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Home My WebLink About20043605.tiff RESOLUTION RE: APPROVE TASK ORDER AMENDMENT #1 FOR MATERNAL AND CHILD HEALTH PROGRAM AND HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS,the Board has been presented with a Task OrderAmendment#1 for Maternal and Child Health Program and Health Care Program for Children with Special Needs between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and the Colorado Department of Public Health and Environment,commencing March 1,2005, with further terms and conditions being as stated in said task order, and WHEREAS, after review, the Board deems it advisable to approve said task order 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 OrderAmendment#1 for Maternal and Child Health Program and Health Care Program for Children with Special Needs between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment,and the Colorado Department of Public Health and Environment be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said task order amendment. The above and foregoing Resolution was,on motion duly made and seconded,adopted by the following vote on the 29th day of December, A.D., 2004. BOARD OF COUNTY COMMISSIONERS W D COUNTY, COLORADO 1861 ( : - Robert D. Masden, Chair erk to the Board Re'�r. ,® ti EXCUSED ♦ �� William H. J e, Pro-Tem Deputy Cler o the Board M. J. Ie AP AS T • David E. Long ounty tt rney Glenn Vaad Date of signature: . 2004-3605 HL0031 / - ()(1; /71-Z, C3CHu S\) C7S Memorandum scirH‘o TO: Robert E. Masden, Chair Board of County Commissioners IFROM: Mark E. Wallace, MD, MPH WI C Director, Department of Public He Ity h n/► and Environment �flW t�XX COLORADO• DATE: December 21, 2004 SUBJECT: Amendment#1 to the MCH/HCP Task Order Enclosed for Board review and approval is Amendment#1 to the MCH and HCP combined task order between the Colorado Department of Public Health and Environment (CDPHE) and Weld County. This amendment is supplemental to the original task order which was approved by the Board of County Commissioners in July of 2004. With the addition of paragraph 16 to Part E, it directs Weld County to comply with all applicable provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). It also requires Weld County to submit an application budget, a final expenditure report, and allows Weld County to charge patients seen at specialty clinics on a sliding fee basis. In previous contract years the application budget, expenditure report, and provision for sliding fees were included in the task orders for the HCP and MCH programs. However, the items were not:originally included in the combined task order this amendment refers to. The effective date of the amendment is March 1, 2005. I recommend your approval of this amendment to the MCH/HCP task order. Enclosure V\rk`� �Cs�i�CS-C^ I3(1 )L's ctc ) tc _J 2004-3605 DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT PSD-MCH DEPARTMENT OR AGENCY NUMBER FLA CONTRACT ROUTING NUMBER 05-00373 TASK ORDER AMENDMENT#1 This AMENDMENT is made this 20TH day of DECEMBER,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)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'h Avenue,Greeley,Colorado 80631,hereinafter referred to as "the Contractor". WHEREAS,the United State Department of Health and Human Services("HHS"),through the Maternal and Child Health Services Block Grant(MCH)has awarded the State Title V federal funds under Notice of Grant Award("NGA) number B04MC02394-01-00(See,Catalog of Federal Domestic Assistance("CFDA")number 93.994); WHEREAS,the parties thereafter entered into a Task Order(Original Task Order),dated June 11,2004,contract encumbrance number PO FLA MCH0500203,contract routing number 05 FLA 00203,whereby the Contractor was to provide to the State the development and enhancement of community-based systems of care for the maternal and child populations; WHEREAS,pursuant to section 25-1.5-101 6)(I),C.R.S.,as amended,the General Assembly of the state of Colorado has declared that the state"has,in addition to all other powers and duties imposed upon it by law,the powers and duties to disseminate public health information." WHEREAS,pursuant to section 25-1.5-101 (r),C.R.S.,as amended,states that the state can,"operate and maintain a program for children with disabilities to provide and expedite provision of health care services to children who have congenital birth defects or who are the victims of bums or trauma or children who have acquired disabilities". WHEREAS,pursuant to section 25-1-709(10(a),C.R.S.,as amended,ftuther states that"[t]he program and services of regional health departments shall include to the greatest extent possible,but not be limited to personal health services, including: maternal and child health services;program for children with disabilities". WHEREAS,to accomplish its statutory duties,the State determined that public health services are desirable in the Contractor's region and the State and the Contractor mutually agree that the most efficient and effective way to provide the public health services is at the local level. WHEREAS,pursuant to section 29-1-201,C.R.S.as amended,encourages governments to make the most efficient and effective use of their powers and responsibilities by cooperating and contracting with each other to the fullest extent possible to provide any function,service,or facility lawfully authorized to each of the cooperating or contracting entities. WHEREAS,pursuant to section 29-1-201,C.R.S.,as amended,further states that all state of Colorado contracts with its political subdivisions are exempt from the state of Colorado's personnel rules and procurement code. Page 1 of4 WHEREAS,the State desires to add a"no cost"change within the current term of the Original Task Order; 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 FLA MCH0500203,contract routing number 05 FLA 00203,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,which is incorporated herein by this reference,made a part hereof,and attached hereto as"Attachment 1". 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. A new paragraph 16. is added to Part E.of the Original Task Order,"ADDITIONAL PROVISIONS"on Page 10 of 11. This new paragraph 16.reads as follows: 16. Contractor shall comply with all applicable provisions of the Health Insurance Portability and Accountability Act of 1996(HIPAA);a HIPAA Business Associate Memorandum of Understanding,is incorporated herein by this reference,made a part hereof,and attached hereto as"Exhibit A". B. A new paragraph 10 is added to Section A of Attachment A of the Original Task Order,on Page 3 of 6. This new paragraph 10.reads as follows: 10. Submission of Federal Fiscal Year 2005-2006 Detailed Line Item Application Budget. On or before May I,2005,the Contractor shall submit to the State for review and approval three"Application Budget and Final Expenditure Report" forms showing the estimated detailed line item finding allocations for the provision of services to each of the three(3)maternal and child populations,i.e.the perinatal population,the child and adolescent population,and the children with special health care needs population for the federal fiscal year 2005-2006 (October 1, 2005,through September 30,2006)Local MCH Plan. A sample format,which the Contractor shall use,was previously referenced in the Task Order as"Attachment D",on Page 4 of 11,in paragraph D.4. Each population's detailed line item application budget shall be submitted via electronic mail to Sally Merrow-E-mail Address: sallv.merrow(a�state.co.us" Page 2 of 4 • C. A new paragraph 13 is added to Section B of Attachment A of the Original Task Order,on Page 6 of 6. This new paragraph 13.reads as follows: 13. The Contractor agrees that any charges for attendance and services at HCP Specialty Clinics sponsored by the Program must conform to the"Sliding Fee Schedule for HCP Clinics, "Attachment Y"and any subsequent amendments thereto,attached hereto,incorporated herein by this reference,made a part hereof. 4. The effective date of this amendment is March I,2005,or upon approval by 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. Page 3 of 4 IN WITNESS WHEREOF,the parties hereto have executed this Amendment on the day first above written. Contractor: State of Colorado Bill Owens,Governor BOARD OF COUNTY COMMISSIONERS OF WELD COUNTY, (a political subdivision of the state of Colorado) for the use and benefit of the Weld County Department t \ of Public Health and Environment By: ��-p'( ill,\\`�Q By: r (Signature of Individual) Exec a Di ector Robert D. Masden 12/29/2004 DEPARTM NT OF PUBLIC (Name of Individual) HEALTH AND ENVIRONMENT BOCC Chair Date: Position (Title) 84-6000813 de ral Employer ID Number E La Program Approval: ` 1861ft' By: � �.. I , (7,f tafLliMSEAL) Attorney General,Ken Salazar By: By: i\-)1 F} Deputy Clerk to the r 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 WELD COUNTY DEPARTMENT OF Leslie M.Shenefelt PUBL,%C. HEALTH AND NVIRONMEN OY: n, M"'"- Wallace, MD, MPH•Director By. ( -sCk Date: �i ns Page 4 of 4 :ZooV 3665 ATTACHMENT 1 Department or Agency Name COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Department or Agency Number FLA Contract Routing Number 05-00203 TASK ORDER This TASK ORDER is made this 11TH day of JUNE 2004 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) for the use and benefit of the Weld County Department of Public Health and Environment,whose address or principal place of business is 1555 North 17°Avenue, Greeley, Colorado 80631,hereinafter referred to as"the Contractor". FACTUAL RECITALS Pursuant to section 25-1.5-101 (j)(I),C.RS.,as amended,the General Assembly of the state of Colorado has declared that the state"has,in addition to all other powers and duties imposed upon it by law, the powers and duties to disseminate public health information." Section 25-1.5-101 (r), C.RS., as amended, states that the state can, "operate and maintain a program for children with disabilities to provide and expedite provision of health care services to children who have congenital birth defects or who are the victims of bums or trauma or children who have acquired disabilities". Section 25-1-709(10(a),C.RS., as amended, further states that"[tjhe program and services of regional health departments shall include to the greatest extent possible,but not be limited to personal health services,including: maternal and child health services;program for children with disabilities". To accomplish its statutory duties,the State has determined that public health services are desirable in the Contractor's region. The United State Department of Health and Human Services ("HIIS"),through the Maternal and Child Health Services Block Grant(MCH)has awarded the State Title V federal funds under Notice of Grant Award("NGA) number B04MC02394-01-00(See,Catalog of Federal Domestic Assistance("CFDA")number 93.994). The State's Prevention Services Division(PSD)is charged with the administration of funds from the Title V MCH Block Grant to improve the health and well being of the maternal and child/adolescent populations through assessing population needs,influencing health policy, engaging in strategic planning and coordinating/implementing best practices and evidenced-based programs. The authority for the administration of the Title V MCH Block Grant,including the maternal, child and children with special health care needs resides in Title V of the Social Security Act, §§ 501-509. Each state that receives MCH funds from the HHS must demonstrate to the HHS that it has served three(3)distinct population groups with the MCH funds. These three(3)distinct population groups are: "the perinatal population", which is defined to include women of childbearing age,pregnant women, and mothers;the"child and youth population",which is defined to include infants,children,and adolescents from birth through age twenty(20); and, the"children with special health care needs population"(CSHCN),which is defined as those children who have,or are at increased risk for a chronic physical,developmental,behavioral,or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. Page 1 of 11 c Ct) -ai7c' The State has formulated a comprehensive statewide plan to carry out a Maternal and Child Health Program, funded by Title V MCH dollars. As part of the comprehensive plan, it is the express intent of the state to support local public health agencies in contributing to a coordinated, efficient statewide program which focuses on specific MCH performance measures set by the MCH state and Federal agencies. Local public health agencies,working in partnership with other community organizations, facilitate the development and enhancement of community-based systems of care for the maternal,and child population. The goal of these systems is to ensure that all families have access to direct care services, as well as, enabling and population-based services that address the issues and health problems delineated in the MCH performance measures. Section 29-1-201,C.R.S. as amended, encourages governments to make the most efficient and effective use of their powers and responsibilities by cooperating and contracting with each other to the fullest extent possible to provide • any function,service,or facility lawfully authorized to each of cooperating or contracting entities. Section 29-x- 201, C.R.S., as amended,further states that all state of Colorado contracts with its political subdivisions are exempt from the state of Colorado's personnel rules and procurement code. The Contractor is a political subdivision of the state of Colorado. The State and the Contractor mutually agree that the most efficient and effective way to provide the above-described services is at the local level. The State and the Contractor previously entered into a Master Contract with contract routing number 05 FAA 00054. This Task Order is issued pursuant to the terms and conditions of that Master Contract. As to the State, authority exists in the Law and Funds have been budgeted, appropriated, and otherwise made available, and a sufficient uncommitted balance thereof remains available for subsequent encumbering and payment in Fund Number 100,Organizational Unit Code 6520 and 6810, Appropriation Code 581,606,and 611,and Object Code 5120 under Task Order contract encumbrance number PO FLA MCH0500203. All required approvals, clearances, and coordination have been accomplished from and with all appropriate agencies. 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 100,Organizational Unit Code 6810, Appropriation Code 609 and Object Code 5120 under Contract encumbrance number PO FLA HCP05000001 for Traumatic Brain Injury Services. All required approvals,clearances, and coordination have been accomplished from and with all appropriate agencies. NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree as follows: A. PERIOD OF PERFORMANCE AND TASK ORDER TERMINATION. The proposed effective date of this Task Order is October 1,2004. However,in accordance with section 24-30-202(1),C.R.S., as amended,this Task Order is not valid until it has been approved by the State Controller, or an authorized designee thereof. The Contractor is not authorized to, and shall not,commence performance under this Task Order until this Task Order has been approved by the State Controller. The State shall have no financial obligation to the Contractor whatsoever for any work or services or,any costs or expenses, incurred by the Contractor prior to the effective date of this Task Order. If the State Controller approves this Task Order on or before its proposed effective date,then the Contractor shall commence performance under this Task Order on the proposed effective date. If the State Controller approves this Task Order after its proposed effective date,then the Contractor shall only commence performance under this Task Order on that later date. The initial term of this Task Order shall commence on the effective date of this Task Order and continue through and including September 30, 2005,unless sooner terminated by the parties pursuant to the terms and conditions of this Task Order. In accordance with section 24-103-503, C.R.S.,as amended, and Colorado Procurement Rule R-24-103-503, the total term of this Task Order, including any renewals or extensions hereof,may not exceed five(5)years. Page 2 of 11 B. SCOPE OF WORK. 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"Scope of Work",which is incorporated herein by this reference,made a part hereof and attached hereto as"Attachment A". C. COMPENSATION: 1. The Contractor shall be reimbursed for the MCH contract services for the initial term of this Task Order. In consideration of those MCH 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 ONE HUNDRED TWENTY-EIGHT THOUSAND THIRTY-EIGHT DOLLARS. ($128,038.00). The Contractor shall be reimbursed for the HCP contract services in accordance with the budget, which is incorporated herein by this reference,made a part of hereof attached hereto as "Attachment B"for the initial term of this Task Order. In consideration for those HCP services timely and satisfactory performed by the Contractor under this Task Order,the State shall cause to be paid to the Contractor an amount not to exceed ONE HUNDRED EIGHTY-NINE THOUSAND NINE HUNDRED FIFTY-ONE DOLLARS,($189,951.00), for a total MCH and HCP financial obligation of THREE HUNDRED SEVENTEEN THOUSAND NINE HUNDRED EIGHTY-NINE DOLLARS,($317,989.00). Of the total financial obligation,TWO HUNDRED THIRTEEN THOUSAND FIVE HUNDRED SIXTEEN DOLLARS,($213,516.00)are identified as attributable to a funding source of the federal government and,ONE HUNDRED FOUR THOUSAND FOUR HUNDRED SEVENTY-THREE DOLLARS,($104,473.00)are identified as attributable to a funding source of the state of Colorado. 2. In addition to the MCH and HCP budgets referenced in paragraph C. 1. above for the initial tam of this Task Order, the Contractor shall be reimbursed by HCP for traumatic brain injury services for a sum not to exceed Eight Hundred Fifty Dollars($850.00)per child upon receipt of an invoice. Payment pursuant to this Task Order shall be made as earned,in whole or in part, from available Federal and State funds encumbered in an amount not to exceed ONE HUNDRED ELEVEN THOUSAND THREE HUNDRED FIFTY DOLLARS($111,350.00)Statewide for Traumatic Brain Injury services for Federal Fiscal Year 2005(October 1,2004 through and including September 30,2005). Of this total financial obligation,ZERO DOLLARS,($0.00)are identified as attributable to a funding source of the federal government and,ONE HUNDRED ELEVEN THOUSAND THREE HUNDRED FIFTY DOLLARS($111,350.00)are identified as attributable to a funding source of the state of Colorado. The liability of the State,at any time, for such payments shall be limited to the unencumbered remaining balance of such funds. If there is a reduction in the total funds appropriated for the purposes of this Task Order,then the State,in its sole discretion,may proportionately reduce the funding for this Task Order or terminate this Task Order in its entirety. D. PAYMENT MECHANISM. 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". Page 3 of 11 2. To receive compensation under this Task Order,the contractor shall submit a monthly or quarterly Task Order Reimbursement Statement for the HCP services only. A sample Task Order Reimbursement Statement is incorporated herein by this reference,made a part hereof, and attached hereto as"Attachment C". All Task Order Reimbursement Statements: shall reference the related Master Contract by its contract routing number and this Task Order by its contract routing number;both of which numbers appear on the first page of each document;shall be based upon the costs of the work and services performed during the term of this 'Task Order;and,shall be supplemented or accompanied by supporting data and subcontractor invoices,if any covering the work shown on the Task Order Reimbursement Statement. 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. Reimbursement during the initial, and any renewal term of this Task Order shall be considered upon affirmation by the State that all services were rendered by the Contractor in accordance with the terms of this Task Order. Reimbursement statements shall be sent to: Aida Diaz Prevention Services Division Colorado Department of Public Health and Environment PSD-HCP-A4 4300 Cherry Creek Drive South Denver, CO 80246 3. Reimbursement under this Task Order,and any renewal or extension hereof, shall be made to the Contractor on a monthly or quarterly basis. Accordingly, the Contractor shall be paid one twelfth (1/12)of the State's financial obligation under this Task Order each month for the first eleven(II) months or one fourth(1/4)for the first three(3)quarters. 4. The final payment for the twelfth(12th)month or fourth (41h)quarter for the initial term of this Task Order,and any renewal or extension hereof, is contingent upon the State's timely receipt of the a Final Expenditure Report from the Contractor by utilizing the"Application Budget and Final Expenditure Report"form incorporated herein by this reference,made a part hereof, and attached hereto as "Attachment D". The Contractor shall submit a separate Final Expenditure Report on the"Application Budget and Final Expenditure Report"for each of the three populations covered under this Task Order;those populations are prenatal,child/adolescent,and children with special health care needs. The final payment for HCP services for the initial term of this Task Order,and any renewal or extension hereof, is also contingent upon the State's timely receipt of the signed submission of the "Task Order Duties and Obligations Certification Form"incorporated herein by this reference, made a part hereof, and attached hereto as"Attachment E". 5. The State shall reimburse the Contractor for actual indirect costs up to the Prevention Services Division's maximum of twenty-five percent(25%)when the Contractor's indirect rate is based on Direct Costs,twenty-seven percent(27%)when the Contractor's indirect rate is based on Salary Only,or thirty percent(30%)when the Contractor's indirect rate is based on Salary and Fringe where no other direct costs are charged. Page 4 of 11 E. ADDITIONAL PROVISIONS. I. The State is responsible to ensure that the program planning,evaluation,and monitoring requirements as described in this Task Order and the Attachments are met by the Contractor. To fulfill these responsibilities,the State has the right to make site visits and schedule any other meetings at the Contractor's location. 