 58.2 per
1,000 compared to 47.4 per 1,000 statewide"'".
In January 2000, a county caseload of 496 families was reported for youth involved in the
justice system, out of school,or involved in dependency and neglect cases""". The HRSA
"Relative Health Importance"table for Weld County suggests that low birth weight
(<2,500 grams),no care in the first trimester and white infant mortality deserve additional
attention and action if these statistics are to be improved in comparison to a peer group of
counties and to the U.S. rate""'.
The need for intensive prenatal and early childhood home visitation interventions in Weld
County is great and has been well detailed in the preceding pages. The challenge to our
community is also effectively presented in the both the Colorado KidsCount 1999 and
2000 Reports and the Community Health Status Report published by the Health
Resources and Services Administration of the U.S. Department of Health and Human
Services. The community and its array of agencies, focused on the needs of low-income
mothers-to-be and their young families,will easily be able to identify 100 women to
voluntarily enroll in the nurse home visitor program proposed in this grant application.
Capability of Applicant
Organizational Structure and Commitment
The commitment to implement and successfully carry forth the intent of the Nurse Home
Visitor Program is vested within the collaboration of community agencies already serving
the target population in Weld County. The lead agency for this initiative is the Weld
County Department of Public Health& Environment under the directorship of Mark E.
Wallace, MD,MPH. The organizational commitment to support this community project
extends from the Board of Commissioners of Weld County through the staff of the
Division of Public Health Education and Nursing and into the many agencies serving
residents of Weld County. Coalitions have been hard at work in Weld County serving
women and their families long before funding became available to expand home visitor
programs in our state. The Department of Public Health&Environment has not only
been an active participant with other agencies but has also frequently taken the lead in
many efforts to improve the health and welfare of Weld County families.
The Board of Commissioners appointed Dr. Wallace to his department director position
in March 2000. However, he has been actively working with the department since 1992
3
when he moved to the community from southern California. Dr. Wallace is a board-
certified family physician with a Master's in Public Health from UCLA. He serves in
many capacities within the greater Greeley community. He provides leadership in
graduate and continuing education for Banner Health Colorado, which operates North
Colorado Medical Center in Greeley. Dr. Wallace is also an elected official serving as
President of the Weld County School District 6 Board of Education. He is a volunteer on
the Greeley Dream Team, Inc., Board of Directors, a not-for-profit organization
committed to helping at risk youth succeed in school. He organized the Primary Care
Access Group to study and recommend changes to meet the needs of low-income people
accessing primary health care in the county. He is fully committed to the successful
implementation of the Nurse Home Visitor Program under the sponsorship of the Weld
County Department of Public Health&Enyironment.
The program as proposed would reside within the Division of Public Health Education&
Nursing that is under the direction of Linda Henry, RN, BSN,MA. She leads a division
consisting of 17 nurses,three nurse practitioners,one social worker, one dietitian, 6
health educators and 17 support staff. Four supervisors and an office manager assist her
in running the daily operations of the division. The Nurse Home Visitor Program staff
would be integrated into the division. It is out of this section that home visitation already
exists through Prenatal Plus, EPSDT and other program activities. The division would be
reorganized to add a fifth section of Community and Family Programs. The Nurse Home
Visitor Program would be placed in this new section under the 0.5 FTE supervision of a
Master's prepared nurse supervisor to be hired under the grant. The department
reorganization would bring another 0.5 FTE support to this new supervisor position to
allow a 1.0 FTE to be hired. To best coordinate home visitation programming, Prenatal
Plus,EPSDT and Presumptive Eligibility activities would be moved into this new section
of Community and Family Programs. The division also has well-developed relationships
with prenatal programs and providers of child and family care services in the county.
Integrating this new program into the division will facilitate coordination of care and
prevent duplication of service while directing clients to the most appropriate program to
meet their needs.
An organizational chart details the positioning of the program within the agency.
4
ORGANIZATIONAL CHART
Weld County Department of Public Health&Environment
I_ Board of County --
Commissioners
Proposed NHVP i
Advisory Board of Community Advisory
Health i Board
Department of Public Health&
Environment
Mark E. Wallace,MD, MPH Consulting Consulting
Pharmacist Pathologist
Executive Director
Medical Director
Public Health Education& Environmental Health Administrative
Nursing Services Services
Linda Henry, RN, BSN,MA Trevor Jiricek, MSEH Judy Nero, BS
Director Director Business Manager
Communicable
Diseases Team
Jill Burch,RN,BSN Communicable Community HIV International
Supervisor Disease&TB Outreach Testing Travel
Children's Health
Team
Cheryl Weinmeister, ,
RN,BSN Health Care Program for Attachment& Child Health &
Supervisor Children with Special Needs Bonding Immunization
Women's Health
Team
Kris Embree,RN,BSN Nurse Practitioner Family STD and Cancer
Supervisor Program Planning Screening Outreach
Community &
Family Programs ---.-_--
Master's-prepared I Nurse Home Prenatal Presumptive
Supervisor to be hired Visitor Program Plus Eligibility&EPSDT
Health Promotion
Gaye Akin,RD,MPH
Supervisor
5
The Weld County Department of Health was started in July 1938 under the direction of
Dr. R. J. Shale. The Greeley Community Nurse and two county nurses became part of
the new department. A health unit and maternity program were planned for the southern
part of the county as early as 1939. The department has provided maternal and child
health services since its inception. Up to this day the department continues to provide
well-child examinations, immunization services, lead screening and health care program
for children with special needs. Over 13,000 vaccinations were administered through the
department and its community outreach activities in 1999.
Maternity services were provided directly through the Public Health Education and
Nursing division until 1998 when these services were incorporated under a contract into
the obstetrical program operated by North Colorado Family Medicine,a family practice
residency program sponsored by North Colorado Medical Center. North Colorado
Family Medicine was started in 1974 in Greeley and since its beginning has provided
consultation and delivery services to county maternity patients and their infants. The
incorporation of the clinical portions of the county's maternity services into those of
North Colorado Family Medicine has increased the physician oversight of the care
delivered to these high-risk patients by the women's health practitioner. This
collaboration has proved hugely successful from a clinical perspective but continues to be
threatened by diminishing reimbursement for women not eligible for Medicaid coverage
of the costs of prenatal care. This public-private cooperative effort afforded services to
over 250 low-income women seeking prenatal care in the county last year.
Home visitation essentially began with the start of the organized department of health and
the recruitment of the first nurses to the agency. The Weld County Department of Public
Health&Environment has supported home visitation programs in a variety of formats
since its inception. Until early in the 1980s acute home health care was part of the health
department home visitation program. At that time the Rural Nursing Visitation
Association(RVNA)was formed as a separate home health agency. The Early Periodic
Screening,Diagnosis and Treatment(EPSDT)Medicaid program left the health
department and was operated through RVNA. In 1999 EPSDT moved back into the
health department and now operates through the Public Health Education and Nursing
division. Prenatal Plus(which had its roots in the Helping Moms programs)was started
in the department in 1994 and provides nursing and social work home visitation services.
For most of its history of providing home visitation services,the department assigned
nurses to designated sections of the county. These nurses provided any type of home
visit upon referral from health and social service agencies in the county. The family
issues addressed in these home visits varied and included children with special needs,
family abuse or neglect situations,high-risk prenatal and postpartum moms and babies,
and health promotion in the elderly (e.g., blood pressure assessments.) With the
increasing pressure from managed care's influence on acute health care the county began
to experience shorter stays following hospitalization and especially after delivery. Early
postpartum hospital discharge lead the agency to focus its home visits on postpartum and
infant exams within twenty-four to forty-eight hours of discharge. Mothers experiencing
difficult deliveries or postpartum complications, at-risk infants (especially the jaundiced
6
and/or breastfeeding baby) and socioeconomically at-risk families needed the expertise of
Baccalaureate trained public health nurses. The department's home visitor services
provided a continued link between the various clinics and agencies serving low-income
women and children in the county.
During the last decade,as Weld County's population living in poverty increased, services
were strained by financial limitations on programs. In addition,managed care contracts
in the Medicaid population directed home visits to agencies other than the health
department. Centralized clinics at the health department were increased as a cost-
efficient way to provide service to more clients. However, even with decreased funding
the department has risen to the challenge of providing home visits to selected high risk
families who qualify under various programs upon referral from community.agencies.
Physical assessment,teaching and linking families with needed services continue to be
addressed by baccalaureate prepared public health nurses making home visits.For the last
six years,funding of Prenatal Plus services (and its"Helping Moms"predecessor)has
allowed our department to expand and compliment the medical component of prenatal
care with home visitation.
Lead by a full time registered nurse,the Prenatal Plus interdisciplinary team consists of a
social worker,a nutritionist, and a part-time nurse and office technician. Qualified
pregnant women receive a comprehensive risk assessment, care coordination,home
visits,nutrition consultation,and psychosocial counseling from the competent and well-
trained team. Prenatal Plus served approximately 120 clients last year. Home visits are
started during pregnancy and continue sixty days after delivery. These visits provide
clients with specific activities that encourages involvement and interaction with the
mother's own individual plan of care. Health education on pregnancy, labor and
delivery, nutrition, community resources, and high-risk behaviors such as substance
abuse are addressed with the client. The Prenatal Plus interdisciplinary team serves as a
respected client advocate in the community. Established resource and referral networks
work in unison to provide the necessary services to meet individual needs.
The department's social worker has been providing a psychosocial perspective and
consultation for the past seven years. Social work duties include counseling, family
advocacy,and community referrals. The expertise in working with families and
community agencies provides a balance to the two teams on which she works—Prenatal
Plus and the Health Care Program for Children with Special Needs. Caseloads from both
programs range from 100 to 130 families per year and 12-18 clients a week are visited in
their homes.
In 1995 the department was awarded a grant from Family Preservation funds to develop a
home visitor program that addressed attachment and bonding issues in high-risk families.
Initially 5-6 families participated in the home visitor program. The program currently has
the capacity to serve 12-14 families. Referrals are received from the Department of Social
Services, the court system, or family therapists. Families receive 6-12 months of
intervention with emphasis on building positive parent and child relationships. A
specially trained bonding nurse addresses nurturing skills,parent-child relationships, and
7
the status of bonding and attachment during the home visit. Home visits are provided to
families who have children in foster care,who are adopting,or who are at risk for abusive
behaviors. Weekly or bi-weekly home visits are made to families at risk. The nurse
works closely with adoptive parents in understanding and responding to the unique
bonding needs of adoptive children. The bonding nurse coordinates collaborative efforts
between community agencies to achieve the best possible plan of care for each child. The
goal of the program continues to be to assure that children at high risk for abuse or
neglect due to poor parenting skills will ultimately experience a safe and nurturing
environment. This successful home visitation program continues to receive positive
recognition in the community as an intervention for at risk families.
The Department of Public Health&Environment is well positioned to serve as the lead
agency for implementing the Nurse Home Visitation Program proposed in this
application. The major strengths of the department are as follows: (1) its long history in
providing maternal-child health and home visitor services to the community; (2)a well-
trained and stable workforce of Baccalaureate prepared public health nurses into which
the new home visitation nurses would be integrated; (3) supervisory staff experienced at
running complex programs under federal and state guidelines; (4) an executive director
clinically competent in caring for women and children(including high risk obstetrics)and
trained in public health who actively participates in a variety of community activities
affecting families; and, (5) a well-developed organizational infrastructure supported by a
recommended 2001 departmental budget of$4.4 million and long-established
relationships with a network of community service agencies.
The Greeley community as well as the most populated surrounding areas of Weld County
is served by many public and private agencies that have increasingly come together in
collaborative relationships to better serve the public. Few other regions with a population
comparable to Weld County can claim a children's clinic,two community health centers,
a family practice residency training program,and a public health department all focused
on meeting the acute and preventive health care needs of the under-served. Additional
community assets include critical service agencies operating under funding from United
Way of Weld County(e.g.,Bright Beginnings)and the North Colorado Medical Center
Foundation(e.g., First Steps). Rounding out the community groups cooperating in this
program proposal are North Colorado Medical Center, Weld County School District 6,
Weld County Department of Social Services, and Weld County Department of Human
Services. Staffs from these various agencies have participated together in multiple
coalitions such as the Shots for Tots/Weld Immunization Coalition and the Teen
Pregnancy Task Force. It is the breadth of agencies working together in Weld County to
improve the health and welfare of women and children that is the community's greatest
strength.
Evidence of Broad-based Community Support
While the Department of Public Health& Environment is taking the lead in preparing
this application,the proposal has emerged due to recognition by the community that few
areas in Colorado have greater need than that in Weld County. Statistics reported by the
8
Colorado Children's Campaign and the Health Resources and Services Administration
present the challenge to our collaboration of agencies. We must work together in new
ways to affect change in the indicators of the health and well being of women and
children in our county. The number of agencies supporting this new program
demonstrates the breadth of commitment to affect change. The table below presents the
key agencies and people involved in supporting this application for the Nurse Home
Visitor Program.
AGENCY KEY PEOPLE IN MISSION OF AGENCY
ORGANIZATION
Weld County Department of ➢ Mark E. Wallace,M.D., To preserve,protect,and promote
Public Health& Environment M.P.H., Executive Director a healthy life and safe
➢ Division of Public Health ➢ Linda Henry,R.N.,M.A., environment for the residents of •
Education and Nursing Director,Division of Weld County.
Community Health
Education and Nursing
Weld County Department of ➢ Judy Griego,Executive
Social Services Director
➢ Social Services Division ➢ Richard Rowe
➢ Assistance Payments ➢ Frank Aaron
Division
➢ General Programs
➢ Child Support
Weld County Department of ➢ Walter J.Speckman,
Human Services Executive Director
➢ Employment Services of ➢ Leticia Galindo,Family
Weld County Community and Parent
➢ Family Educational Network Partnerships Specialist
of Weld County ➢ Julie Streeter,
Disabilities/Mental Health
Specialist
➢ Tere Keller-Amaya,Director
of Family Educational
Network of Weld County
➢ Beverly Sanchez,Director of
Operations
United Way of Weld County ➢ Judy Kron,Director of To increase the organized
➢ Coordinator of Weld County Community Problem Solving capacity of the community to
Early Intervention and Programs respond to human care needs and
Collaboration to help solve community health
➢ Sponsor of Community and human care problems.
Agency Staffings
Weld County Early Intervention
Collaboration
➢ First Steps of Weld County ➢ Noelle Hause,Ed.D.,L.P.C., To provide a broad-based
Executive Director prenatal,postpartum and
➢ Ellen Laurence,R.N. parenting service that is consumer
focused and consists of referral,
education,advocacy and support.
➢ Bright Beginnings ➢ Sheila Avers To make a Warm Welcome Visit
in the homes of newborns in
Weld County.
➢ c.a.r.e.
9
AGENCY KEY PEOPLE IN MISSION OF AGENCY
ORGANIZATION
> Family Connects
> North Range Behavioral
Health
Monfort Children's Clinic > Bob Francella,Executive
Director
> Gary Schrenk,President,
North Colorado Medical
Center Foundation
➢ Masroor Kakakhel,M.D.,
Medical Director
Sunrise Community Health > Mike Bloom,Executive To provide access to quality,
Center Director comprehensive family health care
> Beth Griffin,PA-C,Medical services for the residents of
Director Greeley and surrounding areas
and to address the special needs
of our community's medically
underserved and migrant
populations.
North Colorado Medical Center— > Jon Sewell,Administrator To serve the health needs of
Banner Health System > Joanne Fenton,R.N., communities both large and small
> Monfort Family Birth Center Assistant Administrator for across the nation in the nonprofit
> Emergency Department Patient Care Services tradition by excelling in clinical
> Pediatrics > Jeff Abbett,R.N.,Director of care,quality service,financial
> Care Coordination Care Coordination stewardship and the creation of
> Pat Aimino,RN,Director of work environments where people
Maternal&Newborn can realize their full potential.
Services
Salud Family Health Centers > Stanley J.Brasher,Executive To provide quality,
> New Horizons Teen Program Director comprehensive primary health
> Mary Ann Martinez Gofigan, services to all the residents of a
Director of Client Services defined catchment area,covering
parts of Weld,Boulder and
Adams Counties,Colorado.
North Colorado Family Medicine > Daniel Fahrenholiz M.D., To educate family physicians to
> Weld County Prenatal Clinic Program Director practice successfully in rural
at Cottonwood Pointe > Eileen Croissant,Clinic communities.
Manager
The Greeley Dream Team,Inc. > Charlotte Jimenez,Executive To partner with the community to
Director help children succeed in school.
➢ Marisol Gutierrez,Office
Assistant
➢ Melanie George-Hernandez,
ETS Assistant Director&
McKinney Coordinator
Weld County School District 6 > Anthony Pariso, To educate all students in a
Superintendent nurturing,challenging,and
> Mark E. Wallace,President, disciplined environment so their
Board of Education performance is a credit to
> Ann Heiman,Secretary, themselves and society.
Board of Education
10
•
Key Agencies
Weld County Department of Public Health& Environment
The applicant lead agency is well described in material preceding this section. The
department was formally organized in 1938 and has operated continuously since that
time. Three divisions constitute the department: Public Health Education and Nursing;
Environmental Health Services; and Administrative Services. The department is lead by
Mark E. Wallace, MD, MPH.
The Weld County Department of Public Health and Environment has established written
agreements in place with the following organizations:
> North Colorado Family Medicine(provides prenatal care services for low-income
women and primary health care)
> North Colorado Medical Center for Med-Aid Contract(provides one-time assistance
for prescription medications for acute medical conditions)
> University of Northern Colorado (provides educational experiences for nursing,
community health, and dietetic students)
> United Way of Weld County for the Community Child Health Plan Plus Advocate.
(advocate will assist individuals and agencies with the enrollment of eligible children
into the Child Health Plan Plus)
> Weld County Food Bank(assist families with an emergency food box and/or
supplemental food)
Informal agreements and referral relationships exist between Weld County Department of
Public Health and Environment and the following agencies:
> A Woman's Place(shelter for abused women and their children)
> Aims Community College(high school graduation program for first-time teenage
mothers, child birth classes,boot camp for dads)
> Amend(a treatment group for abusive men and their partners)
> Board of Cooperative Education Services (BOCES) (provides screening and
developmental services for children from birth through school age)
> Breast Feeding Task Force(promotion for the initiation and duration of breast
feeding)
> Bright Beginnings (home visitation program for all new parents in Weld County)
> Catholic Charities (emergency funds to assist families with gas,utilities and shelter)
> Centennial Developmental Services Inc. (CDSI)(identification and intervention for
children and adults with developmental disabilities)
> Child Advocacy Resource Education (CARE)(parenting classes and support)
> Clothing Resources, Seventh Day Adventist Church, the Light and Life Church,
Salvation Army (provide holiday food baskets, gifts, clothing, furniture and carseats)
➢ Colorado Medicaid Presumptive Eligibility(Medicaid coverage during the
determination of eligibility)
> Colorado Migrant Health Program (health screening and education to the migrant
population)
> Colorado Rural Legal Services (legal assistance for the indigent)
11
> Connections for Independent Living(provides support and housing for disabled
adults)
> Department of Human Services, Family Education Network of Weld County/Head
Start(education and health services)
> Department of Human Services, Employment Services of Weld County Work Force
Center(workplace training and instruction,job readiness training,welfare to work
program and educational assistance)
> Department of Social Services(assist with food stamps, TANF services, child
protection and child care services)
> First Steps of Weld County (prenatal plus case management for high-risk
pregnancies)
> Friends of Man(provides funding for the purchase of eyeglasses,medications,
wheelchairs,prostheses,etc. for needy children and adults)
> Greeley Housing Authority(assistance with application process to provide families
the opportunity for low-income housing)
> Greeley Police and Weld County Sheriff Department(provide carseat and seatbelt
education, intervention for domestic violence and child abuse)
> Greeley Transitional House (temporary shelter for families)
> Guadalupe Center(homeless shelter)
> Island Grove Regional Treatment Center(provides alcohol and drug treatment)
> LEAP, Department of Social Services (assists indigent families with their heating
bills)
> Monfort Children's Clinic (provides health care for indigent children)
> North Colorado Medical Center(regional medical center that provides inpatient
health care to the community)
> North Range Behavioral Health (mental health services provided on a sliding fee
scale)
> Right To Read (adult literacy program)
> Rocky Mountain Planned Parenthood (provides full range of family planning
services)
> RVNA(home health care agency)
> Salud Community Health Center Ft. Lupton(Federally funded community health
center in south Weld County that provides primary health care to the indigent)
> School District Six(Trademark alternative high school and Dream Team)
> Suicide Education Support Services(community suicide education and support)
> Sunrise Community Health Center(Federally funded community health center
providing primary health care to the indigent in the Greeley and outlying region)
> Weld County Transportation (provides transportation from outlying regions in the
county to Greeley or Ft. Lupton for county services)
> Women, Infant and Children(WIC) (nutrition and education for women, infants and
children)
Monfort Children's Clinic
The Monfort Children's Clinic provides complete medical care for children, teens and
young adults through age 21. Clinic staff conduct well child exams, school physicals and
12
sports physicals. Clinic staff also treats children with life-long medical problems. The
Clinic's bilingual and bicultural staff cares about each child and will do whatever they
can to help children get the care they need.
Children may qualify for services at Monfort Children's Clinic if family income is under
$2,600 per month(or$31,500 per year) for a family of four. The Clinic accepts
monolingual Spanish families regardless of income. Clinic staff assists families in
enrolling in programs like Medicaid,the Child Health Plan Plus, and the Colorado
Indigent Care Program.
Monfort Children's Clinic has established written agreements in place with the following
organizations:
> A Kids' Place(for whom Monfort Children's Clinic conducts sexual abuse
examinations)
> Colorado State University(social work interns)
> North Colorado Family Medicine(places family practice residents at the Clinic in
exchange for admitting and following Clinic patients admitted to North Colorado
Medical Center)
> North Colorado Medical Center Pediatric Rehabilitation(conducts OT,PT, speech
and language therapy and other therapies for Clinic patients)
> North Range Behavioral Health (places a mental health counselor in the Clinic
facility to work with Clinic patients)
> Sunrise Community Health Center(offers dental services to 300 children per month
on site in the Clinic)
> The University of Northern Colorado (owns a hearing sound booth in the Clinic and
provides audiology specialists to conduct hearing tests on Clinic patients)
> United Way of Weld County(coordinating a partnership of CHP+providers in the
community with the intention of increasing enrollment.)
Informal agreements and referral relationships exist between Monfort Children's Clinic
and the following agencies:
> Aims Community College(family and life education,nursing students)
> Alternative Homes for Youth(individual,group,family therapy, health assessments
and treatment)
> American Cancer Society (educational materials and program support)
> American Lung Association Asthma Camp(educational and recreational camp for
children with asthma)
> Autism Support Group(support and education for families with autistic children)
> Boy Scouts of America, Longs Peak Council (physicals)
> Boys and Girls Club(referrals and camp physicals)
> Centennial Development Services, Inc. (identification of developmental problems)
> Child Advocacy Resource Education (child abuse identification, parent training and
support)
> Colorado Migrant Health Program(outreach program and referrals)
> Crisis Pregnancy Center of Northern Colorado (testing, counseling,resources and
referrals)
13
> The Greeley Dream Team, Inc. (adolescent education and support)
➢ EPSDT(Medicaid referral and enrollment)
> Family Connects (identification of developmental delays and other problems of
development)
➢ Family Education Network of Weld County—Head Start(education and health
services)
> First Steps of Weld County(prenatal case management referrals)
> Greeley Transitional House(shelter, self-sufficiency case management)
> Greeley Youth Net/Youth Initiative(information and referral)
> Island Grove Regional Treatment Center(education, evaluations and treatments)
> Val Kailassam,MD(volunteer allergist)
➢ Kiwanis Club of Greeley(immunization program support)
> Local Law Enforcement agencies(referrals for sexual abuse examinations and car
seats)
> Med-Aid(provides prescription drugs to medically indigent)
➢ Medicab(medical appointment transportation for disabled)
➢ NCMC Lifetime Wellness (health education and wellness services)
> North Colorado Medical Center(lab services, supplies, computer and other support
services,referrals and admissions)
> Reach Out and Read(program support)
> Real Aloud Greeley(reading awareness and support)
> Regis University(nursing students)
> Sunrise Community Health Center(program support and referrals)
> The Children's Hospital(cardiology,neurology,pediatric rehabilitation and genetics
clinics)
> University of Colorado Health Sciences Center(medical and dental students)
> University of Denver(social work interns)
> University of Northern Colorado(nursing students, nurse practitioner students,
community health education students)
> Weld County Department of Public Health (immunization and other specialty clinics
and services,referrals for teen pregnancy
> Weld County Department of Social Services(Medicaid,Medicare, child protection,
managed care support referrals and program collaboration)
> Weld County School District 6(health education)
> Weld Opportunity School(adolescent education and support)
> WIC(food and nutrition for women, infants and children)
Sunrise Community Health Center
Sunrise Community Health Center is a federally qualified health center and provides
comprehensive primary medical and dental care to predominantly low-income families
without a regard for their ability to pay for services. Staff includes board-certified family
physicians,physician assistants, nurse practitioners,dentists and a diabetic educator.
Sunrise Community Health Center has established written agreements in place with the
following organizations:
14
> A Woman's Place: for whom Sunrise Community Health Center conducts sexual
abuse examinations
> Colorado State University: Social Work and Nutrition Interns
> North Colorado Family Medicine: Alternate training track for three family practice
residents
> North Colorado Medical Center: laboratory, radiology, inpatient and CICP
reciprocity
> North Range Behavioral Health: Places a Mental Health Counselor in the clinic
facility to work with clinic patients
> Monfort Children's Clinic: Sunrise manages on-site pediatric dental services
> The University of Northern Colorado: On-site hypertension identification and control
program
> United Way of Weld County: Coordinating a partnership of CHP+providers in the
community with the intention of increasing enrollment.
> Weld Food Bank: On-site food distribution to Sunrise patients.
> Weld County Head Start: Medical and Dental services for Head Start and Migrant
Head Start students
> Weld County Med-Aid Program: prescription medications for uninsured persons.
➢ EPSDT: Medicaid referral and enrollment
Informal agreements and referral relationships exist between Sunrise Community Health
Center and the following agencies:
> Aims Community College: family and life education,nursing students
➢ American Cancer Society: smoking cessation educational materials and training
> Autism Support Group: support and education for families with autistic children
> Centennial Development Services, Inc.: Identification of developmental problems
> Child Advocacy Resource Education: child abuse identification,parent training and
support
> Crisis Pregnancy Center of Northern Colorado: testing,counseling,resources and
referrals
> Family Connects: identification of developmental delays and other problems of
development
> First Steps of Weld County: prenatal race management referrals
> Greeley Transitional House: shelter, self-sufficiency case management
> Island Grove Regional Treatment Center: education,evaluations and treatments
> Local Law Enforcement agencies: referrals for sexual abuse examinations and car
seats
➢ Medicab: medical appointment transportation for disabled
➢ NCMC Lifetime Wellness: health education and wellness services
> University of Colorado Health Sciences Center: medical, dental,nurse practitioner
and physician assistant students
> University of Northern Colorado: nursing students, nurse practitioner students,
community health education students
> Weld County Department of Public Health: referrals to and from immunization
clinics, well-child clinics, family planning clinics, and prenatal clinics
15
> Weld County Department of Social Services: Medicaid, Medicare, child protection,
managed care support referrals and program collaboration
> King Sooper's Pharmacy: management of pharmacy services and manufacturer's Free
Medications Program.
North Colorado Family Medicine
North Colorado Family Medicine is a family practice residency training program
sponsored by North Colorado Medical Center. It has operated in the community since
1974 and offers full-spectrum primary care. Staff includes an interprofessional faculty of
board-certified family physicians, family nurse practitioners, licensed professional
counselors, a women's health practitioner and a doctor of pharmacy. Family practice
residents and family nurse practitioner students also provide medical care to patients
under the supervision of faculty. In 1999,the clinic had 53,000 visits for medical care.
North Colorado Family Medicine has formal agreements in place with the following
organizations:
> Monfort Children's Clinic: clinical teaching by staff pediatrician in exchange for
accepting hospital admissions from the Clinic.
> Sunrise Community Health Center: teaching site for three family practice residents
and 0.5 FTE of funded faculty support to coordinate the teaching site.
> Weld County Department of Public Health and Environment: medical consultation
and colposcopy services.
> North Colorado Medical Center: clinical laboratory and diagnostic radiology services.
> Insurance companies: health care contracts.
> University of Northern Colorado School of Nursing: nurse practitioner students and
paid nurse practitioner faculty support.
> University of Wyoming School of Pharmacy: doctoral students
Informal agreements and referral relationships exist between North Colorado Family
Medicine and the following agencies:
> Centennial Development Services, Inc.: Identification of developmental problems
> Child Advocacy Resource Education: child abuse identification,parent training and
support
> Greeley Transitional House: shelter, self-sufficiency case management
> Island Grove Regional Treatment Center: education,evaluations and treatments
> MediCab: medical appointment transportation for disabled
> North Colorado Medical Center's Lifetime Wellness Program: health education and
wellness services
> University of Colorado Health Sciences Center: medical students
> Weld County Department of Public Health: referrals to and from immunization
clinics,well-child clinics, family planning clinics, and prenatal clinics
> Weld County Department of Social Services: Medicaid, Medicare, child protection,
managed care support referrals and program collaboration
> Weld County Med-Aid Program: prescription medications for uninsured persons
16
United Way of Weld County
United Way of Weld County is a key community agency not only for its fundraising
activities but also for its assistance and leadership in community problem solving and
program planning. The agency coordinates many of the community's service
organizations targeting the population of interest to the Nurse Home Visitor Program.
Under the grant United Way would coordinate the community agency staffing component
of the program that is critical to meaningful collaboration between home visitation and
case management agencies. United Way will assist in integrating the visiting nurses from
this new program into the existing community staffing meetings. Through this
mechanism referrals will be coordinated and avoid potential duplication of services while
also finding the agency best suited for that individual client's needs and risks.
United Way supports many community activities targeting a wide population. Programs
receiving financial support from United Way and directed at young women and families
are listed below.Agencies that address the unique needs of the elderly population are
excluded from this listing. Programs are categorized into major focus areas. These
agencies would serve as important referral sources and targets for the Nurse Home
Visitor Program.
• HELPING CHILDREN AND STRENGTHENING FAMILIES
A KID'S PLACE(AKP)
Executive Director: Teresa Huizar-Humes
D. A Kid's Place is an assessment center that offers a safe, child-friendly location
when victims of abuse are interviewed. This reduces trauma to children.
D. CASA trains community volunteers to advocate for the best interests of abused
and neglected children in the court system and for timely case resolution
BRIGHT BEGINNINGS
Coordinator: Sheila Avers
➢ Bright Beginnings Warm Welcome volunteers visit their neighbors who are
parents of new infants and provide a gift,developmental information,
community resources and ongoing support.
D. The program is directly
coordinated by United Way of Weld County.
CHILD ABUSE PROTOCOL PROJECT
CONTACT: Judy!Cron
➢ A coalition of professionals, facilitated by United Way to develop and update a
written document outlining the rules,procedures, standardized reporting
process,and communication between parties handling child abuse in Weld
County.
➢ The Protocol Project is a training component to assure professionals
are familiar with current requirements.
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CHILD ADVOCACY RESOURCE AND EDUCATION (c.a.r.e.)
Acting Director: Gwen Schooley
> Child Advocacy Resource and Education offers community education and
intervention regarding parenting issues and child abuse prevention to
individuals, groups or families.
> Programs are presented in a multi-modal form.
CHILD CARE SUBSIDY PROJECT/FAMILY SUPPORT NETWORK
> The Child Care Subsidy Program assists low-income working families with
child care needs for a temporary time period that helps move them toward
dependence and productivity and resource referrals for employees in the area
of child and elder care.
> The program is directly coordinated by United Way of
weld County.
> The Family Support Network works with the business community to develop
family friendly workplaces,through consultation, support and education. The
program contracts with employers to provide child care subsidy to employees
The program is directly coordinated by United Way of Weld County.
CHILD CARE SUBSIDY PROJECT/FAMILY SUPPORT NETWORK
> The Child Care Subsidy Program assists low-income working families with
child care needs for a temporary time period that helps move them toward
dependence and productivity and resource referrals for employees in the area
of child and elder care. The program is directly coordinated by United Way of
weld County.
HIGHLAND DAY CARE CENTER
Executive Director: Marilyn Fuqua
> Highland Day Care Center provides child care services to families in north
Weld County. Programs include infant and toddler care, preschool, full/half day
child care and school-age care.
PRO BONO MENTAL HEALTH PROGRAM OF WELD COUNTY
Program Director: Roger Pranke
> The North Range Behavioral Health Pro Bono Project is a program that
provides pro-bono mental health counseling for children and families who have
no other resources.
CHILD CARE RESOURCE AND REFERRAL
Program Director: Rudy Pisano
> Child Care Resource and Referral Services offers a single entry,
comprehensive referral service which provides child care referrals to parents
based on type of care, age of child(ren), location, and schedule.
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• KEEPING YOUTH ON TRACK
BOY SCOUTS, LONGS PEAK COUNCIL
Scout Executive: Reed Brannon
Weld Executive: Mario Gonzales
> Through experiential learning, Scouting helps youth develop essential skills
and personal characteristics, such as self reliance, leadership,responsibility,
self-esteem and initiative,that will last a lifetime.
BOYS AND GIRLS CLUBS OF WELD COUNTY
Executive Director: Carey Bryan
> Boys and Girls Clubs serve primarily disadvantaged youth 6-18 years old after
school,on Saturdays, and throughout summer. These youth are served through
activities dedicated to educational, social,health,citizenship,vocational and
leadership development.
EATON BASEBALL PROGRAM
Board President: Dale Souther
> The Eaton Baseball Program provides a meaningful experience for youth age
6 to 18 through baseball and softball instruction as well as recreational and
competitive games.
FORT LUPTON RECREATION PROGRAM
Recreation Director: Paul Piper
> The Fort Lupton Recreation Program provides a healthy, instructional and
enjoyable environment for young athletes. Volunteer coaches are an essential
part of the program. The program uses youth within the community for
officiating and umpiring to provide local youth employment opportunities.
GIRL SCOUTS, MOUNTAIN PRAIRIE COUNCIL
Executive Director: Kay Stevens
> Girl Scouting is a program of contemporary and traditional activities based on
leadership,values and diversity open to all girls ages 5 to 17.
HIGHLAND RECREATION PROGRAM
Office Manager: Tammy Osborne
> Highland Recreation Program provides youth,kindergarten through 8th grade,
with recreational programs which foster physical,emotional, and social
development.
KERSEY RECREATION PROGRAM
Recreation Director: Dawn Schrader
> Kersey Recreation Program provides the community with recreational
programs such as dance, arts and crafts, karate,basketball, baseball, soccer,
swimming, and various special interest classes.
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LASALLE RECREATION PROGRAM
Recreation Director: Charlotte Bond
> LaSalle Recreation Program is a program serving youth ages 4 to 18, in the
community and surrounding rural areas. The program includes activities such
as baseball, softball, soccer, flag football,volleyball,and basketball.
THOMPSON RIVERS RECREATION PROGRAM
Recreation Director: Laura Wilson
> Thompson Rivers Recreation Program provides recreational programs such
as baseball, soccer, basketball, and other activities for youth in Johnstown and
Milliken.
WELD COUNTY PARTNERS
Executive Director: Michael Muskin
> Partners provides programs for at-risk youth, including one-to-one mentoring
with adult volunteers,Esperando activity program, and Juvenile Restitution
Project.
WINDSOR RECREATION PROGRAM
Recreation Director: Don Shedd
> Windsor Recreation Program provides a wide variety of leisure activities for
area residents of all ages. These activities include sports teams and
instruction and cultural activities.
• ASSISTING PEOPLE THROUGH CRISIS
A WOMAN'S PLACE
Executive Director: Sharon Mitchell
> A Woman's Place is a domestic violence program assisting victims and their
children with safe shelter, 24-hour crisis line, individual/group counseling,
legal/personal advocacy, support services. Services are available in Greeley
and Ft. Lupton.
AMERICAN RED CROSS,FRONTIER BRANCH
Executive Director: Linda Glendenning
> American Red Cross helps the community prevent,prepare for, and cope with
emergencies on a 24 hour basis. These services are directed by volunteers.
GREELEY TRANSITIONAL HOUSE
Executive Director: Linda Akers
> Greeley Transitional House provides shelter, food, case management to
homeless families.
> It offers a supportive environment in which families in crisis
can live temporarily while reestablishing their independence.
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GUADALUPE SHELTER-CATHOLIC CHARITIES NORTHERN
Executive Director: Ernest Giron
> Guadalupe Center provides emergency shelter,meals and case management
services for homeless families and individuals. In this safe,caring environment,
homeless people are assisted in breaking the cycle of poverty and moving
toward self-sufficiency.
SUICIDE EDUCATION& SUPPORT SERVICES OF WELD COUNTY
Executive Director: Linda Chase
> Suicide Education& Support Services provides free educational
presentations,training and support services to the communities of Weld
County in the areas of suicide prevention, intervention and postvention.
WELD COUNTY LEGAL SERVICES
Administrator: Anne Williams
> The purpose of Weld County Legal Services is to encourage lawyers living and
working in Weld County to provide legal services to the poor and to coordinate
and otherwise assist in the provision of these services.
WELD FOOD BANK
Executive Director: Leona Martens
> The Weld Food Bank works to alleviate hunger and reduce food waste by
providing an efficient,centralized system for collecting, storing, and distributing
food..
CATHOLIC CHARITIES NORTHERN-EMERGENCY ASSISTANCE
PROGRAM
Executive Director: Ernest Giron
> Catholic Charities Northern provides rental assistance, utility assistance, local
bus passes and and assistance with other basic needs to help individuals and
families. Information,referral and case management services are provided to
assist people through difficult times.
• SUPPORTING HEALTH, WELLNESS& DISABILITIES
CENTENNIAL DEVELOPMENTAL SERVICES, Inc.
Executive Director: Mary Lu Walton
> Centennial Development Services,Inc. (CDSI)promotes full community
inclusion for persons with developmental disabilities residing in Weld County.
Services and support available to eligible persons and their families include
Early Intervention Services, Family Support Services,Children's Extensive
Services, Before and After School/Summer Camp Services, Adult
Comprehensive Services(specialized habilitation, community access,
employment, residential),Adult Supported Living Services, Transportation,and
Case Management.
➢ Adult Services
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> Children and Family Support
CONNECTIONS FOR INDEPENDENT LIVING
Executive Director: Beth Danielson
> Connections for Independent Living assists people with a wide range of
disabilities to make their own choices and to live full, independent lives.
ISLAND GROVE TREATMENT CENTER
Executive Director: B J Dean
> Island Grove Regional Treatment Center offers a full range of services:
prevention,crisis intervention,detoxification, evaluations, referrals, transitional
residential treatment,outpatient, and intensive outpatient services.
MED-MD PRESCRIPTION ASSISTANCE PROGRAM
Contact: Shannon Quinn
> Med-Aid Prescription Assistance Program is a partnership between United
Way of Weld County and NCMC Foundation that provides prescriptions for
qualifying clients. It focuses on children and elderly who have no other financial
means to be able to afford prescriptions.
NORTH RANGE BEHAVIORAL HEALTH
Executive Director: Dale Peterson
> North Range Behavioral Health is a comprehensive community mental health
center providing case management,treatment,social rehabilitation, vocational,
day care,residential and inpatient services to persons residing in Weld
County.
RVNA HOME CARE SERVICES
Executive Director: Crystal Day
➢ RVNA Home Care Services provides quality professional nursing,therapy,
social services,and personal care services in the comfort and safety of the
patient's own home. RVNA is a Medicare/Medicaid certified agency which
also receives reimbursement from private insurance, private pay and grants
such as United Way. The agency is nationally accredited by JCAHO.
The Weld County Department of Social Service
Social Services programs are administered under the supervision of the State and the
County Commissioners. Most regulations governing the programs are made by the
federal and state governments who in turn interpret the legislation of Congress and the
State Legislature in writing program rules.
A staff of approximately 160 caseworkers,technicians,and support personnel provides
services and determines eligibility for programs. Financial need is the main factor
measured for the Income Maintenance programs. Other needs, such as the need to protect
a child from abuse or neglect, determine whether services are provided in other programs.
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Program costs are shared by Federal, State and County and vary by category.
The Department of Social Services is responsible for administering three types of
programs for the citizens of Weld County. (I)"Protective or Social Services" programs
provide direct or intervention services for families, children and adults. (2)"Assistance
Payments"programs provide for basic survival needs-food, shelter, clothing, medical,
and job preparation. (3)"Child Support"program provides assistance in obtaining
financial and medical support from non-custodial parents.
Services to which nurse home visitor clients could possibly need referral are listed below
for the Department of Social Services. The applicant agency has existing referral
relationships with these programs through current nursing and social work services
provided out of the department.
SOCIAL SERVICES DIVISION
Protective Services to Children
Ongoing and Intake Units: Program area for the protection of battered, abused,neglected
and dependent children.Primary responsibility of this service is the protection of children
who are battered and abused, severely neglected and/or dependent. Age limits within this
program area are generally birth to 18 years of age. All cases that meet this definition will
be the responsibility of this program area and personnel assigned to it.
> Adult Services: Primary objective of this program is to provide protective services to
adults, age 18 and over,who are being exploited,abused,neglected, or are
incompetent and need supervision. This unit also provides services to the age and
disabled in assisting them with Home Care Allowance.
> Youth in Conflict: Program area for youth ages 12 to 18. This unit serves children
who are experiencing difficulty with the community or parents and require
intervention by this Department,usually through court order. Many youth have been
adjudicated as status offenders by the court,i.e.,dependent or neglected or juvenile
delinquents. The goal of this unit is to assist the youth in making the best possible
social adjustment with parents and society.
> Resource Services: This unit provides resource/support services to other unit
previously described. Support services in this area are Family Preservation/Family
Support programs, adoption and relinquishment services, and foster care
certifications.
> Adoption Services: Services for the subject child(ren)of Dependency/Neglect action
who has been legally freed for adoption. Services extend to pre and post finalized
adoptive parents including application process,home studies, and supportive services.
> Foster Care Certification: Services include recruitment, application processing,
orientation, certification, support, monitoring, and ongoing training of County foster
homes.
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ASSISTANCE PAYMENTS DIVISION
> Assistance Payments assists the elderly, the disabled, children and their caretakers.
The Food Stamp program assists those who are also employed but do not earn enough
to support their families.
> Any request for financial help or income maintenance assistance requires that certain
criteria of eligibility, or need,must be met. Once eligibility is established,
redetermination of continuing eligibility is made periodically or whenever a client's
personal situations change. Generally, an applicant is determined eligible or"needy"
if their resources and income fall below established standards.
> Assistance may be granted to the elderly under the Old Age Pension program, to the
disabled under the Aid to the Needy Disabled program,to the Blind under the Aid to
the Blind program,to children under the Temporary Assistance to Needy Families
(TANF)program. The Weld County General Assistance Fund may assist persons in
emergency situations whose needs are not met by these Assistance Payments
Programs.
> Aid to the Needy Disabled(AND): The Aid to the Needy Disabled program assists
persons with physical or mental impairments that prevent self-support. This program
is administered and financed in conjunction with the Social Security Income program
(SSI). Determination of eligibility for SSI is made by the Social Security
Administration. The Department's AND program supplements SSI payments to the
recipient. For those applicants who are at least 18 years of age with short-term
disability, final determination of medical disability to qualify for the Department's
AND program is made based on medical examination by local doctors.
> Aid to the Blind(AB): The Aid to the Blind program provides financial assistance to
those persons who are at least 18 years of age and who are legally blind. This
program is also administered and financed in conjunction with the Social Security
Administration's Supplemental Security Income program (SSI)and eligibility for SSI
is determined by the Social Security Administration. The Department also offers
medical treatment to clients to prevent total blindness.
> Old Age Pension(OAP): The Old Age Pension program provides financial and
medical assistance to Colorado residents who are in need and have reached the
minimum age of 60.Nursing Home Care is also provided under the Old Age Pension
program.
> Home Care Allowance: This program provides additional funds to financially eligible
clients to allow them to pay a provider to assist them with non-skilled services they
are unable to accomplish themselves due to disability. Examples of these types of
services would be housekeeping, laundry, meal preparation, and grocery shopping.
> Home Community Based Services(HCBS): This program provides full Medicaid for
long term care. It is designed for people who are at risk of nursing home placement
due to their health and desire to remain at home or in an assisted living facility.
> Nursing Home Care: Medicaid is available to provide assistance with the cost of
nursing home care. Applicants must qualify both medically and financially for the
program. Resource limits vary depending on marital status, number in family
receiving public assistance, and the first continuous period of institutionalization.
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D. Estate Recovery: Estate Recovery is a federally mandated program to help pay for
medical costs for the increasing number of people in need of care. The Colorado
Department of Health Care Policy and Financing recovers medical care costs from the
estates of certain former recipients.
D. Programs for Medicare Beneficiaries: Income guidelines change in mid March every
year. Recipients must be eligible for Medicare Part A.
Family and Children Categories
D. Colorado Works in Weld County-Temporary Assistance to Needy Families(TANF):
The Colorado Works in Weld County Program provides temporary financial and/or
medical assistance to households with children. Income maintenance payments vary
according to the size of the family and the income of the parents. The goal of the
TANF program is to assist individuals in becoming self-sufficient and/or return to the
work force as soon as possible. Collaboration and coordination with the Job Services
and other community agencies provide immediate employment,training, and other
support opportunities to individuals applying for or receiving TANF benefits.
➢ Child Care/Day Care: The Child Care Program's mission is to provide families with
financial assistance for child care to their choosing;to provide families with timely
and efficient access to quality child care;and to assist families in meeting their self
sufficiency goals by providing referrals to needed support services.
➢ Baby Care/Kids Care: The Baby Care and Kids Care Program provides Medicaid
benefits to pregnant women and children born after September 30, 1983. Eligibility is
based on income and resources as are other categorical programs but the income
guidelines are considerably higher. The objectives of this Medicaid program is to
make sure adequate health care is available to children and hopefully set the state for
a healthy adult population.
D. Low Income Energy Assistance Program(LEAP): The Low Income Energy
Assistance Program provides for assistance with heating costs for low-income
households from November through April. Assistance may also be available through
LEAP for emergency utility shut off situations and heating or furnace repairs.
General Programs:
➢ Food Stamps: The Food Stamp program is sponsored by the United States
Department of Agriculture to provide better nutrition and increased food purchases
power for low income families. The amount of stamps issued is determined by the
amount of income and expenses during the certification period.There are also
resource or asset limitations that are applied to determine eligibility.
➢ Fraud: Experienced investigators employed by the Department evaluate complaints
from the public which allege that recipients are fraudulently receiving assistance. If
evidence is sufficient, appropriate action is taken to establish the recovery of funds
expended and/or referrals are made to the District Attorney for prosecution.
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CHILD SUPPORT
The Department makes an intensive effort to obtain financial and medical support from
non-custodial parents no matter where they may be located. It works in close cooperation
with the County Attorney's Office in obtaining court ordered child support when
necessary. The Child Support Unit is responsible for the following functions:
> Establishment: The goal of the Child Support Enforcement office is to have an
enforceable order in each case. Some cases will already contain an order from a
previous action, e.g., divorce. In most situations, however,there will not be a court
order for child support.
> Paternity: A paternity case is handled much like an establishment case,except that
paternity has not been determined. Some alleged fathers will admit paternity and will
voluntarily sign a stipulation. Some will not voluntarily acknowledge paternity and
will request that genetic testing be done.
> Enforcement: The goal of the enforcement unit is to collect from absent parents who
have been ordered to pay child support.
The Weld County Department of Human Services
Employment Services of Weld County is an integrated system that offers meaningful
employment and training programs and services as feasible. The major programs
administered are the Workforce Investment Act Program for adults, dislocated workers,
and youth;basic labor exchanges under the Wagner-Peyser Act; Welfare to Work;
AmeriCorps; Youth Crime Prevention and Intervention programs; the Employment
components for the Colorado Works in Weld County;and the Employment First Food
Stamp Job Search Program.
Each unit supports different programs and functions. These units and the staff would be
responsible to help implement the recruitment of clients for the Nurse Home Visitor
Program and for effective interagency referrals.
Employment Services would support this program through outreach during its
recruitment process for its youth programs and its other subsidized programs.
Employment Services would also inform clients of the services available under the Nurse
Home Visitor Program.
The Family Educational Network of Weld County(FENWC)is a department of the Weld
County Department of Human Services. FENWC's mission is to provide children and
families with a high quality,comprehensive program which promotes self-esteem, fosters
social and educational competence, develops independence, and enables children and
families to be lifetime learners and responsible, valued members of the community.
FENWC is a comprehensive early childhood development program. FENWC has been
serving in Weld County and surrounding counties for over 25 years. The population
served is low-income children and families with or without special needs. Head Start
Program areas include education and early childhood development,health,mental health,
26
disabilities and parent involvement. Head Start services families in Greeley, Gilcrest,
Platteville, Frederick, and Hudson during nine months of the year in half day session and
two full-day,full-year sessions. The Migrant Head Start Program services families furing
four months of the year in Greeley, Fort Morgan, Frederick, Olathe, and Grand Junction.
The Department of Human Services has established collaborations in the following areas:
Nutrition/Food
> Weld County School District 6(Greeley/Evans)
> Weld County School District RE-1 (Gilcrest/Platteville)
> St. Vrain School District RE-1J(Frederick)
> Weld County School District RE-3J (Hudson)
> Weld County School District RE-5J(Milliken)
> Child Adult Care Food Program/USDA(All sites)
Colorado Preschool Project
> Weld County School District RE-1 (Gilcrest/Platteville)
> Weld County School District RE-3J(Hudson)
> Weld County School District RE-5J(Milliken)
Disabilities Services
> Board of Cooperative Educational Services (Milliken/Gilcrest/Platteville, Eaton,Ault,
Pierce)
> Weld County School District RE-3J(Hudson)
> North Colorado Medical Center(Greeley, Frederick, Fort Morgan)
Mental Health Services
> North Range Behavioral Health (All Head Start and Migrant Head Start sites in Weld
County and Fort Morgan)
Health Services
> Plan de Salud del Valle Community Health Center(Frederick/Hudson)
> Colorado Department of Health and Environment Farm Worker Health Program
(Entire migrant catchment area)
> Sunrise Community Health Center(Greeley/Milliken)
The Greeley Dream Team, Inc.
The Greeley Dream Team is a not-for-profit agency dedicated to serving low-income and
first generation families in School District 6 since 1987. Students and families are served
through a number of programs that are funded by a variety of sources. Assistance is also
provided through established collaborations with the University of Northern Colorado
and Aims Community College. Projects under the umbrella of the The Greeley Dream
Team include:
> Educational Talent Search Program—serving 750 students in grades 6-12
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> McKinney Homeless Project—a Weld County District 6 program contracted to the
Dream Team
➢ YCPI Leadership—a program serving students in one of the district's alternative
schools
> Family Visits for the Foster Care—a program at the Weld County Department of
Social Services that is funded through the Families, Youth and Children Commission
Referral Sources
The Weld County Department of Public Health and Environment has well-established
relationships with many agencies currently serving low-income mothers-to-be and their
families. These relationships extend beyond serving together on community coalitions
and task forces. Work integration occurs in several areas with the Department of Social
Services, the Department of Human Services,North Colorado Family Medicine,Monfort
Children's Clinic, Sunrise Community Health Center and the United Way of Weld
County CHP+Collaborative. In addition to building upon the existing strong interagency
relationships a Community Advisory Board is proposed in this application. The advisory
board would provide oversight of the collaborative effort and assist in holding the
department, its director, and program staff accountable to the community. The advisory
board would be constituted with 8-10 community representatives from the leading
collaborative agencies and at least one representative from the target population. This
advisory board would meet monthly during the implementation phase of the program and
then quarterly thereafter. Examples of service and referral integration and collaboration
are detailed in the following pages.
Perhaps the closest working relationship between the applicant agency and other
community resources has been with providers of prenatal care and pregnancy case
management. There are three main providers of prenatal care to low-income women in
the county in addition to the Department of Public Health and Environment: Sunrise
Community Health Center,North Colorado Family Medicine,and Plan de Salud del
Valle. The largest single provider of prenatal services to low-income women in the
county is Sunrise Community Health Center. They have actively provided prenatal care
to the community since opening in the early 1970s. The applicant agency has had
established referral patterns with Sunrise for over 25 years.
North Colorado Family Medicine is the next largest provider of comprehensive
pregnancy services to low-income women in Weld County. With the transition in 1998
of the clinical components of the county's own maternity program to North Colorado
Family Medicine, entry into prenatal care for low-income women was streamlined.
North Colorado Family Medicine has provided medical consultation and back up to the
applicant agency since 1974. The transition of services to North Colorado Family
Medicine was facilitated by the applicant agency continuing to employ the clinical staff
for over a year after the services had been moved off site. Even with this assistance and
the contract for services, North Colorado Family Medicine sustains a net operating loss
for this program of$50,000 - 100,000 annually in addition to donating$15,000 of in-kind
services. North Colorado Family Medicine also continues to provide medical
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consultation to the Department of Public Health through on site consultation clinics and
colposcopy services.
In addition to contractually providing the county's clinical maternity services,North
Colorado Family Medicine provides intrapartum and delivery services to nearly all low-
income women delivering at North Colorado Medical Center. These services are
provided to Sunrise Community Health Center through a long-standing agreement
between the two clinical entities. An excellent working relationship has existed between
Sunrise, Family Medicine and Public Health for the last 25 years and has facilitated
access to pregnancy services by most of the county's low-income population. In 1999,
North Colorado Family Medicine provided services to over 900 women seeking
pregnancy-related care.
Plan de Salud del Valle operates health centers in seven communities throughout northern
Colorado,two of which are in Weld County. As with the other clinics listed above
prenatal care is offered in addition to comprehensive primary care services to low-income
families. Plan de Salud has worked closely with the applicant agency in southern Weld
County with both agencies having offices in Fort Lupton. In addition to established bi-
directional referral patterns for maternity care,Plan de Salud has been active in the Weld
Immunization Coalition and other collaborative efforts.
Sunrise Community Health Center,North Colorado Family Medicine and Plan de
Salud—all providers of comprehensive primary care services to low-income families—
would play key roles as referral sources and linkages for health care. Both formal and
informal agreements are in place between the applicant agency and these health care
centers. From one site alone it is estimated from 1999 data that nearly 300 first-time low-
income mothers-to-be would be identified for possible referral into the Nurse Home
Visitor Program.
Another community asset with which the applicant agency has a close relationship is the
North Colorado Medical Center Foundation's Monfort Children's Clinic. Since opening
its doors following a huge outpouring of community support through fundraising to build
the facility, Monfort Children's Clinic has worked aggressively to meet the medical,
dental, social and educational needs of low-income children in and around Greeley. The
Children's Clinic and the applicant agency have worked collaboratively on issues of
immunization,prenatal care, adolescent health and children with special needs. Well-
established mechanisms for bi-directional referrals have been in place for five years
between the Children's Clinic and the applicant agency.
All of the health care clinics listed above are committed not only to successful
implementation of the Nurse Home Visitor Program but also to positively affecting the
indicators of well-being for women and children in Weld County. Executive Directors
from three of the health centers have served together for five months on the Primary Care
Access Group investigating community solutions to better meet the access to health care
needs of low-income families. Joining these directors in addressing these community
29
concerns are representatives of North Colorado Medical Center and the Department of
Social Services.
North Colorado Medical Center will also be a source of referrals to the visitor program.
The medical center's care coordination team,directed by Jeff Abbett, RN, has worked
closely with staff of the applicant agency for several years to meet the health care needs
of low-income families. With many of the more than 2,000 women delivering each year
accessing antepartum services at the medical center,the hospital's care coordinators
would be additional sources of referrals into the program. The leadership of the medical
center is committed to supporting the successful implementation and effective referral to
the Nurse Home Visitor Program.
United Way of Weld County,and its many supported agencies,would also be key referral
sources for the Nurse Home Visitor Program. United Way currently coordinates a twice-
monthly community agency staffing where collaboration in making referrals is facilitated
between the agencies providing home visitation and case management services. The
applicant agency and United Way are joining with a community-wide collaborative to
increase enrollment in the Child Health Plan Plus. The Director of Community Problem
Solving and Programming for United Way of Weld County has committed to integrate
the Nurse Home Visitor Program staff into the community agency staffing. This would
facilitate the coordinated referral of clients into the program.
Internal referrals to the program will be generated from the EPSDT staff already working
in the applicant agency. Program staff is required to contact all Medicaid-eligible clients.
With the reorganization of programs within the lead agency to place EPSDT and
Presumptive Eligibility services under the same supervision internal referrals between
these programs will be facilitated.
The director of the applicant agency is also an elected official serving as the President of
the Board of Education for the school district with the largest student enrollment in the
county. In addition,he also serves as a director from Region 4 on the Board of Directors
of the Colorado Association of School Boards. Region 4 represents most of the school
districts in Weld County. The applicant agency has worked effectively with many of the
school districts in the county on immunization,well-child,children with special needs,
tobacco prevention,driver's education and abstinence programming. Schools have been
represented on the Teen Pregnancy Task Force since it began meeting to address the high
rate of teen pregnancy in Weld County. Weld County School District 6 would be a key
agency in making referrals of low-income teens pregnant for the first time.
Effective working relationships have existed between the referral sources as listed above
for many years. The limiting factor impacting the ability of these agencies to positively
affect the indicators of well being of women and children in Weld County results not
from a lack of cooperative effort but from inadequate funding to implement programs
with sufficiently intense interventions. The Nurse Home Visitor Program would be an
opportunity for the community to demonstrate that with additional training, staffing and
funding, a real difference could be made in the health and welfare of low-income first-
30
time mothers and their children. These participating agencies each serve a high enough
volume of low-income mothers and children that recruiting 100 participants will not be
the issue. The challenge, instead, will be to avoid flooding the program with participants
as soon as it becomes operational.
Referral Linkages
Service integration and referral coordination between the applicant agency and the
Department of Social Services has become well-established during the last decade and
includes:
> Placement of an EPSDT worker from the applicant agency on site at Social Services.
> Location of a Medicaid outstation worker at the Department of Public Health and
Environment.
> Family Bonding program referrals and collaborative home visits between the
applicant agency and Social Services.
> Interagency cooperation with Medicaid and the Health Care Program for Children
with Special Needs.
> Assistance by the applicant's social worker with food stamps, T.A.N.F. services,
housing assistance, child protection and child care services as needed by clients of
the lead agency.
The Department of Human Services is an important agency in this proposal because of
the programming that it currently provides to low-income families. The applicant agency
has established referral patterns with both the Family Educational Network of Weld
County and the Employment Services of Weld County. These agencies, operated by the
Department of Human Services, exchange referrals with the applicant agency in the areas
of Health, Dental and Nutrition; Family Partnership; and Parent Involvement
programming. The Department of Public Health and Environment has also referred
clients to Human Services for remedial education and employability skills training while
accepting trainees into the various divisions of the department for Welfare to Work
training experiences.
Important interagency referral relationships between the departments of Human Services
and Public Health include:
> Temporary Assistance to Needy Families
> Food Stamp Work Program
> Welfare to Work Program
➢ HeadStart
> Family Support Program
> Children with Special Needs
The Greeley Dream Team, Inc. also serves as a referral linkage between the applicant
agency and services to help at-risk students succeed in school. Dream Team counselors
working in several schools would be important collaborators for the Nurse Home Visitor
Program. The Director of the applicant agency has the privilege of serving as member of
the Board of Directors of the Greeley Dream Team and has secured its support of the
31
Nurse Home Visitor Program as an additional asset to add to the community's
armamentarium to support successful outcomes.
Coordination with Existing Visitation Programs
Coordination of the Nurse Home Visitor Program with existing visitation programs is in
the best interest not only of resource utilization by clients but also of program acceptance
by community agencies. United Way of Weld County has agreed to expand its monthly
community staffing meetings of agencies providing home visitation and case
management services to include the Nurse Home Visitor Program staff. Client consents
would be adapted to integrate the new staff into the releases so that they would be able to
participate in the staffing. Referrals made directly to the Nurse Home Visitor Program
would be"staffed" at these once or twice monthly meetings. This process would provide
the structure for collaborative integration and allow for the appropriate triage of clients to
the program best able to meet the individual's needs. Service duplication or confusion
would also be avoided by the teams from the various programs coming together for these
staffings under the sponsorship and coordination of United Way of Weld County.
Plan for Recruitment and Retention of Nurses
All staff proposed under this grant application would be employees of Weld County in
the Department of Public Health and Environment. The department currently has over 80
people working in the various divisions and programs. Hiring Registered Nurses with a
Bachelor of Science Degree in Nursing is a standard requirement of the lead agency for
all nursing positions. The department has also successfully attracted nurses who are
Master's prepared and bilingual in Spanish. County government personnel policies
provide for standardized employment practices. Weld County is an Equal Opportunity
Employer. The department is able to write specific job descriptions for designated
positions and would do so for staff sought for this new program. In this way specific
skills, experiences and interests could be considered in recruitment efforts. The agency
has demonstrated a commitment to recruit bilingual,bicultural staff whenever possible.
Positions for Nurse Home Visitor Program staff would first be posted internally. A
number of staff has already expressed an interest in moving into the visitor program.
Positions not filled by internal candidates would then be posted in the community.
Outside agencies, including other home visitation programs,have already begun referring
potential candidates to the department. The lead agency is able to place classified ads in
local and regional newspapers to solicit applicants. Networking with University Schools
of Nursing,hospitals,clinics, local public health agencies, and the state health department
have also proven successful in the past for recruiting nursing staff.
The applicant agency has been very successful at hiring qualified nurses. Bilingual nurses
in the community have already indicated an interest in applying for the Nurse Home
Visitor positions. The department currently has four bilingual nurses on staff and this
makes it easier to recruit additional Spanish-speaking nurses because candidates know
that the agency will share workloads among bilingual staff. In addition,the department
32
has been successful at attracting four Master's prepared nurses who are presently on staff.
Cultural sensitivity has been a strong characteristic of the lead agency's recruitment
practices.
A strong collaborative relationship between the applicant agency and the University of
Northern Colorado School of Nursing has helped in recruiting nursing staff. Many of the
department's nurses are graduates of the University. The department also hosts many of
the University's nursing students on clinical rotation. These clinical rotations have strong
home visitation components affording a wonderful opportunity to expose potential
candidates to the work of the department.
The department has been fortunate in that it has not had difficulty in recruiting Bachelors-
prepared nurses. Many of the department's nurses formerly worked at the regional
medical center and were quite familiar with the population to be served even prior to
coming to work for the agency. These nurses have also found the preventative aspect of
Public Health as a very rewarding alternative to acute, inpatient care and the working
conditions much more desirable. These factors have aided the agency in its recruitment
efforts.
The turn over of nursing staff in the applicant agency is very low. Most nurses who
resign do so because of family obligations and not because of dissatisfaction with their
roles. Health Department employees are also eligible for attractive and competitive
benefits offering another incentive for staff recruitment and retention. Weld County
government also encourages and supports employees with professional growth training.
Of all agencies with the potential to support a new nurse visitor program,the applicant
agency is best positioned in the community to attract and retain qualified nursing and
support staff in a stable operating environment.
The Weld County Department of Public Health and Environment will be the lead agency
and administrative entity for the Nurse Home Visitation Program. The clinical nurse
supervisor and the data entry clerk would operate out of the department's main office in
north Greeley. Office space,desks,phones, and access to office and clinical equipment
would be available. Past experience and conversations with collaborating agencies
indicates that the best chances of successful integration will occur if visiting nurses are
deployed throughout the community at sites where clinical encounters are anticipated.
This grant proposes such a deployment of nursing staff even though all would remain
employees of the applicant agency, be supervised by the department supervisor and be
ultimately accountable to the department director.
One of the nurse home visitors would be housed at the department's main office in
Greeley with access to supplies and office space. This nurse would establish a
relationship with the staff and clients at North Colorado Family Medicine—one of the
largest providers of clinical services to pregnant women. The other three nurse home
visitors would be stationed in strategic sites around Greeley and Weld County.
33
One site would be the county's southern branch office in Fort Lupton. A new facility is
planned in southwestern Weld County and the nurse would move to this site as soon as
construction was completed. Office space and access to the county's computer network
would be available from this location. The southern Weld County population is
expanding and the Plan de Salud Clinic has a growing indigent population to service.
Outstationing a nurse at this southern location would facilitate home visits and contact
with the clinics and service agencies in that area. It would also serve to strengthen the
collaboration and coordination with Plan de Salud in Fort Lupton.
Sunrise Community Health Center in Greeley,the largest provider of prenatal services to
low-income women,would be a third location for outstationing of a nurse home visitor.
This site would facilitate coordination of services with First Steps of Weld County that
provides most of the prenatal case management for Sunrise clients. Office space and
access to telephone and supplies would be made available by Sunrise. The applicant
agency would provide,through Nurse Home Visitor grant funding, a computer and
modem access to the county computer network.
The fourth site for deployment of a nurse home visitor would be at Monfort Children's
Clinic in Greeley. The Children's Clinic is a primary health care provider for many of the
indigent children in the greater Greeley area.This site is where many of the first time
mothers would be likely to take their children for health care. Location of a nurse visitor
at this site would increase coordination of referrals to and from the many medical, dental,
educational and social support services provided on-site at the Clinic. Office space and
access to supplies would be made available by the clinic. The applicant agency would
provide,through grant funding, a computer and modem access to the county computer
network.
Grant funding is sought to provide each nurse visitor with a cell phone and cellular phone
service. Each nurse would also have a department voice mailbox and e-mail address
through the lead agency. A single central phone number in the applicant department
would be made available to community agencies to make referrals easy. The nursing
supervisor would meet regularly with the visitation staff and assist with their integration
into the department's regular staff meetings and activities.
Placement of nurse visitor program staff within the Weld County system provides for a
stable operating environment. The infrastructure to support such a program is already in
place. The health department has been in operation for over 60 years and is a credible and
accountable agency funded in part by local taxes. A physician director with a Master's in
Public Health brings added stability and expertise to the agency. Department leadership is
very committed to making this program successful and to providing support to the staff
who would be working in this program.
A critical factor in predicting success of the visitor program will be the recruitment of a
nursing program supervisor who has a passion for such a project. This application
proposes increasing the half-time Master's prepared nurse supervisor to a full time
position by reorganizing internal resources to support another 0.5 FTE. The applicant
34
agency would direct part of an existing supervisory position to create a full-time position.
Creating a full-time position might make the position more attractive and help in the
recruitment of an outstanding candidate.
Recruiting nurses dedicated to the Home Visitation Model will be essential to the
program's success. During the interview and selection process, questions would be asked
of the applicants that would identify their commitment to the integrity of the project.
Demonstration of a stable past work history, strong work ethic and excellent references
will be additional qualities important to the agency's recruitment plan.