2. Contractor shall cooperate with the State and provide all requested records regarding recipients for whom services were provided under this Task Order. 3. The Contractor shall cooperate with the State to ensure that the program planning, evaluation,and monitoring requirements as described in this Task Order and the Attachments are met This cooperation includes, but is not limited to participation in mutually agreed upon site visits at the • Contractor's location,and any other meetings required by the State. • 4. Contractor shall retain and use all revenues generated by the individual MCH Programs for services in those programs. 5. The State will not accrue any liability for non-payment of care coordination fees by HMO providers or other third party payers. The State will facilitate negotiations with the Contractor during collection efforts,however timely notification by the Contractor to the State and third parties will be essential. 6. Contractor shall assure attendance of at least one local MCH/HCP staff representative to state or regional teleconferences,meetings,and/or videoconference meetings,as negotiated,that the state may organize to address priority MCH/HCP needs,promote learning groups,increase skills as MCH/HCP practitioners and/or carry out state and local MCH planning activities.. 7. Title V, Section 504(b)(6). Title V funds may not be used to pay for any item or service(other than an emergency item or service)furnished by an individual or entity convicted of a criminal offense under the Medicare or any State health care program(i.e., Medicaid, Maternal and Cbild Health, or Social Services Block Grant Programs). Page 5 of 11 8. The Contractor agrees to provide services to all Program participants and employees in a smoke-free environment in accordance with Public Law 103-227,also known as"the Pro-Children Act of 1994",(Act). Public Law 103-227 requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health,day care, early childhood development services, education or library services to children under the age of 18,if the services are funded by Federal programs either directly or through State or local governments,by Federal grant, contract,loan,or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed,operated,or maintained with such Federal funds. The law does not apply to children's services provided in private residences;portions of facilities used for inpatient drug or alcohol treatment;service providers whose sole source of applicable Federal funds is Medicare or Medicaid;or facilities where WIC coupons are redeemed. Failure to comply with the provision of Public Law 103-227 may result in the imposition of a civil monetary penalty of up to$1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. By signing this Task Order,the Contractor certifies that the Contractor will comply with the requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision of services for children as defined by the Act. The Contractor agrees that it will require that the language of the Act be included in any subcontracts which contain provisions for children's services and that all contractors shall sign and agree accordingly. 9. The Contractor certifies,to the best of its knowledge and belief,that no federally appropriated funds have been paid or will be paid by or on behalf of the Contractor,to any person for influencing or attempting to influence an officer or employee of any agency,a Member of Congress,an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of this Task Order, and the extension,continuation,renewal, amendment,or modification of this Task Order,or any grant,loan,or other cooperative agreement that utilizes Federal funds. If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, Member of Congress,an officer or employee of Congress in connection with this Task Order,or any other grant,loan, or other cooperative agreement,then the Contractor shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying" in accordance with its instructions. The Contractor shall require that the language of this certification be included in the award documents for subawards at all tiers(including subcontracts, subgrants,and contracts under grants,loans,and cooperative agreements)and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. This certification is a prerequisite for making or entering into this transaction imposed by section 1352,title 31,U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than$100,000 for each such failure. 10. The Contractor will not charge for services those individuals of families at or below the official poverty guidelines,updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. 9902(2);in accordance with Title V, Section 501 (1)(B)and Section 505 (5)(D). The 100 percent of poverty gross income guideline for farm or non-farm families is currently at$9 310 for a family of 1,$12490 for a family of 2; $15 670 for a family of 3; $18,850 for a family of 4; $22,030 for a family of 5; $25210 for a family of 6; $28390 for a family of 7; and$31,570 for a family of 8. For families of more than eight,add $3 180 for each additional member. (The same increment applies to smaller family sizes also.) Page 6 of 11 If any charges are imposed for services to clients who are above the 100%of poverty level,such charges must be on a sliding scale which takes into account the client's family size, income and resources. These charges and the sliding fee scale must be made available to the general public and to all clients and must be based on the agency's usual and customary cost for the service. Clients must understand they will not be denied services for inability to pay any of the sliding fee charges. 11. The Contractor shall protect the confidentiality of all applicant or recipient records and other materials that are maintained in accordance with this Task Order. Except for purposes directly connected with the administration of this Task Order,no information about or obtained from,any applicant or recipient shall be disclosed in a form identifiable with the applicant or recipient without the prior written consent of the applicant or recipient,or the parent or legal guardian of a minor applicant or recipient with the exception of information protected by Colorado statute as it applies to confidentiality for adolescent services in which case the adolescent minor and not the parent or legal guardian must provide consent or, as otherwise properly ordered by a court of competent jurisdiction. The Contractor shall have written policies governing the access to, and duplication and dissemination of, all such information. The Contractor shall advise its employees, agents,servants,and subcontractors,if any, that they are subject to these confidentiality requirements. 12. Contractor shall ensure that the provisions of Section 601 of Title VI of the Civil Rights Act of 1964 are carried out. That Act states that "no person in the United States shall on the ground of race, color,or national origin, be excluded from participation in,be denied the benefits of,or be subjected to discrimination under any program or activity receiving Federal financial assistance." The Office of Civil Rights has concluded that it is the responsibility of any program which is a recipient of funds from the Department of Health and Human Services to ensure that clients who do not speak or understand English well,be provided interpretation services to ensure that the service provider and the client can communicate effectively. The Contractor shall have policies and procedures to ensure that interpretation services are available for clients with Limited English Proficiency and will advise such clients that an interpreter will be provided for them. If a client has their own interpreter,they shall be advised that the Contractor will provide an interpreter if the client so chooses. 13. The services or activities under this Task Order may be carried out by the Contractor itself,or through subcontracts with other providers or,through collaborative partnerships with other community partners. The State authorizes the Contractor to subcontract some,or all,of the services that are to be performed under this Task Order. However,a subcontractor is subject to all of the terms and conditions of this Task Order. Additionally,the Contractor remains ultimately responsible for the timely and satisfactory completion of all work performed by any subcontractor(s)under this Task Order. If the Contractor desires to subcontract some,or all,of the services that are to be performed under this Task Order,the Contractor shall obtain the prior, express,written consent of the State before entering into any subcontract Page 7 of 11 14. 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; 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; 1. 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 Option to Renew letter process described below, shall be made by a formal amendment to this Task Order executed in accordance with the Fiscal Rules of the State of Colorado. Page 8 of 11 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. 15. The State may renew this Task Order through a"Task Order Option to Renew 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 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,the Task Order Option to Renew Letter shall include the following information: A. Identification of this Task Order by its contract routing number 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. The intended effective date of the renewal;and, E. A provision stating that the Task Order Option to Renew 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 Option to Renew Letter shall become an amendment to this Task Order. Except for the General and Special Provisions of the Master Contract,the Task Order Option to Renew 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 option to renew 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 Option to Renew Letter to the State by the date indicated in the Task Order Option to Renew Letter. If the Contractor does not agree to and accept the proposed renewal term,or fails to timely return the partially executed Task Order Option to Renew Letter by the date indicated in the Task Order Option to Renew 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 Option to Renew 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. Page 9 of 11 F. 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 10 of 11 IN WITNESS WHEREOF,the parties hereto have executed this Task Order as of the day first above written. CONTRACTOR: STATE: BOARD OF COUNTY COMMISSIONERS STATE OF COLORADO OF WELD COUNTY Bill Owens.Governor (a political subdivision of the state of Colorado) for the use and benefit of the Weld County Department of Public Health and Environment By: 11/1_ By: Name: William H. Jerke For the Executive Dir tar Title: BOCC Chair Protem DEPARTMENT OF LIC HEALTH FEIN: 84-6000813 11 2 AND ENVH4ONM��E ju Date: t 8 2004 Date: ci " 9 ue-t � ` =�11'l/vG"" v'! PROGRAM APPROVAL: f 11861 !tr -pap-al O�CS . '- .. '_7,-/ -Z By: " .4 14, ( �� D_.sty C erk to the 6C/n D 1 tPi a6V APPROVALS: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts.This contract is not valid until the State Controller, or such assistant as he may delegate, has signed it.The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below,the State of Colorado may not be obligated to pay for the goods and/or services provided. STATE CONTROLLER: Leslie M. Shenefelt WELD CG; iT\ DEPARTMENT l� _ LIC H At ,�DM E��ONM T By J-±Th BY: / Q�' Date: Cl , 3G' o.5 Mark E. Wallace, MD, MPH-Director Page 11 of 11 3IC Q/ Task Order Attachments A through X For Board of County Commissioners Of Weld County Contract Routing Number 05-FLA-00203 Attachment A Scope of Work Under this Task Order,a local public health agency, such as the Contractor shall provide the core public health services of assessment,policy development,and assurance on behalf of the prenatal population,the child and adolescent population,and the children with special health care needs as described and defined in"Attachment H", "Core Public Health Services Delivered by MCH Agencies",which is incorporated herein by this reference,made a part hereof, and attached hereto. A. Maternal and Child Health The Contractor shall provide leadership, in coordination with public and private community partners,in the development and implementation of a county maternal and child health(MCH)plan. The State shall provide: guidance and technical assistance to the Contractor to support the implementation of its MCH plan for federal fiscal year 2004-2005 and for the development of its MCH Plan for the federal fiscal year 2005- 2006. 1. The plans are to be based on an assessment of the health status needs of the maternal-child populations and of the health system resources of a community. These plans are further designed to: a. Contribute to the accomplishment of the State's priorities,performance measures, and outcome measures, as identified in "Attachment 1", which is incorporated herein by this reference,made a part hereof, and attached hereto; b. Provide for the continuation of the core public health services of assessment,policy development,and assurance on behalf of the maternal-child populations and in implementing the 10 essential services for this population in partnership with (.DPHE, as identified in"Attachment J"",which is incorporated herein by this reference,made a part hereof, and attached hereto; c. Work with public and private community partners to plan for the development and maintenance of resources that assure access to direct care and services for vulnerable women,children, and adolescents,such as those who are low-income,uninsured, underinsured,or who live in rural or underserved areas or who are from ethnic or cultural minority communities and may experience language or cultural barriers to services; d. Facilitate outreach and enrollment efforts,including having information and applications on site,to increase enrollment of eligible children and adolescents,including those with special health care needs,in Medicaid(Colorado Baby Care/Kid's Care Program)or Colorado Child Health Plan Plus+(CCHP); e. Refer families participating in any and all programs in its agency such as WIC,EPSDT, Immunization Clinics, Family Planning, HCP, etc. to appropriate enabling and direct care service programs in the community. All pregnant women in need of resources for prenatal medical care shall be provided with information about programs such as Prenatal Plus, WIC, etc., as needed. The Contractor shall provide all individuals seeking reproductive health services: with information about pregnancy planning,the consequences of unintended pregnancies, and,referrals to comprehensive family planning services; and Page I of 6 f Work with public and private community partners to plan for the development and implementation of population-based approaches for addressing MCH performance measures/priority issues for children and adolescents in the community. 2. Operational Plan Implementation. The Contractor shall implement its"Local Agency Maternal and Child Health Operational Plan"(Operational Plan)for those services and activities which shall be completed in federal fiscal year 2004-2005 (October 1, 2004,through September 30,2005). The Operational Plan previously developed by the Contractor, in consultation with the State,based on an assessment of the health status needs of its maternal-child populations and of the health system resources of its community and shall utilize in full or in part the best-practice templates developed for specific performance measures by CDPHE staff This Operational Plan is incorporated herein by this reference,made a part hereof, and attached hereto as"Attachment K", titled, "Weld County MCH Plan". 3. Submission of the MCH Final Expenditure Report for Federal Fiscal Year 2003-2004: On or before December I, 2004, the Contractor shall submit to the State for review and approval a"Final Expenditure Report"for federal fiscal year 2003-2004(October 1,2003,through September 30, 2004). A sample format has previously referenced in the Task Order as"Attachment D",on Page 4 of II,in paragraph D. 4. The Contractor shall report actual expenditures and the match separately for the perinatal,child health and children with special health care needs programs showing both the funds received from the State via this Task Order and other sources of funding available for match. The agency's Director or Authorized Representative shall sign the final expenditure report prior to submitting it to the State. The final payment for the term of October 1, 2003,through September 30,2004 is contingent upon the State's timely receipt of all three(3) fully completed and signed Final Expenditure Reports,which shall be sent to: Sally Merrow Prevention Sen'ices Division Colorado Department of Public Health and Environment PSD-MCH-A4 4300 Cherry Creek Drive South Denver,CO 80246 4. Submission of Federal Fiscal Year 2003-2004 Actual Budget Allocations. On or before December I, 2004,the Contractor shall submit to the State a"Core Public Health Application and/or Expenditure Report"form showing the Contractor's actual budget allocations for the provision of services to the prenatal population,the child and adolescent population,and the CSHCN • population for the federal fiscal year 2003-2004(October 1,2003,through September 30,2004) Local MCH Plan. A sample format, which the Contractor shall use,is incorporated herein by this reference,made a part hereof, and attached hereto as"Attachment L. 5. Submission of Final MCH Report for Federal Fiscal Year 2003-2004: On or before January 15, 2005,the Contractor shall submit Final MCH Report for the contractor's FY 2003-2004(October 1,2003,through September 30, 2004)activities. Instructions for submitting the Final MCH Report are incorporated herein by this reference,made a part hereof, and attached hereto as "Attachment M". Page 2 of 6 6. Submission of Numbers Served Report for Federal Fiscal Year 2003-2004. On or before January IS,2005,the Contractor shall submit to the State, for review and approval, a completed"Number of Individuals Served(Unduplicated)Under Title V Report",for those services provided by the Contractor in federal fiscal year 2003-2004(October 1,2003,through September 30, 2004). A sample format is incorporated herein by this reference,made a part hereof, and attached hereto as "Attachment N". Submission of 6-Month Progress Report for Federal Fiscal Year 2004-2005: On or before May I, 2005,the Contractor shall submit a 6-Month Progress Report for the first six months(October 1, 2004—March 31, 2005)of the contractor's FY 2004-2005 activities. Instructions for submitting the 6-Month Progress Report are incorporated herein by this reference,made a part hereof, and attached hereto as"Attachment O". • 8. Submission of Local MCH Plan for Federal Fiscal Year 2005-2006: On or before May I, 2005, the Contractor shall submit a "local Maternal and Child Health Plan"(Local MCH Plan)for federal fiscal year 2005-2006(October I, 2005 through September 30,2006). The Local MCH Plan shall consist of two sections, I. Statement of Need, which is an assessment of the health needs of the three(3)maternal and child populations,i.e. the perinatal population, the child and adolescent population and the children with special health care needs population using the Performance Measure Checklist, a sample is incorporated herein by this reference,made a part hereof, and attached hereto as"Attachment P"; and 2. Operational Plan, which is the Contractor's future plan to address the priority needs of these populations. Instructions for submitting the local MCH Plan are incorporated herein by this reference,made a part hereof, and attached hereto as"Attachment Q". The Contractor shall submit the Operational Plan of the Local MCH Plan utilizing a standard table format, which is incorporated herein by this reference, made a part hereof, and attached hereto as, "Attachment R". The Operational Plan shall be made up of one or more state-prepared models that have been provided to the Contractor under separate cover or a combination of state-prepared models and agency-developed objective and activities templates. 9. Submission of Federal Fiscal Year 2005-2006 Estimated Funding Allocations. On or before May 1, 2005, the Contractor shall submit to the State for review and approval a"Core Public Health Application and/or Expenditure Report"form showing the estimated funding allocations for the provision of services to the prenatal population,the child and adolescent population, and the CSHCN population for the federal fiscal year 2005-2006(October 1, 2005,through September 30, 2006) Local MCH Plan. A sample format,which the Contractor shall use, was previously referenced in this Attachment as"Attachment L", on Page2 of 6, in paragraph A. 4 B. Health Care Program for Children with Special Needs(HCP) 1. Contractor shall engage in defined core public health activities designed to enhance the health status of children with special health care needs. The"Suggested Children with Special Health Care Need Activities", attached hereto as"Attachment S",which is incorporated herein by this reference and made a part hereof, and the suggested activities that appear within the HERMAN document,which was provided to the Contractor in March 2004, shall be used,if appropriate, as guidance. These activities shall include direct or enabling services, population-based activities and infrastructure building activities as described in "Attachment H", "Core Public Health Services Delivered by MCH Agencies". Page 3 of 6 2. The Local MCH Plan is designed to:contribute to the accomplishment of the National MCH CSHCN 6 Core Outcomes and Performance Measures,as identified in"Attachment T which is incorporated herein by this reference and made a part hereof 3. Contractor shall perform in accordance with the HCP Performance Measures,located in Section I.A. of the HERMAN Document,which was provided to the Contractor in March 2004. 4. Contractor shall ensure that all IRIS users attend IRIS and security training and meet the"HCP Regional Office Standards for Usage of IRIS II", and any subsequent amendments thereof, attached hereto as"Attachment U",incorporated herein,by this reference,made a part hereof. 5. Contractor shall implement the"IRIS II Security Policy and Procedures",and any subsequent amendments thereof, attached hereto as"Attachment V",incorporated herein by this reference, made a part hereof. 6. On or before December 1,2004,the Contractor shall submit to the State a signed "Duties and Obligations Certification Form",previously referenced as"Attachment E,in paragraph D. 4.,on Page 4 of 11 of this Task Order. The final payment for the Task Order term of October 1,2003 through and including September 30, 2004, is contingent upon the State's timely receipt of the signed submission of the Duties and Obligations Certification Form. 7. On or before January 15, 2005,the Contractor shall submit,to the State Program Consultant Part 1-A of the HERMAN Document,which shall be provided to the Contractor by the State on or before October 1,2004. 8. On or before May 1, 2005 the Contractor shall submit to the State HCP Program Consultant, portions of the HERMAN Document, which shall be provided to the Contractor by the State on or before October 1,2004, as outlined in "HERMAN Document Instructions for HCP Regional Office MCH Plan for FY06", attached hereto, incorporated herein by this reference,made a part hereof as"Attachment W". 9. The Contractor shall serve the population of children and their families who fall within the MCH definition of children with special health care needs(CSHCN): "Children with special health care needs are those who have or are at risk for a chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children generally." (Developed by the Federal Bureau of Maternal Child Health in 1995.) Recipients served shall be children residing or whose families have residence in Weld County. 10. The Weld HCP Regional Office staff shall work cooperatively with the public health nurses (PHNs)from Weld County. Page 4 of 6 11. The HCP Discipline Regional Coordinators funded through this Task Order shall serve the CSHCN who reside or whose families have residence in the counties as defined below: A. The Audiology Regional Coordinator shall serve Weld County. B. The Nutrition Regional Coordinator shall serve Weld County. C. The OT/PT Regional Coordinator shall serve Weld County. D. Speech Regional Coordinator shall save Weld County. E. Parent Consultant shall serve Weld County. F. Vision Regional Coordinator shall serve Weld County. 12. The Weld HCP Regional Office(HCP RO) shall provide care coordination for families who have children with Traumatic Brain Injury (TBI) through the TBI Trust Fund Pilot Project, in accordance with the following process: A. Upon receiving a referral packet of information from the state office, the HCP RO shall "register"the child into IRIS and assign a Care Coordinator. The Care Coordinator shall provide care coordination for up to one(1) year for each child. B. The Care Coordinator shall contact the family to set up an appointment to develop a care coordination plan that is reasonable to accomplish within one(1)year. The Care Coordinator shall develop the care coordination plan by reviewing the needs described on the TBI Trust Fund application, asking the family to describe their priority wants or needs and consulting the HCP RO multi-disciplinary team and/or community providers/agencies. The Care Coordinator shall complete the HCP care coordination plan form, sign the plan, and obtain a signature from the family. C. Upon obtaining a signed care coordination plan,the Care Coordinator shall send an invoice, in the amount of Eieht Hundred Fifty Dollars($850.00)per child,to: Rasa Eglite Prevention Services Division Colorado Department of Public Health and Environment PSD-HCP-A4 4300 Cherry Creek Drive South Denver,CO 80246 D. The Care Coordinator shall implement the care coordination plan. E. The Care Coordinator shall enter demographic information, registration, status, referrals, concerns, and encounters into the IRIS Database to document care coordination plan, activities, and outcomes. F. The Care Coordinator shall have care coordination plans available for Audit purposes. G. The Care Coordinator shall provide the state family satisfaction survey to the families that received care coordination at the end of the one-year period and encourage them to respond. Page 5 of 6 H. The Regional Office multi-disciplinary team shall provide technical assistance to the Care Coordinator,as needed. The HCP RO and Care Coordinator shall use the"HCP Policy and Procedures for Care Coordination Services for Children and Youth with Traumatic Brain Injury", incorporated herein,by this reference, attached hereto as"Attachment X", for documentation of services on the IRIS database and maintaining client records. J. The Contractor, HCP RO, and Care Coordinator shall comply with any and all local agency HIPAA regulations;take all appropriate steps to maintain client confidentiality, and obtain any necessary written permissions or agreements for data analysis or disclosure of protected health information, in accordance with the Health Insurance Portability and Accountability Act of 1996(HIPAA)regulations,including,but not limited to, authorizations,data use agreements,business associate agreements,as necessary. Failure to comply with any applicable provision of HIPAA shall constitute a breach of this Task Order. Page 6 of 6 Attachment B APPLICANT: Weld County Department of Public Health and Environment PROJECT: Health Care Program for Children with Special Needs (HCP) FOR THE PERIOD: OCTOBER 1, 2003 through SEPTEMBER 30, 2004 Funded by CDPHE > Cr P 17,''l*1 r, -:.ty Regional Office: (1/12 payable monthly October through August, September's payment contingent upon receipt of Final Expenditure Report and Duties and Obligations Certification Fom) 167,901 Sub-total HCP Regional Office: 167,901 HCP Regional Coordinators: (line item billing) Regional Coordinator Training and Travel 2,500 Parent Consultant 10,000 Audiology 2,000 Travel for Colo. Academy of Audiology meeting 250 Occupational or Physical Therapy 2,500 Nutrition 2,300 Vision 1,000 Speech 1,500 Sub-total Regional Coordinators 22,050 Total HCP Weld County Regional Office 189,951 Page 1 of I INVOICE NUMBER ATTACHMENT C REIMBURSEMENT STATEMENT TO: Aida Diaz FROM: Colorado Department of Public Health and Environment Health Care Program for Children with Special Needs (HCP) 4300 Cherry Creek Drive South, PSD- HCP-A4 Denver, Colorado 80246-1530 FAX: ( 303 ) 782-5576 DATE OF EXPENDITURE: TYPE OF FROM: Final PROGRAM: Bill? FEDERAL ID TO: Yes NUMBER: O No Reimbursement Description of Expenditure Local Agency Match Amount Requested Total 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: Contractor N.tut.d of Reimbursement Amount Change? 0 Yes 0 No Initial: Attachment D APPLICATION BUDGET AND FINAL EXPENDITURE REPORT CONTRACTOR: Please submit a separate form for each population group listed below and indicate which group this form is being submitted for: CHILD/ADOLESCENT POPULATION PRENATAL POPULATION CHILDREN WITH SPECIAL HEALTH CARE NEEDS POPULATION FINAL EXPENDITURE REPORT DUE DATE: December 1,2004(For The Period Of:October 1,2003 through September 30,2004) APPLICATION BUDGET DUE DATE: May 1,2005(For The Period Of:October 1,2005 through September 30,2006) Annual Full Total SOURCE OF FUNDS Salary Time Amount Received — Rate Equivalent Required OTHER' from CDPHE PERSONAL SERVICES: Contractual/Fee for Service Supervising Personnel Fringe P.cents: Rale= TOTAL PERSONAL SERVICES $ $ S OPERATING EXPENSES(whicb are not pad of indirect): TOTAL OPERATING EXPENSES $ $ 4 TRAVEL EXPENSES(In-state/Out-state) TOTAL TRAVEL EXPENSES 1 S S Contractual TOTAL CONTRACTUAL EXPENSES $ $ $ Total Direct Costs(Personal Servlces+Operating+Travel+contactual) 4 1 S ADMINISTRATIVEANDIRECT COST TOTAL ADMINISTRATIVEJINDIRECT COSTS $ $ $ TOTAL PROJECT COST $ $ $ 'Source of funding for"Other"(Match or In-kind)Is.Maternal and Child Health Programs Local/County Funding S Medicaid(will not be used to match) Patient Fees S Other(List): 4 $ 3 TOTAL $ May the NON FEDERAL funds be used as match? YES NO • Signature of Authorized Representative Date Page 1 of I Attachment E COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS(HCP) DUTIES AND OBLIGATIONS CERTIFICATION FORM DUE DATE: December 1,2004 TO: Aida Din Colorado Department of Public Health and Environment Health Care Program for Children with Special Needs (HCP) 4300 Cherry Creek Drive South PSD-HCP-A4 Denver, Colorado 80246-1530 Telephone: (303)692-2370;FAX#:(303)781-5576 FROM: TYPE OF PROGRAM: FEDERAL ID NUMBER: This is to certify that the"Duties and Obligations of the Contractor"have been performed per Contract Routing Number for the period of October I,2003 through September 30,2004. SIGNATURES: Contractor or Authorized Designee Date HCP Regional Office Team Leader Date This section is to be completed at the HCP State Once I hereby certify that all requirements have been met and final payment of$ for the services during the period of October 1,2003 through September 30,2004 is authorized SIGNATURES: HCP Program Consultant Date HCP Program Director or Authorized Designee Date l vf2YmW[PK'LNY MACE mPOMD con tk:TAXtACJ IROI I-DODi9 aOBLIGATIONS flit,IXOC [Date] Sample Task Order Change Order Letter Attachment F State Fiscal Year****-**** Task Order Change Order Letter Number Contract Routing Number** *** ***** Program This Task Order Change Order Letter is between the Colorado Department of Public Health and Environment and the Legal Name of the Contractor. This Task Order Change Order Letter is issued in accordance with paragraph F.3.of the Master Contract with contract routing number ** *** *****and,paragraph C3.of the Task Order with contract routing number ********** and contract encumbrance number** *** **********. That Task Order has been amended by Task Order Change Order Letter**.contract routing number** ********. (Strike or modify as appropriate) The Task Order,as amended is hereinafter referred to as the"Original Task Order".The Original Task Order is incorporated herein by this reference,made a part hereof,and attached hereto as "Attachment*"The parties hereto agree that for the term from ******** **, **** through********* ** **** the maximum amount payable by the State for the work referenced in part B.of the Original Task Order is • increased/decreased by*Dollars,(S*.**)for an amended total financial obligation of the State to the Contractor of *Dollars, (*.**). The revised Scope of Work and the revised Budget are incorporated herein by this reference, made a part hereof and attached hereto as`Attachment 1"and"Attachment 2",respectively. The first sentence in paragraph C.1,of the Original Task Order is hereby modified accordingly. All other terms and conditions of the Original Task Order are hereby reaffirmed. The proposed effective date of this Task Order Change Order Letter is ********* ** ****. However, in accordance with section 24-30-202(1),C.RS.,as amended,the effective date of this Task Order Letter is the date it is approved by the State Controller. In no event shall this Task Order Change Order Letter be deemed valid until it shall have been approved by the State Controller or such assistants as he may designate. 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,Denver,Colorado 80246,Mail Code:*****-**.One Original of this Task Order 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 SAMPLE ONLY By. SAMPLE ONLY Name: For the Executive Director Title: DEPARTMENT OF PUBLIC HEALTH FEIN; AND ENVIRONMENT APPROVALS: FOR THE STATE CONTROLLER: PROGRAM State Controller Leslie M.Shenefelt By SAMPLE ONLY By SAMPLE ONLY Page 1 of 1 [Date] Sample Task Order Renewal Letter Attachment G State Fiscal Year****-****, Task Order Renewal Letter Number *, Contract Routing Number** *** ***** **********program This Task Order Renewal Letter is between the Colorado Department of Public Health and Environment and the Legal Name of the Contractor. This Task Order Renewal Letter is issued in accordance with paragraph F4.of the Master Contract with contract routing number" *** ***** and,paragraph C.3, of the Task Order with contract routing number** *** ***** and contract encumbrance number** *** *****. That Task Order has been amended by Task Order routing number** ********. (Strike or modify as appropriate.) The Task Order, as amended,is hereinafter referred to as the"Original Task Order_ The Original Task Order is incorporated herein by this reference,made a part hereof, and attached hereto as"Attachment*". The Parties hereto agree that the Original • Task Order is renewed for the tam from"*"""*s *r** through ********* ** ****. The maximum amount payable by the State for the continued performance of the work referenced in Part B.of the Original Task Order for this renewed term is Dollars,(S`.").The amended total financial obligation of the State to the Contractor is DOLLARS, (S*.**). The Budget for the renewed term is incorporated herein by this reference,made a part hereof and attached hereto as"Attachment 1". The first sentence in paragraph Ca,of the Original Task Order is hereby modified accordingly. All other terms and conditions of the Original Task Order are hereby reaffirmed The proposed effective date of this Task Order Renewal Letter is********* *• **** However,in accordance with section 24-30-202(1),C.RS.,as amended,the effective date of this Task Order Renewal Letter is the date it is approved by the State Controller.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 "originals of this Task Order 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 Task Order 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. SAMPLE ONLY By. SAMPLE ONLY Name: For the Executive Director Title: DEPARTMENT OF PUBLIC HEALTH FEIN: APPROVALS: FOR THE STATE CONTROLLER PROGRAM: State Controller Leslie M. Shenefelt By. SAMPLE ONLY By. SAMPLE ONLY Page 1 of 1 Attachment H CORE PUBLIC HEALTH SERVICES DELIVERED BY MCH AGENCIES DIRECT HEALTH CARE SERVICES: (GAP FILLING) Examples: Basic Health Services, and Health Services for CSHCN ENABLING SERVICES: Examples: Transportation,Translation,Outreach, Respite Care,Health Education,Family Support Services,Purchase of Health Insurance, Case Management,Coordination with Medicaid, WIC,and Education POPULATION-BASED SERVICES: Examples: Newborn Screening,Lead Screening,Immunization, Sudden Infant Death Syndrome Counseling,Oral Health, Injury Prevention,Nutrition and Outreach/Public Education INFRASTRUCTURE BUILDING SERVICES: Examples: Needs Assessment,Evaluation,Planning,Policy Development, Coordination,Quality Assurance,Standards Development,Monitoring, Training,Applied Research,Systems of Care,and Information Systems MCI1"-?9 8 10/20/91 Page 1 oft DEFINITIONS OF THE FOUR TYPES OF SERVICES BY WHICH THE CORE PUBLIC HEALTH SERVICES ARE PROVIDED BY MATERNAL AND CHILD HEALTH PROGRAMS AS DEFINED BY THE MATERNAL AND CHILD HEALTH BUREAU As of October 1,2003 1. Direct Health Care Services Direct health care services are defined as basic health services. Such services are generally delivered"one on one"between a health professional and a patient in an office,clinic or emergency room. Basic services include what most consider to be ordinary medical care,inpatient and outpatient medical services,allied health services,drugs,laboratory testing,x-ray services,dental care,and pharmaceutical products and services. State Title V programs may support services such as prenatal care,child health,school health and family planning by directly operating programs or by funding local providers. Direct health care services also include health care services for children with special needs. 2. Enabling Services Enabling services are defined as services that allow or provide for access to and the derivation of benefits from the array of basic health care services. Enabling services include transportation,translation,outreach,respite care,health education,family support services,purchase of health insurance,case management,and ' coordination of care. These kinds of services are especially necessary for the low-income population which is disadvantaged,geographically or culturally isolated,and for those with special and complicated health needs. 3. Population-Based Services Population-based services are defined as services which are intended and available for the entire population, rather than for a selected group of individuals. Disease,prevention,health promotion and statewide outreach come under this heading. Oral health,injury prevention,nutrition and outreach and public education are topics which also belong in this category. Population-based services are generally available for women and children regardless of whether they receive care in the public or private sector or whether or not they have health insurance. 4 Infrastructure Building Services Infrastructure building services are defined as those services that are directed at improving and maintaining the health status of a population. Included among those services are development and maintenance of health systems,standards,and guidelines,training,data,and planning. Needs assessment,evaluation,policy development,quality assurance,information systems,and applied research are all contained within the - infrastructure umbrella. I:Vegg6CONIRACISWY 05'MCH-Ha,Combined ContraR,Atbdammt H-Page 2-RYnmid Dcfkcw doc Page 2 of 2 Attachment I MATERNAL AND CHILD HEALTH(MCH) PRIORITIES,PERFORMANCE MEASURES,AND OUTCOME MEASURES As of October 1,2003 Colorado bMCH Priorities 1. Reduce teen pregnancy and unintended pregnancy in women of all ages 2. Improve perinatal outcomes 3. Reduce child and adolescent morbidity and increase health and safety in child care settings 4. Reduce overweight among children and adolescents,addressing physical activity and nutritional habits 5. Improve efforts to reduce unintentional and intentional injury,addressing motor vehicle crashes,suicide,child abuse and other violence 6. Improve immunization rates for all children 7. Increase access to health care(including behavioral health care) 8. Improve state and local infrastructure by increasing capacity to analyze data,carry out evaluations,develop quality standards,and assure availability of services to all children,including children with special health care needs 9. Reduc,substance abuse(alcohol,tobacco,and drugs) 10. Improve oral health and access to oral health care National Performance Measures 1. The percent of infants who are screened for conditions mandated by their State-sponsored newborn screening programs(e.g.phenylketonuria and hemoglobinopathies)and receive appropriate follow-up and referral as defined by their state 2. The percent of children with special health care needs age 0 to 18 years whose families partner in decision making at all levels and are satisfied with the services they receive 3. The percent of children with special health care needs age 0 to18 who receive coordinated,ongoing comprehensive care within a medical home 4. The percent of children with special health care needs age 0 to 18 whose families have adequate private and/or public insurance to pay for the services they need 5. The percent of children with special health care needs age 0 to 18 whose families report the community-based service systems are organized so they can use them easily 6. The percent of youth with special health care needs who received the services necessary to make a transition to all aspects of adult life Page 1 of3 7. The percent of children of 19 to 35 month olds who have received full schedule of age appropriate immunizations against Measles,Mumps,Rubella,Polio,Diphtheria,Tetanus,Pertussis,Hemophilus Influenza,and Hepatitis B 8. The rate of birth(per 1,000)for teenagers aged 15 through 17 years 9. Percent of third grade children who have received protective sealants on at least one permanent molar tooth 10. The rate of deaths to children aged 14 and younger caused by motor vehicle crashes per 100,000 children 11. Percentage of mothers who breast feed their infants at hospital discharge 12. Percentage of newborns who have been screened for hearing impairment before hospital discharge 13. Percent of children without health insurance 14. Percent of potentially Medicaid-eligible children who have received a service paid by the Medicaid program 15. The percent of very low birth weight infants among all live births 16. The rate(per 100,000)of suicide deaths among youths 15 through 19 17. Percent of very low birth weight infants delivered at facilities for high-risk deliveries and neonates 18. Percent of infants born to pregnant women receiving prenatal care beginning in the first trimester State Performance Measures 1. The proportion of high school students reporting having drunk alcohol in the past month 2. The proportion of all pregnancies that are unintended 3. The incidence of maltreatment of children younger than 18(including physical abuse,sexual abuse,emotional abuse,and/or neglect) 4. The proportion of high school students reporting regular use of tobacco products 5. The proportion of children and adolescents attending public schools who have access to research-based health education and to basic preventive and primary,physical and behavioral health services through school-based health centers 6. The percent of Medicaid-eligible children who receive dental services as part of their comprehensive services 7. The rate of homicides among teens 15-19 • 8. The proportion of WIC children who are overweight 9. The percent of women with inadequate weight gain during pregnancy 10. The rate of injury hospitalization among children 19 and younger Page 2 of 3 Nationally Chosen Outcome Measures 1. The infant mortality rate per 1,000 live births 2. The ratio of the black infant mortality rate to the white infant mortality rate 3. The aece,,a1 mortality rate per 1,000 live births , 'She pc). _•onatal mortalityrate per 1,000 live births 5. The perinatal mortality rate per 1,000 live births State Chosen Outcome Measure 1. The low birth weight rate per 1,000 live births Revised July 15,2003 JIPeggyV_ONIRACIS'WY ON dH.HCP Combined Cont acMtbcbmcal I-MCH Pie and Performance Measure,03-04.doc • • Page 3 of 3 Attachment d TEN ESSENTIAL PUBLIC HEALTH SERVICES TO PROMOTE MATERNAL AND CHILD HEALTH I. Assess and monitor maternal and child health status to identify and address problems. 2. Diagnose and investigate health problems and health hazards affecting women,children,and youth. 3. Inform and educate the public and families about maternal and child health issues. 4. Mobilize community partnerships between policymakers,health care providers,families,the general public,and others to identify and solve maternal and child health problems. 