A key role of the lead agency will be to retain valuable employees. Investing time and
money to facilitate training can help with retention. Removing barriers to successful
implementation of the program will also be important functions of program and
department leadership. It will be vital for staff to feel successful about what they are
doing. Empowering staff to meet goals and facilitating broad based community support
will help ensure the effectiveness of the program. Building in time for team building
activities and to facilitate collegial relationships with other nurse home visitors will also
increase the likelihood of successful program implementation and viability. The work of
the nurse home visitor is likely to be stressful and difficult at times. Stress management
training will help staff develop healthy coping mechanisms.
Management Information System Capabilities
The applicant lead agency already operates an integrated computer network. Nearly all
employees have computers at their workstations. Weld County has a centralized
Information System Support staff that has consistently helped the department in meeting
the computer needs of all programs in which the agency currently participates. The
agency and IS staff are experienced at implementing,working with and debugging
programs and databases. The home visitor program data and support staff requested in
this grant application will be housed in the lead agency's administrative division. This
will improve access to county IS support and other staff experienced with the
department's databases. Weld County IS staff will assist with the setup of computers and
the required program software. The applicant agency would comply fully with the
Clinical Information System requirements as specified by the National Center for
Children,Families and Communities.
Quality assurance activities will include monthly audits of compliance with program
requirements. Assurance and performance improvement activities will be built around
the Clinical Information System that is central to the data tracking and documentation
tracking. The program supervisor and support staff will coordinate these audits and nurse
visitor staff will review the results at regularly scheduled meetings. The results of these
audits will lead the team to corrective actions that will change system policies and
practices to better support compliance with program requirements. Local agency staff
will also coordinate quality assurance activities with the National Center for Children,
Families and Communities as they look at the performance of all Nurse Home Visitor
Programs in the state.
35
Quarterly reports summarizing Quality Assurance findings would be shared with the
Community Advisory Board as another mechanism to hold the collaborative of agencies
wholly accountable for successful implementation.
Collaborative Implementation Plan
Collaborative implementation and community ownership of the proposed Nurse Home
Visitor Program is a hallmark of this application. A core group representing agencies
concerned about the high rate of teen pregnancies in Weld County has been meeting
collaboratively to look at a community approach to better understanding the underlying
•
causes and to suggest possible programming solutions. The Teen Pregnancy Task Force
has looked at ways to especially target the teen population in an attempt to avoid
unplanned second pregnancies. An extensive peer advocacy program has been discussed
but funding to implement such a cooperative effort has been lacking. In addition to the
Teen Pregnancy Task Force all of the prenatal and child health providers are engaged
with each other in conversations about how to understand and address the high rate of
late entry into prenatal care and poor fetal outcome statistics plaguing our community.
The Nurse Home Visitor Program proposed in this application would place all program
staff within the Department of Public Health and Environment where ultimate
accountability and decision-making authority would rest. However, three critical actions
would form the foundation of the program's collaborative implementation. First,nurses
would be strategically deployed in partnerships with health care providers around the
county who are the primary source of care for low-income women and their children.
This will increase the likelihood of program acceptance and facilitate referrals between
the partners. As noted previously in this application,partnership placements with
Monfort Children's Clinic, Sunrise Community Health Center, Plan de Salud/Southern
Weld County and North Colorado Family Medicine are planned.
The community home visitor agency staffings coordinated by United Way of Weld
County would be a second process whereby collaborative implementation and
community ownership would occur. Integrating the new Nurse Home Visitor Program
staff into existing staffing meetings where referrals are coordinated and client's needs are
matched with available programming will avoid confusion and duplication of services.
This process would serve to build upon the community assets rather than replace or
disrupt them.
A third critical action toward collaborative implementation would be creation of a Weld
County Nurse Home Visitor Program Community Advisory Board. Eight to ten
representatives from community agencies and providers would be joined by at least one
representative from the target population. The board would represent the broad interests
of the community and would serve two functions. It would be an advisory group to the
director of the lead agency who is ultimately accountable for the successful
implementation of the program and compliance with protocols. The board would help
problem solve issues of collaboration and ensure a group dynamic focused on improving
36
outcomes. The board would also not only hold the lead agency accountable to the
community but also demonstrate community investment in the program.
Representatives from the following agencies would likely constitute the Community
Advisory Board:
• Sunrise Community Health Center
• The North Colorado Medical Center Foundation's Monfort Children's Clinic
• North Colorado Family Medicine
• Plan de Salud del Valle
• United Way of Weld County
• • First Steps of Weld County
• Weld County Department of Public Health and Environment, Division of
Public Health Education and Nursing
• North Colorado Medical Center
• Weld County Department of Social Services
• Weld County Department of Human Services
• Community member from target population
The board would meet monthly during implementation of the program and then quarterly
thereafter.
Request for Waivers
No waivers are requested in this application.
Geographical Placement of Applicant
This proposal is designed to strategically place visiting nurses around the county.
Southwestern Weld County is an area that is growing rapidly and where residents often
cross county lines into Boulder and Adams Counties seeking services. Placement of a
nurse visitor in this area could help advance implementation of similar programming in
northern Adams and eastern Boulder Counties.
Budget and Budget Justification
In submitting its request for funding,the Weld County Department of Public Health and
Environment is requesting$114,499 in personnel costs for fiscal year one (1/l/0lthrough
6/30/01). This funding would support the hiring of 0.5 FTE of a Master's prepared
nursing supervisor, 4.0 FTE Baccalaureate prepared registered nurses, and 0.5 FTE of
office support/data entry. The department's personnel costs for fiscal year one are$946
greater than the sample budget due to the Weld County salary schedule for professional
personnel. Through internal reorganization, the department would bring funding for an
additional 0.5 FTE of nursing supervisor salary.These funds would combine with the
requested grant funds to accommodate the hiring of a full-time Master's prepared nursing
37
supervisor overseeing both the nurse home visitation program and other complementary
community and family programs.
Direct costs for operating expenses in fiscal year one include$600 for office supplies
calculated at$100 per month; $6,750 for program supplies calculated at$145 per family;
$750 for copies and forms calculated at$1,500 per year; $300 for postage calculated at
$50 per month; and$900 for telephones calculated at$150 per month. The department is
actually charged$30 per month for each workstation telephone. Support for five
additional telephones at $30 per month is requested in fiscal year one.
Four cellular telephones are requested in fiscal year one at a total purchase cost of$500.
Local pricing allows the purchase of these phones for$100 less than that projected in the
sample budget. Cellular phone usage fees are requested in the amount of$1,200 for
fiscal year one. These costs are$600 less than the sample budget reflecting local market
rates for cellular phone plans.
The proposal seeks $4,500 during fiscal year one to support medical supplies. This
amount is$3,750 more than that presented in the sample budget. The department's
anticipated costs are associated with the supplies necessary to prepare four separate home
visitation bags that would include otoscopes,ophthalmoscopes, sphygomanometers,
stethoscopes, thermometers, and a convertible adult/infant scale with carrying case. The
projected cost for these supplies reflects actual expenses incurred by the department for
purchases of similar equipment.
Other staff development funding is requested at$1,000 for fiscal year one. Mileage
reimbursement of$6,100 is requested. Mileage costs are calculated at 20 trips per family
per year,20 miles roundtrip each visit,and a reimbursement level of $0.305 per mile.
Given the size of Weld County,it is anticipated that the calculation used in the sample
budget of 10 miles per roundtrip would be inadequate to cover actual costs. The actual
Weld County rates for mileage reimbursement is$0.305 per mile. This differs from the
$0.31 per mile reimbursed in this sample budget.
This results in a subtotal for direct operating costs of$33,825 for fiscal year one.
Direct costs for travel are projected at$2,451 for fiscal year one. This is$1,299 less than
the estimate provided in the sample budget. Cost savings are anticipated because nurses
will share hotel rooms and the distance to be traveled from Greeley to Denver is less than
the average distance calculated in the sample budget. Direct costs for training and
technical assistance provided by the National Center for Children,Families, and
Communities is$15,350 for fiscal year one. This requested amount does not vary from
that presented in the sample budget.
Direct costs for equipment is$11,225 covering the costs for 5 computers with Microsoft
Office installed and 2 modems to support remote access to the County's computer
system. Requested funding support for computers is $9,195 higher than that presented in
the sample budget due primarily to the County's request for 4 computers above that
38
presented in the sample budget. The sample budget presented support for only one
computer. In addition, the County is requesting support for the purchase of 2 modems to
facilitate remote access to the County's computer network by the outstationed nurses.
Indirect costs for training and technical assistance is calculated at 26%of the training and
technical assistance direct costs. This results in a budget request of$3,991.
Contributions from other funding sources include donated indirect costs of$22,682 for
fiscal year one. While community agencies are donating office space, personnel support,
and office supplies,the value of these in-kind donations has not been calculated for the
purposes of this budget presentation.
Separate liability insurance will not be required given that the staff supported by this
funding request would be Weld County employees and would therefore be covered by the
County while performing their job responsibilities.
The total budget amount requested from the Colorado Department of Public Health and
Environment for fiscal year one is $175,831. With the addition of in-kind donated
indirect costs calculated at 12.9%of direct program costs,an additional $22,682.20 is
presented in the budget proposal for fiscal year one. This results in a total annual budget
for fiscal year one of$198,513.20.
Community Support of Program
Monfort Children's Clinic and Sunrise Community Health Center would be donating
office space, office supplies, land-line telephone service and staff time to this project.
North Colorado Family Medicine would be donating staff time to make and receive
referrals from the program. United Way of Weld County would be donating the staff
time to coordinate the community agency staffing meetings and to provide meeting
space. The Departments of Social Services and Human Services would both donate all
staff time associated with making and receiving referrals related to services provided by
these agencies. All representatives to the Community Advisory Board would be donating
their time to the project. Weld County Department of Public Health and Environment
would donate indirect costs of$22,682 for fiscal year one. These commitments of in-
kind donations would be sustainable for the life of the program.
39
Appendix B: Letters of Support
41
M 0 N F 0 R T
tom' j Eve
1'
Chi Wrens
CLINIC
C A A r M e s o w K r Y
November 1, 2000
Colorado Board of Health
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
• Denver, Colorado 80246-1530
Dear Colorado Board of Health Members:
The North Colorado Medical Center Foundation's Monfort Children's Clinic strongly supports the
Weld County Department of Public Health and Environment's application to receive funding for the
Nurse Home Visitation Program.
Kids Count statistics for the past few years reveal that Weld County has one of the highest teen
pregnancy rates in Colorado. Weld County also ranks near the bottom of all Colorado counties for
mothers receiving early prenatal care, and in the lower 1/3 of counties for births to single moms.
Weld also has a large proportion of infants born to low-income mothers. We know that these factors
all lead to problems later in life. Although there are efforts underway to provide a coordinated
response to these problems, the Nurse Home Visitation Program will propel our efforts to reverse
these negative and troubling trends.
Monfort Children's Clinic has a history of collaboration with the Health Department to address the
needs of low-income mothers and babies. We have had Health Department employees routinely
work at our facility to improve prenatal education and to assist families with birth control planning
and methods. We refer clients to the Health Department for many needed services and provide
support for their clients through age 21 with healthcare needs.
We are committed to supporting the Nurse Home Visitation Program and would provide in-kind office
space for a Nurse Home Visitor based in our facility. This would provide many opportunities for the
Nurse to meet regularly with our medical team, our social worker, a mental health counselor, and
other health professionals working in our facility for referrals and information exchange.
I have attended many community meetings leading to this opportunity and there is strong
enthusiasm for the program. We believe that Weld County really needs and would dramatically
benefit from this program and respectfully request that you seriously consider Weld County's
application. Thank you for your consideration of this request.
Best Regards,
Bob Francella
Executive Director
100 North 11th Avenue • Greeley,CO 80631-2011 • (970)352-8898 • FAX: (970)351-7075 • E-MAIL:mcclinic@pawneenet.com
`%w it
sunrise Iv
COMMUNITY HEALTH CENTER, INC. ANNIVERSARY
October 31, 2000
Colorado Board of Health
Colorado Department of Public Health & Environment
4300 Cherry Creek Drive South
Denver, CO 80246-1530
Dear Colorado Board of Health Members:
•
I am pleased to provide this letter of support for the Weld County Department of Public Health
and Environment's application to receive funding for the Nurse Home Visitation Program.
Weld County has one of the highest teenage pregnancy rates in Colorado and a large
proportion of infants born to low-income mothers. This program will respond to an important
need in our community.
Sunrise Community Health Center has a history of effective collaboration with the Weld County
Department of Public Health and Environment to address the needs of low-income mothers and
babies. We refer clients to the Weld County Department of Public Health and Environment for
family planning, immunization and well-child services. Sunrise provides medical and dental
services to patients referred from the WCDPHE. And Sunrise has a long-standing collaborative
relationship with the Health Department around the provision of environmental sanitation and
safety services to Weld County Migrant Farmworkers.
Sunrise is committed to providing support for the Nurse Home Visitation Program. Specifically,
we will host one of the Nurse Home Visitors—including providing required office space,
computer and related administrative services. Additionally, our professional and case
management staff will refer families to the NHV Program. And, our medical and dental staff will
be a referral source for all NHV Program staff.
As a member of the Teen Pregnancy Work Group, Sunrise has worked with the Weld County
Department of Public Health and Environment, and other area agencies, to create a dynamic
community-based collaborative network that is ready to fully support the Nurse Home Visitation
Program.
Thank you for considering funding for this vital program.
Sincerely,
Michael Bloom, Executive Directdr
/sh
P.O. Box 1870 • 1028 5th Ave. • Greeley,CO 80632 • (970)356-6014 • Fax(970)353-9906
foold
North Colorado Family Medicine
North Colorado Medical Center
October 27,2000
Colorado Board of Health
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver,CO 80246-1530
Dear Colorado Board of Health Members:
North Colorado Family Medicine(NCFM)is pleased to support the Nurse Home Visitation Program
proposed in the application made to you by the Weld County Department of Public Health and
Environment(WCDPHE). We strongly encourage your approval of the proposal and recommendation
for full funding of the program.
Our organization has a long history of collaboration with the Weld County Department of Public Health
and Environment dating back to the start of our program in 1974. NCFM has formal agreements with
WCDPHE to provide medical consultation to clients on site at the department's clinic in Greeley. The
consultations include family planning,well child,and sexually transmitted and communicable diseases.
Out of our clinic in Greeley,we also operate,under contract,WCDPHE's clinical prenatal program
serving low income women. Referrals between the two agencies occur frequently and efficiently.
NCFM provided over 40,000 medical visits in 1999 to families in the Greeley area. Forty percent of
these visits were uncompensated or reimbursed through Medicaid. NCFM staff include family
physicians,family and women's health nurse practitioners,and mental health therapists. Key people in
our agency who are supportive of this program include Daniel Fahrenholtz, MD,Program Director,
Joanne Fenton,RN,North Colorado Medical Center Assistant Administrator,Patient Care Services;and
myself.
Our community has a tremendous need for programming and services focused on improving outcomes
for first-time mothers and their children. We are committed to collaborating with WCDPHE,Sunrise
Community Health Center,Monfort Children's Clinic,North Colorado Medical Center,First Steps and
other home visitation programs,social and human service agencies,and the community at large to
achieve outcomes in the target population.
Sincerely,
fy elects acz.
Eileen Croissant
Clinic Manager,NCFM
EC/cm
Residency Training Program • 1600 23rd Ave. • Greeley,CO 80634 • 970-356-2424 • ncmcgreeley.com
ar&
SALUD
Family Health Centers
ADMINISTRATIVE OFFICES October 26,2000
111s second Shed
Fort Lupton,co 80621 Colorado Board of Public Health and Environment
303-892-6401 4300 Cherry Creek Drive South
fax 303-892-tsn Denver,CO 80246-1530
HEALTH CENTERS
BRIGHTON • To the Colorado Board of Health:
30 S.20th Avenue,Suite A
Brighton,CO 80801 Plan de Salud del Valle,Inc.is pleased to provide this letter of support for
303-659-4000
fax 9395 the Weld County Department of Public Health and Environment's
application to receive finding for the Nurse Home Visitation Program.
COMMERCE CITY
6075 Parkway Drive,Sub 16C
Commerce City,co eoo22 Salud is a network of community health centers operating in ten service
303-2864903 sites in five counties in north central and northeastern Colorado,including
taxes southern Weld County. Salud was founded 30 years ago,and today serves
ESTES PARK more than 35,000 clients who otherwise would not have access to health
541 Big Thompson�t Suite B care. More than 70 percent of Salud's clients are of Hispanic ethnicity.
P.OEstes Parts Co &617 Salud collaborates with organizations serving the same target population in
970-586-szao each of the counties it serves,including county health departments;Women,
fax 970-586-0292 Infants and Children; County Social Service Departments;and organizations
FORT LUPTON that support low-income expectant mothers.
1115 Second Street
Fort Lupton,CO 80621
333-857-2771 303-92-0004 Key staff in our organization which would support the collaborative efforts
tax 303192-1511 of this program are Stanley J.Brasher,executive director and Mary Ann
FORT MORGAN Martinez Gofigan,director of client services. Salud has a long history of
909 E Rairoad Avenue collaboration with the Weld County Department of Public Health and
Fort 467 Morgan,CO 80701
97 4 303-530-2071 Environment. We are committed to continuing that collaboration for the
tax 970-867.7607 Nurse Home Visitation Program by referring eligible clients.
FREDERICK
630 Main street Sincerely,
FrederickCO 80530
303413333-20500 303-026-7681
fax 303-825-7664
LONOMONT Stanley J.Bra
231 East 9111 Avenue
Longmont co-60501 Executive Director
303-776-3250 303-444-7944
fax 303-682-929
SALUD Family Health Cantos
is=recited by
•
a w eunalas'-
RECEIVED CC T 3 0 2000
ti
North Colorado Medical Center
Banner Health Colorado
October 27, 2000
Colorado Board of Health
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver, CO 80246-1530
Dear Colorado Board of Health Members:
North Colorado Medical Center/Banner Health Colorado is very pleased to support the
Weld County Department of Public Health and Environment's application for funding of
the Nurse Home Visitation Program.
North Colorado Medical is a 324 bed tertiary care center with level II nursery services
and over 2200 births annually. As a provider of matemal/child services in Northern
Colorado we are very concerned about the high rate of teen pregnancies and the
increasing number of infants born to low-income mothers. The Nurse Home Visitation
Program will help to insure successful outcomes for infants and families in our
communities.
North Colorado Medical Center has worked very closely and effectively with the Weld
County Department of Public Health and Environment to assure that we continue to meet
the needs of infants and mothers who lack the financial resources to obtain necessary
care. Members of our Community Care Coordination Team and Monfort Family Birth
Center regularly refer patients to Weld County agencies. Staff from these agencies are
frequently requested to confer with our healthcare team to identify continuing care needs
before mothers and infants are discharged from our facility.
As a member of the Teen Pregnancy Work Group,we and other Weld County agencies
are striving to create a collaborative network of community services to meet the
increasing needs of this under-served population. The Nurse Home Visitation Program is
vital to this continued effort.
We appreciate your consideration for funding of the critical community resource.
Sincerely,
Jon Sewell
NCMC Administrator
1801 16th St • Greeley,CO 80631 • 970-352-4121 • Fax 970-350-6644 • ncmcgreeley.com
sv
North Colorado Medical Center
Banner Flen/h Colorado
October 25, 2000
Colorado Board of Health
Colorado Department of Public Health & Environment
4300 Cherry Creek Drive south
Denver, CO 80246-1530
Dear Colorado Board of Health Members:
I am pleased to provide this letter of support for the Weld County Department of
Public Health & Environment's application to receive funding for the Nurse Home
Visitation Program.
Weld County has one of the highest teenage pregnancy rates in Colorado and a
large proportion of infants born to low income mothers. This program will
respond to an Important need in our community.
Monfort Family Birth Center has a history of effective collaboration with the Weld
County Department of Public Health and Environment to address the needs of
low income mothers and babies. We refer clients for prenatal, postpartum and
newborn services. North Colorado Medical Center is committed to providing
support for the Home Nurse Visitation Program.
If I can be of any further assistance in support of the Weld County Department of
Public Health & Environment's application to receive funding for the Nurse Home
Visitation Program, please do not hesitate to contact me.
Pat Almino, RN, MS
Clinical Director, Maternal & Newborn Services
North Colorado Medical Center
1801 16th St.
Greeley, CO 80631
970-350-6118
paimino@BHSNET.COM
1801 16th St. • Greeley.CO 80631 • 970-352-4121 • Fax 970-350-6644 • ncmcgreeley.com
United Way
of Weld County
814 9th Street P.O.Box 1944 Greeley,CO 80632
970/353-4300 970/353-4738 Fax 800/411-8929 uwwc®ctos.com www.unitedway-weld.org
October 30,2000
Colorado Board of Health
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver, CO 80246-1530
Dear Colorado Board of Health Members:
On behalf of United Way of Weld County, I am pleased to support the application of the
Weld County Department of Public Health and Environment's application to receive
funding for the Nurse Home Visitation Program.
Weld County's need for this program is well documented. Our high teen pregnancy rate,
our high poverty rate and the continuing low grades on the Colorado Children's
Campaign Kid Count Report Card all show our need for additional resources to support
mothers and their babies.
As the coordinating entity for the Weld County Early Intervention Collaboration,United
Way recognizes the need for additional resources in our community to provide home
visitation to first time mothers. We feel this program will be an important addition to
current services, as no current providers can offer the level of service provided by this
nurse home visitation program.
This is an important opportunity to strengthen the community collaboration already
happening in Weld County. We currently are working with the Weld County Health
Department and other children's health providers to enroll children in the Child Health
Plan Plus(CHP+). Under the leadership of the Weld County Health Department's
director, Dr. Mark Wallace,numerous other community initiatives are under way.
Coordination of the nurse home visitation program with other home visitation programs
is a critical piece of maximizing limited resources in our community. We will be pleased
to host the community agency staffings (currently held monthly)to help guarantee
referrals and service delivery of home visitation services are offered in a collaborative
manner and support individual family needs. We will provide as our in-kind donation
the meeting space, staff support and logistical support(mailings,record keeping,etc.)to
the staffing process.
.Jo 6rzcecrloo as ,�o iruue ea04 9ns° cononic o to tiazonan caw ones/fosco# *does consonantly
/ral//a anti/vinano came faeolilorna.
We are pleased to offer our support to this important program for Weld County. Thank
you for giving serious consideration to funding a Weld County Nurse Home Visitation
Program.
Sincerely,
Judy ICron, Director41-3-1T.tenc---
Community Problem Solving and Programs
DEPARTMENT OF HUMAN SERVICES
ADMINISTRATION
1551 NORTH 17TH AVENUE
WI . PO BOX 1805
lige
GREELEY,CO 80632:ww WEBSITEw.co.weld.co.us
353-3800
• FAX(970)3r$-3975
COLORADO
October 24,2000
Colorado Board of Health
Colorado Department of Public
Health and Environment
4300 Cherry Creek Drive South
Denver,Colorado 80246-1530 -
Dear Colorado Board of Health Members:
I am pleased to provide this letter of support for the Weld County Department of Public Health and
Environment's application to receive funding for the Nurse Home Visitation Program.
Weld County has one of the highest teenage pregnancy rates in Colorado and a large proportion of
infants born to low-income mothers. This program will respond to an important need in our
community.
The Weld County Division of Human Services has a history of effective collaboration with the Weld
County Department of Public Health and Environment to address the needs of low-income mothers
and babies. We refer clients to the Weld County Department of Public Health and Environment for
a variety of needed services,and provide support for their clients with Head Start, Migrant Head
Start,child care,Employment and Training,and job seeking needs. The Weld County Division of
Human Services is committed to providing support services for the Nurse Home Visitation Program.
As a member of the Teen Pregnancy Work Group,I have worked with the Weld County Department
of Public Health and Environment,and other area agencies,to create a dynamic community-based
collaborative network that is ready to fully support the Nurse Home Visitation Program.
Colorado Board of Health October 24,2000 Page 2
The Weld County Division of Human Services provides financial support for the Nurse Home
Visitation Program by contributing in-kind services in the areas of Head Start,Migrant Head Start,
child care,Employment and Training,and job seeking,to assure the sue ns of this program.
Thank you for considering funding this vital program.
Sincerely
0
W . Speckman
've Director
WJS/sgt
DEPARTMENT OF SOCIAL SERVICES
PO BOX A
GIZEELEY,CO 80632
liv WEBSITE:www.co.weld.co.us
Administration and Public Assistance(970)352-1551
C Child Support(970)352-6933
O
COLORADO
October 27,2000
•
Colorado Board of Health
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver,COO 80246-1530
Dear Colorado Board of Health Members:
The Weld County Department of Social Services is providing a letter of support for the
Weld County Department of Public Health and Environment's application to receive
funding for the Nurse Home Visitation Program.
The Weld County Department of Social Services has a history of effective collaboration
with the Weld County Department of Public Health and Environment to address the
needs of low-income mothers and babies. These areas of effective collaboration are as
follows:
1. The Weld County Department of Public Health and Environment is an important
member of our Child Protection,which reviews cases of abuse and neglect. In
addition,my Department contracts with the Weld County Department of Public
Health and Environment to provide assessment and services to families with
children of attachment disorders.
2. The Weld County Department of Public Health and Environment provides an
entrance for families to Medicaid as a Presumptive Eligibility Site and to the
Children's Health Plus Program as an Eligibility Site. The Weld County
Department of Public Health and Environment has provided in-kind support for
our Medicaid Program by allowing us to station our Medicaid staff in their
facility. For purposes of maintaining eligibility for my Department's Temporary
Assistance for Needy Families and to meet the needs of other low-income
families,the Weld County Department of Public Health and Environment
provides necessary immunization access and services.
3. The Weld County Department of Public Health and Environment provides a focus
point for planning and collaboration with health providers and community
agencies for meeting the health care needs of the community.
Colorado Board of Health Page 2
October 27, 2000
The Weld County Department of Social Services is committed to providing support
services for the Nurse Home Visitation Program.
As a member of the Teen Pregnancy Work Group, I have worked with the Weld County
Department of Public Health and Environment,and other area agencies,to create a
dynamic community-based collaborative network that is ready to fully support the Nurse
Home Visitation Program. •
Thank you for considering funding this vital program.
Sincerely,
i
y A. riego
ector
S SCHOO4
OC\ O
<S
o
W 7� o
GREELEY � EVANS
&t araflureto&8tat5$ke
Tony Pariso,Superintendent
October 30, 2000 811 15th Street•Greeley,Colorado 80631
970-352-1543
Colorado Board of Health
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver, CO 80246-1530
Dear Colorado Board of Health Member.
Weld County School District 6 is pleased to provide a letter of support for the Weld
County Department of Public Health and Environment's application to receive funding for
the Nurse Home Visitor Program.
School District 6, serving the communities of Greeley and Evans, is the largest school
district in Weld County with an enrollment of over 15,000 students. In addition to
traditional elementary (12), middle (5) and high schools (3)the district offers an Arts &
Literacy Magnet elementary along with a variety of alternative middle and high school
programs. The District also has several charter school options including K-12, K-8 and
8-12 programs. Five elementaries have school-wide Title I programs. As an indicator of
the economic status of families with children attending district programs, over 50% of
students are eligible for free and reduced lunch.
The school district is aware of the high teen pregnancy rate in Weld County and has
worked collaboratively with community agencies to support young mothers in completing
their education. A representative from the school district has participated in the Teen
Pregnancy Task Force coordinated by the Department of Public Health and
Environment. The school district and the local health department have worked
collaboratively on referrals for immunization, well-child, and children with special needs
services for students.
The District and Board of Education support efforts to help kids complete school despite
adversity. We recognize that a Nurse Home Visitor Program directed at first-time, low-
income mothers and their children will offer additional support to young families in our
community. We look forward to continued collaboration with the Weld County
Department of Public Health and Environment and support its application for funding of a
Nurse Home Visitor Prog Q �j 5
cerely. flAA&A ' A-'eLefc��x-r-C�
Anthony Pa o Mark E. Wallace
Superintendent President, Board of Education
Cr 1
811 Fifteenth Street
111 / / Greeley,Colorado 80631
970-351-6410
/ Fax 970-353-8042
October 20,2000
Colorado Board of Health
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver, CO 80246-1530
Dear Colorado Board of Health Members:
I am pleased to provide this letter of support for the Weld County Department of Public
Health and Environment's application to receive funding for the Nurse Home Visitation
Program.
Weld County has one of the highest teenage pregnancy rates in Colorado and a large
proportion of infants born to low-income mothers. This program will respond to an
important need in our community.
The Greeley Dream Team has a history of effective collaboration with many agencies,
including the Weld County Department of Public Health and Environment,who address
the needs of low-income mothers and babies. We have a large base of young students
who we would refer to the Weld County Department of Public Health and Environment
for information on services such as pre-natal care, STD's and child immunizations. We
are also available to provide a variety of educational support services to clients who
might be referred to us from the Nurse Home Visitation Program.
As a member of the Teen Pregnancy Work Group,I have worked with the Weld County
Department of Public Health and Environment,and other agencies, to create a dynamic
community-based collaborative network that is ready to fully support the Nurse Home
Visitation Program.
The Greeley Dream Team can provide in-kind staff support to assure the success of this
program.
Thank you for considering funding this vital program.
Sincerely,
Charlotte Ji ez
Executive Director
Reference Data Sources
Source:Greeley/Weld Economic Development Action Partnership,Inc.
Includes Evans,Garden City,Greeley and LaSalle.
I"Source: US Bureau of the Census,Census of the Population;Colorado State Demographers Office;and
Claritas, Inc.as reported by the Greeley/Weld Economic Development Action Partnership,Inc.
'"Source: Colorado Division of Local Government as reported by the Greeley/Weld Economic
Development Action Partnership,Inc.
"Source: US Bureau of the Census,Census of the Population;Colorado State Demographers Office;and
Claritas, Inc.as reported by the Greeley/Weld Economic Development Action Partnership,Inc.
'n Source: US Bureau of the Census,Census of the Population;Colorado State Demographers Office;and
Claritas, Inc.as reported by the Greeley/Weld Economic Development Action Partnership,Inc.
""Source:Claritas,Inc.as reported by the Greeley/Weld Economic Development Actin Partnership,Inc.
"Source:Colorado Children's Campaign,Colorado 1999 KidsCount! Report Card.
"Source:Colorado Children's Campaign,Weld County 1999 KidsCount! Report Card.
Source:Colorado Children's Campaign,Colorado 1999 KidsCount! Report Card.
"Source: US Bureau of the Census
"'Source: Weld County Department of Social Services data provided to the Weld County Primary Care
Access Study Group,September 2000.
""Source:Colorado Department of Public Health&Environment, 1999 Live Births,September 2000 draft.
"Source:Colorado Department of Public Health&Environment, 1999 Live Births,September 2000 draft.
""Source: Colorado Department of Public Health&Environment, 1999 Live Births,September 2000 draft.
" Source: Colorado Children's Campaign, Weld County 1999 KidsCount! Report Card.
"""Source: Colorado Department of Public Health&Environment, 1999 Live Births,September 2000
draft.
`""'Source:North Colorado Medical Center,Maternity and Newborn Services Activity Data,January 1—
December 31, 1999.
Source:North Colorado Family Medicine financial data provided to the Weld County Primary Care
Access Study Group.
X Source:North Colorado Family Medicine financial data provided to the Weld County Primary Care
Access Study Group,September 2000.
Source: Summarization of Teen Pregnancy Reports,prepared for North Colorado Medical Center,March
29, 1998 by Ken McConnellogue.
'""'Source: Summarization of Teen Pregnancy Reports,prepared for North Colorado Medical Center,
March 29, 1998 by Ken McConnellogue.
n"'Source: Colorado Children's Campaign,Weld County 1999 KidsCount! Report Card.
nu'Source:Colorado Children's Campaign,Weld County 1999 KidsCount! Report Card.
Source: Weld County Department of Social Services.
"x"'Source:National Center for Health Statistics,Vital Statistics Reporting System, 1995-1997 as reported
by the U.S. Department of Health and Human Services,Health Resources and Services Administration,
Community Health Status Report for Weld County,Colorado July 2000.
42
ATTACHMENT D
APPLICANT: WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT I___
PROJECT: NURSE HOME VISITOR PROGRAM I
I II
BUDGET 1
1 i I
FOR THE PERIOD: 01/01/01 -06/30/01
I Annual Number I Total I Source of Funds;
Salary ' Months I I Amount I 'Applicant Requested
Rate Budget I i Reguired, and Other ' from CDPHE
PERSONAL I i
Nurse 1 37,7761 6! 18,8881 18,888
Nurse2 37,7761 6i, 18,8881 18,888
Nurse 3 37,7761 61 18,8881 18,888
Nurse 4 37,776. 6 18,888 18,888
1 I
Office Technician III(.5 FTE) 11,251 6 5,626 5,626
ContractuaVFee for Service: — -
Supervising Personnel:
Nurse Supervisor(.5 FTE) 1 20,841 6 10,421 10,421
1
Fringe Benefits: Rate=25% 45,7991 22, 22,900
- ----
Total Personal 114,491 0 114,499
OPERATING - -----
(include only costs not part of — ----..-----
indirect) I.
-- --
-
Office Supplies I j 600 600
Program Supplies I I 6,750 1 6,750
Copies—forms 755 i___
0 -
750
Postage 3 900
300
Telephone I 900 Eli
Cellular Phones Usage Fees I 1,200 _ , 1,200
Medical Supplies 4.500 4,500
Other Staff Development 1,000 1,000
Materials 10,000 10,000
NCCFC Training I I 1,750 1,750
NCCFC 1 I _�_
. NCCFC Clinical Info.System Support! I 1.000 _ - 1,000
NCCFC Purchase of System&TA 2,600 I _ 2,600
NCCFC Indirect at 26% 3.991 _ 3,991
NCAST Training 3,500 _ 3,500
NCAST&PIPE Training Materials 1 t i 2,215_ — _ 2.215
1 I
-!