5. Provide leadership for priority-setting,planning,and policy development to support community efforts to assure the health of women,children,youth and their families. 6. Promote and enforce legal requirements that protect the health and safety of women,children,and youth,and ensure public accountability for their well-being. 7. Link women,children,and youth to health and other community and family services,and assure access to comprehensive,quality systems of care. 8. Assure the capacity and competency of the public health and personal health workforce to effectively address maternal and child health needs. 9. Evaluate the effectiveness,accessibility,and quality of personal health and population-based maternal and child health services. 10. Support research and demonstrations to gain new insights and innovative solutions to maternal and child health- related problems. 7\PegeCtUThACTSWy OSMCH-HCP Cmbined Cadmd Atisc nia,t 1-10 Bssadiel PH Services doc(a.-04/10/09) Page l of l Attachment K Weld County MCH Plan October 1, 2004 — September 30, 2005 0 DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT 1555 N. 17th Avenue Greeley, CO 80631 WEBSITE: www.co.weld.co.us ' ADMINISTRATION: (970) 304-6410 C FAX: (970) 304-6412 O PUBLIC HEALTH EDUCATION & NURSING: (970) 304-6420 FAX: (970) 304-6416 • ENVIRONMENTAL HEALTH SERVICES: (970) 304-6415 COLORADO FAX: (970) 304-6411 Weld County Department of Public Health and Environment MCH Plan for FY 2004-2005 Contact: Linda Henry R.N., B.S.N., M.A. Director of Public Health Education and Nursing Telephone: (970) 304-6420 ext. 2304 Email: (henry@co.weld.co.us PERFORMANCE MEASURE CHECKLIST-PART I CSHCN MEASURES-MARCH 2004 • WELD COUNTY Priority Need ; w n U Explanation or Description U i :? a.'$ V R ° U o .. .2 a I e e.. u a ° °. — ,_ . Checked Boxes cn 0 f air'. a0 = Q m a o Z ° o `° m < f 0 v) Z U C CSHCN Goal 1: Families MCH Indicator of CSHCN Family Partici- of CSHCN will partner in pation Level was 18/18 in the data set released decision-making at all in March 2004,up from 1/18 in the 2003 data levels and will be satisfied set. with the services they Have established a parent support group for receive X X 4 Spanish-speaking families. Large parent response for the Weld County NPM 2:Percent of families Respite Project with the formation of a Parent of children with special Advisory Group which is currently meeting needs who participate in N/A 57.4 55.0 N/A monthly. decision-making and are satisfied with services Education of HCP team done. Will finish CSHCN Goal 2: All presentation and evaluation tool by end of children with special needs FY 2004. will receive regular, Not much publicity,activity of medical ongoing comprehensive initiative project in Weld County to date. care within a medical home NPM 3: Percent of children N/A 51.7 50.0 N/A X 3 with special needs with a medical home Number of children without insurance has CSHCN Goal 3: All increased by 278%from FY 2003 to the first families of children with half of FY 2004. special health care needs Circumstances resulting in increase are (CSHCN) will have beyond control of those in HCP program, i.e. adequate private and/or T caseload, inability to hire additional staff public insurance to pay for to handle caseload d/t financial constraints, the services they need capping of enrollment in CHP+, Weld Bowl- a-thon not being held this year. Other NPM 4: Percent of children agencies must deal with these issues. with special needs with N/A 58.2 55.0 N/A X X X adequate insurance 6 Will continue to assist HCP families as able. PERFORMANCE MEASURE CHECKLIST-PART I CSHCN MEASURES-MARCH 2004 WELD COUNTY Q u a C Priority Need 9 c a c a `o V o C m •a W U o Explanation or Description to H N is L e u. :° i .°.: y ' °' eo 2 .� m u v c & $ For u 'z `" �" w S V �° — U N 21/23 !A d m ti e eZ a ° � — Checked Boxes Cl) Z OIL � O C.A. © et 4 c ti W U a Q Z Z u CSHCN Goal 4: All Hearing screening meets or exceeds the state children will be screened goal. early and continuously for special health care needs Regional Vision Coordinator hired on 4-16-04. NPM 1: Percent of infants receiving newborn Responsibility for Newborn Hearing screening N/A 98.0 98.0 All X X X Screening Program referrals follow-up recently transferred to HCP Regional Office. NPM 12: Percent of newborns receiving 5 newborn hearing screening 96.8 96.2 95.0 N/A X X X before discharge CSHCN Goal 5: No progress has been made on the MOU Community based service with Family Connects(Part C), systems for CSHCN and Collaboration between the two agencies is their families will be minimal. organized for easy use NPM 5: Percent of families of children with special needs reporting service 1 systems organized for easy N/A 77.4 75.0 N/A X use CSHCN Goal 6: All youth This goal has not been well addressed during with special health care the first half of FY 2004. The HCP team needs will receive services believes it is a priority and has elevated its to transition to adult life importance for FY 2005. NPM 6: Percent of children with special needs who received services to 2 transition to adult life N/A 5.8 6.0 N/A X • PERFORMANCE MEASURE CHECKLIST-PART II MCH MEASURES-MARCH 2004 WELD COUNTY p Priority Need c • u u m C t c o ' : ' U o A o :k A Explanation or Description 0 u y u ON. U Cy 01, c t C u .2 - e `- e ` For U - S '- V c .c .11 ;5 s d `n 2 cog.g. v it Checked Boxes vi Z .7Fi O4, 0 ,t 9 c h w ' a a z zU ADOLESCENT HEALTH MEASURES Yes yes Title X and state family planning funds NPM 8: Teen(ages 15 Sexual Abstinence program funded by through 17)birth rate 43.2 26.8 28.0 43.0 Title V and County dollars. Yes Yes The Weld County Department of Public NPM 16: Rate of suicide Health and Environment participates on the deaths among youths age Weld County Suicide Education and Support 15.19 14.8 13.0 12.0 5,0 Services Board.There are several sources of funds for projects addressing youth suicide. yes Yes WCDPHE participates and supports Weld Old SPM 5: Rate of motor County Drive Smart and the P.A.R.T.Y vehicles deaths,ages 15-19 39.3 27.3 19.1 9.2 program that provides education to youth on risky behavior associated with driving.• Yes No WCDPHE has a STEPP grant that addresses SPM 4(Old SPM 6):The prevention of tobacco use in youth. percent of high school students using tobacco N/A 34.4 26.3 21.0 regularly No No nf This indicator should be addressed by all SPM 1: The percent of high communities in Colorado. school students who report drinking in previous month N/A 50.9 48.0 11.0 No No nf This indicator should be addressed by SPM 7 (Old SPM 10)Rate communities in Colorado. of homicide among teens ages 15-19 4.9 8.0 5.0 3.0 PERFORMANCE MEASURE CHECKLIST-PART II MCH MEASURES-MARCH 2004 WELD COUNTY c • Priority Need 4- cc v' is � 'I- 5 t g d N c a -in c c Explanation or c � v a V - r= . = d ° V V u " e o 0 • U y - U 9 - t c .a e .. ` o c.c. 8 I r. Checked Boxes cn z j f O a. a O a w 9 o z y 4, U a Z z CHILD HEALTH MEASURES yes yes no Preventive Block Grant Immunization grant to WCDPHE NPM 7: Percent of children Local funds through age two with Mobile Medical Unit completed immunizations N/A 75.4 90.0 90.0 Weld County Immunization Coalition I yes Yes Sunrise Community Health provides WIC SPM 8(Old SPM 12): services for WCDPHE clients. Percent of children on WIC who are overweight 22.2 8.7 8.5 5.0 Np yes Yes United Way of Weld County has a Child SPM 3: The incidence of Abuse Community Coalition and several maltreatment of children Agencies that provide services to families. less than IS (physical, sexual or emotional abuse and/or neglect) 6.0 7.4 5.8 10.3 yes yes Drive smart of Weld County SPM 10: Rate of injury hospitalization among children less than 19 years 260.6 321.5 251.0 N/A Np yes Drive Smart Weld County coalition works NPM 10: Rate of death for on reduction of all MV deaths in the County. 0-14 year olds due to motor vehicle crashes 6.6 4.9 3.0 9.2 yes yes Drive smart of Weld County National Outcome Measure Catholic Charities of Weld County 6: Child Death Rate(ages 1- 14) 24.2 21.7 20.3 N/A PERFORMANCE MEASURE CHECKLIST-PART II MCH MEASURES-MARCH 2004 • WELD COUNTY Priority Need 9 c u a G e U A c A m Explanation or Description m m .E . o u v a j s .E p d ` v ,V ` V c t w For U '� � x V - z a s c w t Z a - Checked Boxes Z O � � JOt- OQ v e ae in -t Z yes The North Colorado Health Alliance is SPM 5:The percent of developing a planning grant to implement a children in public schools School Based Health Clinic for 2 district 6 with access to health elementary schools. education and to care through school based health 0.0 7.6 ' 8.75 N/A centers yes yes There are 3 SED(Satellite eligibility sites) NPM 13: Percent of sites in Weld County. WCDPHE, Sunrise, children without insurance N/A 12.9 15.0 0.0 and Salud yes WCDPHE manages EPSDT services to NPM 14: Percent of insure children's access to Medicaid eligible Medicaid-eligible children benefits. receiving a Medicaid-paid service N/A 84.7 93.0 N/A INFANT HEALTH MEASURES yes yes WCDPHE, Sunrise Community Health, NPM 15:Percent of Very First Steps of Weld County use services of Low Birth Weight live Prenatal Plus Case management. Medicaid births 1.2 1.3 1.0 0.9 reimbursement and community funds are used toa support these activities. yes yes Same as above NPM 17: Percent of very low birth weight infants delivered at Level III hospitals 70.6 71.0 75.0 90.0 Yes Yes Same as above State Outcome Measure 1: Low Birth Weight Rate 7.5 8.7 7.5 5,0 PERFORMANCE MEASURE CHECKLIST-PART II MCH MEASURES-MARCH 2004 WELD COUNTY Priority Need 8 e Ts `o_ Explanation or Description • i°27 m O d " L d Q.. O o`• m C 40 OE y C tr N C G y V For (5 t iu is V V c .° . 5 s e : :+ a ° a Checked Bores z a " $ o z z E a z z" Yes yes Nurse family partnership at WCDPHE National Outcome Measure United Way of Weld County 1: Infant mortality rate 6.4 6.2 5.7 4.5 Yes yes Same as above National Outcome Measure 3: Neonatal Mortality rate 4.2 4.2 3.9 2.9 np National Outcome Measure 2: Black/White infant mortality ratio N/A 2.9 1.9 N/A Yes Yes NFP at WCDPHE National Outcome Measure Weld County United Way 4: Post neonatal Mortality rate 2.3 2.0 1.8 1.2 ORAL HEALTH MEASURES Yes Sunrise Community Health Dental Clinic • I"New Oral Health Dental Clinic Measure: Percent with EPSDT recruits dentists and refers clients to caries experience 61.3 61.6 N/A 42.0 dentists accepting Medicaid. Yes Same as above NPM 9: Percent of third • Could have sealants done on mobile health graders with protective unit. sealants 28.5 29.3 35.0 50.0 PERFORMANCE MEASURE CHECKLIST-PART II MCH MEASURES-MARCH 2004 WELD COUNTY . u 0 is C C Priority Need 9 0 yc c °o Explanation or Description o ccu w u a a C" cc= c cn to .` d = 7 `o o : For V G " 'r' V S. _ c t c s i el e Z a . - Checked Boxes Q 4 Z H Z V Yes Sunrise Community Health 2n°New Oral Health Measure: Percent with 26.2 26.3 N/A 21.0 untreated decay Yes Yes EPSDT at WCDPHE and Sunrise SPM 6(Old SPM 8): Community Health Percent of Medicaid- eligible children receiving dental care 19.5 28.3 27.0 57.0 PERINATAL HEALTH MEASURES yes WCDPHE Family Planning SPM 2:The percent of Weld County Abstinence education births that are unintended NFP 41.8 39.2 36,0 30.0 PN+ yes yes yes United Way of Weld County NPM 18: Percent of infants "Promises of Weld County" whose mothers received North Colorado Health Alliance first trimester prenatal care 73.8 79.1 85.0 90.0 Np Yes Yes Yes Prenatal+at WCDPHE and First Steps of SPM 9(Old SPM 13: Weld County women with inadequate • weight gain during pregnancy 21.4 23.5 20.0 N/A Yes North Colorado Medical Center host a NPM 11: Percent of Breastfeeding clinic. mothers breastfeeding at hospital discharge 85.5 83.5 87.0 75.0 PERFORMANCE MEASURE CHECKLIST-PART II MCH MEASURES-MARCH 2004 WELD COUNTY ` ` c Priority Need c a c « h V e, Z O0 ; gal Explanation or Description 0 L y V w r4 o °' co c ooL c h. .2 •VI N i e For U "' z L' 2 w' 5 O w' O °0 w eZ I! V Checked Boxes O � a O z Yes Yes Promises for Children National Outcome Measure Sunrise Community Health 5: Perinatal Mortality rate 9.8 10.1 8.0 4.5 MCH Performance Indicator (NPM 18): The percentage of infants born to pregnant women receiving prenatal care beginning in the first trimester. Contact Person: Debb e Kasyon, Women's Health Section, deborah.kasyonAstate.co.us or(303)692-2497. Goal 1: Increase first trimester enrollment into prenatal care. Objective 1 (Long-term) Outcome Evaluation Outcome/Progress Increase the first trimester enrollment from a baseline of 73.8% First trimester enrollment rate in Weld County as in FY2002 to 77% by 2008 in Weld County. measured by birth certificate data. Activity Process Evaluation 1.1 Analyze first trimester enrollment data—Cohid, vital statistics Data analyzed and high-risk groups identified. —to determine the groups of women at highest risk for not accessing prenatal care in Weld County. Short-Term Objective #1: Maintain Provider Capacity Outcome Evaluation Outcome/Progress By September 30, 2005, maintain the number of clients served The number of appointments available for and number of appointments available with prenatal care Medicaid/uninsured clients. providers through Sunrise Community Health Center for Medicaid and uninsured clients. Number of clients: Number of appointments: Activity Process Evaluation 1.1 Provide infrastructure support to Sunrise Community Health 1.1 Infrastructure support provided and capacity Center to maintain their capacity to provide prenatal care to maintained. Medicaid and uninsured low-income women. 1.2 Meet with Sunrise Community Health Center to monitor 1.2. Meetings held. capacity to admit prenatal patients. 1.3. Refer pregnant clients who access Weld County Department 1.3. Pregnant clients referred to Sunrise Community of Public Health and Environment's (WCDPHE) services to Health Clinic. Sunrise Community Health Clinic. 1.4 Maintain first trimester enrollment community outreach 1.4 Community outreach campaign maintained: campaign. 1.5 Maintain involvement with the Promises Coalition of Weld 1.5 Involvement with Promises Coalition County. maintained. C\MCH\mch04-0S\Weld\WELD FY04-OS MCH TEMPLATE-PN CARE 1ST TRIMESTER REVISED.doc 9/2/2004 Immunizations Goal: Achieve and maintain effective vaccination coverage levels for universally recommended vaccines among children Immunization Rates (HP 2010) Sample long-term objective: Outcome Evaluation: Outcome/Progress: By September 2010, increase to 90% the proportion of young children 19-35 Data source not available at this time months in Weld County who receive all vaccines that have been recommended Utilize future state/county data for universal administration. sources when available Sample short-term objective: By September 30,2006, 85%of immunization providers in Weld County will County-wide assessment of utilize and demonstrate compliance with the recommended strategies to immunization providers utilization of improve immunization coverage from the Revised Standards for Child and strategies to improve vaccination Adolescent Immunization Practices developed by the National Vaccine coverage from the Revised Advisory Committee(NVAC) and published by the National Immunization Standards for Child and Adolescent Program(NIP) Immunization Practices developed by the National Vaccine Advisory Committee(NVAC)and published by the National Immunization Program(NIP)completed as both a pre and post measure Sample short-term objective: By September 30,2005, the Weld County Department of Public Health and Environment will collect baseline information regarding childhood vaccination Immunization data compiled and rates in Weld County, and identify barriers to obtaining immunizations from barriers identified, including the the agency clinics,community health centers, schools when appropriate and immunization rate for 19-35 month private providers in the community olds in Weld County. Activities Process Evaluation Outcome/Progress 1.1 Assessment of current community provider activities and planning • Assess which agencies/coalitions are addressing child and adolescent Document assessment activities. immunizations • Assess which providers are providing vaccinations Community stakeholder group has • Conduct meetings with stakeholders/coalition(physicians, midlevel met, membership is documented, and providers,school nurses, childcare centers, faith based settings) a plan of action with defined roles for • Use/adapt existing CDPHE assessment tool to gather information each member is completed from health care clinics, schools, day care providers to establish a Identify/implement assessment tool, baseline for immunization rates and also identify perceived barriers to gather and compile data to document I:\MCH\mch04\Weld\WELD FY04.05 MCH TEMPLATE-IMMUNIZATIONS.DOC Immunizations getting immunizations immunization rates and perceived barriers to getting immunizations 1.2 Make available the Revised Standards for Child and Adolescent Number of trainings and copies of the Immunization Practices developed by the National Vaccine Advisory Revised Standards for Child and Committee(NVAC) and published by the National Immunization Program Adolescent Immunization Practices (NIP) to all immunization providers and community stakeholders/coalition developed by the National Vaccine Advisory Committee(NVAC) that were disseminated—percentage of providers reached. 1.3 Implementation of strategies to improve vaccination coverage Number and proportion of reminder • Systems are used to remind parents/guardians,patients, and systems utilized by immunization healthcare professionals when vaccinations are due and to recall providers in the county those who are overdue • Office or clinic-based patient records reviews and vaccination Number of Immunization providers coverage assessments are performed annually patient record reviews and • Healthcare professionals practice community-based approaches vaccination coverage assessments completed annually • Document activities of community stakeholder group/coalition to improve immunization rates in the community. Resources Primary MCH Contact—Cathy White,RN,MSN School Age and Youth Child Health Nurse consultant,303-692-2375, cathy.white@state.co.us For More Information Contact: • Joni Reynolds, Immunization Nurse Consultant at ioni.revnolds(aIstate.co.us/phone 303 692-2363 On-line Resources: • Copy of the Revised Standards for Child and Adolescent Immunization Practices go online at http://www.cdc.eov/nip/recs/rev-inunz-stds.htm • Standards for Child and Adolescent Immunization Practices article published in Pediatrics go online at http://www.cdc.gov/nip/recs/rev-inunz- stds,htm Local health department contact for this goal area: Name:Trish McClain, RN Phone: 970/304-6420,ext. 2302 Email: pmcclain@co.weld.co.us • I:\MCH\mch04\Weld\WELD FY04-05 MCH TEMPLATE-IMMUNIZATIONS .DOC HCP End-of-year Report and MCH-Plan (HERMAN Document) Agency Name: Weld County Public Health and Environment Date of Report: May 3, 2004 Contact Person for Report: Lori McCarty, RN, BSN Contact Person's Phone Number: (970) 304-6420 extension 2309 Contact Person's Email: lmccarty@co.weld.co.us Due January 15, 2005 GOAL 1: Families of CSHCN will partner in decision-making at all levels and will be satisfied with the services they receive. Note: The family members referred to in measures 4.7. - 4.7.6.on the next few pages may be someone other than the HCP Family Coordinator. A variety of parents can be used for the different activities mentioned. 1. Surveilla ce of Need. Contract Performance,Local Statistics,and Current Regional Activities A. Contract Performance Measures Contract Performance Measure Measurement 4.7. Assure family members participate as advisors in program Regional Office Team Leader will provide at least one example of and policy-making activities on a regular basis. family participation in program and policy activities. Local Report—Goal 1,I.A.4.7.: Performance Measure Measurement 4.7.1. Family members participate on advisory committees and/or Team Leader will provide: task forces and are offered training, mentoring and reimbursement, 1. Description of how Family Consultant team member is mentored when appropriate. for role on team and identify who has provided mentoring and training. 2. Documentation of reimbursements made to family members for training opportunities. Local Report—Goal 1,I.A.4.7.1.: • Page 2 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Performance Measure Measurement 4.7.2. Financial support(financial grants, technical assistance, Team Leaders shall provide: travel and child care) is offered for parent activities or parent groups, • Documentation of the financial support provided to the Regional in particular the Annual Family Consultant Team Meeting. Family Consultant to attend the Annual Family Consultant Team Meeting. • Documentation of travel and child care support provided to parents or parent groups. Local Report—Goal 1, LA.4.7.2.: • Performance Measure Measurement 4.7.3. HCP Family Consultants and/or other family members are Team Leader will provide: involved in in-service training of HCP staff, local health care • Documentation of how families, in particular the HCP Regional providers and families. Family Consultant, are utilized for their expertise in providing training in areas such as: • Family centered care • Medical Home • Community resources • Family-professional partnerships. Family Consultant or in their absence Team Leader will provide: • Documentation of trainings conducted by the consultant and/or other family members, which list topic, attendance and evaluation. Local Report—Goal 1, I.A.4.7.3.: • Page 3 of 43 . • 1:\MCH\mch04\Weld\WEL.D HERMAN.DOC(LB-PB) Performance Measure Measurement 4.7.4. Family members are hired staff or consultants to the HC:) Use same measurement as listed for Performance measure 4.2. Team regional office for their expertise as a family member of a child V ith Leader will include relation to the CSHCN for the person who is filling special health care needs. the position of Regional Family Consultant. Local Report—Goal 1, I.A.4.7.4.: Performance Measure Measurement 4.7.5. Family members of diverse cultures, which represent the Team Leaders will submit information on how family members self- diversity of the community, are involved in all of the above activities. identify their ethnic and racial background. Team Leader will provide documentation of financial support provided families from ethnic and diverse backgrounds for training activities. Local Report—Goal 1,I.A.4.7.5.: Performance Measure Measurement 4.7.6. Family members are involved in the Children with Special Team leaders will provide a description of how family members Health Care Needs elements of the MCH Plan. contributed to the CSHCN elements of MCH Plan by methods such as: I. Public hearings to assist in the development of the MCH Plan 2. Focus groups for families 3. Family members invited to participate in the development of the MCH Plan. 4. Family member surveyed to gather information for needs assessments • Local Report—Goal 1, I.A.4.7.6.: Page 4 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB Due January 15, 2005 GOAL 1: Families of CSHCN will partner in decision-making at all levels and will be satisfied with the services they receive. B. Final Report on MCH 2004 Plan for the period of October 1, 2003 through September 30, 2004. Activity Evaluation—Outcome Measures Copy in selected activity from MCH 2004 Plan Copy in selected evaluation-outcome measures from MCH 2004 Plan During FY 2004,the Weld County HCP Regional Office will assist and I. The HCP newsletter will be sent to all HCP families once each quarter during FY support the HCP Parent Consultant in the creation of an active family 2004. The newsletter will be issued in both English and Spanish. support network in Weld County. 2. A monthly support group for Spanish-speaking families will be established by • January I,2004. 3. Because the current support group in Eaton is at capacity,a 2nd monthly support group for English-speaking families will be established by May I,2004. Local Report— Goal 1, I.B.: Write in final report of outcome measures for MCH 2004 Plan: Due May 1, 2004 GOAL 1: Families of CSHCN will partner in decision-making at all levels and will be satisfied with the services they receive. C. Relevant Data/Statistics Local Report— Goal 1, I.C.: As anticipated last year, family representation and participation with HCP has improved dramatically since the addition of Rhonda Stute as our Family Coordinator. During FY 2003 Rhonda documented 32 contacts with the community. She attended meetings with Empower Colorado, Parent to Parent(serving on their board), El Grupa Vida and Strengthening Latino Families in addition to initiating a Spanish-speaking support group for families in Greeley and the surrounding area. She made one formal presentation about the new role of HCP to Strengthening Latino Families and offered a training session on TABOR to Weld County Department of Public Health staff. During FY 2003 the Weld Neurology Clinic coordinator conducted a limited survey of families attending the transitional neurology clinic. All nine families were pleased with the services they received, A survey of foster families conducted in the spring of 2002 by the • Weld County United Way Child Coalition Intervention Committee documented the need for respite care in our county. Family Page 5 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Connects, the Weld County Early Childhood Connections agency,conducts a family satisfaction survey every year. Results from this survey are still being tabulated. As anticipated, the MCH Indicator for CSHCN degree of Family Participation has improved dramatically. In 002, the Weld County score was 0/18; in 2003 the score was 1/18 and in 2003, following the employment of Rhonda Stute, the score sose to 18/18. Due May 1. 2004 GOAL 1: hamilies of CSHCN will partner in decision-making at all levels and will be satisfied with the services they receive. D. Other Regional Activities and Resources Guidance/Recommendations to Include: • List the family advocacy or support groups that are available for families with CSHCN in your county(ies). Update last year's list if appropriate. Local Report— Goal 1, I.D. : The HCP parent support group for Spanish-speaking families meets the 2nd Monday of each month. There are 4 families that participate on a regular basis. The group is working on ways to increase its membership. Other Support Groups in the area include: • Northeast Colorado Autism/PDD Support Group 2"d Tuesday at 7:00pm Greeley Recreation Center 651 10th Avenue Contact: Susan Locke 356-7314 • Persons with Brain Injury Support Group 3r°Saturday at 11:30am 5754 West 11th Street Suite 206 Contact: Michelle Sauder or Sue Zamora 330-5326 • Eaton Parent Support Group 4th Monday at 6:00pm Eaton Evangelical Free Church 1325 3rd Street,Eaton Contact: Dianne Stille 454-3023 Pare 6 of 43 i:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) • Due May 1, 2004 • GOAL 1: Families of CSHCN will partner in decision-making at all levels and will be satisfied with the services they receive. E. Progress on Activities Selected in MCH 2004 Plan Activity Evaluation—Outcome Measures Copy in selected activity from MCH 2004 Plan Copy in selected evaluation-outcome measures from MCH 2004 Plan During FY 2004,the Weld County HCP Regional Office will assist and I. The HCP newsletter will be sent to all HCP families once each quarter support the HCP Parent Consultant in the creation of an active family during FY 2004. The newsletter will be issued in both English and Spanish. support network in Weld County. 2. A monthly support group for Spanish-speaking families will be established by January I,2004. 3. Because the current support group in Eaton is at capacity,a 2n°monthly support group for English-speaking families will be established by May I, 2004. Local Report— Goal 1, I.E.: Write in progress toward outcome measures for MCH 2004 Plan: To date,only two Parent Newsletters have been drafted and sent to families—one was released in December of 2002 and one was released in January 2004. English and Spanish versions were available for both newsletters. This does not meet our current goal of one newsletter each quarter. It has been difficult to carve out the time necessary for Rhonda to draft these publications because of her other active roles on the team. She is currently working on a new publication which should be ready for release later this month. The Spanish-speaking parent support group was established in March 2003, well ahead of the deadline of January 1, 2004. With the exception of August 2003, the group has met on a monthly basis. An English-speaking parent support group sponsored by HCP has not been established as of yet. The initiation of the Weld County Respite Project with heavy involvement of both English and Spanish speaking families has taken priority. . On January 30, 2004 the Weld County HCP team hosted the first Family to Family Health Information Network training held in the state of Colorado! While notification of the training was sent to every family enrolled in HCP and Part C services in Weld County, the majority of participants were professionals. Several parents did attend and reported the conference as highly valuable to them. Should the training be offered in Weld County in the future, more extensive advertisement will be done. Page 7 of 43 I:\MCH\mch04\Weld\WELD HERMAN.D0C(LB-PB) Due May 1, 2004 GOAL 1: Families of CSHCN will partner in decision-making at all levels and will be satisfied with the services they receive. H. SELF-ASSESSMENT AND PRIORITIZATION Guidance • Write a brief assessment statement on the progress toward achieving this Goal. Address the following: • Degree to which Contract Performance Measures,4.7—4.7.6, were achieved in contract year 10/1/02 through 9/30/03. Note if your Family Participation Level Score went up or down from previous year. • Have the current levels of in-service training and outreach activities provided by your Family Regional Coordinator been effective? • Is there financial and mentoring support for your Family Regional Coordinator available? • List new resources or barriers related to promoting family involvement you've become aware of since 10/1/03 to present date. • State how you assess this Goal's priority, related to the other 6 Goals, for your region for your MCH 2005 Plan. Local Report- Goal 1, II. (SEE THE CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN)CHECKLIST) Due May 1, 2004 GOAL 1: Families of CSHCN will partner in decision-making at all levels and will be satisfied with the services they receive. III. CSHCN/MCH 2005 PLAN-For The Period Of October 1, 2004 Through September 30,2005 Activity Evaluation —Outcome Measures A. Current agency activities are fulfilling contract performance measures and are contributing to achieving Goal 1 in our community by 2010. Continue current activities as described: During FY 2005,the Weld County HCP Regional Office will assist I. The HCP newsletter will be sent to all HCP families once each quarter and support the HCP Parent Consultant to continue the development during FY 2005. The newsletter will be issued in both English and Spanish. of an active and sustainable family support network in Weld County. 2. Because the current support group in Eaton is at capacity,a 2nd monthly support group for English-speaking families will be established by May I, 2005. Page 8 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB•PB) • • CSHCN Template Objectives Evaluation—Outcome Measures • By September 30, 2005, collect information to assist in determining a baseline level of satisfaction families enrolled with HCP have with the services they receive. 1. Survey HCP families to discern baseline level of 1. Family Satisfaction survey will be sent to all HCP families renewing satisfaction with the care they receive. their care coordination services during FY 2005. 2. 75%of families will complete the survey and return to the Weld Regional Office. 3. Data will be tabulated bejinning in FY 2006. Due January 15, 2005 GOAL 2: All children with special health care needs will receive regular, ongoing comprehensive care within a medical home. I. Surveillance of Need: Contract Performance,Local Statistics, and Current Regional Activities A. Contract Performance Measures Contract Performance Measure Measurement No Contract Performance Measure related to this Goal • Page 9 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) . Due January 15, 2005 GOAL 2: All children with special health care needs will receive regular, ongoing comprehensive care within a medical home. B. Final Report on MCH 2004 Plan for the period of October 1, 2003 through September 30, 2004. Activity Evaluation—Outcome Measures The HCP Regional Office Team will increase their own 1. By December 31, 2003, HCP Team Leader will train Regional Team, awareness of the medical home concept and prepare to including regional discipline coordinators, in the concept of the disseminate information related to Colorado's Medical Home medical home. Initiative to local stakeholders. 2. By June 1, 2004, HCP Regional team members will adapt CO Medical Home Initiative information for this county and create a power point or formal presentation to educate key stakeholders in the community. 3. By September 30, 2004, HCP Regional Team will develop an evaluation tool to measure stakeholder knowledge after participation in the formal presentation developed above. Local Report—Goal 2, I.B.: Write in final report of outcome measures for MCH 2004 Plan: • Due May 1, 2004 GOAL 2: All children with special health care needs will receive regular, ongoing comprehensive care within a medical home. C. Relevant Data/Statistics Guidance on Statistics to Include: • * IRIS Report #24-Medical Home Summary. Number and percent of children on HCP caseload who have a Medical Home. • * IRIS Report # 30-Concern Report by age. Number and percent of children on HCP caseload who have Primary Care Needs/Medical Home as a concern. • * IRIS Report#31A, number of children in the HCP program who receive care coordination for any concern. • Evidence of the availability of primary care to children in your county(ies), such as average waiting times to be seen for well-child/ preventive care in private practices and FQHC community health clinics and whether your area is designated as a high need area for primary care. Page 10 of 43 L\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Local Report- Goal 2,I.C.: According to IRIS Report#24, only one child out of the 386 (0.3%) enrolled in HCP through the Weld County Regional Office has a medical home which meets all four criteria as defined by the Colorado Medical Home Initiative. On a brighter note,280 children (72,4%) indicate they seek medical care from a consistent primary care provider. IRIS Report#30 indicates that 24 clients had primary care/medical home listed as a concern. Because the total county caseload varies widely among IRIS reports, it is difficult to identify what percentage of the overall caseload these children represent. For the purposes of this report, the total number of children will be considered to be 386; therefore,approximately 6%of the caseload had primary care/medical home listed as a concem at some point during FY 2003. Many of these children were new to the area and needed assistance in establishing a primary care provider. A glance at the list of children still showing this concern as unresolved indicates that the care coordinators are not being diligent in updating IRIS when a concern has been resolved. This skews the data and will be addressed during the remainder of FY 04. Weld County does not have any areas designated as high need for primary care providers. An unofficial survey of the three FQHC's in Weld (Sunrise, Monfort Children's Clinic and Ft. Lupton Salud) indicate that most children will be seen the same day or the next day at the latest. Private family practices indicate they can usually see clients within one or two days. Private pediatric practices stated they can sometimes see children the same or next day,but the wait can be as long as a week. Due May 1, 2004 GOAL 2: All children with special health care needs will receive regular, ongoing comprehensive care within,a medical home. D. Other Regional Activities and Resources Guidance on Information to Include: • Community collaborations or initiatives related to the Medical Home,such as collaboration with Part C regarding Physician Outreach • Outreach activities geared toward key stakeholders, including families and primary care providers, about the medical home concept and providing primary care to CSHCN • The agency or coalition that is taking the lead on medical home efforts in your county(ies) and the role of your agency. • How HCP care coordination services promote the medical home concept Local Report- Goal 2,I.D.: There have been no formal community collaborations or initiatives related to Medical Home in Weld County to date. Discussions around joint presentations to primary care providers have been held with Part C, but no action has been taken to date. No formal outreach activities have been initiated. No agency has taken the lead on this issue, although HCP is poised to assume this role in the future. All members of the HCP interdisciplinary team promote the concept of medical home as opportunities arise in the community. Care coordinators work closely with primary care providers. One example of this is the close relationship between the Neurology Clinic care coordinator, Dr. Reiley and individual primary care providers. PCPs are invited to attend appointments with their patients, notified of any Page I I of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) . immediate needs by phone call or a letter immediately following clinic and receive a written copy of Dr. Reiley's dictation. One family practice physician actually attended clinic with his patient and family. • Due May ? ; 2004 GOAL 2: All children with special health care needs will receive regular, ongoing comprehensive care within a medical home. E. Progress on Activities Selected in MCH 2004 Plan • Activity Evaluation—Outcome Measures The HCP Regional Office Team will increase their own 1. By December 31, 2003,HCP Team Leader will train Regional Team, awareness of the medical home concept and prepare to including regional discipline coordinators, in the concept of the disseminate information related to Colorado's Medical Home medical home. Initiative to local stakeholders. 2. By June I,2004, HCP Regional team members will adapt CO Medical Home Initiative information for this county and create a power point or formal presentation to educate key stakeholders in the community. 3. By September 30, 2004,HCP Regional Team will develop an evaluation tool to measure stakeholder knowledge after participation in the formal presentation developed above. Local Report—Goal 2, I.E.: Write in progress toward outcome measures for MCH 2004 Plan: All team members viewed the Medical Home Initiative video at the January 16, 2004 Regional Coordinators Meeting. In addition,medical • home has been a topic of discussion for all disciplines during their conference calls and face to face meetings. Parents have also been exposed to the concept through the Spanish-speaking support group and the Family to Family Health Information Network training held on January 30, 2004. Page 12of43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB•PB) Due May 1, 2004 GOAL 2: All children with special health care needs will receive regular, ongoing comprehensive care within a medical home. II. SELF-ASSESSMENT AND PRIORITIZATION Guidance • Write a brief assessment statement on the progress toward achieving this Goal. Address the following: • Has the level of awareness of the medical home concept, among key stakeholders, including families and providers, in your communities increased? • Has the need of families in your region for primary care and care coordination services increased or decreased? • Have your care coordination activities been effective in linking families to primary care providers? • Has the availability of primary care in your region increased or decreased? • List new resources or bathers related to promoting medical home you've become aware of since 10/1/03 to present date. • State how you assess this Goal's priority related to the other 6 Goals, for your region for your MCH 2005 plan. Local Report - Goal 2,II. (SEE THE CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN)CHECKLIST): Page 13 of43 L\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Due May 1, 2004 • GOAL 2: All children with special health care needs will receive regular, ongoing comprehensive care within a medical home. III. CSHCN/MCH 2005 PLAN- For The Period Of October 1, 2004 Through September 30,2005 Objective 1: By September 30,2005, increase by 50% the number Outcome Eval 1: The number of providers witl:.vhom HCP regional of PCP's that consult with HCP RO compared to offices provided consultation increased from(will previous year. provide baseline number at end of FY 2004) to 50% increase at the end of FY 2005. • Activity l: Review IRIS data entry procedures with team Process Eval I: Report number of practices/providers that RO has members and establish last year's starting consulted in the region using IRIS community and baseline for number of consultations/encounters individual client encounters. Use same method at end of RO had with primary care physicians/practice 2005 fiscal year to see if activities increased by 50%. settings for resources, referrals, care coordination,and other HCP services. • Activity 2: Contact primary care practices throughout region Process Eval 2: Number of community encounters with PCP practice and complete the 'Title V Assessment of settings. Report the results of completed assessments. Practice Needs-A Practice Inquiry and Options for Menu of Support"* Document contacts with PCP offices as community encounters in IRIS. Activity 3: Survey PCP'practices on their desire to }mow Process Eva! 3: Number of surveys completed and report of results more about best practices and resources r/t Universal Newborn Hearing Screening, NB Metabolic, developmental, and/or early vision screening. Activity 4: FOR RO's WHO CONDUCT HCP SPECIALTY Process Eval 4: Number of "reverse referral" forms sent out to PCPs • CLINICS: Send out "Reverse Referral"* forms prior to a child's HCP Specialty Clinic visit. as part of pre-clinic activities. Document in IRIS when completed form is received and other pre-clinic or post clinic consultations with PCP. Page 14 of43 • 1:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB, References: Title V Assessment of Practice Needs- A Practice Inquiry and Options for Menu of Support"* `Reverse Referral Form"* Due January 15, 2005 GOAL 3: All families of children with special health care needs (CSHCN)will have adequate private and/or public insurance to pay for the services they need. I. Surveillance of Need: Contract Performance, Local Statistics, and Current Regional Activities A. Contract Performance Measures Contract Performance Measure Measurement 1.1. Implement the program for HCP Direct Service Benefits for * Due to discontinuing of Direct Service Benefits, there was not a Site eligible children according to the time lines,policies and procedures Visit Survey completed in 2003. described in the HCP Policy& Procedure and IRIS Help File. Monitoring of IRIS Data System by State Office • • Local Report- Goal 3,I.A., 1.1. : Contract Performance Measure Measurement 2.1. Assist in public awareness and enrollment activities for Provide necessary information in sections below. programs such as Medicaid, CHP+, and SSI. Local Report-Goal 3,I.A.,2.1. : Page 15 of43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Due January 15, 2005 GOAL 3: All families of children with special health care needs (CSHCN)will have adequate private and/or public insurance to pay for the services they need B. Final Report on MCH 2004 Plan for the period of October I, 2003 through September 30,2004. Activity Evaluation—Outcome Measures Copy in selected activity from MCH 2004 Plan Copy in selected evaluation-outcome measures from MCH 2004 Plan Current agency activities are fulfilling contract performance Contract Performance Measures as reported in the HERMAN Document measures and are contributing to achieving Objective 3 in our due January 15, 2005. community by 2010. Continue current activities as described. • Local Report—Goal 3, I.B.: Write in progress toward outcome measures for MCH 2004 Plan: Due May 1, 2004 GOAL 3: All families of children with special health care needs (CSHCN)will have adequate private and/or public insurance to pay for the services they need C. Relevant Data/Statistics Guidance • * IRIS report #26. Number of children in HCP caseload also enrolled in SS1 for your county(ies). Percent of total caseload. • * IRIS report # 30, number and percent of caseload with insurance concerns • * IRIS report #57C, referral report indicating the number of clients referred to Medicaid, CHP+and SSI and other third party payers. * IRIS Reports for HERMAN are to be for the date range of 10/1/02 through 9/30/03, for children 0-21, and for current caseload for date range unless otherwise stated. Multi-county Regional Offices are to report Regional Totals and County Subtotals as appropriate. You may request assistance for running reports through the IRIS HOT LINE# 1-800-886-7689 x2383. Local Report-Goal 3,I.C.: IRIS Report#14 indicates that a total of 35 children had no insurance or were HCP-RQD during FY 2003. 