Sub Total Operating —1 —
_ � i 41,056 0 41,056
TRAVEL: 6,100
Mileage 6,100
Travel to Trainings 2,451' 2,451
Sub Total Travel 8,551 0 8,551
I L
—
EQUIPMENT: I i G
Computers with MS software(5) i • 10,8751
Modems 2 10,875
Cellular Phones(4) 500j 350
4 5001 ! 500
!
Sub Total Equipment 11,7251 0I 11,725
Administrativefindirect 12.9% i 22,682 22,6821 0
TOTAL PROJECT H 4 198,51 22,682 175,831
'Source of Funding for"Applicant I
and Other -- --
I i —
LocaVCounty" 22,6821 I
Medicaid Funding — ,
Patient Fees j
Other —
Total Applicant and Other 22,682 —
r- - -
I I
"Are these local funds used to I , --- I -
match any other grant? ---- Yes I No
X 141(b\iLf- 2-1--ttttH __._ .
Signature of Director or Authorized Representative 1
INVOICE NUMBER
CONTRACT REIMBURSEMENT STATEMENT
TO: FROM:
FAX: ( ) DATE OF EXPENDITURE:,
TYPE OF FROM: Final
PROGRAM: NURSE HOME VISITOR PROGRAM Bill?
FEDERAL ID TO: 0 Yes
NUMBER:
0 No
Description of Expenditure Local Agency Match Reimbursement Total
Amount Requested
I ,
w
z
z
F7 .
GRAND TOTAL
This is to certify that the above expenses were incurred per Contract # and we are requesting reimbursement for same.
SIGNATURE (CONTRACTOR): DATE:
I hereby certify that all contract requirements have been met and the amounts are correct. Payment is authorized.
AUTHORIZED DESIGNEE (STATE): DATE: 17�
• Laza.144411.1.r IWSIw.r l Aral CW.0Yu 0N. Willi
STATE OF COLORADO
Bill Owens,Governor
Jane E.Norton,Executive Director tire:
Dedicated to protecting and improving the health and environment of the people of Colorado
4300 Cherry Creek Dr.S. Laboratory and Radiation Services Division
• ■
Denver,Colorado 80246-1530 8100 Lowry Blvd. *HIT
•
Phone(303)692-2000 Denver CO 80230-6928
TDD Line(303)691-7700 (303)692-3090 Colorado Dep aliment
Located in Glendale,Colorado of Public Health
http://www.cdphe.state.co.us and Environment
Sample Contract Change Order Letter Attachment F
State Fiscal Year**- **, Contract Change Order Letter Number**, Contract Routing Number**-*****
***************Program
Pursuant to paragraph**of the contract with contract routing number ***** and contract encumbrance number
*********** (as amended by Contract Renewal Letter** contract routing number**-*****.and/or Contract Change Order
Letter***contract routing number**-*****,if any),hereinafter referred to as the"Original Contract"(a copy of which is
attached hereto and by this reference incorporated herein and made a part hereof)between the State of Colorado,Department
of Public Health and Environment and Contractor's Legal Name for the term from **,***• through
********* ** **** the parties agree that the maximum amount payable by the State for the eligible services referenced in
paragraph**of the Original Contract is increased/decreased by dollar amount DOLLARS ($*.**)for a new total financial
obligation of the State of dollar amount DOLLARS ($*.**). The revised work plan,which is attached hereto as
"Attachment 1",and the revised budget,which is attached hereto as "Attachment 2",are incorporated herein by this
reference and made a part hereof. The first sentence in paragraph ** of the Original Contract is hereby modified accordingly.
All other terms and conditions of the Original Contract are hereby reaffirmed. This amendment to the Original Contract is
intended to be effective as of********* **,**a However,in no event shall this amendment be deemed valid until it shall
have been approved by the State Controller or such assistant as he may designate.
Please sign,date,and return all**originals of this Contract Change Order Letter by********* ** **** to the attention of:
************ ************,Colorado Department of Public Health and Environment,4300 Cherry Creek Drive
South,Denver,Colorado 80246,Mail Code: *****-**. One original of this Contract Change Order Letter will be returned
to you when fully approved.
Contractor's Legal Name STATE OF COLORADO
(legal type of entity) Bill Owens,Governor
By: By:
Name: For the Executive Director
Title:: DEPARTMENT OF PUBLIC HEALTH
FEIN: AND ENVIRONMENT
APPROVALS:
FOR THE STATE CONTROLLER: PROGRAM:
Arthur L.Barnhart
By: By:
NHVP CONTRACT DRAFT vnve+mv4,EE JEW Page 18 of 17
STATE OF COLORADO
Bill Owens,Governor
Jane E.Norton,Executive Director
Dedicated to protecting and improving the health and environment of the people of Colorado ti
* C:4 ; *
4300 Cherry Creek Dr.S. Laboratory and Radiation Services Division * , *
Denver,Colorado 80246-1530 8100 Lowry Blvd. •187 s
Phone(303)692-2000 Denver CO 80230-6928
TDD Line(303)691-7700 (303)692-3090 Colorado Department
Located in Glendale,Colorado of Public Health
http://www.cdphe.srate.co.us and Environment
[Date] Sample Contract Renewal Letter Attachment G
State Fiscal Year 20**-**, Contract Renewal Letter Number**. Contract Routing Number*!*****
*************** program
Pursuant to paragraph**of the contract with contract routing number**-*****and contract encumbrance number
(as amended by Contract Change Order Letter**,contract routing number**-*•*** and/or Contract Renewal
Letter** contract routing number**-***** if any),hereinafter referred to as the"Original Contract"(a copy of which is
attached hereto and by this reference incorporated herein and made a part hereof)between the State of Colorado,Department
of Public Health and Environment and Contractor's Legal Name, for the renewal term from **,****,through
********* **,**** the parties agree that the maximum amount payable by the State for the eligible services referenced in
paragraph"* of the Original Contract is increased/decreased by dollar amount DOLLARS ($*.**)for a new total financial
obligation of the State of dollar amount DOLLARS ($*.**). The work plan,which is attached hereto as"Attachment 1",
and the budget,which is attached hereto as "Attachment 2",are incorporated herein by this reference and made a part hereof.
The first sentence in paragraph**of the Original Contract is hereby modified accordingly. All other terms and conditions of
the Original Contract are hereby reaffirmed. This amendment to the Original Contract is intended to be effective as of
** ****. However,in no event shall this amendment be deemed valid until it shall have been approved by the
State Controller or such assistant as he may designate.
Please sign,date,and return all ** originals of this Contract Renewal Letter by********* **,**** to the attention of:
************ ************ Colorado Department of Public Health and Environment,4300 Cherry Creek Drive
South,Denver,Colorado 80246,Mail Code: *****-**. One original of this Contract Renewal Letter will be returned to you
when fully approved.
Contractor's Legal Name STATE OF COLORADO
(legal type of entity) Bill Owens,Governor
By: By:
Name: For the Executive Director
Title: DEPARTMENT OF PUBLIC HEALTH
FEIN: AND ENVIRONMENT
APPROVALS:
FOR THE STATE CONTROLLER: PROGRAM:
Arthur L.Barnhart
By: By:
MN?CONTRACT DRAFT 2/O2/6/001/LEE JOSEPH Page 19 of 17
Bill Owens,C STATE OF COLORADO
Governor
Jane E.Norton,Executive Director
Dedicated to protecting and improving the health and environment of the
people olColorado 4300 Cheny Creek Dr.S. Labor
Denver,Colorado 80246-1530 8100 L� Radiation Services Division
Phone(303)692-2000
Denver CO 80230.6928
MD Line plea 691-7700 (303)692-3090 rays'
Located in Glendale,Colorado
Colorado D enttn[
http://www.cdphestate.co.us of Public Health
April and Environment
23,2001
Task Order Renewal Letter
Nurse Home Visitor Program
State Fiscal Year 2001 -02, Task Order Renewal Letter Number 1, Contract Routing Number 02-00183
Pursuant to Part F_5.of the Master Contract with contract routing number 00-FAA00008 and paragraph D2 of the Task Order
with contract routing number 01-00942 and contract encumbrance number PO FAA FHS0100942 hereinafter referred to as
the"Original Task Order"(a copy of which is attached hereto and by this reference incorporated herein and made a part
hereof)between the State of Colorado,Department of Public Health and Environment 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 10°Street,3'"floor,Greeley,Colorado 80631 for the use and benefit of the WELD COUNTY
DEPARTMENT OF PUBLIC HEALTH for the renewal term from July 1,2001 through June 30,2002 the parties agree
that the maximum amount payable by the State for the eligible services referenced in part B of the Original Task Order is
increased by Three Hundred Twenty Thousand Nine Hundred And Thirty-Three Dollars ($320,933.00)for a new total
financial obligation of the State of FOUR HUNDRED NINETY SIX THOUSAND SEVEN HUNDRED SIXTY-FOUR
DOLLARS ($496,764.00). The year two budget,which is attached hereto as"Attachment D-I",is incorporated herein by
this reference and made a part hereof. The first sentence in paragraph CC=1 of the Original Task Order is hereby modified
accordingly. All other terms and conditions of the Original Task Order are hereby reaffirmed. This amendment to the
Original Task Order is intended to be effective as of July 1,2001. However,in no event shall this amendment be deemed
valid until it shall have been approved by the State Controller or such assistant as he may designate.
Please sign,date,and return all 4 originals of this Task Order Renewal Letter by May 21,2001 to the attention of:Lee Joseph
—PISCY A-4,Colorado Department of Public Health and Environment,4300 Cherry Creek Drive South,Denver,
Colorado 80246, One original of this Task Order Letter Renewal will be returned to you when fully approved.
Board Of County Commissioners Of Weld County STATE OF COLORADO
Bill Owens,Governor
By: By:Name: - , , aa j 5 09 2001) For the Ez cutive hector
Title: Chair Protem DEPAR ENT OF PUBLIC HEALTH
FEIN: 84-6000813 AND ENVIRONMENT
APPROVALS:
FOR THE STATE CONTROLLER: PROGRAM:
Arthur L.Barnhart
By: aa,-
By:
WELD COUNTY DEPARTMENT OF
PUBLIC HEALTH AND 1/t✓'OL ENVIRONMENT VI /,,
°BY: / &xtx'�L.e t „..266/-/-23a._
Mark E. Wallace, MD, MPH.Director
ATTACHMENT D-1
APPLICANT: WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
PROJECT: NURSE HOME VISITOR PROGRAM
--
BUDGET I
FOR THE PERIOD: 07/01/01 -06/30/02 I I —
Annual I Number !
Total I Source of Funds I,
Salary I Months , Amount j *Applicant Requested
PERSONAL Rate ( Budget I Reguired j and Other I from CDPHE
Ariane Rowe I I
Eva Rodriguez 39,973 12: 39,9731j I 39,973
Tracy Lujan 39,973 12: I 39,973
Debbie Pettit 39,973 121 39,973 39,973
39,973
Off.Tech. III (.5 FTE)
I 39,777 12 i 39,7771 39,777
11,838 72 11,8381 11,838
Off.Tech, 111- Interpreter(.5 FTE) 11,667 121 11,6671
Contractual/Fee for Service: 11,667
Supervising Personnel: I
Nancy Weber(.5 FTE) 22,506 121 I 22,506
22,506
1
Sub Total Salaries 205,707 I 205,707
_ 205,707
Fringe Benefits: Rate=3O% 61,712 61,712
61,712
Total Personal 267,419 267,419
0 267,419
OPERATING
(Include only costs not part of
--
Indirect)
Office Supplies
Program Supplies 1,200 1,200
Copies—forms 7,250 7,250
Emergency fund 1,500
400 1,500
Postage
Telephone 600 600
Cellular Phones Usage Fees 3'90 3,900
Medical Supplies 3,900 2,400 2,400
Furniture 585585
Incentives 681 681
Team Retreats 5,300 1,300
Other Staff Development 1,600 1,600
NCCFC Training 1,750 _ 1,750
NCCFC Materials 0
NCCFC Clinical Info.System Support 0
5'2� 5,200
NCCFC Purchase of System&TA 0
NCCFC Indirect at 26% 7547
NCAST Training 1,547
PIPE Training 3,500 3 500.,
NCAST&PIPE Training Materials 1,775 1,775
Sub Total Operating 39,188
0 38,788
TRAVEL:
Mileage
12,200 12,200
Travel to Trainings
2.526 2.526
— 1 '
Sub Total Travel
14,726, 0 �26
� I 1
f i
EQUIPMENT: I I
Computers with MS software(5)
Modems(2) I I
Cellular Phones(4)
-
Sub Total Equipment (
0 0 0
Administrative/Indirect @ 12.9°k
41,4521 41,452 0
TOTAL PROJECT I 362,785
41,452 320,933
'Source of Funding for"Applicant
and Other"
Local/County— 41,452
Medicaid Funding
Patient Fees I —
Other
Total Applicant and Other 41,452
"Are these local funds used to
match any other grant? Yes_ No_X_
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVRIONMENT
BUDGET VARIANCES NARRATIVE FOR 7/1/01 THROUGH 6/30/02
Weld County Department of Public Health and Environment is submitting a request for funding
in the amount of$320,933 for the upcoming Year 2 activities of the Nurse Family Partnership
program. Weld County proposes to contribute an additional $41,452 for indirect costs. The
budget categories and expected expenses are reflective of the suggested sample budget for the
program.
Our proposed variations from the sample budget include:
Furniture -$ 681 for a storage cabinet for nurse supplies, and client resources. This will
help designate our supplies from other agency supplies, as there is limited space in the
agency.
Incentives - $5,300 for developmental toys and family resources for the promotion of
appropriate play and interaction with babies and children.
Team Retreats -$1600 ($400 x 4) for quarterly scheduled opportunities for team building,
in an off work site setting for a day.
Emergency Fund-$400 for client emergencies such as necessary food, bottled water, or
transportation. These items will be accessed with necessary, urgent situations only. A
petty cash type of system will be used, and expenditures will be limited to$10-$15.
Personnel-$15,167 for a half-time Office Technician III to serve as an interpreter. Weld
County's Hispanic population is estimated at 30% according to the 2000 census. We
anticipate many of our clients to be monolingual Spanish speaking.
Telephone—This line item includes an additional$1,400 to provide phone line service
for the modems at our two outlying locations to connect with our agency's computer
network.
STATE OF COLORADO
Bill Owens,Governor
Jane E.Norton,Executive Director coto
Dedicated to protecting and improving the health and environment of the people of Colorado f'
4300 Cherry Creek Dr.S. Laboratory and Radiation Services Division y *
Denver,Colorado 80246-1530 8100 Lowry Blvd. 4.‘4.6*
Phone(303)692-2000 Denver,Colorado 80230-6928
TDD Line(3031691-7700 (303)692-3090 Colorado Department
Located in Glendale,Colorado
ofpt
http//www.cdphe.state.co-us
and Environment
t
ronnmeme nt
May 17,2002 Task Order Renewal Letter
Task Order Renewal Letter Number O2, Contract Routing Number 03 FAA 00290
•
State Fiscal Year 2002-2003 Nurse Home Visitor Program
Pursuant to Part F_5.of the Master Contract with contract routing number 02 FAA 00008 and paragraph D.2.of the Task Order with
contract routing number 01 FAA 00942 and contract encumbrance number PO FAA FHS0100942 as amended by Task Order Renewal
Letter L contract routing number 02 FAA 00183 hereinafter referred to as the"Original Task Order"(a copy of which is attached hereto
and by this reference incorporated herein and made a part hereof)between the State of Colorado,Department of Public Health and
Environment and Board of County Commissioners of Weld County for the renewal term from July 1,2002 through June 30,2003,the
parties agree that the maximum amount payable by the State for the eligible services referenced in Part B of the Original Task Order is
increased by THREE HUNDRED FORTY-TWO THOUSAND SEVEN HUNDRED FIFTY-EIGHT DOLLARS ($342,758.00)for a
new total financial obligation of the State of EIGHT HUNDRED ONE THOUSAND THREE HUNDRED FORTY DOLLARS AND
SEVEN CENTS ($801,340.07). This year's budget,which is attached hereto as"Attachment 1",is incorporated herein by this reference
and made a part hereof. The first sentence in paragraph C_!.of the Original Task Order is hereby modified accordingly. All other terms
and conditions of the Original Task Order are reaffirmed. The proposed effective date of this Task Order Renewal Letter is July I.2002.
However,in accordance with section 24-30-202,C.R.S.,as amended,in no event shall this Task Order Renewal Letter be deemed valid
until it shall have been approved by the State Controller or such assistant as he may designate.
Please sign,date,and return all four(4)originals of this Task Order Renewal Letter by June 11.2002,to the attention of: Peppy Becker
Colorado Department of Public Health and Environment,4300 Cherry Creek Drive South,Denver,Colorado 80246-1530,Mail
Code:PSD-HCP-A4. One original of this Task Order Renewal Letter will be returned to you when fully approved.
Board of County Commissioners of Weld County STATE OF COLORADO
(a political subdivision of the state of Colorado) Bill Owens,Governor
By: 4i44l�L4-lA By: 1
Name: Glenn Vaad For the Execute a Direyyyy r
Title: Chair DEPARTMENT OF 1'Fl LIC HEALTH
FEIN: 84-6000813 AND ENVIRONMENtt
Date: May 77. 2002
FOR THE STATE CONTROLLER: PROGRAM APPROVAL:
Arthur L.Barnhart,State Controller
By: By:
Date:
WELD COUNTY DEPARTMENT OF
PUBLIC HEALTH AND ENVIRONMENT ��
BY: 1MCvealll t C 4�0.Q_ME" '�
\HCPc"n.,en\coxnwcrswt V Y 03\wrimwdd srr 03 Task Order Renewal Liter doc Mark E. Wallace, MD, MPH•Director
t�,3—/33/
APPLICATION BUDGET AND/OR EXPENDITURE REPORT FORM Attachment 1
Weld County Health Dept FOR THE PERIOD: 7/01/02 TO 6/30/03
PROJECT:NURSE HOME VISITOR PROGRAM
Annual No.of Total SOURCE OF FUNDS
Requested/
Salary Months Amount Received
Rate Budget FTE Required OTHER* from CDPHE
PERSONAL SERVICES:
Nurse Supervisor-Nancy Weber $46,866.00 12 50% $23,433.00 $23,433.00
Nurse-Mane Rowe $42,484.00 12 100% $42,484.00 _-_ _ $42,484.00
Nurse-Eva Rodriquez $42,484.00 12 100% $42484.00 $42,484.00
Nurse-Traci Lujan $42,48400 12 100% $42,484.00 $42,48400
Nurse-Geri Holton $42,131.00 12 100% $92 131.00
Erma Gonzalez $42,131.00
Clerk-E
525 276.00 12 50% $12.638 00 _.. $12,638.00
$000
$0.00
Contractual/Fee for Service
$000
$0.00
.-Supervising Personnel _ $0.00
Nursing Director $0,00 12 10% $0.00 50 00 _ $0.00
Fringe Benefits: Rate=30% 61,696.00 000 _ j6t 696_00
Total Personal Services $267,350.00 $0.00 $267,350.00
OPERATING EXPENSES(whkh are not part of indirect):
Office RenWtilities $0.00 $0.00 $0.00
Office Supplies $1200.00 $1,200.00
Client Support Materials $3,500.00 $3,500.00
Printing and Postage $2,500.00 _$,500_00
Phone-Office and Cellular $5,100.00 --- __--
55,100.00
Program medical supplies $500.00 $5500.00
Professional Development $1,500.00
$1 5 00.00
$0.00 $0.00
$0.00 $0_00
$000 $0.00
Total Operating $14,300.00 $0.00 $14.300.00
EQUIPMENT
0 00.00
Computer 8 Software 200 0 $200.00
Total Equipment $200.00 $0.00 $200.00
TRAVEL(In-state/Out-state)
Visit'Oubeach Mileage 12,73000 - - 12.73000
NCCFC/UCHSCTraininy-Travel 1,600.00 1,600.00
State Meeting Travel 3,00000 3,00000
Total Travel •
T $17,330.00 $000 $17,33000
TRAINING 8 TECHNICAL ASSISTANCE-NCCFC/UCHSC
Clinical Training 8 Support $0.00 $000
Training Materials $0.00 $0.00
Purchase of Clinical Info.System(OS) 50.00 $000
Technical Assistance $5,200 00 $5200.00
NCCFC Contract Indirect Costs $1,352.00 $1,352.00
PIPE Materials $824.00 — --— $824.00
Total Training 8 Tech.Assistance
$7,376.00 $0.00 $7,376.00
NCAST TRAINING 8 MATERIALS
NCAST TRAINING 8 MATERIALS $1,120.00 $1,120.00
Total NCAST Training&Materials
$1,120.00 $0.00 $1120.00
Total Direct Costs(Personal Services+OperatinglTraveHcontractual) $307,676.00 $0.00 5307,676.00
ADMINISTRATIVE/INDIRECT COST
11.74% 535,082.00 $0.00 $35,082.00
Total Administrative/Indirect Costs $35,082.00 $0.00 $35,08200
TOTAL PROJECT COST 342,756.00 0.00 342,758.00
Source of funding for"Other"(Match or In-kind)
WELD County Contributions $
$
$
$
TOTAL $0.00
May the NON FEDERAL funds be used as match? YES NO
Signature of Authorized Representative Date
Fier v112 2 - BUDGE 1/PPtFCRM.as
ese,.n
Weld County NFP Program, 2002-03
Budget Narrative
Personal Services
The salaries for our current staff of four full time RNs, '/z time Data Assistant and 'h of
the full time supervisors position, are included in this section. RN's generally have a full
caseload of clients to follow and recruit. Benefits are calculated per Weld County policy and
schedule.
Operating Expense
• Office supplies are utilized by the staff to provide client notebooks, charts,files and
general organization.
• Client support materials in the second year will provide an age appropriate item for
developmental stimulation of infants/toddlers, and resource materials or tools for
parents.
• Printing expenses are derived from duplication of program forms, facilitators,
educational materials, and printing program brochures and program promotion
materials to use in the community. Postage is for client and program contacts.
• The phone line item includes one year of office phones and cellular phone service and
equipment for 5 RN staff.
• Health and program supplies will include batteries for scales, program camera, film,
and replacement of small items in the visiting bags (tape, gloves, demonstration
items)
• Professional development is available to provide team or individual training in
program related fields.
Equipment Expense
• There are no entries in this category
Travel
• Team and individual travel to trainings and meetings in Denver is budgeted in the
amount of$1600
• Mileage reimbursement for program visits is calculated for the number of RNs 4.1
(Supervisor does a small number of visits)X 25 clients X 2 visits/mo
X 15 mile average distance X .345 reimbursement X 12 months.
Weld County is a large county of 4000 square miles, and clients are actively recruited in all areas
of the county.
Training and Technical
• NCCFC training for remaining staff to finish T2 and T3 of the series.
NCAST
• One RN will attend the NCAST training series
Administrative Costs
• Administrative/Indirect costs are calculated at 12.9%
• The hosting agency provides office space,utilities, office equipment, printers,
copiers, accounting services, personnel services, and housekeeping.
APPLICANT: WELD COUNTY DEPARTMENT OF PUBLJC HEALTH AND ENVIRONMENT
I I
PROJECT: NURSE HOME VISITOR PROGRAM
BUDGET
FoLthe period 712002-6/2003
Annual Number Total Source of Funds
Salary Months Amount *Applicant Requested
Rate Budget Reguired and Other from CDPHE
PERSONAL
Ariane Rowe 42,484 12 42,484 42,484
Eva Rodriguez 42,484' 12 42,484 42,484
Tracy Lujan 42,484, 12 42,484 42,484
Gerri Holton 42,131 12 42,131 42,131
Erma Gonzalez(.5 FTE) 12 12,638 12,638
Contractual/Fee for Service:
Supervising Personnel:
Nancy Weber(.5 FTE) 12 23,433 23,433
Fringe Benefits: Rate=30% 50,875 61,696 61,696
Total Personal 267,350 0 267,350
OPERATING
(include only costs not part of
indirect)
Office Supplies 1,200 1,200
Client Support 3,500 3,500
Printing and Postage 3,100 3,100
Phone-Office and Cellular 5,100 5,100
Program health supply 500 500
Professional Development 1,500 1,500
0
0
Equipment
0 � 0
0
0
0
NCCFC Training 2,822 2,822
NCCFC Materials 0
NCCFC Clinical Info.System Support 0
NCCFC Purchase of System&TA 0
NCCFC Indirect at 26% 0
NCAST Training 1,120 1,120
PIPE Training 0
NCAST&PIPE Training Materials
Sub Total Operating 18,842 0 18,842
TRAVEL:
Mileage-local visits 12,730 12,730
Travel to Trainings 1,600 1,600
Sub Total Travel 14,330 0 14,330
EQUIPMENT:
Computers with MS software(5)
Modems(2)
Cellular Phones(4)
Sub Total Equipment 0 0 0'
Administrative/Indirect @ 11.74% 35,281 0
TOTAL PROJECT 335,804 0 335,804
''Source of Funding for"Applicant
and Other"
Local/County"
Medicaid Funding
Patient Fees —T
Other
Total Applicant and Other 0
Are these local funds used to
match any other grant? Yes No X
X
Signature of Director or Authorized Representative
March 14,2003 TASK ORDER CHANGE ORDER LETTER
Task Order Change Order Letter Number 21, Contract Routing Number 03 FAA 00865
State Fiscal Year 2002-.2003, Nurse Home Visitor Proeram
This Task Order Change Order Letter is issued pursuant to paragraph F. of the Master Contract identified as
contract routing number 00 FAA 00008 and paragraph E.17.of the Task Order identified as contract routing
number 01 FAA 00942 and contract encumbrance number PO FAA FII50100942 This Task Order Change Order
Letter is between the COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT and
BOARD OF COUNTY COMMISSIONERS OF WELD COUNTY. The Task Order has been amended by Task
Order Renewal Letter M contract routing number 02 FAA 00183 and Task Order Renewal Letter 02,contract
routing number 03 FAA 00290. 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 July 1.2002,through June 30.2003. The
maximum amount payable by the State for the work to be performed by the Contractor during this current term is
decreased by Sixteen Thousand Four Hundred Eleven Dollars ($16,411.001 for an amended total financial
obligation of the State of SEVEN HUNDRED EIGHTY-FOUR THOUSAND NINE HUNDRED TWENTY-
NINE DOLLARS AND SEVEN CENTS ($784,929.07). The revised Budget is incorporated herein by this
reference,made a part hereof,and attached hereto as"Attachment 1". The first sentence in Part C,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 May 1.2003
whichever is later.
Please sign,date,and return all four(4)originals of this Task Order Change Order Letter by April 14,2003 to the
attention of:Peen Becker,Colorado Department of Public Health and Environment,4300 Cherry Creek
Drive South,Mail Code PSD-HCP-A4,Denver,Colorado 80246-1530. One original of this Task Order Change
Order Letter will be returned to you when fully approved.
BOARD OF COUNTY COMMISSIONERS STATE OF COLORADO
OF WELD COUNTY Bill Owens,Governor
(a politic division of the state of Colorado)
By: - --, •. ' By:
Name: David E. Lon• For e Execu v rector
Title: Chair 04 02 2013,I���� DEPARTME F PUBLIC HEALTH
FEIN: 8460 1813 AND ENVIRO NT
CNA(Seal) �. Rr,^e. -1 ,9 PROGRAM APPROVAL:
Q'1449
By: .//J . .- �:�11,. 'ter 9� By:
Deputy Clerk t" *- <
ALL CONTRA t /ys.
t_� t•PROVED BY S CONTROLLER
CRS 2430-202 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. Ifperformance 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:
Arthur L.Barnhart
By; WELD COUNTY DEPARTMENT OF
Date: PUBLIC HEALTH A D ENVIRON
Revised:08/30/02 BY
Mark E. Wallace, D, MPH-Director
Page 1 of 1
3-On I
Attachment 1
As Modified by Task Order Change Order Letter Number 01
Contact Reuling Number 03 FAA 00185
APPLICATION BUDGET AND/OR EXPENDITURE REPORT FORM
Weld County Health Dept. FOR THE PERIOD: 7/01/02 TO 6/30/03
PROJECT:NURSE HOME VISITOR PROGRAM
Annual No.of Total SOURCE OF FUNDS
Requested/
Salary Months Amount Received
Rate Budget FTE Required OTHER' from CDPHE
PERSONAL SERVICES:
Nurse Supervisor-Nancy Weber $46,866.00 12 50% $23,433.00 $23,433.00
Nurse-Mane Rowe ' $42,484.00 12 100% $42,484.00 $42,484.00
Nurse-Eva Rodriquez $42,484.00 12 100% $42,484.00 $42,484.00
Nurse-Traci Lujan $42,484.00 12 100% $42,484.00 $42,484.00
Nurse-Gerd Holton $42,131.00 12 100% $42,131.00 $42,131.00
Clerk-Enna Gonzalez $25,276.00 12 50% $12,638.00 $12,638.00
ConiractuaWee for Service
0.00
Supervising Personnel $0.00
Nursing Director . $0.00 12, 10% $0.00 $0.00 $0.00
Fringe Benefits: Rate=30% - 61.696.00 0.00 $61 696.00
Total Personal Services $267,350.00 $0.00 $267,350.00
OPERATING EXPENSES(whlch are not part of Indirect):
Office Rent/Utilities $0.00 $0.00 $0.00
Office Supplies $1,200.00 $1,200.00
Client Support Materials $3,500.00 $3,500.00
Printing and Postage $2,500.00 - $2,500.00
Phone-Office and Cellular $5,100.00 $5,100.00
Program medical supplies $500.00 $500.00
Professional Development $1,500.00 $1.500.00
Total Operating $14,300.00 $0.00 $14,300.00
EQUIPMENT p
50.00
Computer&Software 200 0 $200.00
Total Equipment $200.00 $0.00 $200.00
TRAVEL(In-statelOUFSGte)
Visit/Outreach Mileage 12.730.00 12.730.00
NCCFCNCHSC Training Travel 1,600.00 1,600.00
State Meeting Travel 3,000.00 3,000.00
Total Travel $17,330.00 $0.00 $17,330.00
TRAINING&TECHNICAL ASSISTANCE-NCCFCIUCHSC
Clinical Training a Support $0.00 $0.00
Training Materials $0.00 $0.00
Purchase of Clinical Info.System(CIS) $0.00 $0.00
Technical Assistance $5,200.00 $5.200.00
LESS REDUCED CHARGES TECHNICAL ASSISTANCE 43,714.00 $0.00 -$3,71400
NCCFC Contract Indirect Costs - $1,352.00 $1,352.00
PIPE Materials $824.00 $824.00
Total Training&Tech.Assistance $3,662.00 $0.00 $3 662.00
NCAST TRAINING&MATERIALS
NCAST TRAINING&MATERIALS $1,120.00 $1,120.00
LESS REDUCED CHARGES NCAST 4700.00 4700.00
Total NCAST Training&Materials $420.00 $0.00 $420.00
Total Direct Costs(Personal Services+Operatinq+TraveHContractuall $303,262.00 $0.00 $303.262.00
ADMINISTRATRIFJINDIRECT COST
11.74% $35,082.00 $0.00 $35,082.00
Total Administrative/Indirect Costs $35.082.00 $0.00 $35,082.00
LESS SFY 03 FUNDING REDUCTION 411,997.00 $0.00 411,997.00
TOTAL PROJECT COST 326,347.00 0.00 326,347.00
'Source of funding for"Other(Match or In-kind)
WELD County Contributions $
$
$
$
TOTAL $0.00
May the NON FEDERAL funds be used as match? YES NO
Signature of Authorized Representative Date
WEtcOJCOLakyleNred Pap 1 b1 Brawl 2/25/03
May 9,2003 TASK ORDER OPTION TO RENEW LETTER
Task Order Renewal Letter Number 03, Contract Routing Number 04 FAA 00065
State Fiscal Year 2003-2004, Nurse Home Visitor Prorram
This Task Order Option to Renew Letter is issued pursuant to paragraph F. of the Master Contract identified as
contract routing number 00 FAA 00008 and paragraph D. of the Task Order identified as contract routing number
01 FAA 00942 and contract encumbrance number PO FAA F850100942. This Task Order Option to Renew Letter
is between the COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT and BOARD
OF COUNTY COMMISSIONERS OF WELD COUNTY. The Task Order has been amended by Task Order
Renewal Letter 01 contract routing number 02 FAA 00183 Task Order Renewal Letter 02 contract routing number
03 FAA 00290 and Task Order Change Order Letter 01 contract routing number 03 FAA 00865. 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 current term of July 1,2003 through June 30,2004. The maximum amount payable by the State for the
work to be performed by the Contractor during this current term is increased by Three Hundred Sixty-Six
Thousand Two Hundred Thirty-One Dollars,f$366,231.00)for an amended total financial obligation of the State
of ONE MILLION ONE HUNDRED FIFTY-ONE THOUSAND ONE HUNDRED SIXTY DOLLARS AND
SEVEN CENTS ($1,151,160.07). The revised Budget is incorporated herein by this reference,made a part hereof,
and attached hereto as"Attachment J". The first sentence in Part C.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 July 1,2003 whichever is later.
Please sign,date,and return all four(4)originals of this Task Order Option to Renew Letter by June 12,2003,to
the attention of:Peery Becker,Colorado Department of Public Health and Environment,4300 Cherry Creek
Drive South,Mail Code PSD-HCP-A4,Denver,Colorado 80246-1530. One original of this Task Order Option
to Renew Letter will be returned to you when fully approved.
BOARD OF COUNTY COMMISSIONERS STATE OF COLORADO
OF WELD COUNTY Bill Owens,Governor
(a political ivision of the state of Colorado)
By: By:
• I a E , • t /I' t 3 For the Executive r tor
�- Ti .�,air I DEPARTMENT OF LIC HEALTH
t./ X11 r
ql4,:. `0813 ;/J,/� ,,�0/r/q/► / /� AND ENVIRONMENT
i mat a� yq a AT1 1'?�N /D' �'^`r.�(
�tpat ' PROGRAM ROYAL:
•
j6e 'grnty a to the Board
By:
PU- 7 Clerk to the Board /
ALL CONTRACTS MUST BE APPROVED BY( ST CON OLLER
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:
Arthur L.Barnhart
WELD COUNTY DEPARTMENT OF
By: PUBLIC HEALTH AND ENVIRON NT
Revised:08/30/02 Date: r� n
Mark E. Wallace. MD, MPH-Director
Page 1 of I
Attachment J
APPLICATION BUDGET AND/OR EXPENDITURE REPORT FORM
APPLICANT:WELD COUNTY DEPARTMENT OF PUBLIC HEALTH&ENVIRONMENT FOR THE PERIOD: 7101/03 TO 6/30/04
PROJECT:NURSE HOME VISITOR PROGRAM
SOURCE OF FUNDS
Annual No.of Total Requested/
Salary Months Amount Received
Rate Budget FTE Required OTHER' from CDPHE
PERSONAL SERVICES:
Public Health Nurses,Supvr.&Clerk 5.00 FTE 12 5.00 $205,654.00 $205,654.00
Pius 5%funding-Salary Increase $10,283.00 $10,283.00
Fringe Benefits: Rate=32.00% $69,035.00 $0.00 $69,035.00
Total Personal Servkes $284,972.00 $0.00 $284,972.00
OPERATING EXPENSES(whkh are not part of Indirect):
Office Rent/1.8110es-County Buiding Services $0.00 $0.00 $0.00
Office Supplies $1,200.00 $1,200.00
Client Support Materials $3,000.00 $3,000.00
Ferns/Facilitators/Outreach Materials $1,500.00 $1,500.00
Postage $600.00
$600.00
Advisory Board $0.00
$0.00
Telephone $1,200.00 $1,200.00
Computer Network/Internet Fees $360.00 $360.00
Cel Phones $2,500.00 $2,500.00
Medical&Program Supplies $300.00 $300.00
Professional Development $1,500.00 $1,500.00
Utilities,Bldg.Mail.8 insurance $0.00 $0.00
Finance d HR
3000 $0.00
Total Operating $12,160.00 $0.00 $12,160.00
EQUIPMENT
Computer,Software&Office Eqpt. $0.00 $0.00 $0.00
Total Equipment $0.00 $0.00 $0.00
TRAVEL(In-state/Out-stab)
VkilOubeach Mieage $16,320.00 $16,320.00
NCCFCNCHSC Training Travel $0.00 $0.00
NCAST Travel
$0.00 $0.00
Total Travel $16,320.00 $0.00 $16,320.00
TRAINING&TECHNICAL ASSISTANCE-NCCFCIUCHSC
Clinical Training&Support $0.00 woo
Training Materials $0.00
$0.00
Purchase of Cllnkal In/o.System(CIS) $0.00 $0.00
Technical Assistance $6,000.00 $6,000.00
NCCFC Contract Indirect Costs $1,560.00 $1,560.00
PIPE Materials $200.00 $200.00
Total Training&Tech.Assistance $7,760.00 $0.00 $7,760.00
NCAST TRAINING&MATERIALS
NCAST TRAINING&MATERIALS $100.00 $100.00
Total NCAST Training&Materials $100.00 $0.00- $100.00
Total Direct Costs(Personal Servkes+Operatlng+TraveNContractual) $321,312.00 $0.00 $321,312.00
ADMINISTRATIVEIINDIRECT COST
13.98%of Total Died Costs $44,919.00 $0.00
$44,919.00
Total Administrative/Indirect Costs $44,919.00 $0.00 $44,919.00
TOTAL PROJECT COST $366,231.00 $0.00 $366,231.00
*Source of funding for"Other-(Match or In-kind)
Weld County Health Contributions $0.00
$
$
$
TOTAL $0.00
May the NON FEDERAL funds be used as match? YES NO
Signature of Authorized Representative Date
Weld FY04 r6 aMPUM Pagel of 1 yypet
Attachment A through Attachment J
Attachment B
STATE OF COLORADO
Bill Owens,Governor
Douglas H.Benevento,Acting Executive Director �o4•Coto
Dedicated to protecting and improving the health and environment of the people of Colorado He i
4300 Cherry Creek Dr.S. Laboratory and Radiation Services Division
a
Denver,Colorado 80246-1530 8100 Lowry Blvd. +1876
Phone(303)692-2000 Denver,Colorado 80230-6928
TDD Line(303)691-7700 (303)692-3090 Colorado Department
Located in Glendale,Colorado of Public Health
http✓/www.cdphe.state.co.us and Environment
Date: January 21,2004
To: Nurse Home Visitor Program/Nurse-Family Partnership Grantees
From: Esperanza Y. Zachman, Nurse Home Visitor Program Manager
Re: REVISED Progress Report and Budgets for FY2004-05 Continuation Funding Requests
Attached please find the instructions to complete the revised Progress Report and Budgets for FY04-05,
FY05-06 and F106-07. The state fiscal year (FY)is defined as July 1st through June 30th of the following
year. These documents need 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, March 5,2004 for consideration of continued funding for FY04-05. 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. The National Center is the
facility designated in the Nurse Home Visitor Program 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 services at the community level.
The budget you submit for FY04-05 is the budget that will be used for the renewal of your contract for
FY04-05, should you receive continuation funding. The budgets you submit for FY05-06 and FY06-07
are prospective budgets that will be used to estimate the future costs of the program and other
planning purposes. 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. We do not want to have unspent
funds at the end of the fiscal year that could have otherwise been utilized for services at another site.
Per the State Performance Audit, the program will continue to be under close scrutiny for cost-effective
use of the appropriated funds.
We know that the Medicaid integration process has been protracted and, at times, confusing and
uncertain. We greatly appreciate your patience and assistance with this issue. The CDPHE has
continued working with the Colorado Department of Health Care Policy and Financing to claim
Medicaid payment for the NI-IVP. As it stands today,we will be pursuing the Targeted Case
Management Medicaid claim, despite earlier correspondence,for services provided by the nurse home
visitors to those clients who are Medicaid-eligible. As you know, approximately seventy-seven percent
of the families being served are Medicaid eligible. We are estimating that approximately seventy-five
percent of the services provided would qualify for payment as Medicaid Targeted Case Management
services. The state funds from the Tobacco Settlement Agreement used to pay for these Medicaid
services to Medicaid-eligible clients could thus be matched by federal Medicaid funds on a 1:1 ratio as
approved by the federal Centers for Medicaid and Medicare Services.
If authorized by the current legislature to proceed with the Medicaid billing in FY2004-05, the Medicaid
reimbursement process would mean that the individual grantee sites would need to bill Medicaid for
the clients served each month that are Medicaid eligible. Each agency selected to receive 2004-05 Nurse
Home Visitor Program funds will be expected to certify that it is currently or will become a Medicaid
provider and will bill Medicaid for Targeted Case Management services provided through the Nurse
Home Visitor Program (see Attachment F).
We will not know if we are to move forward with the Medicaid funding process until later in the
legislative session. Therefore,we need to ask each agency applying for funding for FY04-05 to submit
the FY04-05 budget without allowance for any Medicaid reimbursement. If the Medicaid option is
implemented, it may be necessary to amend the budgets for FY04-05. CDPHE will then work very
closely with each funded agency in the development of the budget amendment and the
implementation of the Medicaid billing process.
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.
Finally, 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 303-692-2943 or by e-mail at ey.zachman@state.co.us
Thank you.
H:\WPDOCS\NHVP\Application\0405ProgressReports\04R5CoverLetter.doc
Colorado Department of Public Health and Environment (CDPHE)
Of'fA
NURSE HOME VISITOR PROGRAM (NHVP)
Jell • (Nurse-Family Partnership)
FY 2003-04 PROGRESS REPORT
and
FY 2004-05,FY 2005-06 and FY 2006-07 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 FY 04-05, FY 05-06 and FY 06-07 Budgets
and Narratives must be received by CDPHE on or before March 5, 2004 by 5pm and must be stapled or
binder clipped. Please submit one (1) original and three (3)sopies to:
Esperanza Y. Zachman, Program Manager
NHVP/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 5, 2004 but after 5:00 p.m. or postmarked on or before March 5, 2004 but
not received by CDPHE until after March 5, 2004 5:00 p.m.
> 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 of the University of Colorado Health Sciences Center. The budget requests for FY04-05 will be
compared to the actual spending from last year and this year. The National Center will monitor the progress
of each operating agency in serving the number of clients which the agency has committed to serve in its
contract with the CDPHE Nurse Home Visitor Program and in maintaining a quality implementation of the
Nurse-Family Partnership as measured by, but not limited to, dient enrollment, client attrition, staffing and
submission of data as determined by benchmarks from the Nurse-Family Partnership's clinical research trials
and from experience implementing the Nurse-Family Partnership nationally. The National Center will
implement a process for agencies that are not implementing the program in a quality manner as determined by
the criteria referenced above whereby a negotiated implementation 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 2004 Board of Health meeting.
Please feel free to call Esperanza Y. Zadunan, NHVP Program Manager at 303.692.2943 or email at
ey.zachman@state.co.us with any questions or needs. If you have any budget related questions, you may also
call Lee Joseph, NHVP Fiscal Officer at 303.692.2318 or email at lee.joseph@state.co.us
1
PROGRESS REPORT CONTENTS
> FY03-04 Progress Report questions for the time period of March 1, 2003 through February 28, 2004.
> Attachment A: Response to Site Review Letter dated November 19,2003.
> Attachment B: Budget Page to be used for—
FY04-05-July 1, 2004 through June 30, 2005
FY05-06-July 1, 2005 through June 30, 2006
FY06-07-July 1,2006 through June 30, 2007
➢ Attachment C.1 and Attachment C.2: Sample Budget and Detailed Narrative
> Attachment D: Rules Conceming the Colorado Nurse Home Visitor Program
> Attachment E: Assurance of Intention to Meet Program Requirements
> Attachment F: Medicaid Assurance
> Attachment G: Cover Sheet
2
FY 2003-04 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, 2003—February 28,2004. Each response must begin with the respective title, letter or
number.
A. FUNDING LEVEL: The amount of Nurse Home Visitor Program funds (Tobacco Settlement money)
awarded to the program for the current fiscal year(July 1, 2003 through June 30,2004).
B. CLIENT INFORMATION: The actual number of clients enrolled and number of clients who are active
as of March 1, 2004.
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 six (6) 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 if needed.
Comment on the successes and challenges you encountered since March 1, 2003 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? Please explain.
c. Describe your process for assuring that referrals are received early in the 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.
2. Enrolling and Retaining Clients
a. If you have not met your contractual active enrollment goal of 100 families (50 families for
programs with waivers) 7-9 months after nurses attended T1, please explain why. In addition,
detail the strategies of how you plan to reach that goal, including who is responsible for
implementing these strategies and a timeline of when these strategies will be implemented.
b. Please provide two strategies that your nurses have successfully used to keep clients actively
involved in the program.
c. How do you monitor client attrition,in addition to using the CIS?
d. Have you seen any trends among the clients you have lost? What changes have you made in
response to the attrition you have experienced? How effective have these changes been?
3. Nurse Retention and Recruitment
3
a. , 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?
b. What have the nurses found to be their greatest challenges?Greatest needs? How have you helped
meet these needs?
c. If applicable, what has caused nurses to leave their positions in the program?
d. 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?
e. Do you have a transition plan to prevent client attrition should there be nurse turnover? Please
attach.
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. Please provide two samples of coalition meeting minutes from the last year.
5. Broad-Based Community Support
a. Beyond support from your board, how has your overall community support changed over the last
year?
b. What actions have you taken to develop new community support and maintain existing
community support for the program?
c. How has the Implementing Agency administration helped support this program? Has it impacted
program implementation? Please provide specific examples from the past year.
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. What
makes certain ones successful?If not successful,what are you currently working on to improve this
coordination and relationship?
7. Integration of CIS
a. Are you reviewing CIS reports on a monthly basis? If not,why?
i. Describe how you have used CIS reports on a regular basis to ensure fidelity to the model and
achievement of key benchmarks.
ii. How are you assuring visits are made according to the frequency recommended by NCCFC?
iii. How are you ensuring domains and treatment plans are being covered appropriately?
iv. Is there a particular area on which you have focused and what time-framed objectives have you
set for this area?
8. General Program Implementation
a. What have been the most significant challenges experienced by the program? Describe what
unexpected or unusual circumstances have impacted the program's implementation or continuing
operation? (Example: staff turnover among nurses or implementing agency staff changes)
4
•
b. , Share other successes your site has had in the past year.
FY 04-05,FY 05-06 and FY 06-07 Budget
The state fiscal year (FY)is defined as July ht through June 30th.
Please submit a 12-month budget (Attachment B) for FY04-05, FY05-06 and FY06-07 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 C.1 and C.2) for guidance in what should be included in your budget. The structure
of your site may be different than the .5 FTE Supervisor, four 1.0 FTE Nurses and .5 FTE Data Entry Clerk used
to create this sample budget. We will take the differences into account when reviewing the budgets.
Within the sample budget the allocations for some items vary from year to year. For sites reaching the end of
their first three-year cyde, please review the following line items carefully:
Client Support Materials: Estimate the number of clients graduating in the following year and then
budget $145 per client to fill those spots. This does not include clients that leave due to attrition. Explain
how you arrived at your estimates.
Copies of Forms/Facilitators: Based on the estimate of graduating dients in 04-05, estimate the cost of
copies that need to be made for new replacement clients in 04-05 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.
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 04-05 budget, please justify those in each budget
narrative. For example, if you are asking for more than the budgeted amount for "Visit Mileage", please
explain the formula you used to arrive at your proposed dollar amount and why you need the additional
funding. 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 all requests for increased funding will be granted.
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 fiscal year 04-05 and prospective budgets for fiscal year 05-06,
and fiscal year 06-07 for the implementation of the NHVP. Applicants may use the Budget Request Form
(Attachment B) or another spreadsheet format that provides all the requested information. The budget
5
provided for fiscal year 04-05, as approved by the Board of Health upon the recommendation of the
National Center, will be the budget for the contract for fiscal year 04-05 if the Applicant is approved for
funding. The budgets for fiscal year 05-06 and fiscal year 06-07 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.
c. Equipment Costs: 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. Category A 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.
f. 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 costs, 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.
6
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
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 expects 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
7
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 48 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.
H:\WPDOCS\NHVP\Application\0405ProgressReports\U05ProgrgsReport.doc
8
Colorado Department of Public Health and Environment(CDPHE)
1/)* 4300 Cherry Creek Drive South,PSD-A4
Denver,Colorado 80246
• 303-692-2943
•
r ` ey,zachmanestate_co_u1
NURSE HOME VISITOR PROGRAM (NHVP)
GRANT APPLICATION TIME LINE
January 2004
•
January 20,2004 Grant Application Packets available.
January 20-February 6,2004 Question and Answer Period open.
February 13,2003 Answers to questions available on the website.
March 5,2004 (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 5,2004 (5:00 PM) Deadline for New and Expansion Grant Applications.
Materials must be received by this date.
March 8-9, 2004 Application Qualification Screening by CDPHE.
March 10-29, 2004 Review and Evaluation of Qualified Applications by the
National Center for Children, Families and Communities,
University of Colorado Health Sciences Center.
April 5, 2004 Funding Recommendations of the National Center for
Children, Families and Communities forwarded to the State
Board of Health.
April 2004 State Board of Health Deliberation and Action on Funding
Recommendations.
April-June 30,2004 Contracting Process between CDPHE and selected applicants
for July 1, 2004 through June 30, 2005.
FY 2003-04 PROGRESS REPORT CHECKLIST
❑ A Progress Report for the time period of March 1,2003 through February 28,2004
❑ Attachment A: Response to Site Review Letter dated November 19, 2003
A separate Budget for...(Attachment B)
❑ FY04-05-July 1, 2004 through June 30, 2005
❑ FY05-06-July 1, 2005 through June 30, 2006
❑ FY06-07-July 1,2006 through June 30,2007
❑ A detailed Budget Narrative to justify projected expenses for each of the corresponding budgets
submitted.
❑ Attachment E: Assurance of Intention to Meet Program Requirements
❑ Attachment F: Medicaid Assurance
❑ Attachment G: Cover Sheet
❑ One (1) original and Three(3)copies of the completed Progress Report and Budgets
(Must be stapled or binder clipped.)
H:\WPDOCS\NHVP\Application\0405ProgressReports\040$Timeline and Checklist doc
Please contact Esperanza Y. Zachman, NHVP Manager, at 303.692.2943 or
ey.zachman@state.co.us to request Attachment A for your site. Attachment A is
individualized by grantee. Thank you.
Attachment A: Name of NHVP 2003-04 Grantee
NURSE HOME VISITOR PROGRAM(NHVP)
(Nurse-Family Partnership)
2003-04 Grantee Response to Site Review Letter Date November 19, 2003
In two (2) single-spaced pages or less, please response to each of the stated issues emphasizing your
progress-to-date where applicable. These issues can be found in your site review letter dated November
19, 2003 from the National Center for Children, Families and Communities and Colorado Department of
Public Health and Environment.
The following are specific issues that have been discussed for the site:
H:\WPDOCS\NHVP\Applicatlon\U405PmgresReports\IAttadA)blank.doc
NURSE HOME VISITOR PROGRAM ATTACHMENT B
APPLICATION BUDGET AND/OR EXPENDITURE REPORT FORM
APPLICANT: FOR THE PERIOD:
PROJECT:
SOURCE OF FUNDS
Annual No.of Total
Requested I
Salary months Amount Received
Rate Budget FTE Required Other Sources' from CDPHE
Personal Services:
Contractual/Fee for Service
Supervising Personnel
Fringe Benefits: Rate=
TOTAL PERSONAL SERVICES ,$ $ S
Operating Expenses(which are not part of indirect):
TOTAL OPERATING $ $ $
Equipment Expenses
TOTAL EQUIPMENT $ $ $
Travel Expenses
TOTAL TRAVEL _ $ $ $
NCCFC/UCHSC Training&Technical Assistance
TOTAL TRAINING&TECH ASSISTANCE $ $ 3
NCAST Traing&Materials
TOTAL NCAST COSTS $ $ $
TOTAL DIRECT COSTS(Persorui Servtces+operaerg.Travd.Comrectuai) $ $ $
Indirect Costs
TOTAL INDIRECT COSTS $ $ $
TOTAL PROJECT COST $ $ $
OTHER SOURCES of FUNDING(Match or In-kind)
$
$
TOTAL OTHER SOURCES $
Signature of Authorized Representative Date
Rev.5/10f2004 BUDGETAPPLFORMXLS BSS
- l ,
c k ter.-r mtils
l at S7>lhils'.jl Attachment C.1
NFP SAMPLE SITE BUDGET
100 FAMILIES
Personnel Costs(Estimate)
Base Fringe Total %Effort Year 1 Year 2 Year 3 Total
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 27,072.00 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 1,200.001 3,600.00
Client Support Materials $145/family 13,500.00 500.00 500.00 14,500.00
Copies of Forms/Facilitators $1500 per year 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 @.31/mi/yr 6,200.00 6,200.00 6,200.00 18,600.00
Sub-Total(Administrative) I 36,460.00 18,110.00 18,110.00 72,680.00
Sub-Total for Personnel&Administrative 263,567.00 256,574.00 268,499.00 788,640.00
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
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 1 10,000.00 10,000.00
NCAST Training(Not payable to NFP-Site arranges for this training directly with NCASI)
Appx.$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 305,309.00 264,134.00 276,059.00 845,502.00
"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.
H:\WPDOCS\NHVP\Application\0405New&Expand\(AttachE.1)0405 Samp]eBudgetdoc
.: .:,-1"4111.1ty Attachment C.2
:,,'Partrat<hip NFP Detailed Narrative for Sample Site Budget 2003-2004
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%)
including 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$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.
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.
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
1
• VCR/TV monitor
• Still and video camera
• 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.
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. NFP Training Materials -Includes the following:
• Set of Prenatal, Infancy and Toddler Guidelines
• Study guides for Guidelines
• Sell-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
2
, • ,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.
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 dose 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 Tl, and a regional location for T2 and T3 (for a total of 9 days of training)
include travel, meals, and hotel. Generally, Nurses attend T2 approximately 4 months after T1 and T3
approximately 10 months after Tl.
3
, 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
• 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.
H:\WPDOCSNHV Application 2x405HadgetNuntive.doc
4
• Attachment D
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(1)(a),C.R.S.,as one whose accreditation may be accepted in lieu of board approval.
(12) "Nurse Home Visitor Program" or"Program" means a program that is described in§25-31-104(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 costs include but
are not limited to,travel costs and training materials;
(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 internet 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§1.2(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§1.2 (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§1.2(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;
(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 describing 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 close 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.
1.5 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,include 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 costs 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;
(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 protocols 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 and 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 shall, 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.
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) MI 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.
(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 disclose 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§1.8,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.
H:\WPDOCS\NHVP\Application\0405ProgfasRepons\(AcuchD)0405RWes.doc
�.� Attachment E
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:
H:\WPDOCS\NHVP\Application\0405ProgressReports\(AttachE)0405Assurance.doc
• Attachment F
ASSURANCE of INTENTION to be an active MEDICAID PROVIDER:
Applies to all NURSE HOME VISITOR PROGRAMS
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 commencing July 1,2004. All Nurse Home Visitor Program sites
will be required to become an active Medicaid provider,if not already,and must be willing to bill
Medicaid for TCM services.
Please assure that the applicant entity is either an active Medicaid provider or will become on by July 1,
2004.
Presently an active Medicaid Provider.
Will become an active Medicaid Provider by July 1,2004.
Name of Applicant Entity:
Name of Authorized Signer:
Signature of Authorized Signer:X
Date:
H:\WPIYrS\NHVP\Application\0305ProgressReports\UuachF)O405Medicaid.doc
Attachment G
pF
FO..
Colorado Nurse Home Visitor Program
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2004-05 PROGRESS REPORT and BUDGETS
COVER SHEET for CONTINUATION FUNDING REQUESTS
1. Name of Applicant Entity:
Address/City/Zip
2. Name of person completing the Progress Report:
Position/Title:
Telephone: FAX:
E-Mail:
3. Name of Authorized Signer:
Position/Title:
Telephone: FAX:
E-Mail:
Signature:X
4. Grant request for July 1,2004 through June 30, 2005:$
5. County(ies)to be served:
6. Number of mothers to be served:
H:\W PDOCS\NHVP\Application\(AttachB)0405AppCvfihcdoc
Attachment C
Weld County NFP Budget Narrative for 2004-2005
The contractor acknowledges that a portion of the costs of
providing these Nurse Home Visitor services shall come from sources
other than Tobacco Master Settlement Funds provided in this contract. .
It is anticipated that state designed Medicaid reimbursement for Targeted
Case management services will provide the additional funds to complete
the budget.
Personal
• The amounts in this section reflect the salaries and benefits of four staff members in
the position of Community Health Nurse II, a .5 FTE Office Technician III staff
person, and a .5 RN supervisor. The RN personnel involved in these positions each
have three years of experience in the Nurse Family Partnership program. 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 6 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. Craft paper, scissors, markers, and
glue are often utilized by staff to complete client projects and learning activities.
Other materials assist with general program organization and storage.
• 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 2004-05,
40% ($5800) of the $145 will be utilized on families, based on the stages of our client
caseload. 30% is designated in year 2005-06, and 30% in year 2006-07. ($4350).
• Copy costs for the 2004-05 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
prices are $.06 per page, and $.09 for double sided printing. A caseload of 100 clients
requires nearly 20,000 printed forms in their visit materials.
• 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.
• Five 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.
NFP Clinical Training and Support
• There is no anticipated need for NCCFC training or materials in the year 2004-05.
All current staff have completed the series of three trainings for the NFP program.
In the event of needing to hire and train a replacement RN or supervisor, it would
be required to add the customary costs of the entire NCCFC training, lodging,
materials and support.
• CIS program access and technical assistance is anticipated to be an expense of
availability is expected to cost $7560.
NCAST Training and Materials
• There is no anticipated need for NCAST training in the year 2004-05. All current
staff have completed the series of NCAST trainings and certifications. In the
event of needing to hire and train a replacement RN or supervisor, it would be
required to add the customary costs of the entire NCAST training, lodging,
materials, and support.
• A small amount of NCAST materials will be necessary to complete client
assessments. It is required to purchase the screening materials from the NCAST
program directly.
Travel
• Program visits are calculated for 25 clients with an average of 2 visits per month.
Two nurses have a 10 mile round trip average, and 2 nurses have a 30 mile around
trip average.
• 50 visits x 10 miles x 12 months x $.355 reimbursement= $2130 x 2 nurses = 4260
50 visits x 30 miles x 12 months x $.355 reimbursement= 6390 x 2 nurses = 12780
• The reimbursement rate of$.355 /mile is determined by the Weld County
government. Total visit mileage expense is expected to be $17, 040. A 1% increase is
projected in the reimbursement rate for the years 2005-06 and 2006-07.
Equipment
• The anticipated equipment expense is the cost of five replacement cell phones in the
year 2005-06.
a — Attachment D
STATE OF COLORADO
Bill Owens,Governor
Douglas H.Benevento,Acting Executive Director -of Coto
Dedicated to protecting and improving the health and environment of the people of Colorado yr
4300 Cherry Creek Dr.S. Laboratory and Radiation Services Division
Denver,Colorado 80246-1530 8100 Lowry Blvd. ,r 1g76�.
Phone(303)692-2000 Denver,Colorado 80230-6928 - --
TDD Line(303)691-7700 (303)692-3090 Colorado Department
Located in Glendale,Colorado of Public Health
httpd/www.cdphe.state.co.us and Environment
Date: January 20, 2004
From: Esperanza Y. Zachman, Colorado Nurse Home Visitor Program Manager
Re: 2004-05 New and Expansion Grant Application
Attached please find the application guidance for new and expansion grants from the Colorado Nurse
Home Visitor Program for FY2004-05 (July 1, 2004 through June 30, 2005). The guidance for new
applications should be followed for any entity that has not received funding from the Nurse Home
Visitor Program previously(Categories A and B). The guidance for expansion grants should be
followed for those applicants who are currently receiving funding from the Nurse Home Visitor
Program and who are applying to receive funding for serving an additional set of families. The
applications need to be received at the Colorado Department of Public Health and Environment
(CDPHE) on or before 5:00 PM, March 5,2004, as directed in the instructions. The applications will be
reviewed for completeness by the CDPHE staff and reviewed for content by staff of the National
Center for Children, Families and Communities of the University of Colorado Health Sciences Center
(the National Center). The National Center is the facility designated in the Nurse Home Visitor
Program legislation to make recommendations to the Colorado State Board of Health regarding the
granting of Nurse Home Visitor Program funds to entities that will deliver services at the community
level. The recommendations of the National Center will be considered and acted upon by the State
Board of Health at its April meeting.
A note of clarification is that the Nurse Home Visitor Program is the name of the program established
by the State Legislature to utilize a portion of the state's Tobacco Settlement Agreement fund to
provide nurse home visitor services to first-time pregnant women and their children. The name of the
specific program currently being implemented at the local level is The Nurse-Family Partnership. All
of the current grantees are replicating the Nurse-Family Partnership program developed by the
National Center.
As directed in the Nurse Home Visitor Program legislation,the CDPHE has been working with the
Colorado Department of Health Care Policy and Financing to claim Medicaid payment for Medicaid
Targeted Case Management services provided by the nurse home visitors to those clients who are
Medicaid-eligible. Approximately seventy-seven percent of the families being served are Medicaid
eligible. We are estimating that approximately seventy-five percent of the services provided would
qualify for payment as Medicaid Targeted Case Management services. The state funds from the
Tobacco Settlement Agreement used to pay for these Medicaid services to Medicaid-eligible clients
•
could thus be matched by federal Medicaid funds on a 1:1 ratio as approved by the federal Centers for
Medicaid and Medicare Services.
If authorized by the current legislature to proceed with the Medicaid billing in FY20O4-05, the Medicaid
reimbursement process would mean that the individual grantee sites would need to bill Medicaid for
the clients served each month that are Medicaid eligible. Each agency selected to receive 2004-05 Nurse
Home Visitor Program funds will be expected to certify that it is currently or will become a Medicaid
provider and will bill Medicaid for Targeted Case Management services provided through the Nurse
Home Visitor Program.
We will not know if we are to move forward with the Medicaid funding process until later in the
legislative session. Therefore,we need to ask each agency applying for funding for FYO4-05 to submit
the FY64-05 budget without allowance for any Medicaid reimbursement. If the Medicaid option is
implemented, it may be necessary to amend the budgets for FYO4-05. CDPHE will work very closely
with each funded agency in the development of the budget amendment and the implementation of the
Medicaid billing process.
Finally, please note that you are asked to submit budgets for three years with this grant application.
The budget you submit for FYO4-05 is the budget that will be used for the FY04-05 contract, if approved
by the National Center and the State Board of Health. The budgets for FY 05-06 and FYO6-07 are
prospective budgets that will for estimating the future costs of the program and other planning
purposes. It is important that you give serious consideration to the development of the prospective
budgets as they will be reviewed again when you request continuation funding for those future years,
should you be awarded a grant for FY04-05.
Please contact me with any questions or comments. I can be reached by phone at 303-692-2943 or by e-
mail at ey.zachman@state.co.us. As you will see in the timeline of the application guidance, the
Question and Answer Period for New and Expansion Grant Applications is January 20, 2004 through
February 6, 2004. Thank you for your interest in the Colorado Nurse Home Visitor Program.
H:\WPDOCS\NHVP\Application\0405New&Expand\1.Coverl.etter0405.doc
Colorado Department of Public Health and Environment(CDPHE)
oe 4300 Cherry Creek Drive South,PSD-A4
Denver,Colorado 80246
303-692-2943
' * ah_ruarifistate.co.us
state.co.us
NURSE HOME VISITOR PROGRAM (NHVP)
2004-2005 GRANT APPLICATION TIME LINE AND CHECKLIST
January 2004
January 20, 2004 Grant Application Packets available.
January 20-February 6,2004 Question and Answer Period open.
February 13,2003 Answers to questions available on the website.
March 5,2004(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 5,2004(5:00 PM) Deadline for New and Expansion Grant Applications.
Materials must be received by this date.
March 8-9, 2004 Application Qualification Screening by CDPHE.
March 10-29, 2004 Review and Evaluation of Qualified Applications by the
National Center for Children, Families and Communities,
University of Colorado Health Sciences Center.
April 5, 2004 Funding Recommendations of the National Center for
Children, Families and Communities forwarded to the State
Board of Health.
April 21, 2004 State Board of Health Deliberation and Action on Funding
Recommendations.
April-June 30, 2004 Contracting Process between CDPHE and selected applicants
for July 1, 2004 through June 30, 2005.
GRANT APPLICATION CHECKLIST
Cover Sheet with authorized signature (Attachment B)
Assurance Form for Categories A and C with authorized signature(Attachment C)
Grant Narrative
Budget Request Form(Attachment D)
Budget Narrative
Medicaid Assurance(Attachment G)
Seven(7)Copies of the completed application
COLORADO NURSE HOME VISITOR PROGRAM
2004-2005 GRANT APPLICATION PACKET OVERVIEW
•*n 76'* Issued January 2004
Applicants may apply for funds for a program which provides services to low-income,first-time mothers through
home visits by nurses as either:
CATEGORY A APPLICANTS:A nurse home visitor program,which means a program that provides home visits
by nurses to low-income,first-time mothers which utilizes the program training requirements,program protocols,
program management information systems,and program evaluation requirements established by rule of the State
Board of Health.
CATEGORY B APPLICANTS: An alternative nurse home visitation program, which means a program that
provides home visits by nurses to low-income first-time mothers but does not utilize the program training
requirements, program protocols, program management information systems, and program evaluation
requirements established by rule of the state board of health but which can show that the program:
1. Has been in operation in the state as of July 1, 1999 for a minimum of five years; and
2. Has achieved a significant reduction in each of the following:
• Infant behavioral impairments due to use of alcohol and other drugs,including nicotine;
• The number of reported incidents of child abuse and neglect among families receiving services;
• The number of subsequent pregnancies by mothers receiving services;
• The receipt of public assistance by mothers receiving services;and
• Criminal activity engaged in by mothers receiving services and their children.
CATEGORY C APPLICANTS: A nurse home visitor program expansion,which means a program
that is already funded under the Colorado Nurse Home Visitor Program and seeks to obtain additional
funding to serve an increased number of families.
APPLICATION PACKET CONTENTS:
I. Background,Overview and Goals of the Colorado Nurse Home Visitor Act
II. Definitions
III. Eligible Applicants
IV. The Statement of Work for Nurse Home Visitor Program Applicants(Category A),for
Alternative Nurse Home Visitation Program Applicants(Category B)and for Nurse Home
Visitor Program Expansion Applicants (Category C)
V. Application Instructions for Grant Application for Nurse Home Visitor Program
Applicants (Category A), for Alternative Nurse Home Visitation Program Applicants
(Category B), and for Nurse Home Visitor Program Expansion Applicants(Category C)
ATTACHMENTS:
•
Attachment A Rules Concerning the Nurse Home Visitor Program
Attachment B Cover Sheet to Accompany Grant Application
Attachment C Assurance Sheet for Nurse Home Visitor Program Applicants
(Category A and Category C Applicants)
Attachment D Budget Request Form
Attachment E Sample Site Budget and Narrative for Categories A and C Applicants
Attachment F Computer Requirements for Clinical Information System
Attachment G Medicaid Assurance
Attachment H Provisions of Contracting with the State
Attachment I Estimates of First-Time and Low-Income Mothers
APPLICATION DEADLINE:
Completed applications must be received by FRIDAY,MARCH 5,2004 5:00 p.m. Please submit
Seven(7) COPIES to:
Nurse Home Visitor Program Manager
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South,PSD-A4
Denver,CO 80246-1530
Applications will not be accepted/considered if they are:
> Late including received on March 5,2004 but after 5:00 p.m.or postmarked on or before March 5,
2004 but not received by CDPHE until after March 5, 2004 5:00 p.m.