77 children(19.9 %of the caseload)had SSI during FY 2003 according to the data from IRIS report#26. Report#30 indicates 103 children(26.7%of the caseload)have insurance concerns. Page 16 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Use of the referral screen by HCP care coordinators and team members has been very limited. This will be corrected during the remainder of FY 2004. Due May 1, 2004 GOAL 3: All families of children with special health care needs (CSHCN)will have adequate private and/or public insurance to pay for the services they need D. Other Regional Activities and Resources • Guidance/Recommendations to Include: • Describe any significant new community efforts related to assuring that CSHCN have adequate health insurance, including the lead agency or coalition(Your agency may or may not be involved in these efforts). • Role and level of involvement of your agency in the region's activities. Local Report—Goal 3,I.D.: All agencies in Weld County continue to work hard to assure that children with special needs have adequate health insurance. The Weld County Department of Public Health and Environment continues to serve as a SED site, although CHP+ no longer pays to staff an outreach worker here. Due May 1, 2004 GOAL 3: All families of children with special health care needs (CSHCN)will have adequate private and/or public insurance to pay for the services they need E. Progress on Activities Selected in MCH 2004 Plan Activity Evaluation—Outcome Measures Copy in selected activity from MCH 2004 Plan Copy in selected evaluation-outcome measures from MCH 2004 Plan Current agency activities are fulfilling contract performance Contract Performance Measures as reported in the HERMAN Document measures and are contributing to achieving Objective 3 in our due January 15, 2005. community by 2010. Continue current activities as described. Local Report— Goal 3, I.E.: Write in progress toward outcome measures for MCH 2004 Plan: The efforts that were successful in previous years have not weathered the storm of a faltering economy and state budget cuts. In FY 2003 35 children(9%of the total caseload) were self-pay or depended on HCP to assist them with medical expenses. All 11 children who received HCP only benefits during FY 2003 closed prior to June 15,2003. In the first half of FY 2004 the number of children without insurance rose to 74 (25%of the caseload)an increase of 278%. Page 17 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) • Families applying for Medicaid benefits in Weld County must now wait between 2 and 6 months for their application to be processed. Weld EPSDT outreach workers believe this backlog can be attributed to a rise in the number of applications, funding constraints which prohibit the hiring of additional staff and Medicaid's decision to give first priority to applications from pregnant women. The cap on CHP+enrollees has prevented families falling off of Medicaid from submitting their applications. Three HCP staff and two EPSDT outreach workers attended the HIFA Waiver Public Forum in Ft. Collins on December 11, 2003. The percentage of the caseload enrolled in SSI has remained steady at about 70%. Families continue to wrestl vith the laborious process of documenting their need to continue receive SSI and HCP staff continue to assist with applications, renewals and providing medical information as we are able under the restrictions of HIPAA. One local family recently lost benefits when the father received a lump sum disability settlement for an injury that will prevent him from working at all. The family had just made the difficult decision to proceed with a vagal nerve stimulator implant to control their child's intractable seizures and is now forced to postpone the surgery until funding or insurance can be established. The Weld County HCP Emergency Fund has been used to assist uninsured children with special needs with their most pressing medical needs. Unfortunately, the Greeley Realtors Association is not planning on hosting their annual Bowl-a-thon event this year. The funds left over from last year will need to be stretched until summer 2005. Due May 1, 2004 • GOAL 3: All families of children with special health care needs (CSHCN)will have adequate private and/or public insurance to pay for the services they need II. SELF-ASSESSMENT AND PRIORITIZATION Guidance • Write a brief assessment statement on the progress towards achieving this Goal. Address the following: • Trends in your RO HCP caseload regarding SSI enrollment. • Have your Care Coordination activities been effective in improving access to insurance or third payor coverage? • List new resources or barriers related to adequate private/public insurance you've become aware of since 10/1/03 to present date. • State how you access this Goal's priority related to the other 6 Goals for your region for your MCH 2005 plan. Local Report- Goal 3, II. (SEE THE CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN)CHECKLIST): Page 18 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Due May 1, 2004 GOAL 3: All families of children with special health care needs (CSHCN)will have adequate private and/or public insurance to pay for the services they need III. CSHCN/MCH 2005 PLAN- For The Period Of October 1, 2004 Through September 30, 2005 Activity Evaluation—Outcome Measures A. Current agency activities are fulfilling contract Contract Performance Measures as reported in the HERMAN Document performance measures and are contributing to achieving due January 15, 2005. Goal 3 in our community by 2010. Continue current activities as described. • Page 19 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) i ' Due January 15, 2005 GOAL 4: All children will be screened early and continuously for special health care needs I. Surveilla, .:e of Need: Contract Performance, Local Statistics, and Current Regional Activities A. Contract Performance Measures Contract Performance Measure Measurement 3.1. Assure that Audiology Regional Coordinator(s) work with Audiology Regional Coordinators will provide: birthing facilities in their region to implement or maintain an Early 1. Annual Report(reporting tool to be provided by State Hearing Detection and Intervention program(Universal Newborn Audiology Consultant) utilizing data from the Newborn Hearing Screening) that will: Evaluation Screening and Tracking (NEST) that indicate outcomes of newborn hearing screening for hospitals in their 3.1.1. Screen 95%of all newborns before one month of age and region, referral rate, and follow up outcomes. preferably prior to hospital discharge. 2. Summary of improvement plan(s) for individual hospitals in 3.1.2. Have a Refer rate for further evaluation of 4% or less of all their region that are not meeting the recommended guidelines newborns screened before discharge. for Universal Newborn Hearing Screening. 3.1.3 Provide documentation of follow-up on all infants who failed 3. Documentation of IRIS Community Encounters for site visits or missed screening: including referral to appropriate medical, with hospitals. audiologic and early intervention services. Local Report-Goal 4,I.A. 3.1, 3.1.1., 3.1.2., and 3.1.3.: Due January 15, 2005 GOAL 4: All children will be screened early and continuously for special health care needs B. Final Report on MCH 2004 Plan for the period of October 1,2003 through September 30, 2004. Activity Evaluation—Outcome Measures Copy in selected activity from MCH 2004 Plan Copy in selected evaluation-outcome measures from MCH 2004 Plan Current agency activities are fulfilling contract performance Contract Performance Measures as reported in the HERMAN Document measures and are contributing to achieving Objective 4 in our due January 15, 2004 community by 2010. Continue current activities as described. Local Report- Goal 4, I.B.: Write in progress toward outcome measures for MCH 2004 Plan: Page 20 of 43 I:\MCH\mch04\Wald\WELD HERMAN.DOC(LB-PB) Due May 1, 2004 GOAL 4: All children will be screened early and continuously for special health care needs C. Relevant Data/Statistics Guidance • Number of infants identified as CSHCN in your county(ies)by CRCSN. Obtain your county(ies)report through CRCSN Statistical Researcher Russel Rickard at (303)692-2623, russel.rickard@state.co.us or CRCSN main number 303-692-2649. Local Report- Goal 4,I.C.: 134 infants were identified as having special needs in 2003 as identified by the Colorado Responds to Children with Special Needs registry. Due May 1, 2004 GOAL 4: All children will be screened early and continuously for special health care needs D. Other Regional Activities and Resources Guidance/Recommendations to Include: • Participation of your agency or others in CDPHE's early vision screening project and results of any screening efforts conducted in your county(ies) e.g. numbers screened,referral rate, follow up outcomes. • Local Child Find activities related to developmental screening and your agency's role. • Local EPSDT activities related to assuring access to well-child check ups for CSHCN with Medicaid and your agencies role. • How infants identified by CRCSN in your county(ies)are being monitored for special health care needs and developmental delays. Results of your monitoring efforts. • Training efforts that may have occurred in your county(ies)related to the importance of screening,appropriate screening tools,and best practices for vision, hearing,developmental,behavioral, mental health, oral health, or metabolic screening. • Within the HCP Sponsored Specialty Clinic(s)held in your county(ies), any regular screenings and follow up practices that take place beyond the specialty medical assessments that are conducted. Local Report—Goal 4, I.D.: The Weld Regional Office has not participated in CDPHE's early vision screening project this year. Child Find coordination shifted successfully from Part C to individual school districts in the county. Currently seven school districts hold family fairs and screening activities. HCP care coordinators continue to make the initial referral to Grace Bean at Family Connects and she forwards the referral to the appropriate school contact person. Page 21 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) The Weld County Department of Public Health and Environment continues to operate as a SED site for Medicaid,with two EPSDT outreach workers stationed in our nursing division. The relationship between HCP and EPSDT is excellent, w itli collaboration working in both directions. EPSDT personnel are able to verify type of Medicaid coverage and eligibility spans (as their data system allows)and HCP staff assist with EPSDT contacts for children enrolled in the HCP program. The two Weld EPSDT outreach workers handle a very large caseload,but Health Care Policy and Finance has prohibited their sharing of numbers for the purposes of this report. Prior to January 1, 2004 the CRCSN referrals were made to Family Connects,our local Part C agency. Follow up was done by sending out a letter and waiting for the family to respond. Referrals to HCP were rarely if ever made. No formal trainings related specifically to screening topics occurred in Weld County during FY 2003. No screening programs are associated with the HCP Neurology Clinic, the only specialty clinic currently being held in Weld County. A fledgling attempt to re-establish the Developmental Evaluation Clinic system in Greeley was begun in FY 2003. Due May 1, 2004 GOAL 4: All children will be screened early and continuously for special health care needs E. Progress on Activities Selected in MCH 2004 Plan (Activities for 2003 Plan that fit under these Goals) Activity Evaluation—Outcome Measures Copy in selected activity from MCH 2004 Plan Copy in selected evaluation-outcome measures from MCH 2004 Plan Current agency activities are fulfilling contract performance Contract Performance Measures as reported in the HERMAN Document measures and are contributing to achieving Objective 4 in our due January 15, 2004 community by 2010. Continue current activities as described. Local Report—Goal 4, I.E.: Write in progress toward outcome measures for MCH 2004 Plan: The Weld County hearing screening rate of 96.8%continues to exceed the HP 2010 benchmark of 95%set as the Colorado FY 2005 goal. Deanna Meinke, Regional Audiology Coordinator, has done an excellent job of working with North Colorado Medical Center to make this program successful. The local HCP team is gradually taking over the follow up for infants that have been identified by the Colorado Newborn Hearing Screening Program. This responsibility recently began in March, and the team is still working to determine how this process can be efficiently accomplished. Currently, the team leader and regional audiologist are working together to contact • and follow up on the handful of children that have been identified since the beginning of 2004. Page 22 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Tiffany Daley, OT has just agreed to become the Weld County Regional Office Vision Coordinator. She has a special interest in vision issues and is a welcome addition to our staff. She will begin exploring the range of screening efforts in our county during the 2nd half of FY 2004. The Weld County Regional Office assumed responsibility for following up on the CRCSN notifications as of January 1,2004. In January, the referral list began coming directly to the Weld County HCP Regional Office. Follow-up has been slow to date because of staff limitations. The recent addition of a 0.25 FTE RN care coordinator should help to eliminate this difficulty. HCP will work closely with Part C to make sure that all families identified have been made aware of the services available to them. Resumption of the D &E clinic has been frustrating for members of the HCP team. No one in the regional office has been notified prior to the two trial clinics that have been held in the last year. Furthermore, HCP regional consultants who have been asked to staff these clinics as part of their other job responsibilities report that the clinics have been disorganized and frustrating for the families and pediatricians. On January 16, 2004 Paula Hudson attended a meeting of the HCP Regional Coordinators to discuss D &E clinics with the team and the two local D&E coordinators. At that time, it was determined that North Colorado Medical Center is still waiting to receive signed contracts from the Colorado Department of Public Health and Environment and that 4 clinics would be scheduled for calendar year 2004. No further word has been received regarding these clinics. • Page 23 of 43 IA MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Due May 1, 2004 GOAL 4: All children will be screened early and continuously for special health care needs II. SELF-ASSESSMENT AND PRIORITIZATION Guidance • Write a brief assessment statement on the progress towards achieving this Goal. Address the following: • Were the Contract Performance Measures related to Newborn Hearing Screening Goals achieved in your region? • Was ongoing follow-up and monitoring of children identified by CRCSN and NICU referrals effective in linking families to services or early identification of concerns? • Was EPSDT effective in assuring access to well child checks? Did these well child checks include a developmental component? • Were Child Find screenings accessible to all families in your county(ies)? Are Child Find follow-up services effective? • Were the screening and follow-up services conducted at HCP Specialty Clinics in your county(ies)effective? • List new resources or barriers related to early and continuous screening you've become aware of since 10/1/03 to present date. • State how you assess this Goal's priority related to the other 6 Goals for your region for your MCH 2005 plan. Local Report—Goal 4, II. (SEE THE CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN) CHECKLIST): Due May 1, 2004 GOAL 4: All children will be screened early and continuously for special health care needs III. CSHCN/MCH 2005 PLAN-For The Period Of October 1, 2004 Through September 30,2005 Activity Evaluation—Outcome Measures A. Current agency activities are fulfilling contract Contract Performance Measures as reported in the HERMAN Document performance measures and are contributing to achieving due January 15, 2005 Goal 4 in our community by 2010. Continue current activities as described. Page 24 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB•PB) Due January 15, 2005 GOAL 5: Community based service systems for CSHCN and their families will be organized for easy use. I. Surveillance of Need: Contract Performance, Local Statistics, and Current Regional Activities A. Contract Performance Measures Contract Performance Measure Measurement 2.2. Use the HCP multidisciplinary team(speech,audiologist, The Regional Office Team Leader will describe how the needs of OT, PT, nutrition,social work,parent,and nurse)to address the the child and family are met through multidisciplinary care child's medical and mental health care needs and family resources and coordination. supports for services and/or care coordination. The development of a Care Coordination Plan should be part of the multidisciplinary Provide two examples of this team process. Use examples that process for families enrolled for HCP direct service benefits. involved at least three different disciplines on the multidisciplinary team. Local Report-Goal 5, I.A.,2.2.: • Page 25 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Contract Performance Measure Measurement 2.3. Collaborate with Part C to assist in the development of a Note: Multicounty Regional Offices should describe all Early system of early intervention services for children birth through age Childhood Connection agencies that serve their region. two. Regional Office Team Leader will: 2.3.1. Identify children enrolled both in HCP and Part C. Work 1. Desrribe interagency coalitions or agreements in your with the family and the Part C service coordinator to identify and county(ies)that include both HCP and Part C. determine the role of HCP in developing and implementing the IFSP. 2. Provide the number of children dually enrolled in HCP and Part C. 3. Describe how service coordination occurs for children who are dually enrolled in HCP and Part C, including the HCP team involvement in developing the IFSP. 4. Provide data of the number of children served by Part C in your county(ies) and discuss whether the number served indicates adequate identification of CSHCN in the 0-3 year old population. 5. Describe HCP's role in public awareness and outreach to identify children eligible for HCP and/or Part C (Child Find). Local Report-Goal 5,I.A., 2.3., and 2. 3. 1.: Contract Performance Measure Measurement 2.4. Create and maintain a plan for providing The Regional Office Team Leader will describe a plan for translation/transcription/interpretation services through the Regional providing translation/transcription/interpretation services to Office. families in the Region. Local Report-Goal 5,I.A., 2.4.: Page 26 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PE) Due January 15, 2005 GOAL 5: Community based service systems for CSHCN and their families will be organized for easy use. B. Final Report on MCH 2004 Plan for the period of October 1,2003 through September 30,2004. Activity Evaluation—Outcome Measures Copy in selected activity from MCH 2004 Plan Copy in selected evaluation-outcome measures from MCH 2004 Plan' During FY 2004, the Weld County Regional HCP Office will 1. By July 1, 2003, formalize draft Memorandum of Understanding improve collaboration between Part C (Family Connects)and between HCP and Part C. HCP. 2. By end of FY 2004,HCP collaboration with Part C will improve as evidenced by: • CRCSN report will be shared with HCP Regional Office on a monthly basis. • At least one HCP Care Coordinator will become trained as a Part C service coordinator. • An HCP Care Coordinator will be the lead service coordinator for all infants and toddlers with complex medical conditions eligible for Part C services. • HCP Care Coordinators will be advised of IFSP meetings for all children dually enrolled in HCP and Part C. HCP Care Coordinators will document their participation in this process appropriately in IRIS. 3. HCP Care Coordinators will receive training on the IRIS referral screen by 10/01/2003. All community referrals will be entered into IRIS on a consistent basis during FY 2004. Local Report— Goal 5, I.B.: Write in progress toward outcome measures for MCH 2004 Plan: • Page 27 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Due May 1, 2004 GOAL 5: Community based service systems for CSHCN and their families will be organized for easy use. C. Relevant Data/Statistics Guidance • * IRIS Report#31A, number of children in the HCP program who receive care coordination for any concern. (Same as Goal 2,I.C.) • * :RIS report#57C. Numbers of families referred to other community agencies, the agencies to which they were referred,and the number of referrals completed. • * IRIS report#31B. Frequency of occurrence of the top five concerns for which care coordination was provided among HCP Caseload. • * IRIS report#62. Total number and type of community encounters. * IRIS Reports for HERMAN are to be for the date range of 10/1/02 through 9/30/03, for children 0-21,and for current caseload for date range unless otherwise stated. Multi-county Regional Offices are to report Regional Totals and County Subtotals as appropriate. You may request assistance for running reports through the IRIS HOT LINE# 1-800-886-7689 x2383. Local Report of what the data above means to you. Goal 5,I.C.: IRIS Report 31A seems of limited use in defining the number of children receiving care coordination for any concern as statistics are entered according to the individual concerns, There is no way to determine whether every child is receiving care coordination for at least one concern. In Weld County a child enrolled in the HCP program is enrolled in order to receive care coordination at some level. It can therefore be assumed that 100%of the caseload is receiving care coordination. IRIS Report#57C is only able to retrieve data for one client individually. It is not a summary report for the entire caseload • The top 6 concerns for the HCP caseload were Administrative Activity(99.3%), Health Medical Needs—Child (88.1%), Other(63.7%), Insurance (59.7%), Communication (50.5%)and Dental Care (30.2%). IRIS Report#62 indicates that 82 Community Encounters were made during FY 2003. 51%of the encounters were meetings,24% phone calls, approximately 10% trainings, 5%presentations and the remainder were correspondence and community screenings. The top 3 reasons for these contacts were Outreach, Professional Development and Capacity Building. Page 28 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB•PB) Due May 1, 2004 GOAL 5: Community based service systems for CSHCN and their families will be organized for easy use. D. Other Regional Activities and Resources Guidance/Recommendations to Include: • Community interagency coalitions that are working to build a better system of service for CSHCN • Evidence of successful collaborations or gaps in collaboration among agencies in your communities • Formal or informal agreements and collaborations between your agency and local Part C agencies and school districts in your county(ies) • Local Report—Goal 5,I.D.: The Early Childhood Connections Advisory Council continues to meet on a monthly basis with representation from several county Child Finds, Head Start, Department of Social Services, Part C, Envision—the Community-Center Board(CCB) and public health(HCP). Part C and the CCB work well together to provide services to children eligible for Part C early intervention services,sharing funding streams to help assure that families are able to access the services they need. Family Connects continues to work on a general memorandum of understanding between themselves and other agencies in the community. The MOU remains in draft form. During FY 2003, one school nurse in Weld County District #6 (Greeley)has consistently included HCP care coordinators in IEP reviews for children enrolled in the schools she serves. Page 29 of 43 1:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Due May 1, 2004 GOAL 5: Community based service systems for CSHCN and their families will be organized for easy use. E. Progress on Activities Selected in MCH 2004 Plan (Activities for 2004 Plan that fit under these Goals) Activity Evaluation -Outcome Measures Copy vi selected activity from MCH 2004 Plan Copy in selected evaluation-outcome measures from MCH 2004 Plan During FY 2004, the Weld County Regional HCP Office will 1. By July 1, 2003, formalize draft Memorandum of Understanding improve collaboration between Part C(Family Connects)and between HCP and Part C. HCP. 2. By end of FY 2004,HCP collaboration with Part C will improve as evidenced by: • CRCSN report will be shared with HCP Regional Office on a monthly basis. • At least one HCP Care Coordinator will become trained as a Part C service coordinator. • An HCP Care Coordinator will be the lead service coordinator for all infants and toddlers with complex medical conditions eligible for Part C services. • HCP Care Coordinators will be advised of IFSP meetings for all children dually enrolled in HCP and Part C. HCP Care Coordinators will document their participation in this process appropriately in IRIS. 3. HCP Care Coordinators will receive training on the IRIS referral screen by 10/01/2003, All community referrals will be entered into IRIS on a consistent basis during FY 2004. Local Report—Goal 5,I.E.: Write in progress toward outcome measures for MCH 2004 Plan: The Memorandum of Understanding with Family Connects (Part C) is still in draft form at this time. It will continue to be a priority for completion by the end of this fiscal year. CRCSN reports are now being received and followed up on by HCP staff. This process began in January 2004 and the procedure is still being developed. Janis Pottoroff was to have provided Part C service coordination training in January. Due to large caseloads and changes in staff, this has not been accomplished. The failure to refer medically involved infants and toddlers to HCP continues to be of great concern to the HCP team. HCP care coordinators are rarely included in the IFSP process. It is hoped the MOU will delineate referral guidelines and a standard procedure for making these referrals. The goal for improved collaboration remains the end of FY 2004. Training for use of the IRIS referral screen was held on April 26, 2004. Use of this screen should improve during the 2" half of FY 2004. Page 30 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB•PB) The top five concerns for care coordination in FY 2004 remain exactly the same as FY 2003. It is concerning that the "Other"concern is used so frequently. The HCP team leader will work with care coordinators to eliminate the use of this option as it is impossible to quantify the situations it covers. In October 2003, the HCP team was eligible to receive $13,729 from the state to use on a project of their choosing. Because respite care in Weld County is desperately needed, the team chose to look into replicating Alamosa's Adventure Center. The team attended the training sponsored by HCP on October 17, 2003 and decided if one mom could do it in Alamosa, a whole team could certainly be successful in Weld County! The team began meeting monthly in January, researching other respite programs,state licensing requirements,the scope of services available in Weld County and anything else they could think of Field trips were taken to Greeley's Eldergarden,Centennial Developmental Services, Inc. and the Ft. Collins Respite Care Inc. The following vision and mission statements were developed by the end of January: Vision Statement: To establish accessible,community-based respite care in Weld County available 24 hours per day, 7 days per week for families of children with special needs. Mission Statement: The mission of this parent-driven program is to assist in the development of temporary,specialized child care one Saturday per month for families of children with special needs to provide relief from the ongoing responsibilities of caring for their children. A bilingual power point presentation and flyer were developed and presented to the staff at the Weld County Department of Public Health and Environment on February 10, 2004. A community informational meeting was then held on February 17, 2004. Because the majority of families planning to attend were monolingual Spanish speaking,the presentation was made in Spanish with interpretation into English—a new experience for everyone involved! Interested parents volunteered and a parent advisory council was formed. This group began meeting in early March and community interest and involvement has been overwhelming. The University of Northern Colorado Schools of Nursing and Special Education have committed to recruiting student volunteers and are making connections with other departments to promote the program and recruit more volunteers. Envision,the Boys and Girls Club and United Way are also actively involved. A board of directors has been formed and will begin to meet in May. Target date for the first trial run of the respite program is July 10, 2004. This project has become a great example of the power of community collaboration. • Page 31 of 43 I:\MCH\mcho4\Weld\WELD HERMAN.DOC(LB-PB) • Due May 1, 2004 GOAL 5: Community based service systems for CSHCN and their families will be organized for easy use. II. SELF-ASSESSMENT AND PRIORITIZATION Guidance • Write a brief assessment statement on the progress toward achieving this Goal. Address the following: • Were the Contract Performance Measures related to this Goal achieved? • Did the number of children receiving care coordination services increase, decrease or stay the same? • Did the number of referrals to other agencies and number of referrals completed increase,decrease or stay the same? • Were these community encounters improving communication and collaboration with other agencies in your region? • Did the number and nature of community encounters in your county(ies) increase,decrease,or stay the same? • Were your community encounters effective in improving communication and collaboration with other agencies in your region? • State how you assess this Goal's priority related to the other 6 Goals for your region for your MCH 2005 plan. Local Report- Goal 5, II. (SEE THE CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN)CHECKLIST): • • • • • • Page 32 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PD) Due May 1, 2004 GOAL 5: Community based service systems for CSHCN and their families will be organized for easy use. III. CSHCN/MCH 2005 PLAN-For The Period Of October 1,2004 Through September 30,2005 Activity Evaluation—Outcome Measures A. During FY 2005,the Weld County Regional HCP Office 1. By April 1, 2005, formalize draft Memorandum of Understanding will improve collaboration between Part C (Family between HCP and Part C. Connects)and HCP. 2. By end of FY 2004,HCP collaboration with Part C will improve as evidenced by: • At least one HCP Care Coordinator will become trained as a Part C service coordinator. • An HCP Care Coordinator will be the lead service coordinator for all infants and toddlers with complex medical conditions eligible for Part C services. • HCP Care Coordinators will be advised of IFSP meetings for all children dually enrolled in HCP and Part C. HCP Care Coordinators will document their participation in this process appropriately in IRIS. B. During FY 2005,HCP will make 5 community contacts 1. By the end of FY 2005, HCP services will be listed in the Weld with partners who provide support services for CSHCN. County 211 Directory. 2. By the end of FY 2005,three presentations to community partners will be documented using Community Encounters in IRIS. • 3. By the end of FY 2005,two community partners will be invited to present information about their programs at Regional Coordinators Meetings. Page 33 of 43 I:\MCmmch04\Weld\WELD HERMAN.DOC(LB-PB) Due January 15, 2004 • GOAL 6: All youth with special health care needs will receive services to transition to adult life. I. Surveilla ce of Need: Contract Performance,Local Statistics,and Current Regional Activities A. Contract Performance Measures Contract Performance Measure Measurement No Contract Performance Measure related to this Goal Due January 15, 2005 GOAL 6: All youth with special health care needs will receive services to transition to adult life B. Final Report on MCH 2004 Plan for the period of October 1,2003 through September 30, 2004. Activity Evaluation—Outcome Measures Copy in selected activity from MCH 2004 Plan Copy in selected evaluation-outcome measures from MCH 2004 Plan I. Identify and explore already existing training programs to a. By May 1, 2004 contact school districts, Weld County Rehabilitation improve care coordination skills related to transition issues Services and other area agencies that provide transitional services for for family members, case managers, care coordinators, youth to determine type of services provided,contact and eligibility service coordinators, HCP team members, and/or providers information,etc. in your region. b. By August I, 2004 create an information sheet listing pertinent information for all county transition resources for HCP Care Coordinators and any other interested stakeholders. 2. Improve consistency of including appropriate transitional c. Development and implementation of a tickler system that reminds goals in care plans for children and youth receiving care care coordinators of the need to address transition goals for youth coordination services through HCP. receiving care coordination services through HCP. d. Evidence of the presence of transitional goals in care plans of children age 14 and older 75%of the time or greater based on chart audit or site visit survey. Local Report—Goal 6, I.B.: Write in progress toward outcome measures for MCH 2004 Plan: Page 34 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Due May 1, 2004 GOAL 6: All youth with special health care needs will receive services to transition to adult life C. Relevant Data/Statistics Guidance on Statistics to Include: • Population in your county(ies)age 14-20 and estimate of CSHCN in this age range. Obtain from Co-hid at http://www.cdphe.state.co.us/cohid/ • IRIS report# 3. HCP caseload age 14 years and older. (Current caseload by Age with Diagnosis; use ages 14-21) • IRIS report#30. Number and percent of caseload, ages 14-21, with transition concerns. (Concern Report by Age,use ages 14-21 Concern Transition.) Local Report—Goal 6, I.C.: Population statistics from 2002 indicate there are 69,141 children between the ages of 14 and 20 living in Weld County. It is expected that 8089 (11.7%)are children with special needs. IRIS report#3 indicates there were 122 children ages 14 and older in the current caseload for FY 2003. Of the 122 children ages 14 and older, only 8 had transition listed as a concern during FY 2003. Due May 1, 2004 GOAL 6: All youth with special health care needs will receive services to transition to adult life D. Other Regional Activities and Resources Guidance on Information to Include: • HCP team's role and activities in the community related to transition of adolescents to adult life. • The role and capacity of the School District(s), CCB's, Vocational Rehab, and Family Advocacy services to assure appropriate transition for adolescents in your county(ies). • Any Healthy and Ready To Work (HRTW)activities/projects in your county(ies) Local Report—Goal 6,I.D.: HCP has not participated in any community activities related to transition in the past 3 years. The role and capacity of the school districts, CCB, Vocational Rehab and Family Advocacy groups is not known. The HCP team is unaware of any Health and Ready to Work projects underway in Weld County. Page 35 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Due May 1, 2004 GOAL 6: All youth with special health care needs will receive services to transition to adult life E. Progress on Activities Selected in MCH 2004 Plan (Activities for 2004 Plan that fit under these Goals) Activity Evaluation—Outcome Meas,..es Copy in selected activity from MCH 2004 Plan Copy in selected evaluation-outcome measures from MCH 2004 Plan I. Identify and explore already existing training programs to a. By May 1, 2004 contact school districts, Weld County Rehabilitation improve care coordination skills related to transition issues Services and other area agencies that provide transitional services for for family members, case managers, care coordinators, youth to determine type of services provided,contact and eligibility service coordinators, HCP team members, and/or providers information,etc, in your region. b. By August I, 2004 create an information sheet listing pertinent information for all county transition resources for HCP care coordinators and any other interested stakeholders. • 2. Improve consistency of including appropriate transitional c. Development and implementation of a tickler system that reminds care goals in care plans for children and youth receiving care coordinators of the need to address transition goals for youth receiving coordination services through HCP. care coordination services through HCP. d. Evidence of the presence of transitional goals in care plans of children age 14 and older 75%of the time or greater based on chart audit or site visit survey. Local Report—Goal 6, I.E.: Write in progress toward outcome measures for MCH 2004 Plan: There has been very little work done toward these outcome measures during the first half of FY 2004 due to the amount of time spent on the respite project.•The team is aware of the importance of transition planning and has attempted to assist one or two families with their planning efforts, but a full scale implementation has not been attempted. Centennial BOCES, serving Weld County School Districts RE-1, RE-2, RE-5J, RE-7, RE-9,RE-10, RE-11, RE-12 and Weld Opportunity High School, has a School to Work Alliance Program(S.W.A.P,) in place. This program assists young adults, ages 16-25 with mild to moderate disabilities, develop and follow a career path to employment. The program strives to place young adults in to jobs related to their interests, teaches basic employment skills and supports employers during the initial placement period and for the following year. Rhonda Stute has attended five transition trainings sponsored by the ARC of Denver. She will be presenting information to the Weld Regional team later this year. In addition, a parent has agreed to speak to the group about the information she has gathered while working through the systems with her 18 year old son. There is much work yet to be done in this area. Page 36 of 43 I:M1CH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Due May 1, 2004 GOAL 6: All youth with special health care needs will receive services to transition to adult life II. SELF-ASSESSMENT AND PRIORITIZATION Guidance • Write a brief assessment statement on the progress toward achieving this Goal. Address the following: • How has the population of children age 14-20 in your community(ies)changed? Is this reflected in any changes in your HCP caseload? • Have the number of transition plans for 14-20 year old clients in your HCP caseload increased, decreased or stayed the same? • Does your region have the capacity to provide transition services for youth aged 14 to 20? • List new resources or barriers related to youth receiving transition services you've become aware of since 10/1/03 to present date. • State how you assess this Goal's priority related to the other 6 Goals for your region for your MCH 2005 plan. Local Report-Goal 6, II. (SEE THE CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN)CHECKLIST): • Page 37 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Due May 1, 2004 GOAL 6: AU youth with special health care needs will receive services to transition to adult life HI. CSHCN/MCH 2005 PLAN-For The Period Of October 1, 2004 Through September 30,2005 Evaluation—Outcome Measures Objective 1: By September 30 2005, at least 50% of the youth Outcome Eval 1: The number of youth between 14 and 21 in the between 14 and 21 in the RCP caseload will have HCP caseload who have discussed medical services discussed the shift to an adult provider with their transition with their doctors. pediatric primary care provider and/or specialists. Activity 1: Identify youth who are close to or qualify for adult Process Eval 1: Care coordinators will complete the transition services and have not discussed with their survey questions with each renewal done for all doctors the shift to adult provider by surveying children between 14 and 21 during FY 2005. youth and families to determine who could receive assistance. Use transition survey questions. Activity 2: Discuss with youth and families the need to begin Process Eval 2: IRIS documentation of the number of youth and steps toward transition to adult services. Offer parents that team members have contacted and support and information, to build confidence, provided with support and information services. knowledge and empower youth and families to Report anecdotal experiences of youth and parents approach their doctors. who approached their doctors in the region. Future Activity: During FY 2005, follow up contact or repeat survey with youth and parent(s) regarding status of having discussion regarding transition with their doctors. • Page 38 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB•PB) Due January 15, 2004 GOAL 7: The regional model of operation for HCP will provide high quality, efficient services to families, providers, and state and local partners I. Surveillance of Need: Contract Performance, Local Statistics,and Current Regional Activities A. Contract Performance Measures Contract Performance Measure Measurement 4.1. Complete and submit the HCP Contract Performance Report The Regional Office Team Leader will submit the Contract by January 15, 2004. Performance Report to their State Program Consultant by January 15, 2004. Local Report- Goal 7, l.A.,4.1.: Contract Performance Measure Measurement 4.2. Each regional office team will consist of staff,either as FTE, The Regional Office Team Leader will provide: contracted,or shared with another regional office,which includes the 1. Names of team members, their discipline,dates of hire,number of following core disciplines: nursing,nutrition, audiology,early hours per month if contract or percent of time if FTE, and other intervention specialist for hearing loss,speech, occupational therapy community agencies they work for, if applicable. or physical therapy, social work,parent or family advocate. To the 2. A list of any additional specialist(s)involved with the team on a extent possible, it is desirable to hire or contract with professionals periodic basis. • who are also working,or have worked, in other care systems or 3. A summary of community coordination activities for each community programs, (e.g., mental health,school district, community discipline member of team. health center,community center board, Part C). In addition, 4. A description of the involvement of the multidisciplinary team in the specialists in community assessment, planning and evaluation, and needs assessment planning process, the writing of the Contract epidemiology are highly encouraged to be part of the team. The Performance Report,and MCH Plan. Multidisciplinary team will assist in ongoing needs assessment and facilitation of efforts to coordinate community health and support services for children with special health care needs(CSHCN). Local Report-Goal 7,I,A.,4. 