> Received without required number of copies.
> Faxed
➢ Emailed
Please feel free to call Esperanza Y.Zachrnan,NHVP Program Manager at 303.692.2943 or email at
ey.zachman@state.co.us with any questions or needs. If you have any budget related questions,you
may also call Lee Joseph,NHVP Fiscal Officer at 303.692.2318 or email at lee.joseph@state.co.us.
H:\W PDOCS\NHVP\Application\0405Overview.doc
' 2004-2005 NURSE HOME VISITOR PROGRAM (NHVP)
Colorado Department of Public Health and Environment(CDPHE)
I. BACKGROUND, OVERVIEW AND GOALS
A. The Colorado Department of Public Health and Environment (CDPHE) is administering the Nurse
Home Visitor Program (NHVP), as provided for in the Nurse Home Visitor Program Ad, section 25-31-
101, et.seq., C.R.S., as amended, (the "Act"), which is funded through the State's Master Tobacco
Settlement Agreement. The NHVP, which provides educational, health and other resources for new
young mothers during pregnancy and the first years of their infants' lives, has been proven to
significantly reduce the amount of drug, including nicotine and alcohol, use and abuse by mothers, the
occurrence of criminal activity committed by mothers and their children under fifteen years of age, and
the number of substantiated incidents of child abuse and neglect. Such a NHVP has also been proven to
reduce the number of subsequent births, increase the length of time'between subsequent births, and
reduce a mother's need for other forms of public assistance.
B. The overall goals of the NHVP are:
1. Improve pregnancy outcomes by helping women practice sound health-related behaviors,
including decreasing the use of cigarettes, alcohol, and illegal drugs and by improving their nutrition;
2. Improve child health and development by helping parents provide more responsible
and competent care for their children; and
3. Improve the economic self-sufficiency of families by helping parents develop a vision for their
own future, continue their education, and find jobs.
C. The NI-WP is limited to low-income, first-time mothers, beginning as early as possible in pregnant
women or until one month postpartum. Enrollment is restricted to women whose income is at or below
200%of the Federal Poverty Guidelines, and who have not had any previous live births.
D. As required in the Act, the National Center for Children, Families and Communities (National
Center) is the "Health Sciences Facility" as selected by the President of the University of Colorado.
Under the Act, as the designated Health Sciences Facility, the National Center is responsible for
monitoring the administration of the NHVP to ensure that the NHVP is implemented according to the
program training requirements, program visit protocols, program management information systems, and
program evaluation requirements established by the Rules. Consequently, successful Applicants will be
required to strictly adhere to the visit protocols, procedures and data collection requirements detailed in
the Rules (Attachment A) unless they apply and are contracted with as an Other Nurse Home
"Visitation" Program. Each successful Nurse Home Visitor Program Applicant will be required to enter
into a contract with the National Center who will provide the required training, technical assistance and
materials.
II. DEFINITIONS
"Ad"means the Nurse Home Visitor Act, C.R. S. 25-31-101 et seq.
i
"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.RS., but does qualify as an exception program as
defined in§25-31-104(4),C.R.S. and section 1.10 of the Rules.
"Applicant" means any Entity (Contractor or New Entity) submitting a Proposal to the Department to
implement the NHVP.
"Board" means the State Board of Health.
"Category A" means Applicants that are applying to fund the implementation of the Nurse Home Visitor
Program(NHVP).
"Category B"means Applicants that are applying to fund Alternative Nurse Home Visitation Programs.
"Category C" means Applicants who are applying to fund a NHVP Program Expansion Site.
"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.
"Contract" means the binding written agreement between an Entity selected for funding to implement
the NHVP and the Department.
"Contractor"means an Entity that has already contracted with the Department to implement the
Program and is now applying to be an Expansion Site.
"Department"means the Colorado Department of Public Health and Environment (CDPHE).
"Entity" means any nonprofit, not-for-profit, or for-profit corporation, religious or charitable
organization, institution or 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.
"Expansion Site" means a site where the Contractor is already serving at least one-hundred low-income,
first-time mothers (or less if granted a waiver by the Board), through a Contract from a previous fiscal
year, and the same Contractor is applying for additional funding to enable it to serve additional low-
income,first-time mothers.
"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.
"First-time" means a mother who has had no previous live births.
"Low-income" means an annual income that does not exceed two hundred percent of the federal poverty
guidelines.
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"National Center" means the National Center for Children, Families and Communities (NCCFC), located
at the University of Colorado Health Sciences Center, that was selected as the Health Sciences Facility by
the President of the University of Colorado, pursuant to the Ad.
"New Entity" means any Entity that has not previously received funding from the Department for the
NHVP.
"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(1)(a), C.R.S., as one whose accreditation may be accepted in lieu of board
approval.
"Nurse Home Visitor Program" (NHVP) or "Program" means a program established pursuant to §25-31-
101,C.R.S. et seq. and meets the requirements of the Rules.
"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 unavailable within the community, in which
case the Entity must show that an appropriately qualified Nurse without a master's degree is available.
"Proposal" means the final document that is submitted by an Applicant with the goal of receiving a
Contract to implement the NHVP or Alternative Nurse Home Visitation Program.
"Rules"means the final rules that were adopted by the Board on November 15,2000.
"State" means the State of Colorado.
"Visit Protocols" mean nurse home visit guidelines addressing, at a minimum, prenatal, infancy and
toddler development and covering topics such as positive birth outcomes, parental life course
development and parenting skills.
III. ELIGIBLE APPLICANTS
Any Entity or combinations of Entities located in the State are eligible to apply. Applicants must strictly
adhere to all applicable federal and state laws, rules and regulations that have been or may hereafter be
established.
IV. STATEMENT OF WORK
Category A=Nurse Home Visitor Program Applicants
Category B=Alternative Nurse Home Visitation Program Applicants
Category C= Nurse Home Visitor Program Expansion Site Applicants
A. Overview of NI-IVP. (Category A/B/C) The NHVP is a voluntary program in which nurses visit the
homes of low-income, first-time mothers starting as early as possible during pregnancy or up to one
month postpartum and continuing through the child's second birthday. Visits take place on a weekly or
bi-weekly basis and cover topics like: improving pregnancy outcomes through better health care,
3
improving parenting skills, and empowering mothers to take charge of their own lives. Nurses shall use
comprehensive visit protocols to assist them in counseling their clients.
B. Eligibility of Clients. (Category A/B/C) The Applicant shall enroll only low-income women who
have had no previous live births. If a birth certificate is issued, it is considered a live birth. Enrollment
preference is given to women enrolled anytime prior to the 28th week of pregnancy, but mothers and
their babies may be enrolled up to the end of the first month of the baby's life.
C. Number of Clients. (Category A/B/C) Each Applicant shall be expected to provide services to a
minimum of one-hundred, low-income, first-time mothers in the community, except when waivers are
granted by the Board because the population base of the community does not have the capacity to enroll
one-hundred eligible women.
•
D. Caseloads. (Category A/B/C) Each full-time (40 hours/week)nurse will carry a caseload of no
more than 25 active families at one time. Each part-time nurse (20 hours/week)will carry a caseload
of no more than 13 active families at one time. An active client is defined as (1) a dient that has no
activity status codes (e.g. site discharged the client, client declined further participation,maternal
death, etc.) (2)the client is pregnant or has a child under 2 years old, or 3) has had at least one home
visit in the last 90 days.
E. Staffing Requirements. (Category A/B/C) Every one-hundred families will be served by at least 4
FTE Nurses, lh 1.1_h Nurse Supervisor, and a 1/2 FTE data entry derk/office support person. The
Applicant shall use its best efforts to hire nurses with flexible work hours to best accommodate client
home visits including after-hours and on weekends and who are bilingual,where necessary.
F. Training. (Category A/C) Nurses shall attend the trainings required by the National Center or any
other trainings that meet the requirements of Section 1.6(1) of the Rules Concerning a Nurse Home
Visitor Program. (Please see Attachment A.)
G. Program Guidelines. (Category A/C) Nurses shall use home visit guidelines produced by the
National Center or any other guidelines that meet or exceed the requirements detailed in Section 1.6(2)
and Section 1.7 of the Rules.
H. Clinical Information System. (Category A/C) Applicants shall use a clinical information system that
is required by the National Center, or any other clinical information system that complies with the
requirements in Section 1.6(3)of the Rules.
I. Program Evaluation and Reporting. Section 1.6(4) of the Rules
1. Data. (Category A/C) Applicants shall submit data required by the clinical information system to
the National Center at least once a month.
2. Progress Reports. (Category A/B/C) On or before March 1 of each year for which funding is
received from the Nurse Home Visitor Fund, each Applicant shall submit an annual progress report
to the National Center, the Department and the community in which the Applicant runs the NHVP
that reports on the effectiveness of the NHVP within the community. The progress report shall be
4
written in a manner that is understandable for both the National Center and the members of the
community. Such report shall include, at a minimum, the following information:
a) The amount of moneys received by the Applicant for the current fiscal year;
b) The actual number of clients enrolled and the number of active clients as of March 1;and
c) An evaluation of the program that includes the effectiveness of the program in achieving
its known benchmarks and program outcomes.
J. Record Keeping. (Category A/B/C) Each Applicant must retain any direct pertinent documents,
papers and bookkeeping records involving transactions related to the Contract. These records shall be
maintained for a period of six years after the end of each Contract period and shall be made available to
the State or its auditors upon request.
K. Billing. (Category A/B/C) Contracts shall be on a cost-based reimbursement system. Applicants will
be required to submit detailed monthly or quarterly billings (at their discretion) no later than sixty days
after the end of the billing period, with a description stating their prior month's or quarter's
expenditures. This should include the match according to the categories of the line item budget as
approved and attached to the Contract. The Department shall provide a standard billing form to all
Applicants. Note: An Entity cannot bill the Department for the same individual to participate in Prenatal
Plus and the NHVP at the same time.
L. Budgets for Subsequent Years. (Category A/B/C) Budgets for subsequent years on or before March 1
of the current year, and shall be approved upon renewal of the Applicant's Contract.
V. INSTRUCTIONS FOR GRANT APPLICATION:
A. All Applicants must begin their application with the Cover Page found as Attachment B. Applicants
must specify how the NHVP will be implemented in their communities. The following topics must be
included and will be reviewed and scored on a 100 point total divided among the topics. Please provide
information for each of the topics as described in the following instructions, completing the appropriate
sections for Category A,Category B and Category C, as applicable. Please begin each of the following
sections with its respective title.
1. Assurance of Intention to Meet Program Requirements for the Nurse Home Visitor Program
(No Points) (Category A/C)
Please complete the Assurance Form which is found as Attachment C, assuring that the Applicant
will meet the Program Requirements for Training, Visit Protocols, Program Management
Information System, and Reporting and Evaluation Systems found in Section 1.6 of the Rules,
which is Attachment A.
2. Qualifying Information for Alternative Nurse Home Visitation Programs
(5 Points) (Category B)
Provide information that establishes that the Applicant's Nurse Home Visitation Program has:
a) Been in operation in the state for a minimum of five years,prior to July 1, 1999, and
5
b) Achieved a significant reduction in each of the following:
o Infant behavioral impairments due to use of alcohol and other drugs, including
nicotine;
o The number of reported incidents of child abuse and neglect among families
receiving services;
o The number of subsequent pregnancies by mothers receiving services;
o The receipt of public assistance by mothers receiving services; and
o Criminal activity engaged in by mothers receiving services and their children.
Describe the reporting and evaluation system that the Alternative Nurse Home Visitation
Program will use to submit the annual progress report described in Section IV.I.2. of this
Application.
3. Needs of Population Served (10 Points) (Category A/B/C)
a) Describe in detail the specific needs of the population to be served. Please include socio-
demographic and health characteristics that justify the need for the NHVP, including the number
of first-time, low-income mothers eligible for the NI-IVP. This information should also include
birth and infant mortality data as well as racial and ethnic demographics.
(Category C Applicants must justify the need to serve additional dients. Please describe this
need through examples of unmet referrals, waiting lists, assessment of the capacity of existing
programs or the fact that the population base is such that expansion is warranted.)
b) Include an estimate of the number of families that the Applicant will serve who are eligible for
Medicaid. (No points will be assigned based on the estimated Medicaid population eligible to be
served. Because there is a possibility that this will become a Medicaid reimbursable service, the
information is needed for planning purposes only.)
4. Capability of Applicant (Category A/B)
If the Applicant's site would cover multiple counties and have Nurses housed in different locations,
please include brief information about each of the counties covered by the site in the responses to the
following questions.
a) Organizational Structure, Commitment and Experience(15 Points)
1) Where did the initial interest in the program come from? Briefly describe how support
spread within the Applicant's organization and how commitment exists at all administrative
levels thereof.
2) Describe where in the Applicant's organization the NHVP will be placed and how that
will or will not logically support its development and management. Include an
organizational chart displaying the location of the NHVP in relationship to existing programs.
6
3) Describe the history and experience of the Applicant in providing maternal and child
health care and related services.
4) Describe the Applicant's experience with home visiting as a service delivery strategy.
5) Please provide one or more examples of situations where the Applicant identified an
unmet need in the community and then implemented a program to address those needs. Is
that program still in existence?
6) Summarize the major strengths of the Applicant and the community that will lead to
successful implementation of the NHVP at this site.
7) Describe any concerns the Applicant has about implementation of the NHVP (e.g.
political, organizational, physical space,nursing shortage).
b) Broad Based Community Support(10 Points)
1) Describe the breadth of community support for the NHVP itself and for the Applicant as the
lead organization in its implementation. Include detailed information about the people and
organizations that make up the community coalition that is supporting the NHVP's
implementation. Breadth of community support shall be judged by the diversity and depth of
involvement of those involved in the coalition supporting the NHVP's implementation.
How are these people/organizations supporting Applicant's efforts? Please indude letters of
support (addressed to the Board at the Department's address) with details of their involvement
in bringing the Program to the community and/or their ongoing role once the Program is
implemented (e.g. participation in Supporting Council or Advisory Board).
c) Referral Sources (10 Points)
1) Describe the Applicant's relationship with the schools, prenatal clinics,health care
providers, social services, or other referral sources for the low-income, first-time mothers that
will be served by the NHVP.
2) Describe the nature of those relationships including how long the relationships have been
in place,how formal they are, and prior referral links already established from each relationship.
3) Evidence these referral sources with letters of support(addressed to the
Board at the Department's address) specifically describing how the referral source will work with
the Applicant in recruiting NHVP participants and an estimate of how many monthly referrals
might come from each source.
4) Explain Applicant's plan to reach the expected active enrollment goal (100 families or 50
families if a waiver has been granted for the lower number by the Board of Health) 7-9
months after nurses have attended NCCFC/UCHSC Training 1 (pregnancy).
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d) Referral Linkages (5 Points)
1) Describe the referral linkages that exist between the lead implementing organization and
other service providers such as workforce preparation, legal assistance, housing
organizations, general health care, mental health, substance abuse treatment and childcare.
Describe the nature of those relationships including how long a relationship has been in place,
how formal it is, and the degree to which staff within the Applicant organization have
historically used the services of the linked providers described.
2) Evidence these referral linkages with letters of support (addressed to the Board at the
Department's address) or specifically describing how the possible referral linkages will work
with the Applicant in providing support services to clients enrolled in the NHVP.
e) Coordination with Existing Visitation Programs (10 points)
1) Describe the Applicant's understanding of and coordination with other existing home
visitation programs serving a similar population.
• Please include a brief description of the other home visitation programs (including the
target population, duration of service, staff used to provide the service and target
outcomes).
2) Describe how the NHVP will fit in with and complement the community's current efforts
to meet the needs of the target population. Please include the specific coordination plan
agreed to by all Entities implementing home visiting services for young families,
including any other Entities already delivering the NHVP.
5. Implementation of NHVP with fidelity to NHVP Model(25 Points) (Category C)
a) Describe how Applicant has implemented the Program to date including:
1) Did the Applicant hire the appropriately qualified staff?If not,why?
2) Has the Applicant maintained an appropriate Nurse-client ratio (25 active families for a
full-time nurse)? If not,why?
3) What is the average number of completed visits for the Nurses? Describe any issues
around visit completion.
4) What is the attrition rate for mothers enrolled? Please expand if any issues here, i.e.,
present reasons why women have left the program; break down analysis by pregnancy,
infancy and toddler stages.
5) What percentage of mothers is enrolled prior to the 28th week? What percentage of
mothers is enrolled prior to the 16th week?
6) Describe how Applicant has used monthly reports from the Clinical Information System
to improve quality of services delivered to families.
6. Plans for Expansion of Infrastructure (5 Points) (Category C)
8
Please describe Applicant's plans for building additional infrastructure to support the expansion.
At minimum, please address the following critical success areas related to expansion:
a.) Applicant's program achievements in comparison to program performance guidelines.
b.) Management of timely, complete and accurate data entry and program reporting.
c.) Staff management including where the additional staff will be located and how Applicant
will provide adequate additional supervision and administrative support.
7. Recruitment and Retention of Nurses (10 Points) (Category A/B/C)
Describe the Applicant's plan for hiring and retaining the staff necessary to implement the
NHVP. Include:
a) A recruitment plan to hire at least a half-time master's prepared clinical Nurse Supervisor, a
team of at least four Nurses (preferably bachelor's prepared) to staff the NHVP, and a half time
data entry clerk. Explain whether or not Applicant anticipates having to overcome a nursing
shortage in Applicant's community. If a Master's prepared clinical Nurse Supervisor is not to be
hired, demonstrate that such a person is unavailable within the community and an appropriately
qualified Nurse without a master's degree is available. Describe plans for recruiting
bilingual/bicultural Nurses where necessary.
b) If the proposed service area is multi-county,please indicate if the nurses will be employees
of the implementing agency or employees of a different agency(specify the agency).
c) Describe where the Nurses will be officed. If the proposed service area is multi-county,
please indicate if all the nurses will be located in one office of if they will each be housed in a
different location. Specify the different locations and the number of nurses at each location.
d) Describe how supervision of the nurses will be managed if(1)the nurse supervisor and the
nurse home visitor are in different locations, and/or (2) if the nurse supervisor is employed by
one agency and the nurse home visitor by a different agency.
e) Describe plans for promoting a stable operating environment for the NHVP and preventing
staff turnover (e.g. plans for flexible schedules for staff, how staff will be integrated into
Applicant's other staff, if a multi-county collaborative, how Applicant will bring nurses together
and support them).
f) (Category C) Include a description of the success of prior recruiting efforts and explain the
turnover,if any, that the Applicant has experienced.
8. Success in Recruiting Clients (10 Points) (Category C)
Describe the success of the Applicant's recruitment efforts:
a) How quickly did the Applicant fill the available slots in previous Contracts?
b) How successful was the Applicant in enrolling expecting mothers when they first
presented?
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9. Troubleshooting(10 Points) (Category C)
Implementation of any new program raises challenges. Applicants are encouraged to find creative
and collaborative solutions to issues as they arise.
a) Describe how the Applicant has addressed specific challenges relating to the implementation
of the NHVP.
b) Describe how the Applicant has coordinated with other Existing Home Visitation programs.
c) Describe the support networks the Applicant has established in the community for the Nurses
so that the necessary referrals are made to other resources.
10. Broad Based Community Support(15 Points) (Category C)
a) Describe the community's support for the expansion of the NHVP. Include a discussion of the
community's involvement and support of the implementation of the NHVP so far, and the
ongoing role of the local Supporting Council or Advisory Board, if applicable.
b) Describe the coordination with other programs addressing the same populations, and the
Applicant's efforts to avoid duplication of services.
11. Clinical Information System (5 Points) (Category A)
a) Describe the Applicant's capacity to keep records in a computerized management
information system on participating families and their needs, services provided, progress, and
outcomes.
b) Describe what steps would need to be taken by Applicant to make its current computer
system compatible with the requirements listed on Attachment F.
c) Describe what quality assurance activities are planned to monitor the implementation of the
NHVP.
12. Collaborative Implementation (10 Points) (Category A/B)
Describe Applicant's plan, if any, to work collaboratively with other Entities in either
administering the NHVP directly or through an advisory or oversight board. If the collaboration
will be in administering the NHVP, please describe the responsibilities of each Entity, and who
will have final decision-making authority when issues arise. Please detail whether the other
Entities are counties, municipalities, agencies or organizations. Describe how the Applicant will
assure effective collaboration/oversight.
13. Request for Waiver (0 Points) (Category A/B/C)
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If Applicant plans to seek a waiver from the Board from the requirement that it serve at least one
hundred, low-income, first-time mothers, describe the need for such waiver. Category C
applicants may request increases in increments of 25 families, as appropriate.
14. Geographical Placement of Applicant (2 Points) (Category A/B/C)
Up to two additional points will be awarded to Applicants that are geographically placed in an
area of the State that will advance implementation of the NHVP in communities throughout the
State.
15. Budget and Budget Justification Narrative (15 Points) (Category A/B/C)
a) Budget pages: Provide actual budget for fiscal year 04-05 (July 1, 2004 through June 30, 2005)
and prospective budgets for Fiscal Year 05-06 and Fiscal Year 06-07 for the implementation of the
NHVP. Applicants may use the Budget Request Form found as Attachment D or another
spreadsheet format that provides all the requested information. The budget provided for fiscal
year 04-05, as approved by the Board of Health upon the recommendation of the National Center,
will be the budget for the contract for fiscal year 04-05 if the Applicant is approved for funding.
The budgets for fiscal year 05-06 and fiscal year 06-07 will be used for planning purposes.
Categories A and C should refer to the Sample Budget (Attachment E.1 and E.2) for estimated
costs of many of the requested line items.
b) 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:
1. Personnel Costs: Salaries and fringe benefits for the staff.
2. 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.
3. Equipment Costs: Funding for equipment,including computers and software.
4. 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. Category A 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.
5. 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.
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6. NCAST Training and Materials Costs: Costs of NCAST training and materials.
7. a) Indirect Costs: Implementing agency indirect costs are permitted in the budget but
shall be capped at 25% of total direct costs, 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: Applicants must 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.
b)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
(Attachment E) 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 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.
8. 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 (Attachment E). They may include the contribution of
12
program administrators' time, i.e. an Executive Director, Nursing Director or Program
Manager's time, not to exceed a total of .1 I•lb. 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.
9. If Applicant currently operates the NHVP using funding other than from the Nurse Home
Visitor Fund, Applicant shall:
a) State whether Applicant expects to continue to receive funding from such alternative-
funding source.
b) 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.
10. Additional Points: (5 Points) Additional points will be awarded to Applicants that
provide some community financial contribution, either through partial (or total) waiver of
indirect costs, or through other community funding which shall supplement funding from the
Department, because such contributions evidence the community's commitment to
implementation of the NHVP. These contributions may be for the basic program costs as
presented in the Sample Budget, in which case they would be reported on the Applicant's
Budget as In-Kind Contributions, as discussed under #8, In-Kind Contributions. Or they may
be for some additional items that benefit the program but are not part of the basic program
costs and should be described under this section as other contributions from the agency or the
community. Include a letter of support from each financially contributing organization that
details its level of commitment. If the Applicant needs office space, it may be included in the
budget request. However, office space and/or furniture are often good in-kind contributions
that can be made by the Implementing Agency, the county or others in the community. If
office space is offered as an in-kind contribution, indicate if this indudes any furniture the
staff may need (examples: desks, chairs, file cabinets).
11. Narrative should also address:
a) The sustainability of any other funding sources; and
b) Unique circumstances that cause any budget items in Applicant's Proposal to deviate
by more that 5 percent from the model site budget, attached hereto as Attachment E.
(CategoryA/C)
H:\wPDOC5\NH VP\Appliallon\O4O5Appnf
13
^�' •• Attachment A
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(1)(a),C.R.S.,as one whose accreditation may be accepted in lieu of board approval.
(12) "Nurse Home Visitor Program" or"Program" means a program that is described in§25-31-104(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 costs include but
are not limited to,travel costs and training materials;
(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 Internet 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§1.2(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§1.2 (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§1.2(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;
(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 describing 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
(() 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 close 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.
1.5 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,include 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 costs 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;
(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 protocols 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 and 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 mariner 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 shall, 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.
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.
(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 disclose 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§1.8,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.
H:\WPDOCS\NHVP\Application\(AllachA)a05RulesAoc
Attachment B
Colorado Nurse Home Visitor Program
2004-05 GRANT APPLICATION COVER SHEET
L Name of Applicant Entity:
Address/City/Zip
2. Name of person completing application:
Position/Title:
Telephone: FAX:
E-Mail:
3. Name of Authorized Signer:
Position/Title:
Telephone: FAX:
E-Mail:
Signature:X
1. Grant proposal is for(check one):
Category A: Nurse Home Visitor Program
_Category B: Alternative Nurse Home Visitation Program
Category C: Nurse Home Visitor Program Expansion
5. Grant request for July 1,2004 through June 30,2005: $
H:\WPDOCS\NHVP\Appiication\(AttachB)0405AppCvrSdtt.doc
•
Attachment C
•
ASSURANCE of INTENTION to MEET PROGRAM REQUIREMENTS:
Applies to NEW NURSE HOME VISITOR PROGRAMS (Category A) and
NURSE HOME VISITOR PROGRAM EXPANSIONS (Category C).
Please assure that the applicant entity intends 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:
H:\WPDOCS\NHVP\Appliaiion\(AtlachC)0405Asswance.doc
• 2004-2005 NURSE HOME VISITOR PROGRAM ATTACHMENT D
APPLICATION BUDGET AND/OR EXPENDITURE REPORT FORM
APPLICANT: FOR THE PERIOD:
PROJECT: •
SOURCE OF FUNDS
Annual No.of Total
Requested/
Salary months Amount Received
Rate Budget FTE Required Other Sources" 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 $ $ $
Equipment Expenses
TOTAL EQUIPMENT $ $ $
Travel Expenses
TOTAL TRAVEL $ $ $
NCCFC/UCHSC Training&Technical Assistance
TOTAL TRAINING&TECH ASSISTANCE $ $ $
NCAST Traing&Materials
TOTAL NCAST COSTS $ $ $
TOTAL DIRECT COSTS(Personal Services+Operating+Travel+Contractual) $ $ $
Indirect Costs
TOTAL INDIRECT COSTS $ $ $
TOTAL PROJECT COST $ $ $
OTHER SOURCES of FUNDING(Match or In-kind)
TOTAL OTHER SOURCES $
Signature of Authorized Representative Date
Rev.5I1L200r BUDGETAPPLFORMXLS B5mtlh
'`•u -FalnUY
Attachment E.1
771?,Papraip
x,-w ws NFP SAMPLE SITE BUDGET
100 FAMILIES
Personnel Costs(Estimate)
Base Fringe Total %Effort Year 1 Year 2 Year 3 Total
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 27,072.00 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 $145/family 13,500.00 500.00 500.00 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®.31/mi/yr 6,200.00 6,200.00 6,200.00 18,600.00
Sub-Total(Administrative) I 36,460.00 18,110.00 18,110.00 72,680.00
Sub-Total for Personnel&Administrative 263,567.00 256,574.00 268,499.00 788,640.00
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 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 305,309.00 264,134.00 276,059.00 845,502.00
"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.
H:\WPDOCS\NFn'P\Application\0405New&Expand\(AttachE.1)0405 SampleBudgecdoc
''. lax.Fanily Attachment E.2
NFP Detailed Narrative for Sample Site Budget 2003-2004
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%)
including 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$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.
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.
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
1
• VCR/TV monitor
• Still and video camera
• 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.
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. NFP 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
2
• 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.
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 dose 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 T2 and T3 (for a total of 9 days of training)
include travel, meals, and hotel. Generally, Nurses attend T2 approximately 4 months after Tl and T3
approximately 10 months after Tl.
3
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
• 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.
H\WPDOCSNHVPApphcatpn 405New&Expant(AttcchE.2)0405Hudge04amtiyedoe
4
$\'sIISe-Fan*
0 Partnership
mer p Attachment F
s t-romPart a.saaad
National Center for Children,Families and Communities (NCCFC)
Computer Requirements to Ensure Compatibility with Web Clinical Information System(CIS)
If you are planning to purchase a computer for Nurse Home Visitor Program/Nurse-Family
Partnership, review the specifications listed below. Please contact your network support person to
make sure that they are aware of this program. We are recommending the use of Internet Explorer as
the browser. It is faster and more user friendly in the data entry forms. Netscape requires the use of
the mouse to do data entry.
Specifications:
1. Platform: PC with Pentium processor
2. Screen Resolution: 800 x 600
3. Browser: Netscape 4.x or Internet Explorer 4.x-we prefer Internet Explorer
4. Access Speed: High speed modem or Internet connection via LAN/network
5. Plug-ins: Acrobat (A link will be provided to download if needed)
6. **Cookies: Need to accept
7. **Java Script: Need to accept
8. Sound card and CD-Rom for the CIS tutorial
For more information, please contact:
Gaye Van Buhler
Database Analyst/Administrator
National Center for Children, Families and Communities
vanbuhler.gay@tchden.org
phone: 303-864-5220
fax: 303-864-5236
H:\WPDOCS\NHVP\Application\0405New&PxpandUAttachP)0405OS.doc
Attachment G
• eve•
. ASSURANCE of INTENTION to be an active MEDICAID PROVIDER:
Applies to all NURSE HOME VISITOR PROGRAMS (Category A,B and C).
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 commencing July 1,2004. All Nurse Home Visitor Program sites
will be required to become an active Medicaid provider,if not already, and must be willing to bill
Medicaid for TCM services.
Please assure that the applicant entity is either an active Medicaid provider or will become on by July 1,
2004.
Presently an active Medicaid Provider.
Will become an active Medicaid Provider by July 1,2004.
Name of Applicant Entity:
Name of Authorized Signer:
Signature of Authorized Signer:X
Date:
H.\WPDOCS\NHVP\Application\0405New&ExpandMAttachC)0405Medicaid.doc
• Attachment H.1
SAMPLE ONLY
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
DEPARTMENT OR AGENCY NUMBER
***
CONTRACT ROUTING NUMBER
** r****
PURCHASED SERVICES CONTRACT
(Federal Funds Only)
This Contract is made this****day of********* **** by and between:the state of Colorado,acting by and through the
DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT,whose address or principal place of business is 4300 Cherry Creek
Drive South,Denver,Colorado 80246 hereinafter referred to as"the State";and,LEGAL NAME OF ENTITY(legal type of entity),
whose address or principal place of business is JStreet Address,City,State and Zip Code',hereinafter referred to as"the Contractor".
WHEREAS,the[United State Department of**********("US****"),through the**********("***")] [General Assembly]has
awarded the State[federal funds under Notice of Cooperative Agreement Award(`NCAA")number**********to perform
**********,(see, Catalog of Federal Domestic Assistance("CFDA")number**.***)to perform***********;
WHEREAS,the State has formulated a comprehensive State plan,with associated budgets,to disburse these funds throughout the state
of Colorado;
WHEREAS,under this comprehensive State plan,the State shall allocate these funds to qualified entities to provide**********to the
citizens of the state of Colorado on behalf of the State;
WHEREAS, [insert additional"WHEREAS"clauses as needed];
WHEREAS,as of the made date of this Contract,the State has a currently valid Group II purchasing delegation agreement with the
division of finance and procurement within the Colorado Department of Personnel and Administration;
WHEREAS,the Contractor was selected by the State in accordance with the applicable provisions of the Colorado Procurement Code as
the[lowest] [most responsive and responsible]bidder pursuant to[Invitation for Bids] [Request for Proposals] [(IFB)][(RFP)]number
*********to(describe what product or service is to be purchased from the Contractor); [strike it'inapplicable and insert:WHEREAS,
this is a sole source procurement made in accordance with the applicable provisions of section 24-103-205, C.RS.,as amended,and
Colorado Procurement Rule R-24-103-205-01];
WHEREAS,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 of this Contract in Fund Number
***,Appropriation Account***, and Organization Number****,under Contract Encumbrance Number**********;and,
WHEREAS, all required approvals,clearances, and coordination have been accomplished from and with all appropriate agencies.
NOW THEREFORE,in consideration of their mutual promises to each, stated below,the parties hereto agree as
follows:
A. EFFECTIVE DATE AND TERM. The proposed effective date of this Contract is********** ** ****. However,in accordance
with section 24-30-202(1), CRS.,as amended,this Contract is not valid until it has been approved by the State Controller,or an
authorized designee thereof. If the underlying NCAA authorizes the State to pay all allowable and allocable expenses of a contractor as
of the effective date of that NCAA,then the State shall reimburse the Contractor for any allowable and allocable expenses of the
Contractor that have been incurred by the Contractor since the proposed effective date of this Contract. If the underlying NCAA does not
authorize the State to pay all allowable and allocable expenses of a contractor as of the effective date of that NCAA,then the State shall
only reimburse the Contractor for those allowable and allocable expenses of the Contractor that are incurred by the Contractor on or after
the effective date of this Contract. The initial term of this Contract shall commence on its effective date and continue through and
including************,****. This Contract is funded entirely with federal funds. Therefore,the State's liability for payment for all
services rendered,or goods supplied,under this Contract is contingent upon the State's receipt of those federal funds. If the State does not
receive all,or any part,of the federal funds necessary to pay its obligations under this Contract,then the State may immediately amend or
terminate this Contract without further liability to the State. If the State receives additional federal funding for the purposes of this
Contract,then this Contract shall automatically renew for the period covered by those additional federal funds. Unless expressly modified
by the Contract,the total term of this Contract,including all automatic renewals,bilateral options to renew, and extensions,may not
exceed that period of time authorized in the original procurement method used to select the Contractor.
B. DUTIES AND OBLIGATIONS OF THE CONTRACTOR. [Describe in sufficient detail what the Contractor is to do under the
Contract. References to an attached Scope of Work are appropriate,e.g.,A. . . . shall perform in accordance with the Scope of Work
which is incorporated herein by this reference,made a part hereof, and attached hereto as"Attachment*."]
C. DUTIES AND OBLIGATIONS OF THE STATE.
I.In consideration of those services satisfactorily and timely performed by the Contractor under this Contract,the State shall cause to
be paid to the Contractor a sum not to exceed DOLLARS. ($0.00)for the initial term of this Contract. Of the total financial
obligation of the State referenced above, amount of Federal Dollars are identified as attributable to a funding source of the United
States government and,amount of State dollars are identified as attributable to a funding source of the state of Colorado.
2.To receive compensation under this Contract,the Contractor shall submit a signed[monthly/quarterly/biannual] "Cost
Reimbursement Statement". A sample Cost Reimbursement Statement is incorporated herein by this reference,made a part hereof,
and attached hereto as"Attachment*". A Cost Reimbursement Statement must be submitted within sixty(60)calendar days of
the end of the billing period for which services were rendered. Expenditures shall be in accordance with those items identified in
Attachment*. These items may include,but are not limited to:the Contractor's salaries,fringe benefits, supplies,travel,operating,
and indirect costs which are allowable and allocable expenses related to its performance under this Contract.
3.Cost Reimbursement Statements shall:reference this Contract by its contract routing number,which number is located on page one
of this Contract;state the applicable performance dates,the names of payees; a brief description of the services performed during
the relevant performance dates;the incurred expenditures;and,the total requested reimbursement. Reimbursement during the
initial,and any renewal or extension,term of this Contract shall be conditioned upon affirmation by the State that all services were
rendered by the Contractor in accordance with the terms of this Contract. Cost Reimbursement Statements shall be sent to:
(Name)
(Division)
Colorado Department of Public Health and Environment
(Mail Code)
4300 Cherry Creek Drive South
Denver,CO 80246
D. GENERAL PROVISIONS.
I. Because this Contract involves the expenditure of federal,state,or private funds,this Contract is subject to, and contingent
upon,the continued availability of those funds for payment pursuant to the terms and conditions of this Contract. If those funds,or
any part thereof,become unavailable as determined by the State,then the State may immediately terminate this Contract.
2. The Contractor warrants that it possesses actual,legal authority to enter into this Contract. The Contractor further warrants
that it has taken all actions required by its applicable laws,procedures,rules,or by-laws to exercise that authority, and to lawfully
authorize its undersigned signatory to execute this Contract and bind the Contractor to its terms and conditions.The person or persons
signing this Contract,or any attachment(s)or amendment(s)hereto,also warrant(s)that such person(s)possesses actual,legal
authority to execute this Contract, and any attachment(s)or amendment(s)hereto, on behalf of the Contractor.
3. As of the effective date of this Contract,and for the full term of this Contract,the Contractor shall obtain and maintain,at its
own cost and expense,the following insurance coverages:
A. As required by applicable state law, standard Workers'Compensation insurance,including occupational disease,which
covers all employees,on or off the work site,while acting within the course and scope of employment,in those amounts that are
prescribed by applicable state law.
B. Comprehensive General Liability insurance or Commercial General Liability insurance,to include bodily injury,
personal injury, and property damage coverage,in the following minimum amounts:
1. Combined single limit of$1,000,000 written on an occurrence basis; and,
2. A general,annual aggregate limit of not less than$2,000,000.
The Contractor must purchase additional insurance if claims against the Contractor reduce the available general aggregate
amount below$1,000,000 during the term of this Contract.
C. Automobile Liability insurance in the following minimum amount:
1. Combined single limit of$1,000,000 written on an occurrence basis.
D. The state of Colorado shall be named as"Additional Insured"on each Comprehensive General Liability insurance policy or
Commercial General Liability insurance policy that directly relates to the Contractor's performance under this Contract.
E. In accordance with section 10-4-109.7,C.RS., as amended,each insurance policy that directly relates to the Contractor's
performance under this Contract shall contain a provision that prevents cancellation of that insurance policy unless the insurer
provides the State with written notice of its intent to cancel that insurance policy,by first class mail, at least forty-five(45)
calendar days before the effective date of cancellation of that insurance policy.
F. As of the effective date of this Contract,the Contractor shall provide the State with a valid Certificate of Insurance
for each insurance policy that directly relates to the Contractor's performance under this Contract.
4. The Contractor certifies that,as of the effective date of this Contract,it has currently in effect all required licenses, certifications,
approvals,insurance,permits, etc.,if any,that are necessary to properly perform the services and/or deliver the supplies specified
in this Contract. The Contractor also warrants that it shall maintain all required licenses,certifications, approvals,insurance,
permits, etc.,if any,that are required to properly perform this Contract,without reimbursement by the State or other adjustment
in the Contract price. Additionally, all employees or subcontractors of the Contractor performing services under this Contract
shall hold,and maintain in effect, all required licenses, certifications,approvals,insurance,permits, etc.,if any,that are
necessary to perform their duties and obligations under this Contract. The Contractor further certifies that,if a foreign
corporation or other entity,it currently has obtained and shall maintain any applicable certificate of authority to do business in
the State of Colorado and has designated a registered agent in Colorado to accept service of process. Any revocation,withdrawal
or nonrenewal of any required licenses,certifications,approvals,insurance,permits,etc.,if any,that are necessary for the
Contractor,or its employees and subcontractors,to properly perform its duties and obligations under this Contract shall be
grounds for termination of this Contract by the State for default without further liability to the State.
5. If this Contract involves federal funds, or compliance is otherwise federally mandated,then the Contractor shall comply with the
requirements of the following:
A. Office of Management and Budget Circulars A-21, A-87,A-102, A-110, or A-122,as applicable;
B. the"Hatch Act"(5 U.S.C. 1501-1508)and Public Law 95-454, Section 4728. These federal statutes declare that federal
funds cannot be used for partisan political purposes of any kind by any person or organization involved in the administration of
federally-assisted programs;
C. the"Davis-Bacon Act"(40 U.S.C.276A-276A-5). This federal Act requires that all laborers and mechanics employed by
contractors or subcontractors to work on construction projects financed by federal assistance must be paid wages not less than
those established for the locality of the project by the Secretary of Labor;
D. 42 U.S.C. 6101 et seq., 42 U.S.C.2000d,29 U.S.C. 794. These federal Acts mandate that no person shall,on the grounds of
race,color,national origin,age,or disability,be excluded from participation in or be subjected to discrimination in any program
or activity funded,in whole or in part,by federal finds;
E. the"Americans with Disabilities Act"(Public Law 101-336;42 U.S.C. 12101, 12102, 12111 - 12117, 12131 - 12134, 12141
- 12150, 12161 - 12165, 12181 - 12189, 12201 - 12213 and 47 U.S.C.225 and 47 U.S.C. 611);
F. if the Contractor is acquiring an interest in real property and displacing households or businesses in the performance of this
Contract,then the Contractor is in compliance with the"Uniform Relocation Assistance and Real Property Acquisition Policies
Act",as amended, (Public Law 91-646,as amended,and Public Law 100-17, 101 Stat. 246-256);
G. when applicable,the Contractor shall comply with the provisions of the"Uniform Administrative Requirements for Grants
and Cooperative Agreements to State and Local Governments"(Common Rule); and,
H. Section 2101 of the Federal Acquisition Streamlining Act of 1994,Public Law 103-355,which prohibits the use of federal
money to lobby the legislative body of a political subdivision of a State.
6. If this Contract involves federal funds, or compliance is otherwise federally mandated,then by signing and submitting this
Contract,the Contractor affirmatively avers that:
A. the Contractor is in compliance with the requirements of the"Drug-Free Workplace Act"(Public Law 100-690 Title V,
Subtitle D,41 U.S.C. 701 et seq.);
B. the Contractor is not presently debarred,suspended,proposed for debarment,declared ineligible,or voluntarily
excluded from covered transactions by any federal department or agency;the Contractor shall to comply with all applicable
regulations pursuant to Executive Order 12549,including, Debarment and Suspension and Participants' Responsibilities,29
C.F.R. 98.510(1990);and,
C. the Contractor shall comply with all applicable regulations pursuant to Section 319 of Public Law 101-121,Guidance for
New Restrictions on Lobbying,including,Certification and Disclosure,29 C.F.R 93.110(1990).
7. To be considered for payment,billings for payments pursuant to this Contract must be received within a reasonable time after the
period for which payment is requested;but in no event no later than sixty(60)calendar days after the relevant performance period
has passed. Final billings under this Contract must be received by the State within a reasonable time after the expiration or
termination of this Contract;but in no event no later than sixty(60)calendar days from the effective expiration or termination date of
this Contract
8. 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.
9. The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless approved in writing
by the appropriate federal agency.
10. In accordance with Office of Management and Budget(OMB)Circular A-133 (Audits of States, Local Governments,and Non-
Profit Organizations),if the Contractor receives federal funds from any source,including State pass through monies,in an aggregate
amount in excess of $300,000.00(June 24, 1997),in a State fiscal year(July 1 through June 30),then the Contractor shall have an
annual audit performed by an independent certified public accountant which meets the requirements of OMB Circular A-133. If the
Contractor is required to submit an annual indirect cost proposal to the State for review and approval,then the Contractor's auditor
shall audit the proposal in accordance with the requirements of OMB Circulars A-21 (Cost Principles for Educational Institutions), A-
87 (Cost Principles for State,Local and Tribal Governments), or A-122(Cost Principles for Non-Profit Organizations),whichever is
applicable. The Contractor shall furnish one(1)copy of the audit report(s)to the State=s Accounting Office within thirty(30)
calendar days of issuance;but in no event later than nine(9)months after the end of the Contractor's fiscal year. If(an)instance(s)of
noncompliance with federal laws and regulations occurs,then the Contractor shall take all appropriate corrective action(s)within six
(6)months of the issuance of(a)report(s).
11. The Contractor shall grant to the State,or its authorized agents,access to the records and financial statements of the Contractor
that directly relate to its performance under this Contract. The Contractor shall retain all such records and financial statements for a
period of six(6)years after the date of issuance of a final audit report. This requirement is in addition to any other audit requirements
contained in other paragraphs of this Contract.
12. Unless otherwise provided for in this Contract,for all contracts with terms longer than three(3)months,the Contractor shall
submit a written progress report specifying the progress made for each activity identified in this Contract These progress reports
shall be submitted in accordance with any applicable procedures developed and prescribed by the State. The preparation of progress
reports in a timely manner is the responsibility of the Contractor. If the Contractor fails to comply with this provision,then the
failure:may result in a delay of payment of funds;or,termination of this Contract.
13. The Contractor shall maintain a complete file of all records,documents,communications, and other materials that directly relate
to this Contract. These materials shall be sufficient to properly reflect all direct and indirect costs of labor,materials, equipment,
supplies,and services, and other costs of whatever nature for which a contract payment was made. These records shall be maintained
according to generally accepted accounting principles and shall be easily separable from other records of the Contractor. Copies of
all such records,documents,communications,and other materials shall be the property of the State and shall be maintained by the
Contractor,in a central location as custodian for the State, on behalf of the State,for a period of six(6)years from the date of final
payment under this Contract,or for such further period as may be necessary to resolve any pending matters,including,but not limited
to, audits performed by the federal government.
14. The Contractor authorizes the State, or its authorized agents or designees,to perform audits or make inspections of its records
that directly relate to this Contract for the purpose of evaluating its performance under this Contract at any reasonable time during the
term of this Contract and for a period of three(3)years following the termination of this Contract As such,the Contractor shall
permit the State,any appropriate federal agency or agencies,or any other duly authorized governmental agent or agency,to monitor
all activities conducted by the Contractor pursuant to the terms of this Contract. Such monitoring may include,but is not limited to:
internal evaluation procedures, examination of program data, special analyses,on-site checks,formal audit examinations,or any other
reasonable procedures. All monitoring shall be performed by the State in such a manner that it shall not unduly interfere with the
work of the Contractor.
15. Subject to the Public(Open)Records Act, section 24-72-101,et seq.,C.RS.,as amended,if the Contractor obtains access to any
records,files, or other information of the State in connection with, or during the performance of,this Contract,then the Contractor
. shall keep all such records,files,or other information confidential and shall comply with all laws and regulations concerning the
confidentiality of all such records, files,or information to the same extent as such laws and regulations apply to the State. My
breach of confidentiality by the Contractor,or third party agents of the Contractor, shall constitute good cause for the State to cancel
this Contract,without liability to the State. Any State waiver of an alleged breach of confidentiality by the Contractor,or third party
agents of the Contractor,does not constitute a waiver of any subsequent breach by the Contractor,or third party agents of the
Contractor.
16. Unless otherwise provided for in this Contract,or in a written amendment executed and awl_oved pursuant to Fiscal Rules of the
state of Colorado, all material,information,data,computer software, documentation, studies, and evaluations produced in the
performance of this Contract for which the State has made a payment under this Contract are the sole property of the State.
17. If any copyrightable material is produced under this Contract,then the State, and any applicable federal funding entity, shall have
a paid in full,irrevocable,royalty free, and non-exclusive license to reproduce,publish,or otherwise use, and authorize others to use,
the copyrightable material for any purpose authorized by the Copyright Law of the United States as now or hereinafter enacted.
Upon the written request of the State,the Contractor shall provide the State with three(3)copies of all such copyrightable material.
18. If required by the terms and conditions of a federal or state grant,the Contractor shall obtain the prior approval of the State and
all necessary third parties prior to publishing any materials produced under this Contract. If required by the terms and conditions of a
federal or state grant,the Contractor shall also credit the State and all necessary third parties with assisting in the publication of any
materials produced under this Contract.
19. If this Contract is in the nature of personal/purchased services,then the State reserves the right to inspect services provided under
this Contract at all reasonable times and places during the term of this Contract. "Services", as used in this clause,includes services
performed or written work performed in the performance of services. If any of the services do not conform with the terms of this
Contract,then the State may require the Contractor to perform the services again in conformity with the terms of this Contract,with
no additional compensation to the Contractor for the reperformed services. When defects in the quality or quantity of the services
cannot be corrected by reperformance,then the State may require the Contractor to take all necessary action(s)to ensure that the
future performance conforms to the terms of the Contract; and, equitably reduce the payments due to the Contractor under this
Contract to reflect the reduced value of the services performed by the Contractor. These remedies in no way limit the other remedies
available to the State as set forth in this Contract.
20. If,through any cause attributable to the action(s)or inaction(s)of the Contractor,the Contractor: fails to fulfill,in a timely and
proper manner,its duties and obligations under this Contract;or,violates any of the agreements,covenants,provisions,stipulations,
or terms of this Contract,then the State shall thereupon have the right to cancel this Contract,in whole or in part, for cause by giving
written notice thereof to the Contractor. The written notice shall be given to the Contractor no less than thirty(30)calendar days
before the proposed cancellation date and shall afford the Contractor the opportunity to cure the default or state why cancellation is
otherwise inappropriate. If this Contract is cancelled for default,then all finished or unfinished data, documents,drawings,
evaluations,hardware,maps,models,negatives,photographs,reports,software, studies, surveys, or any other material,medium or
information,however constituted,which has been or is to be produced or prepared by the Contractor under this Contract shall,at the
option of the State,become the property of the State. The Contractor shall be entitled to receive just and equitable compensation for
any services or supplies delivered to, and accepted by,the State. If applicable,the Contractor shall return any unearned advance
payment it received under this Contract to the State. Notwithstanding the above,the Contractor is not relieved of liability to the State
for any damages sustained by the State because of the breach of this Contract by the Contractor. The State may withhold any
payment due to the Contractor under this Contract to mitigate the damages of the State until such time as the exact amount of those
damages is determined. If, after canceling this Contract for default,it is determined for any reason that the Contractor was not in
default,or that the action(s)or inaction(s)of the Contractor was excusable,then such cancellation shall be treated as a termination for
convenience, and the respective rights and obligations of the parties shall be the same as if this Contract had been terminated for
convenience as described below.
21. The State may,when the interests of the State so require,terminate this Contract,in whole or in part,for the convenience of the
State. The State shall give written notice of termination to the Contractor. The written notice shall specify the part(s)of the Contract
terminated. The written notice shall be given to the Contractor no less than thirty(30)calendar days before the effective date of
termination. If this Contract is terminated for convenience,then all finished or unfinished data, documents,drawings, evaluations,
hardware,maps,models,negatives,photographs,reports,software,studies, surveys, or any other material,medium or information,
however constituted,which has been or is to be produced or prepared by the Contractor under this Contract shall,at the option of the
State,become the property of the State. The Contractor shall be entitled to receive just and equitable compensation for any services
or supplies delivered to, and accepted by,the State. If applicable,the Contractor shall return any unearned advance payment it
received under this Contract to the State. This paragraph in no way implies that a party has breached this Contract by the exercise of
this paragraph. If this Contract is terminated by the State as provided for herein,then the Contractor shall be paid an amount equal to
the percentage of services actually performed for, or goods actually delivered to,the State,less any payments already made by the
State to the Contractor for those services or goods. However,if less than sixty percent(60%)of the services or goods covered by this
Contract have been performed or delivered as of the effective date of termination,then the Contractor shall also be reimbursed(in
, addition to the above payment)for that portion of those actual"out-of-pocket"expenses(not otherwise reimbursed under this
Contract)incurred by the Contractor during the term of this Contract that are directly attributable to the uncompleted portion of the
services, of the undelivered portion of the goods,covered by this Contract. In no event shall reimbursement under this clause exceed
the total financial obligation of the State to the Contractor under this Contract If this Contract is canceled for default because of a
material breach of this Contract by the Contractor,then the above provisions for cancellation for default shall apply.
22. Neither the Contractor nor the State shall be liable to the other for any delay in,or failure of performance of, any covenant or
promise contained in this Contract to the extent that the delay or failure is caused by a supervening cause. As used in this Contract,
"supervening cause"is defined to mean: an act of God, fire, explosion, action of the elements,stile,interruption of transportation,
rationing,court action,illegality,unusually severe weather,war,or any other cause which is beyond the control of the affected party
and which,by the exercise of reasonable diligence,could not have been prevented by the affected party. A delay or failure to
perform that is caused by a supervening cause shall not constitute a material breach of this Contract or give rise to any liability for
damages therefor under this Contract
23. The enforcement of the terms and conditions of this Contract,and all rights of action related to that enforcement,shall be strictly
reserved to the State and the Contractor. Nothing contained in this Contract shall give rise to,or allow, any claim or right of action
whatsoever to or by any third person. Nothing contained in this Contract shall be construed as a waiver of any provision of the
Colorado Governmental Immunity Act, section 24-10-101 et seq., C.R.S.,as amended. Any person or entity,other than the.State or
the Contractor,who may receive services or benefits under this Contract shall be deemed an incidental beneficiary only.
24. To the extent that this Contract may be executed and performance of the obligations of the parties may be accomplished within
the intent of this Contract the terms of this Contract are severable. If any term or provision of this Contract is declared invalid by a
court of competent jurisdiction, or becomes inoperative for any other reason,then that invalidity or failure shall not affect the validity
of any other term or provision of this Contract.
25. The waiver of a breach of a term or provision of this Contract shall not be construed as a waiver of a breach of any other term or
provision of this Contract or,as a waiver of a breach of the same term or provision upon subsequent breach.
26. If this Contract is in the nature of personal/purchased services,then, except for accounts receivable,the rights, duties, and
obligations of the Contractor shall not be assigned,delegated,or otherwise transferred, except with the prior, express,written consent
of the State.
27. Unless otherwise provided for in this Contract,this Contract shall inure to the benefit of, and be binding upon,the parties hereto
and their respective successors and assigns.
28. Unless otherwise provided for in this Contract,the Contractor shall notify the State,within five(5)working days after being
served with a summons,complaint,or other pleading in any case that involves any services provided under this Contract and which
has been filed in any federal or state court or administrative agency. The Contractor shall deliver copies of any documents that it was
served with to the State within five working(5)days of the date of service.
29. This Contract is subject to such modifications as may be required by changes in applicable federal or state law,or federal or
state implementing rules,regulations,or procedures of that federal or state law. Any required modification(s)shall be automatically
incorporated into,and be made a part of,this Contract as of the effective date of the change as if that change was fully set forth
herein. Except as provided above,no modification of this Contract shall be effective unless that modification is agreed to in writing
by both parties in the form of a written amendment to this Contract that has been previously executed and approved in accordance
with applicable law.
30. Unless otherwise provided for in this Contract, all terms and conditions of this Contract, and the attachments or exhibits hereto,
that may require continued performance or compliance beyond the termination or expiration date of this Contract shall survive that
termination or expiration date and shall be enforceable as provided for herein.
31. Unless otherwise provided for in this Contract,no term or condition of this Contract shall be construed or interpreted as a waiver,
express or implied, of any of the immunities,rights,benefits,protections,or other provisions of the Colorado Governmental
Immunity Act(CGIA), section 24-10-101,et seq., C.RS., as amended. Liability for claims for injuries to persons or property arising
out of the alleged negligence of the state of Colorado,its departments,institutions, agencies,boards,officials,and employees is
controlled and limited by the provisions of section 24-10-101 et seq., C.RS.,as amended.
32. The captions and headings used in this Contract are for identification only, and shall be disregarded in any construction of the
terms,provisions, and conditions of this Contract.
33. The exclusive venue for any action related to this Contract shall be in the City and County of Denver,Colorado.
, 34. All attachments or exhibits to this Contract are incorporated herein by this reference and made a part hereof as if fully set forth
herein. In the event of any conflict or inconsistency between the terms of this Contract and those of any attachment or exhibit to this
Contract,the terms and conditions of this Contact shall control.
35. This Contact is the complete integration of all understandings between the parties. No prior or contemporaneous addition,
deletion,or other amendment hereto shall have any force or effect whatsoever,unless embodied herein in writing. No subsequent
novation,renewal,addition,deletion, or other amendment hereto shall have any force or effect unless embodied in a written
amendment to this Contact executed and approved in accordance with applicable law.
E. SPECIAL PROVISIONS.
1. CONTROLLER'S APPROVAL. CRS 24-30-202(1)
This contact shall not be deemed valid until it has been approved by the Controller of the State of Colorado or such assistant as he
may designate.
2. FUND AVAILABILITY.CRS 24-30-202 (5.5)
Financial obligations of the State of Colorado payable after the current fiscal year are contingent upon funds for that purpose being
appropriated,budgeted,and otherwise made available.
3. INDEMNIFICATION.
The contractor shall indemnify, save, and hold harmless the State,its employees and agents, against any and all claims,damages,
liability and court awards including costs, expenses, and attorney fees incurred as a result of any act or omission by the Contractor,or
its employees, agents,subcontractors,or assignees pursuant to the terms of this contact.
4. INDEPENDENT CONTRACTOR.4 CCR 801-2
THE CONTRACTOR SHALL PERFORM ITS DUTIES HEREUNDER AS AN INDEPENDENT CONTRACTOR AND NOT AS
AN EMPLOYEE.NEITHER THE CONTRACTOR NOR ANY AGENT OR EMPLOYEE OF THE CONTRACTOR SHALL BE
OR SHALL BE DEEMED TO BE AN AGENT OR EMPLOYEE OF THE STATE. CONTRACTOR SHALL PAY WHEN DUE
ALL REQUIRED EMPLOYMENT TAXES AND INCOME TAX AND LOCAL HEAD TAX ON ANY MONIES PAID BY THE
STATE PURSUANT TO THIS CONTRACT. CONTRACTOR ACKNOWLEDGES THAT THE CONTRACTOR AND ITS
EMPLOYEES ARE NOT ENTITLED TO UNEMPLOYMENT INSURANCE BENEFITS UNLESS THE CONTRACTOR OR
THIRD PARTY PROVIDES SUCH COVERAGE AND THAT THE STATE DOES NOT PAY FOR OR OTHERWISE PROVIDE
SUCH COVERAGE. CONTRACTOR SHALL HAVE NO AUTHORIZATION, EXPRESS OR IMPLIED,TO BIND THE STATE
TO ANY AGREEMENTS,LIABILITY, OR UNDERSTANDING EXCEPT AS EXPRESSLY SET FORTH HEREIN.
CONTRACTOR SHALL PROVIDE AND KEEP IN FORCE WORKERS' COMPENSATION(AND PROVIDE PROOF OF SUCH
INSURANCE WHEN REQUESTED BY THE STATE)AND UNEMPLOYMENT COMPENSATION INSURANCE IN THE
AMOUNTS REQUIRED BY LAW,AND SHALL BE SOLELY RESPONSIBLE FOR THE ACTS OF THE CONTRACTOR, ITS
EMPLOYEES AND AGENTS.
5. NON-DISCRIMINATION.
The contractor agrees to comply with the letter and the spirit of all applicable state and federal laws respecting discrimination and
unfair employment practices.
6. CHOICE OF LAW.
The laws of the State of Colorado and rules and regulations issued pursuant thereto shall be applied in the interpretation,execution,
and enforcement of this contract. Any provision of this contact,whether or not incorporated herein by reference,which provides for
arbitration by any extra judicial body or person or which is otherwise in conflict with said laws,rules, and regulations shall be
considered null and void. Nothing contained in any provision incorporated herein by reference which purports to negate this or any
other special provision in whole or in part shall be valid or enforceable or available in any action at law whether by way of complaint,
defense, or otherwise. Any provision rendered null and void by the operation of this provision will not invalidate the remainder of
this contract to the extent that the contract is capable of execution. At all times during the performance of this contract,the Contractor
shall strictly adhere to all applicable federal and State laws,rules,and regulations that have been or may hereafter be established.
7. VENDOR OFFSET.CRS 24-30-202(1)&CRS 24-30-202.4
Pursuant to CRS 24-30-202.4(as amended),the State Controller may withhold debts owed to State agencies under the vendor offset
intercept system for: (a)unpaid child support debt or child support arrearages;(b)unpaid balance of tax, accrued interest,or other
charges specified in Article 21,Title 39, CRS;(c)unpaid loans due to the Student Loan Division of the Department of Higher
Education;(d)owed amounts required to be paid to the Unemployment Compensation Fund;and(e)other unpaid debts owing to the
State or any agency thereof,the amount of which is found to be owing as a result of final agency determination or reduced to
judgment as certified by the controller.
8. SOFTWARE PIRACY PROHIBITION GOVERNOR'S EXECUTIVE ORDER No State or other public funds payable
under this Contract shall be used for the acquisition,operation or maintenance of computer software in violation of United States
, copyright laws or applicable licensing restrictions. The Contractor hereby certifies that,for the term of this Contract and any
extensions,the Contractor has in place appropriate systems and controls to prevent such improper use of public funds. If the State
determines that the Contractor is in violation of this paragraph,the State may exercise any remedy available at law or equity or under
this Contract,including,without limitation,immediate termination of the Contract and any remedy consistent with United States
copyright laws or applicable licensing restrictions.
9. EMPLOYEE FINANCIAL INTEREST. CRS 24-18-201 & CRS 24-50-507
The signatories aver that to their knowledge,no employee of the State of Colorado has any personal or beneficial interest whatsoever
in the service or property described herein.
IN WITNESS WHEREOF,the parties hereto have executed this Contract on the day first above written.
CONTRACTOR: STATE:
[LEGAL NAME OF ENTITY] STATE OF COLORADO
(legal type of entity) Bill Owens,Governor
By: SAMPLE ONLY By: SAMPLE ONLY
Name: For the Executive Director
Title: DEPARTMENT OF PUBLIC HEALTH
FEIN: AND ENVIRONMENT
Date: Date:
(Seal) ATTEST: PROGRAM APPROVAL:
An attestation is required.
By: SAMPLE ONLY By: SAMPLE ONLY
A corporate attestation is required.
A corporate seal may be affixed if available.
APPROVALS:
COLORADO DEPARTMENT OF LAW
OFFICE OF THE ATTORNEY GENERAL
Ken Salazar,Attorney General
By: SAMPLE ONLY
Date:
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:
Arthur L.Barnhart
By: SAMPLE ONLY
Date:
Revised:09/08/03
Attachment H.2
Agency or Department
Name
Department or Agency
Number
SAMPLE ONLY Contract Routing Number
CONTRACT AMENDMENT #
THIS AMENDMENT, made this day of 20_, by and between the State of Colorado for the use
and benefit of the Department of /or Higher Education Institution (name and mailing address hem) hereinafter
referred to as the State, and (name and address of contracting entity), hereinafter referred to as the Contractor.
FACTUAL RECITALS
Authority exists in the Law and Funds have been budgeted, appropriated, and otherwise made available and a
sufficient unencumbered balance thereof remains available for payment; and
Required approval,clearance, and coordination has been accomplished from and with appropriate agencies; and
The parties entered into a contract dated(made date) for(short description of original contract's purpose). The purpose for
this amendment is described below.
(Brief statement offacts/reasons for the amendment.)
(Brief statement of intention in amending the contract)
NOW THEREFORE, it is hereby agreed that
1. Consideration for this amendment to the original contract, (contract routing number),
(original contract encumbrance number) dated (made date) consists of the payments which shall be made pursuant
to this amendment and the promises and agreements herein set forth.
2. It is expressly agreed by the parties that this amendment is supplemental to the original
Contract, as amended (previous amendment routing number), collectively*, referred to as the "original contract,"
which is, by this reference incorporated herein,that all terms, conditions, and provisions thereof, unless specifically
modified herein, are to apply to this amendment as though they were expressly rewritten, incorporated, and included
herein. (*Note: only use this language if creating amendment#2 or higher)
3. It is agreed the original contract is and shall be modified, altered, and changed in the following respects only:
a.
b.
4. The effective date of this amendment is upon approval of the State Controller or(date), 20_, whichever is later.
5. Except for the "Special Provisions," in the event of any conflict, inconsistency, variance, or contradiction between
the provisions of this amendment and any of the provisions of the original contract,the provisions of this amendment
shall in all respects supersede, govern, and control. The "Special Provisions" shall always be controlling over other
provisions in the contract or amendments. The representations in the Special Provisions concerning the absence of
bribery or corrupt influences and personal interest of State employees are presently reaffirmed.
6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR ARE
CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND
OTHERWISE MADE AVAILABLE.
Date Issued:February 10,2003
IN WITI4ESS WHEREOF,the parties hereto have executed this amendment on the day first above written.
Contractor:• State of Colorado
Bill Owens, Governor
(Full Legal Name)
By: SAMPLE ONLY
(Signature of Individual) Executive Director
Department of Public Health and environment
(Name of Individual)
Date:
Position(Title)
Attorney General, Ken Salazar
By: SAMPLE ONLY
Date:
Social Security Number
or Federal Employer ID Number
Attestation:
By: SAMPLE ONLY (SEAL)
Corporate Secretary,
or Equivalent,
Town/City/County Clerk
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 goods and/or services provided.
State Controller
Arthur L. Bamhart
By: SAMPLE ONLY
Date:
•
Attachment H.3
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
DEPARTMENT OR AGENCY NUMBER
***
CONTRACT ROUTING NUMBER
(SAMPLE)TASK ORDER
**********Program
This Task Order is made this****day of********* �**,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(LEGAL NAME
OF POLITICAL ENTITY)(a political subdivision of the state of Colorado),whose address or principal place of business is
(STREET ADDRESS,CITY,STATE&ZIP CODE), {strike inapplicable text}[acting by and through the] [for the use and benefit of
the] (Legal Name of Entity),whose address or principal place of business is(Street Address, City, State&Zip Code),hereinafter
referred to as"the Contractor".
FACTUAL RECITALS
[THE LANGUAGE IN THIS SECTION IS SAMPLE LANGUAGE ONLY. DO NOT USE IT"VERBATIM"FOR YOUR
PROGRAM YOU WILL NEED TO MODIFY THIS LANGUAGE FOR YOUR PROGRAM'S SPECIFIC STATUTORY
REQUIREMENTS,PURPOSES,AND NEEDS.]
{"Pursuant to section 25-*-***,C.RS.,as amended,the General Assembly of the state of Colorado has declared that . . ." Section 25-*-
*** C.RS., as amended,states that. . ." Section 25****,C.RS.,as amended,further states that. . ." To accomplish its statutory duties,
the State has. . ."]
The[United State Department of**********("US****"),through the********** ("***"), [General Assembly]has awarded the State
[federal funds under Notice of Cooperative Agreement Award("NCAA")number**"******to perform**********. (See, Catalog of
Federal Domestic Assistance("CFDA")number**.***).] [has awarded the State funds from the**********to perform**********.]
The State has formulated a comprehensive State plan,with associated budgets,to disburse these funds throughout the state of Colorado.
Under this comprehensive State plan,the State shall allocate these funds to qualified entities to provide**********to the citizens of the
state of Colorado on behalf of the State.
Section 29-1-201, C.RS. 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.RS., 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**********. 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)***, Organizational Unit
Code(s)**** Appropriation Code(s) *", Program Code(s) ****,Function Code(s)****,Object Code(s)****, and Grant Budget Line
Code(s)****under Contract encumbrance number** **************. All required approvals,clearances, and coordination have been
accomplished from and with all appropriate agencies.
NOW,THEREFORE,in consideration of their mutual promises to each other,stated below,the parties hereto agree as follows:
[TWO PART"A."ARE SET FORTH BELOW. USE ONLY THE PART"A."THAT PERTAINS TO THE FUNDING
SOURCE FOR YOUR PROGRAM.]
& PERIOD OF PERFORMANCE AND TERMINATION. [Use this paragraph if,and only if,the Task Order will be paid for
entirely from federal funds] The proposed effective date of this Contract is********** ** ****. However,in accordance with
section 24.30-202(1), C.R S.,as amended,this Contract is not valid until it has been approved by the State Controller, or an
authorized designee thereof. If the underlying NCAA authorizes the State to pay all allowable and allocable expenses of a contractor
as of the effective date of that NCAA,then the State shall reimburse the Contractor for any allowable and allocable expenses of the
Contractor that have been incurred since the proposed effective date of this Contract. If the underlying NCAA does not authorize the
State to pay all allowable and allocable expenses of a contractor as of the effective date of that NCAA,then the State shall only
reimburse the Contractor for those allowable and allocable expenses of the Contractor that were incurred on or after the effective date
of this Contract. The initial term of this Contract shall commence on its effective date and continue through and including
********** **,****. If the State receives additional federal funding for the purposes of this Contract,then this Contract shall
automatically renew for the period covered by those additional federal funds. This Contract is funded entirely with federal funds.
Therefore,the State's liability for payment for all services rendered,or goods supplied,under this Contract is contingent upon the
State's receipt of those federal funds. If the State does not receive all,or any part,of the federal fluids necessary to pay its obligations
under this Contract,then the State may immediately amend or terminate this Contract without further liability to the State. The total
term of this Contract,including all automatic renewals,bilateral options to renew, and extensions,may not exceed five(5)years.
A. PERIOD OF PERFORMANCE AND TERMINATION. [Use this paragraph if the Task Order will be paid for entirely from
state funds or from mired federal and state funds.] The proposed effective date of this Contract is***************. However,
in accordance with section 24-30-202(1), C.RS.,as amended,this Contract 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
Contract until this Contract 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 Contract.
If the State Controller approves this Contract on or before its proposed effective date,then the Contractor shall commence
performance under this Contract on the proposed effective date. If the State Controller approves this Contract after its proposed
effective date,then the Contractor shall only commence performance under this Contract on that later date. The initial term of this
Contract shall commence on the effective date of this Contract and continue through and including*********** **** unless
sooner terminated by the parties pursuant to the terms and conditions of this Contract. In accordance with section 24-103-503,
C.RS.,as amended, and Colorado Procurement Rule R-24-103-503,the total term of this Contract,including any renewals or
extensions hereof,may not exceed five(5)years.
B. DUTIES AND OBLIGATIONS OF THE CONTRACTOR. The Contractor,in accordance with the terms and conditions of the
Master Contract and this Task Order, shall perform and complete,in a timely and satisfactory manner, all work items described in the
Statement of Work and Budget,which are incorporated herein by this reference,made a part hereof and attached hereto as
"Attachment A".
C. DUTIES AND OBLIGATIONS OF THE STATE.
1. The Contractor shall be compensated in accordance with the rates set forth in Attachment A hereto. In consideration of those
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**********DOLLARS, ($0.00)for the initial term of this Task Order. Of the total financial
obligation of the State referenced above, $*.**are identified as attributable to a funding source of the United States government
and,$*.* are identified as attributable to a funding source of the state of Colorado.
2. Payments under this Task Order shall be made either through the State's Electronic Fund Transfer system or,upon the
Contractor's periodic submission of a duplicate"Task Order Reimbursement Statement".
3. If this Task Order requires the Contractor submit a"Task Order Reimbursement Statement",then the Contractor shall submit a
signed,duplicate[monthly/quarterly/bi-annual] Task Order Reimbursement Statement within sixty(60)calendar days of the
end of the billing period for which services were rendered. A sample Task Order Reimbursement Statement is incorporated
herein by reference,made a part hereof, and attached hereto as"Attachment*". Expenditures shall be in accordance with those
items identified in Attachment*. These items may include,but are not limited to:the Contractor's salaries,fringe benefits,
supplies,travel,operating, and indirect costs which are allowable and allocable expenses related to its performance under this
Task Order.
Each Task Order Reimbursement Statement shall reference the related Matter Contract by its contract routing number and this
Task Order by their respective contact routing numbers. The contract routing numbers are located on page one of these
documents. Each Task Order Reimbursement Statement shall also indicate the applicable performance dates,the names of
payees; a brief description of the services performed during the relevant performance dates; all expenditures incurred;and,the
total reimbursement requested. Reimbursement during the initial, or any renewal,term of this Task Order shall be conditioned
upon affirmation by the State that all services were rendered by the Contractor in accordance with the terms of this Task Order.
Each Task Order Reimbursement Statement shall be sent to:
(Name)
(Division)
Colorado Department of Public Health and Environment
(Mail Code)
4300 Cherry Creek Drive South
Denver,CO 80246
4. [For use with government purchased service contracts only;delete if inapplicable) 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"Attachment*". To be effective, a Task Order Change Order Letter must be: signed by the State and the Contractor; and,
approved by the State Controller or an authorized designee thereof. Additionally, a Task Order Change Order Letter shall
include the following information:
A. Identification of the related Master Contract and this Task Order by their respective contract routing numbers and
affected paragraph number(s);
B. The type(s)of service(s)or program(s)increased or decreased and the new level of each service or program;
C. The amount of the increase or decrease in the level of funding for each service or program and the new total financial
obligation;
D. A provision stating that the Task Order Change Order Letter is effective upon approval by the State Controller,or
designee,or its proposed effective date,whichever is later.
Upon proper execution and approval,a Task Order Change Order Letter shall become an amendment to this Task Order. Except
for the General and Special Provisions of the Master Contract, and the Additional Provisions of the Task Order,if any,the
Task Order Change Order Letter shall supersede this Task Order in the event of a conflict between the two. It is expressly
understood and agreed to by the parties that the task order change order letter process may be used only for increased or
decreased levels of funding,corresponding adjustments to service or program levels, and any related budget line items. Any
other changes to this Task Order,other than those authorized by the task order option to renew letter process described
below,shall be made by a formal amendment to this Task Order executed in accordance with the Fiscal Rules of the state of
Colorado.
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. /Por use with government purchased service contracts only;delete if inapplicable) 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 "Attachment*". 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 finding for each service or program and the new total financial
obligation;
D. A provision stating that the Task Order Option to Renew Letter is effective upon approval by the State Controller, or
designee, or its proposed effective date,whichever is later.
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.
D. ADDITIONAL PROVISIONS.
[THE PROVISIONS LISTED BELOW ARE INTENDED AS EXAMPLES ONLY. DO NOT INCLUDE THEM IN
YOUR PROGRAM'S TASK ORDER IF THEY DO NOT APPLY TO YOUR PROGRAM.]
State Division or Program Specific Requirements which are not covered by the General or Special Provisions of the Master
Contract,ez,
["1. The Contractor shall p 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",Public Law 103-227, ("Act"). . .
"]
["2. The Contractor certifies,to the best of its knowledge and belief,that no federally appropriated funds have been paid or
shall be paid by or on behalf of the Contractor,to any person for influencing or attempting to influence. . ."]
["3. Tide V, Section 504(b)(6). Tide V funds may not be used. . .'�
["4. The Contractor shall protect the confidentiality of all applicant or recipient records. . ."]
["5. The Contractor shall not charge for services those individuals of families at or below the official poverty line. . ."]
[*6. The Contractor shall:(1)inform potentially eligible recipients that the"Colorado Baby Care/Kid's Care Program"
(CBC/KCP)exists. . ."
IN WITNESS WHEREOF,the parties hereto have executed this Task Order as of the day first above written.
CONTRACTOR: STATE:
(LEGAL NAME OF ENTITY) STATE OF COLORADO
(a political subdivision of the state of Colorado) Bill Owens.Governor
[acting by and through the][for the use and benefit of the]
By: SAMPLE ONLY By: SAMPLE ONLY
Name: For the Executive Director
Title: DEPARTMENT OF PUBLIC HEALTH
FEIN: **_******* AND ENVIRONMENT
Date: Date:
(Seal) ATTEST: PROGRAM APPROVAL:
By: SAMPLE ONLY By: SAMPLE ONLY
City,City and County,County,
Special District, or Town Clerk or Equivalent
APPROVALS:
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS 2430-202 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:
Arthur L.Barnhart
By: SAMPLE ONLY
Date:
Revised:12/31/02
•
[Date] SAMPLE TASK ORDER CHANGE ORDER LETTER Attachment*
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 JLEGAL NAME OF CONTRACTORj. The Task Order has been amended by Task Order Option to
Renew Letter**,contract routing number** ********,and/or Task Order Change Order Letter** contract routing number** ***
*****,if any. The Task Order,as amended,if applicable,is referred to as the"Original Task Order". This Task Order Change Order
Letter is for the current term of***********,****,through********* ** ****. The maximum amount payable by the State for the
work to be performed by the Contractor during this current term is increased/decreased by**********Dollars,($*.**)for an amended
total financial obligation of the State of**********DOLLARS, ($*.**). The revised specifications to the original Scope of Work and
the revised Budget are incorporated herein by this reference,made a part hereof, and attached hereto as"Attachment*"and
"Attachment.*". The first sentence in paragraph_*.of the Original Task Order is modified accordingly. All other terms and conditions
of the Original Task Order are reaffirmed. This change to the Task Order shall be effective upon approval by the State controller,or
designee, or on ***********,****,whichever is later.
Please sign,date,and return all**originals of this Task Order Change Order Letter by********* ** ****,to the attention of
************ ************,Colorado Department of Public Health and Environment,4300 Cherry Creek Drive South, Mail
Code***-***-**,Denver,Colorado 80246. One original of this Task Order Change Order Letter will be returned to you when fully
approved.
[LEGAL NAME OF CONTRACTOR] STATE OF COLORADO
(a political subdivision of the state of Colorado) Bill Owens,Governor
By: SAMPLE ONLY By: SAMPLE ONLY
Name: For the Executive Director
Title: DEPARTMENT OF PUBLIC HEALTH
FEIN: AND ENVIRONMENT
(Seal) ATTEST: PROGRAM APPROVAL:
By: SAMPLE ONLY By: SAMPLE ONLY
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS 2430-202 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:
Arthur L.Barnhart
By: SAMPLE ONLY
Date:
Revised:08/30/02
[Date] SAMPLE TASK ORDER OPTION TO RENEW LETTER Attachment*
Task Order Option to Renew Letter Number**, Contract Routing Number***** *****
State Fiscal Year 20**-20" ***************Program
This Task Order Option to Renew Letter is issued pursuant to paragraph*_*.of the Master Contract identified by contract routing number
** ********and paragraph*. *. of the Task Order identified by contract routing number** *** *****and contract encumbrance
number***** **********. This Task Order Option to Renew Letter is between the COLORADO DEPARTMENT OF PUBLIC
HEALTH AND ENVIRONMENT and JLEGAL NAME OF CONTRACTOR'. The Task Order has been amended by Task Order
Change Order Letter**, contract routing number** *** ***** and/or Task Order Option to Renew Letter**,contract routing number
** ******** if any. The Task Order,as amended,if applicable,is referred to as the"Original Task Order". This Task Order Option to
Renew Letter is for the renewal term of********* ** **** through******""** ****. The maximum amount payable by the State
for the work to be performed by the Contractor during this renewal term is**********Dollars, (*.**'for an amended total financial
obligation of the State of**********DOLLARS This is an increase/decrease of($*.**)of the amount payable from the previous term.
The Budget for this renewal term is incorporated herein by this reference,made a part hereof, and attached hereto as"Attachment*".
The first sentence in paragraph*_*.of the Original Task Order is modified accordingly. All other terms and conditions of the Original
Task Order are reaffirmed. This Task Order Option to Renew Letter is effective upon approval by the State Controller,or designee,or on
********* ** **** whichever is later.
Please sign,date,and return all**originals of this Task Order Option to Renew Letter by********* ** ****,to the attention of
************************,Colorado Department of Public Health and Environment,Mail Code********,4300 Cherry
Creek Drive South,Denver,Colorado 80246. One original of this Task Order Option to Renew Letter will be returned to you when
fully approved.
[LEGAL NAME OF CONTRACTOR] STATE OF COLORADO
(a political subdivision of the state of Colorado) Bill Owens,Governor
By: SAMPLE ONLY By: SAMPLE ONLY
Name: For the Executive Director
Title: DEPARTMENT OF PUBLIC HEALTH
FEIN: AND ENVIRONMENT
(Seal) ATTEST: PROGRAM APPROVAL:
By: SAMPLE ONLY By: SAMPLE ONLY
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:
Arthur L.Barnhart
By: SAMPLE ONLY
Date:
Revised:08/30/02
Attachment H.4
SAMPLE ONLY
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
DEPARTMENT OR AGENCY NUMBER
***
CONTRACT ROUTING NUMBER
** *****
LIMITED AMENDMENT #*
This Limited Amendment is made this****day of********* 200*,by and between:the state of Colorado, acting by and through the
DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT,whose address or principal place of business is 4300 Cherry Creek
Drive South,Denver,Colorado 80246 hereinafter referred to as"the State";and,JLEGAL NAME OF ENTITY),(Regal type of
entity]),whose address or principal place of business is JStreet Address,City,State& Zip Code],hereinafter referred to as"the
Contractor".
FACTUAL RECITALS
The parties entered into an original Contract dated Jinsert date here),with contract encumbrance number JPO*************),and
contract routing number J** *** *****1,whereby the Contractor was to provide to the State
[briefly describe what the Contractor was to do under the original Contract].
Please choose one of the following and Insert here—delete items not selected:
1. The State promises to [choose one: increase/decrease]the amount of funds to be paid to the Contractor by **********Dollars,
($*.**)during the current term of the original Contract in exchange for the promise of the Contractor to perform the[choose one:
increased/decreased]work under the Original Contract.
2. The State promises to pay the Contractor the sum of**********Dollars, ($*.**)in exchange for the promise of the Contractor to
continue to perform the work identified in the original Contract for the renewal term of[insert performance period here].
3. The State promises to[choose one: increase/decrease]the amount of funds to be paid to the Contractor by********** Dollars
($*.**)for the renewal term of[insert performance period here]in exchange for the promise of the Contractor to perform the[choose
one: increased/decreased] Scope of Work described herein.
4. The State hereby exercises a"no cost"change to the[insert: budget,specifications within the Scope of Work, or performance
period]within the[choose one: current term of the original Contract or renewal term of the original Contract].
NOW THEREFORE,in consideration of their mutual promises to each other,stated below,the parties hereto agree as follows:
1. Consideration for this Limited Amendment to the original Contract consists of the payments and services that shall be made pursuant
to this Limited Amendment, and promises and agreements herein set forth.
2. It is expressly agreed to by the parties that this Limited Amendment is supplemental to the original Contract, [insert the following
language here if previous amendment(s)have been processed: as amended by [include all previous amendment routing
numbers here] ], which is,by this reference incorporated herein; all terms,conditions,and provisions thereof, unless specifically
modified herein, are to apply to this Limited Amendment as though they were expressly rewritten,incorporated,and included herein.
3. It is expressly agreed to by the parties that the original Contract is and than be modified, altered,and changed in the following
respects only.
A. [Use this paragraph when changes to the funding level of the original Contract occur during the current term of the
original Contract.] This Limited Amendment is issued pursuant to paragraph_*.of the original Contract identified as
contract routing number**********. This Limited Amendment is for the current term of*********** ****,through and
including********* **,****, The maximum amount payable by the State for the work to be performed by the Contractor
during this current term is[choose one:increased/decreased]by **********Dollars ($*.**)for an amended total financial
obligation of the State of**********DOLLARS,($*.**). The revised specifications to the original Scope of Work and the
rkvised Budget,if any, are incorporated herein by this reference and identified as"Attachment*"and"Attachment*". The
first sentence in paragraph_*.of the original Contract is modified accordingly. All other terms and conditions of the original
Contract are reaffirmed.
A. [Use this paragraph when the original Contract will be renewed for another term.] This Limited Amendment is issued
pursuant to paragraph_*.of the original Contract identified by contract routing number** ********. This Limited
Amendment is for the renewal term of***********, **** through and including********* ** ****. The maximum
amount payable by the State for the work to be performed by the Contractor during this renewal term is**********Dollars,
(*.**)for an amended total financial obligation of the State of**********DOLLARS, This is an[choose one:
increase/decrease]of($*.**)of the amount payable from the previous term. The revised specifications to the original Scope
of Work and revised Budget, if any, for this renewal term are incorporated herein by this reference and identified as
"Attachment*"and"Attachment*". The first sentence in paragraph*_*.of the original Contract is modified accordingly.
All other terms and conditions of the original Contract are reaffirmed.
A. [Use this paragraph when there are"no cost changes"to the Budget,the specifications within the original Scope of Work,
or performance period.] This Limited Amendment is issued pursuant to paragraph*_*.of the original Contract identified by
contract routing number** ********. This Limited Amendment[choose one: modifies the Budget, modifies the
specifications to the Scope of Work, or modifies the period of performance]of the original Contract. The revised[choose
one:Budget,specifications to the original Scope of Work,or period of performance]is incorporated herein by this reference
and identified as"Attachment*". All other terms and conditions of the original Contract are reaffirmed.
4. The effective date of this Amendment is date, or upon approval of the State Controller, or an authorized delegate thereof,
whichever is later.
5. Except for the General Provisions and Special Provisions of the original Contract,in the event of any conflict,inconsistency,
variance,or contradiction between the terms and provisions of this Amendment and any of the terms and provisions of the
original Contract,the terms and provisions of this Amendment shall in all respects supersede, govern,and control. The Special
Provisions shall always control over other provisions of the original Contract or any subsequent amendments thereto. The
representations in the Special Provisions to the original Contract concerning the absence of personal interest of state of Colorado
employees is presently reaffirmed.
6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR ARE CONTINGENT
UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND OTHERWISE MADE AVAILABLE.
IN WITNESS WHEREOF,the parties hereto have executed this Form Amendment on the day first above written.
CONTRACTOR: STATE:
[LEGAL NAME OF CONTRACTOR] STATE OF COLORADO
(legal type of entity) Bill Owens,Governor
By: SAMPLE ONLY By: SAMPLE ONLY
Name: For the Executive Director
Title: DEPARTMENT OF PUBLIC HEALTH
FEIN: AND ENVIRONMENT
Date: Date:
ATTEST: PROGRAM APPROVAL:
If the Contractor is a corporation
or governmental entity,then an attestation is required.
(Seal,if available.)
By: SAMPLE ONLY By: SAMPLE ONLY
City,City and County, County,
Special District,or Town Clerk or Equivalent
Corporate Secretary or Equivalent
[Delete inapplicable language]
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS 24-30-202 requires that the State Controller approve all state contracts. This limited amendment 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 goods and/or services provided.
STATE CONTROLLER
Arthur L.Barnhart
By: SAMPLE ONLY
Date:
Revised:10/09/03
Attachment I
Percent of All Births to First-Time Mothers with Incomes Below 200%of the Federal Poverty Level(Poor*):
Colorado PRAMS,1997-2001;Colorado Vital Statistics,2002
Data from 1/12/04
Region(PMR)** 2002Number of 1997-2001 Percent 1997-2001 2002 Number
Live Births First-time and Poor 95%Confidence Interval First-time and Poor
First-time and Poor
Colorado 68,420 21.4 20.3-22.5 13,889-15,395
Region(PMR)** 2002Number of 1997-2001 Percent 1997-2001 2002 Number
Live Births First-time and Poor 95%Confidence Interval First-time and Poor
First-time and Poor
1 1,005 22.8 18.2-27.4 183-275
2 6,801 17.8 15.1-20.5 1,027-1,394
3 40,602 19.9 18.2-21.5 7,390-8,729
4 8,969 24.0 21.6-26.5 1,938-2,377
5 384 20.6 13.8-27.3 53-105
6 706 28.4 22.4-34.3 158-242
7 2,060 28.5 23.2-33.9 478-698
8 637 32.9 27.0-38.8 172-247
9 938 24.8 19.8-29.7 186-279
10 1,034 22.4 18.2-26.6 188-275
11 2,673 27.6 23.4-31.9 625-853
12 1,674 18.9 15.4-22.5 258-377
13 695 31.8 25.3-37.0 176-257
14 242 32.3 22.5-42.1 55-102
Region(PMR) 2002Number of 1997-2001 Percent 1997-2001 2002 Number
Live Births First-time and Poor 95%Confidence Interval First-time and Poor
First-time and Poor
Colorado 68,420 11.9 11.1-12.7 7,595-8,689
*Poor is defined as having an inwme 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,Castilla,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.
H:\WPDOCS\NHVP\Application\0405New&Epand\(Attatld)PRAMS.doc
Attachment E
Weld County NFP Expansion Project 2004-05
Budget Narrative
The contractor acknowledges that a portion of the costs of providing these Nurse Home
Visitor services shall come from sources other than Tobacco Master Settlement Funds
provided in this contract. It is anticipated that state designed Medicaid reimbursement for
Targeted Case management services will provide the additional funds to complete the
budget.
The salaries in this section are designated for 2.0 FTE RN, 025 FTE Data
Assistant and 0.25 FTE nursing supervisor position. RN's will have a full caseload of
clients to follow and recruit, by the end of the first program year. Benefits are calculated
per Weld County policy and schedule. Salary step increases are earned by personnel with
successful completion of 6 month and 1 year intervals. Cost of living increases are
anticipated annually.
All salary cost savings that occur in the contract year, will be utilized to enhance
the program activities and implementation, such as interpreter services.
Operating Expense
• Office supplies are utilized by the staff to provide client notebooks, charts, files,
and general organization.
• Client support materials are calculated on the suggested schedule of$145.00 per
family throughout program participation. In the first year of participation, $80 is
spent per family on program incentives, educational materials, and developmental
tools. The line items for year 2 and year 3 indicate the amount allocated for
family education materials, parenting support information, and tools for
developmental stimulation.
• Printing expenses are derived from duplication of program forms, facilitators,
educational materials, and printing program brochures and program promotion
materials to use in the community.
• Postage is for client and program contacts.
• The phone line item includes office phone equipment and service for all program
staff.
• Computer network fees provide access to the internet system.
• Cell phone usage is calculated at $50 per monthly service package, for 2 RNs for
12 months = $1200
• Health and program supplies will include scales, blood pressure equipment,
batteries, and small items in the visiting bags (tape, gloves, sanitizer,
demonstration items).
• Professional development is available to provide team or individual training in
program related fields.
NCCFC Training
• All nursing staff, including the supervisor will attend the entire sequence of
NCCFC training during the program year. This involves 10 days of training.
• Training materials for the NCCFC sequence cost $350 per nurse. At least 3
nursing staff will participate
• The CIS system will be required to track the program data and activity.
• NCCFC indirect costs are assessed at a program standard of 26%.
• PIPE curriculum materials are provided to each visiting nurse. It is necessary to
purchase a multiple of activity cards and parent handbooks, due to language
differences, and two office sites.
NCAST Training
• 2 RNs will attend the NCAST training sessions.
• The current Weld County NFP site has a set of Keys to Caregiving videos. Two
RNs will all need the entire NCAST training and assessment materials and tools,
with the exception of the Keys to Caregiving video set.
Travel
• Visit Outreach mileage—During the first year of the program expansion, the new
staff will build a full caseload. It is anticipated that two nurses will be assigned in
less populated areas, and will have higher mileage. The formula for mileage is
calculated:
o 50 visits x 10 miles x 12 months x $.355 reimbursement x 1 RN = 2,130
o 50 visits x 30 miles x 12 months x $.355 reimbursement x 1 RN= 6,390
• Travel to NCCFC trainings is figured for 3 nurses, involving 10 nights, 10 days of
per diem costs, and driving mileage.
• NCAST travel expenses will involve 10 nights of lodging, 10 days of per diem
costs, and driving mileage.
Equipment
• Two computers are requested for the program expansion. Computer packages will
be purchased to meet program criteria and agency standards. Installation will be
included in the computer price as contracted by Weld County, with ACS.
• Cell phone equipment will be issued to all visiting staff.
Attachment F
PREVENTION AND INTERVENTION SERVICES FOR CHILDREN AND YOUTH
APPLICATION BUDGET AND/OR EXPENDITURE REPORT FORM
APPLICANT: FOR THE PERIOD:
PROJECT: BUDGET EXPENDITURE REPORT
Annual #of Total SOURCE OF FUNDS
Requested/
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-state)
Total Travel $ $ $
Contractual
Total Contractual $ $ $
Total Direct Costs(Personal Services+Operating+Travel+Contractual) $ $ $
ADMINISTRATIVE/INDIRECT COST
Total Administrative/Indirect Costs $ $ $
TOTAL PROJECT COST $ $ $
'Source of funding for"Other"(Match or In-kind)I.e.Maternal and Child Health programs
Local/county funding $
Medicaid(will not be used to match) $
Patient fees $
Other(list) $
TOTAL $
May the NON FEDERAL funds be used as match? YES NO
Signature of Authorized Representative Date
Page 1 of 1
.
Attachment G
Colorado Department of Public Health and Environment
State Fiscal Year 2004-2005
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 NI-IVP. Below is the information pertaining to the
NI-WP Medicaid reimbursement process.
Contractor Name: Weld County Department of Public Health and Environment
Reimbursement Period: July 1, 2004 To June 30, 2005
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 $190.04
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
Medicaid Contractor Friday, 8:00 a.m.to 5:00 p.m.
You may also contact John Shick, Colorado Department of Health Care Policy
and Financing, at 303-866-4130orjohn.shick@state.co.us ifyou have
questions on the Medicaid enrollment or billing process.
FY 2004-2005 Funding Structure:
Medicaid Reimbursement Rate $190.04
Estimated Medicaid Clients by Site 49.5
Estimated Monthly Medicaid Revenue $9,407
Estimated Annual Medicaid Revenue $112,884
CDPHE Tobacco Funding $285,770
TOTAL FY04-05 NHVP FUNDING $398,654
$278,210
Total FY04-05 Contract Amount
($285,770 minus$7,560 for training and technical assistance costs that CDPHE will pay
directly to NCC FC)
J:\Peggy\CONTRACT5\FY o5W H VP\W eld\Attaclunent G-Weld MeduaN Reembutsement Continuation.doc
Page 2 of 2
Attachment H
Colorado Department of Public Health and Environment
State Fiscal Year 2004-2005
Colorado Nurse Home Visitor Program
MEDICAID REIMBURSEMENT GUIDELINES
FOR EXPANSION 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 1, 2004 To June 30,2005
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 (HMIs)at the end of the month for each mother/child
receiving a visit.
Medicaid Reimbursement Rate $190.04
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
`timely filing"policy(invoices must be submitted to ACS within 120 days
Billing Requirements
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 John Shick, Colorado Department of Health Care Policy
and Financing, at 303-866-4130orjohn.shick@state.co.us ifyou have
questions on the Medicaid enrollment or billing process.
FY 2004-2005 Funding Structure:
Medicaid Reimbursement Rate $190.04
Estimated Medicaid Clients by Site 24.75
Estimated Monthly Medicaid Revenue $4,703
Estimated Annual Medicaid Revenue $56,442
CDPHE Tobacco Funding $158,801
TOTAL FY04-05 NHVP FUNDING $215,243
$148,899
Total FY04-05 Contract Amount
($158,801 minus$9,902 for training and technical assistance costs that CDPHE will pay
directly to NCC FC)
1 VPeggyVCONTRACTSVFY 0SNHVPA Weld AAttachment H-Weld Medicaid Reimbursement Expansion doc
Page 2 of 2
Attachment I
DRAFT CONTINUATION BUDGET
BUDGET AND/OR EXPENDITURE REPORT FORM
APPLICANT: WELD COUNTY DEPT.OF PUBLIC HEALTH&ENV. FOR THE PERIOD: 7/01104 TO 6130105
PROJECT:NURSE HOME VISITOR PROGRAM 0.71480
Annual No.of Total Source of Funds
Salary Months Amount Received from
Rate Budget FTE Awarded CDPHE OTHER`
PERSONAL SERVICES:
Pudic Health Nurses Supvr.&Clerk 12 4.80 $225,683 $161,318
Contractual/Fee for Service-
Budget Redtalrhutlea — $500 $0
Fringe Benefits: Rah= $72,151 $51,574
Total Personal Services $298,334 $212,892 $0
OPERATING EXPENSES(which are not part of indirect):
Office RentfUfilfes-County Building Services $0 $0
Office SuppFes $1,200 $858
Client Support Materials $5,800_ _ $4,146
Forms/Facilitators/Outreach Materials $2,000 $1,430
Copying&Postage __- $600 -_$429
Advisory Board - _ $0 30
Telephone $1,200 $858
Computer Network/Internet Fees -.._ $380 $257.--...
Cell Phones $2,500 $1,787
Medical&Program Supplies -_- $600 $429
Professional Development $2,000 $1,430
Interpreter Services $0 $0
Utilities,Bldg.Maim.&Insurance __. $0 $0
Finance&HR $0 $0
Total Operating $16,250 $11,624 $0
EQUIPMENT
Computer,Software&Office Eqpt. $0 $0
Total Equipment $0 $0 $0
TRAVEL(In-state/Out-state)
Visit/Outreach Mileage $17,040 $12,180
NCCFC/UCHSC Training Travel $1,000 $715
NCAST Travel
Total Travel $18,040 $12,896 $0
TRAINING&TECHNICAL ASSISTANCE-NCCFC/UCHSC
Clinical Training&Support $0 $0 $0
Training Materials $0 .... $0 $0
Purchase of Clinical Info.System(CIS) $0 $0 $0
Technical Assistance $6,000 $0 $6,000
NCCFC Contract Indirect Costs $1,560_ $0 $1,560
PIPE Materials $0 $0 $0
Total Training&Tech.Assistance $7,560 $0 $7,560
NCAST TRAINING&MATERIALS
NCAST TRAINING&MATERIALS $100 $71
Total NCAST Training&Materials $100 $71 $0
Total Direct Costs(Personal Services+Operating+Travel+Contractual) $340,294 $237,482 $7,560
ADMINISTRATIVE/INDIRECT COST
17.15%TDC Cap $58,360 $40,728
Total AdministradveMdlrect Costs $58,360 $40,728 SO
TOTAL PROJECT COST $398,654 $278,210 $7,660
*Source of funding for"Other"(Cash or In-kind)
Including funding from Medicaid sources.
TOTAL
May the NON FEDERAL funds be used as match? YES NO
Signature of Authorized Representative Date
Page 1 of 1
Attachment J
DRAFT EXPANSION BUDGET
BUDGET ANDIOR EXPENDITURE REPORT FORM
APPLICANT: WELD COUNTY DEPARTMENT OF PUBLIC HEALTH&ENV. FOR THE PERIOD: 7101104 TO 6130/05
PROJECT:NURSE HOME VISITOR PROGRAM 0.73117
Annual No.of Total Source of Funds
Salary Months Amount Received from
Rate Budget FTE Awarded CDPHE OTHER*
PERSONAL.SERVICES:
Public Health Nurses,Supvr.&Clerk 12 2.50 $107,956 $78,934Contractual/Fee for Service-
Budget Redistribution $0 $0
Fringe Benefits: Rate= $35,175 --$25,719— - _- -
Total Personal Services $143,131 $104,853 $0
OPERATING EXPENSES(whlch are not part of Indirect):
Office Rent/Utilities-County Buckling Services $0 $O
Office Supplies
$800 $439
Client Support Materials $4,000 $2,925
Forms/Facilitators/Outreach Materials _-
$1,000 $731 _- -
CopingB Posre9e —... _-- $300 $219__
Advisory Board $0 $0
Telephone - $600 $439
Computer NetworMlnternet Fees $180 $132
Cell Phones
$1200 $877
Medical&Program Supplies - _--
$450 $329
Professional Development _ 0$1,000 $731
— -- -
Interpreter Services _-- _..
Utilities,Bldg.Maint.&Insurance $0 $0
Finance&HR
Total Operating $9,330 $8,822 $0
EQUIPMENT
Computer,Software&Office Eqpt. $3,200 $2,340 _-
Total Equipment $3,200 $2,340 $0
TRAVEL fin-state/Out-state)
Visit/Outreach Mileage $8,520 $6,230
NCCFC/UCHSC Training Travel
__. $4,125 $3,016
NCAST Travel -_ —.. - $3,444 -. $2,518
Total Travel $18,089 $11,784 $0
TRAINING&TECHNICAL ASSISTANCE-NCCFCIUCHSC
Clinical Training --- -- - -�-
&Support $6,500 $0 $6,500
Training Materials -_ $875 $0 $875
Purchase of Clinical Info,System(CIS) $0 _ $0 $0
Technical Assistance _. . _. _ $0 _- $0 _.- $0
NCCFC Contract Indirect Costs $2,043 $0 $2,043
PIPE Materials
_.__. -- $484 $0 _. $484
Total Training&Tech.Assistance $9,902 $0 $9,902
NCAST TRAINING&MATERIALS
NCAST TRAINING&MATERIALS _-- $2,081 $1,522
Total NCAST Training&Materials $2,081 $1,522 $0
Total Direct Costs(Personal Services+Operating+Travel+Contractual) $183,733 $127,101 $9,902
ADMINISTRATIVE/INDIRECT COST
17.15%TDC
$31,510 $21,798
Total Administrative/Indirect Costs - —
$31,610 $21,798 $0
TOTAL PROJECT COST $216,243 $148,899 $9,902
'Source of funding for"Other"(Cash or In-kind)
including funding from Medicaid sources.
TOTAL
May the NON FEDERAL funds be used as match? YES NO
Signature of Authorized Representative Date
Page 1 of 1
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