2.: Page 39 of 43 t:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Contract Performance Measure Measurement 4.3. Using the scope of work for each discipline, the Regional The Regional Office Team Leader or Regional Discipline Office Team Leader and State Consultant will develop appropriate Coordinator will report on the discipline team member's priorities priori'ies for that discipline and the Regional Discipline Coordinator and give examples of how those priorities —Pre accomplished. for the contract year. Local Report-Goal 7, I.A.,4.3.: Contract Performance Measure Measurement 4.4. When Regional Discipline Coordinators are shared with The Regional Office Team Leader will document the process used for other HCP regional offices, the appropriate personnel (Regional developing priorities by providing meeting minutes or making them Office Team Leaders, regional coordinators/consultants) will meet available by request. annually to discuss the roles and priorities for the position. The State Consultants would be invited to attend on request. *** An annual meeting to develop priorities within the scope of work should be held prior to the contract renewal date of the Regional Discipline Coordinator. Local Report-Goal 7,I.A.,4.4.: Contract Performance Measure Measurement 4.5. The Regional Office Team Leader will attend two meetings Meeting minutes and attendance as documented by State Office staff per year with the State HCP staff and participate in bi monthly Regional Office Conference calls. 4.5.1. Regional Discipline Coordinators will either attend,or participate by conference call in, Regional Office Team meetings and at least two meetings of all the coordinators for that discipline,as convened by the State Discipline Consultants. 4.5.2. HCP technicians will attend quarterly HCP conference calls. Local Report-Goal 7,I.A.,4. 5, 4. 5.1., and 4.5. 2.: • Page 40 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Contract Performance Measure Measurement 4.6. Ensure all IRIS users attend IRIS Training and meet the State HCP Office will document attendance at IRIS and Eligibility "Standards for Usage of IRIS II". Ensure all HCP Technicians, training sessions. Regional Nursing Coordinators, and Team Leaders attend HCP IRIS and Eligibility training. IRIS security forms will be complete and on file at State Office. Local Report-Goal 7, I.A.,4.6.: Due January 15, 2005 GOAL 7: The regional model of operation for HCP will provide high quality, efficient services to families,providers,and state and local partners B. Final Report on MCH 2004 Plan for the period of October 1,2003 through September 30, 2004. Activity Evaluation—Outcome Measures Copy in selected activity from MCH 2004 Plan Copy in selected evaluation-outcome measures from MCH 2004 Plan Current agency activities are fulfilling contract performance Contract Performance Measures as reported in the HERMAN Document measures and are contributing to achieving Objective 7 in our due January 15, 2004 community by 2010. Continue current activities as described. • Local Report-Goal 7, I. B.: Write in final report of outcome measures for MCH 2004 Plan: Due May 1, 2004 GOAL 7: The regional model of operation for HCP will provide high quality,efficient services to families, providers,and state and local partners C. Relevant Data/Statistics—N/A • Page 41 of 43 1:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) Due May 1, 2004 GOAL 7: The regional model of operation for HCP will provide high quality, efficient services to families, provider. and state and local partners D. Other Regional Activities and Resources • Guidance/Recommendations to Include: Description of any changes or additional resources in your Regional Office and parent agency Local Report—Goal 7, I.D.: All positions with the HCP Regional Team are currently filled! The team continues to function very well together and receives excellent support from the Weld County Department of Public Health and Environment. Due May 1, 2004 GOAL 7: The regional model of operation for HCP will provide high quality, efficient services to families, providers, and state and local partners E. Progress on Activities Selected in MCH 2004 Plan (Activities for 2004 Plan that fit under these Goals) Activity Evaluation—Outcome Measures Copy in selected activity from MCH 2004 Plan Copy in selected evaluation-outcome measures from MCH 2004 Plan Current agency activities are fulfilling contract performance Contract Performance Measures as reported in the HERMAN Document measures and are contributing to achieving Objective 7 in our due January 15,2004 community by 2010. Continue current activities as described. Local Report—Goal 7,I.E.: Write in progress toward outcome measures for MCH 2004 Plan: It was difficult to predict the effect of the loss of direct services on this year's caseload. While the overall caseload decreased following the transfer of the Orthodontia and Hearing Aid programs back to Medicaid, the caseload has gradually been increasing over the first 6 months of FY 2004. Recent referrals are coming from all sectors of the community. With the added workload of the respite project and CRCSN notifications, management has begun a discussion about limiting the number of children the Weld HCP program can enroll. Care coordinators and team members are having difficulty providing care coordination for all children within the standards they have set while attempting to provide population based services and expand the infrastructure in Weld County. The percentage of the caseload with high or moderate acuity levels has increased from 34 in FY 2003 to 40 in the first half of FY 2004. During the 2n°half of the year, Page 42 of 43 I:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) the team leader and Child Health Supervisor will be looking at the overall caseload to determine how to best manage this increased workload. Due May 1, 2004 GOAL 7: The regional model of operation for HCP will provide high quality,efficient services to families,providers,and state and local partners II. SELF-ASSESSMENT AND PRIORITIZATION Guidance • Briefly summarize: • New barriers, developments, resources that you encountered this last year related to your Regional Office Team and parent agency. Local Report-Goal 7, II. (SEE THE CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN)CHECKLIST): The increased funding along with the one time funding for a special grant have freed the HCP team to provide more support for families in Weld County, In addition, the relaxation of some of the budget constraints has allowed members of the team to pursue further training in areas of interest to their practice. Due May 1, 2004 GOAL 7: The regional model of operation for HCP will provide high quality, efficient services to families,providers,and state and local partners III. CSHCN/MCH 2005 PLAN- For The Period Of October 1, 2004 Through September 30, 2005 Activity Evaluation—Outcome Measures A. Current agency activities are fulfilling contract Contract Performance Measures as reported in the HERMAN Document performance measures and are contributing to achieving due January 15, 2005 Goal 7 in our community by 2010. Continue current activities as described. Page 43 of 43 1:\MCH\mch04\Weld\WELD HERMAN.DOC(LB-PB) ' ' Attachment L MATERNAL AND CHILD HEALTH CORE PUBLIC HEALTH SERVICES BUDGET APPLICATION AND EXPENDITURE REPORT CONTRACTOR: Expenditure Rep.irt Due Date: January 15,2005(For The Period Of October 1,2004 through September 30,2005) Budget Application Due Date: May 1,2005(For The Period of October 1,2005 through September 30,2006) January 15,2005: Please provide actual numbers for how the funds were used in the period of October 1,2004 through September 30,2005. May 1,2005: Based on your county plan,please estimate the following based on your MCH funding formula contract amounts for the period of October 1,2005 through September 30,2006. MATERNAL AND CHILD HEALTH REPORTING FOR THE CORE PUBLIC HEALTH SERVICES Section I AMOUNT AND PERCENTAGE ALLOCATED TO: DOLLARS PERCENTAGE CHILD HEALTH PERINATAL HEALTH TOTAL 100% CHILD HEALTH PERCENTAGE ALLOCATED TO: DIRECT SERVICES ENABLING SERVICES POPULATION-BASED SERVICES INFRASTRUCTURE BUILDING SERVICES TOTAL 100% PERINATAL HEALTH PERCENTAGE ALLOCATED TO: DIRECT SERVICES ENABLING SERVICES POPULATION-BASED SERVICES INFRASTRUCTURE BUILDING SERVICES TOTAL 100% Section II • DOLLARS AMOUNT OF FUNDS ALLOCATED TO: CHILDREN WITH SPECIAL NEEDS CHILDREN WITH SPECIAL NEEDS PERCENTAGE ALLOCATED TO: DIRECT SERVICES ENABLING SERVICES POPULATION-BASED SERVICES INFRASTRUCTURE BUILDING SERVICES TOTAL 100% NOTE: Administrative costs can be allocated to each of the above categories as appropriate. Page 1 of 1 Attachment M MATERNAL AND CHILD HEALTH(MCH) INSTRUCTIONS FOR THE FINAL MCH REPORT FOR FY04 Period of October 1,2003 Through September 30,2004 DUE DATE:On or Before January 15,2005 A. Please put the following information at the beginning of the report or on a cover page: 1. Title the Report: "Final MCH Report for FY04" 2. agency name 3. contact person,and 4. contact's telephone number B. Describe any important administrative or organizational changes that affected the implementation of the MCH Operational Plan during the twelve-month period. C. MCH Operational Plan Final Report 1. Perinatal Population: a. Restate the priority needs of the perinatal population for which the MCH fords were used. For each priority need for which MCH funds were used: i. Restate the objective(s),which addressed that priority need. ii. State if the objective was hilly met,partially met,or not met. iii Describe what was accomplished,including summarizing important activities. b. Describe any emerging issues regarding the perinatal population in your community. 2. Child and Adolescent Population: a. Restate the priority needs of the child and adolescent population for which the MCH finds were used. b. For each priority need for which MCH fiords were used: i. Restate the objective(s)that addressed that priority need. ii. State if the objective was fully met,partially met,or not met. iii. Describe what was accomplished,including summarizing important activities. c. Describe any emerging issues regarding the child and adolescent population in your community. Page 1 of 3 . . , . 3. Children with Special Health Care Needs(CSHCN)Population: Follow the instructions provided below for completing the appropriate parts of the HERMAN Document: a. Final MCH/CSHCN Report for FY04 • Complete Section A2. Report in response section the final progress of your evaluation measures. You may cut and paste any appropriate information that you submitted in your earlier progress report in May 2004. This fulfills the Final MCH Report for FY04. b. Name your document using the following formula:Agency Name-HERMAN-January 2005.doc. Example: Jefferson-January 2005.doc. Save your newly named HERMAN document to your hard drive or a floppy disk NOTE: You will be submitting your End of the Year HCP Contract Report(Section At)at this same time. D. Please submit your Final MCH Report for FY04,via e-mail to the state MCH office,for the period of October 1,2003 through September 30,2004,no later than 5:00 P.M.on January 15,2005 to: Jan Reimer—E-mail Address:jan.reimer@state.co.ns E. Please submit your HERMAN Document for FY04,via e-mail to the state HCP office, for the period of October 1,2003 through September 30,2004,no later than 5:00 P.M.on January 15,2005 to: Your State HCP Program Consultant(see attached list for name and e-mail address) Page 2 of 3 HCP PROGRAM CONSULTANTS AND THEIR REGIONAL OFFICE ASSIGNMENTS, E-MAIL ADDRESSES AND PHONE NUMBERS HCP PROGRAM PHONE NUMBERS& REGIONAL OFFICES CONSULTANT E-MAIL ADDRESSES Boulder HCP Regional Office Vickie Thomson 303-692-2458 vickie.thomsonna,state.co.us Denver HCP Regional Office Eileen Forlenza 303-692-2794 eileemforlenzaRstate.co.us El Paso HCP Regional Office Steve Holloway 303-692-2327 stephen.hollowayPstate.co.us Jefferson HCP Regional Office Anne-Marie Braga 303-692-2362 -Broomfield Health Dept. anne-marie.braRa(a,state.co.us Larimer HCP Regional Office Shirley Babler 303-692-2455 Shirley.babler@state.co.us Northeast BC?Regional Office Lynn Bindel 303-692-2392 Ivnn.bindelQsiate.co.us Northwest HCP Regional Office Lynn Bindel 303-692-2392 lynn.bindel@)state.co.us Pueblo HCP Regional Office Steve Holloway 303-692-2327 stephen.holloway(tstate.co.us South Central HCP Regional Office Shirley Babler 303-692-2455 -Las Animas-Huerfano Health Dept. shirley.bablerna,state.co.us Southeast HCP Regional Office Eileen Forlenza 303-692-2794 eileen.forlenzaPstate.co.us Southwest HCP Regional Office Anne-Marie Braga 303-692-2362 annemarie.bragaRstate.co.us Tri-County HCP Regional Office Charla Low 303-692-2423 ch arlalowPstate.co.us Weld HCP Regional Office Lynn Bindel 303-692-2392 Lynn.bindel( )o,state.cons Western Slope HCP Regional Office Karen Fehringer 303-692-2399 -Delta Health Dept. karen.fehrinrer@state.co.us Revised May 24, 2004 l7egeACONIRACRVyY ORMCH-HCP Cambned motradlAlt4n 21-Rini MCH Report foe FY 0/.doc Page 3 of 3 Attachment N Instructions for Completing and Submitting Tables I & H Estimates are acceptable and are preferable to no data. Please estimate to the best of your ability. Columns 2-6 must equal Column 1 and the table is designed to add your input automatically. If a person can be counted in more than one category in a year, select one class only in which to report them. If you cannot provide any information in health insurance coverage, put your total number of clients in column (6), Number Unknown. These data are compiled at the state level and submitted to the Maternal and Child Health Bureau for Form 7 in the MCH Block grant application. Submit both tables with your Final MCH Report for FY04; via e-mail to the state MCH Office,for the period of October 1,2003 through September 30,2004, no later than 5:00 P.M. on January 15, 2005 to: Jan Reimer - E-mail Address: jan.reimer@state.co.us If you need assistance in filling out this form, call Sue Ricketts, Prevention Services Division, Colorado Department of Public Health and Environment, 303-692-2316, or email her at sue.ricketts@state.co.us. Attachment N-MCH Table I and II for FY04 5-25.04-2 Page 1 of 3 Attachment N County: [Name of County] Prepared by: [Person filling out form] Program: [Name of Program] Telephone: [Work number] Email: [Work email] Table I Number of Individuals Served(Unduplicated) Under Title V By Class of Individuals and Health Coverage,FY 2004 October 1,2003 through September 30,2004 Column(1)will automatically total across columns(2)through(6). Columns(1) to(6)will automatically total for Total MCH Population. Input information in yellow shaded areas only. (1) (2) (3) (4) (5) (6) Number Number Number (Automatic) Number with with with Unduplicated Count by Total with Title XIX Other No Number Class of Individual Served Number Medicaid (CHIP) Insurance Coverage Unknown start here: Pregnant women receiving prenatal care' 0 Infants under age one(not elsewhere) 0 Children age 1.22(not elsewhere) 0 Children with special health care needs 0 Other individuals(not elsewhere) 0 Total MCH Population(automatic) 0 0 0 0 0 0 Please take the Total Number shown in Column 1 for Children age 1.22: 0 and estimate the number in each of these age groups: Age 1-4 Age 5.9 • Age 10.14 Age 15-19 Age 20-22 Unknown Total of ages: 0 Total shown above for children age 1.22: 0 Difference: 0 The totals should match and the difference should be zero. Attachment N-MCH Table I and II for FY04 5.25.04-2 Page 2 of 3 Attachment N *Fill out Table ll if you serve pregnant women County: [Name of County] Prepared by: [Person filling out form] Program: [Name of Program] Telephone: [Work number] Email: [Work email] Table II Number of Deliveries Served by Title V Unduplicated County by Race and Ethnicity, FY20 04 October 1, 2003 through September 30, 2004 Input information In yellow shaded areas only. More cells>>> (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Total Oth. Asian or Other Non- and American Pacific and Total Total Hlsp• Un- Total All Races White" Black Indian Islander Unknown Ethnicities Hispanic anic kn. Pregnant women start here: start here: receiving pnc 0 0 0 Count Hispanics In the White column, unless they belong to one of the other racial groups. • Total In Table I for Pregnant women: 0 Total in Table II for Pregnant women: 0 Difference: 0 These totals should match and the difference should be zero. Total All Races Col.(1): 0 Total Elhniclties Col.(7): 0 Difference: 0 These totals should match and the difference should be zero. Attachment N-MCH Table i and II for FY04 5.25.04.2 Page 3 of 3 r , Attachment O MATERNAL AND CHILD HEALTH(MCH)FOR PRENATAL, CHILD HEALTH,AND CHILDREN WITH SPECIAL HEALTH CARE NEEDS POPULATIONS 6-MONTH MCH PROGRESS REPORT FOR FY05 The information in this document provides guidance for the 6-Month MCH Progress Report for the Period of October I,2004 through March 30,2005. REPORT DUE DATE:On or Before May 1,2005. A. Please put the following information at the beginning of the report or on a cover page: • 1. Title the Report: "6-month MCH Progress Report for FY05" 2. agency name 3. contact person,and 4. contact's telephone number B. Describe any important administrative or organizational changes that affected the implementation of the MCH Operational Plan during the first six months of the fiscal year. C. Summarize any significant problems or accomplishments in this 6-month period. D. Describe any emerging issues regarding the MCH population in your community. E. MCH Operational Plan 6-Month Progress Report I. Attach the templates used for the Operational Plan for FY05. Provide a brief description of the progress made on the activities in the Outcomes/Progress Report column. F. Please submit your 6-Month MCH Progress Report For FY 05,via e-mail to the state MCH office,for the period of October 1,2004 through March 30,2005,no later than 5:00 P.M.on May 1,2005 to: Jan Reimer—E-mail Address: ianseimer(a,state.co.us and Your State HCP Program Consultant(see next page for e-mail addresses) Page I of 2 HCP PROGRAM CONSULTANTS AND THEIR REGIONAL OFFICE ASSIGNMENTS, E-MAIL ADDRESSES AND PHONE NUMBERS HCP PROGRAM PHONE NUMBERS& REGIONAL OFFICES CONSULTANT E-MAIL ADDRESSES Eo&der HCP Regional Office Vickie Thomson 303-692-2458 vickie.thomsonRstate.co.us Denver HCP Regional Office Eileen Forleaza 303-692-2794 eileatforlamaPstate.co.us El Paso HCP Regional Office Steve Holloway 303-692-2327 stephen.hollowayO,state.co.us Jefferson HCP Regional Office Anne-Marie Braga 303-692-2362 -Broomfield Health Dept anne-marie.bragastate.co.us Larimer HCP Regional Office Shirley Babler 303-692-2455 shirt ey.babler(a,state-to.us Northeast HCP Regional Office Lynn Bindel 303-692-2392 lytutbindelPstate.co.us Northwest HCP Regional Office Lynn Bindel 303-692-2392 lynn.bindelPstate.co.us Pueblo HCP Regional Office Steve Holloway 303-692-2327 stenhathollowave,state.co.us South Central HCP Regional Office Shirley Babler 303-692-2455 -Las Animas-Huerfano Health Dept. shirley.babler(a,state.co.us Southeast HCP Regional Office Eileen Forlenza 303-692-2794 eileen.forl®zaOstate.co.us Southwest HCP Regional Office Anne-Marie Braga 303-692-2362 annemarie.bragaPstate.co.us Tri-County HCP Regional Office Charla Low 303-692-2423 charla lowAstate.co.us Weld HCP Regional Office Lynn Bindel 303-692-2392 Ivnn.bindelPstate.co.us Western Slope HCP Regional Office Karen Fehringer 303-692-2399 -Delta Health Dept. karen.feLringer(a,siate.co.us Revised May 28,2004 JAPeggy\CONTRACfSFY ON.MCH-HCP Combined Ca fr JtxLmatl o-d-MmhProgres Report FY 05.doc Page 2 of 2 Attachment P PERFORMANCE MEASURE CHECKLIST-PART I CSHCN MEASURES a Priority Need ?• e • E E Up o e •a w a v Explanation or Description t° u N d tL m x ,°� en °�' r L "• a 's For pp, _ G a. .. Checked Boxes U t W Z = V O O v �R 6 .Z. 6 C V1 z �7 E R 5 5 [J c 'O u fti a a z y Z CSHCN Goal 1: Families of CSHCN will partna in decision-making at all levels and will be satisfied with the services they receive NPM 2: Percent of families of children with special needs who participate in N/A 57.4 55.0 N/A • decision-making and are satisfied with services CSHCN Goal 2: All children with special needs will receive regular, ongoing comprehensive care within a medical home NPM 3: Patent of children with special needs with a N/A 51.7 50.0 N/A medical home CSHCN Goal 3: All families of children with special health care needs (CSHCN)will have adequate private and/or public insurance to pay for the services they need NPM 4: Percent of children with special needs with N/A 58.2 55.0 N/A adequate insurance Page1of2 Attachment P - PERFORMANCE MEASURE CHECKLIST-PART I CSHCN MEASURES o Priority Need o Vq o a C3 v Explanation or Description o 'er C 2 r el For 'n � A " .2 �� a ,c .Q ° d ° O S 2 t Y � Checked Boxes rn Z '� 4 504 o tit G'` z o t ° a CSHCN Goal 4: All • children will be screened early and continuously for special health care needs NPM 1: Percent of infants receiving newborn N/A 98,0 98.0 All screening NPM 12:Percent of newborns receiving 96.2 95.0 N/A newborn hearing screening before discharge CSHCN Goal 5: Community based service systems for CSHCN and their families will be organized for easy use NPM 5: Patent of families of children with special needs reporting service N/A 77.4 75.0 N/A systems organized for easy use CSHCN Goal 6: All youth with special health care needs will receive services to transition to adult life NPM 6: Percent of children with special needs who received services to N/A 5.8 6.0 N/A transition to adult life Page 2 of 2 Attachment P PERFORMANCE MEASURE CHECKLIST-PART II MCH MEASURES a C Priority Need o :3 r Vq 1 o ° Explanation or Description - e '' 8 r' Vp a „ °� mr °r d c , .� o Y e For UX � X ° ^ a 9 ° a s °u `w E gin a e `q Checked Boxes Z 5 4O4 Oap 4 o ° hG e z z ADOLESCENT HEALTH MEASURES NPM 8: Teen(ages 15 • through 17)birthrate 26.8 28.0 43.0 NPM 16:Rate of suicide deaths among youths age 15-19 13.0 12.0 5.0 Old SPM 5: Rate of motor vehicles deaths, ages 15-19 27.3 19.1 9.2 SPM 4(Old SPM 6):The percent of high school students using tobacco N/A 34.4 26.3 21.0 regularly SPM 1: The percent of high school students who report drinking in previous month N/A 50.9 48.0 11.0 SPM 7(Old SPM 10) Rate of homicide among teens ages 15.19 8.0 5.0 3.0 Page 1 of 6 Attachment P - PERFORMANCE MEASURE CHECKLIST-PART II MCH MEASURES t r is E a o 'c Priority Need .a v V4 ;el.. 3 o w Explanat.on or Description U i A � � ° .WE �� a � 6 P 7, "Z Cl.tcked Boxes z 4 ao4 Ok " 4 z � 45 e z H z CHILD HEALTH MEASURES NPM 7: Patent of children through age two with completed immunizations N/A 75.4 90.0 90.0 SPM 8 (Old SPM 12): Percent of children on WIC • who are overweight 8.7 8.5 5.0 SPM 3: The incidence of maltreatment of children less than 18(physical, sexual or emotional abuse and/or neglect) 7.4 5.8 10.3 SPM 10: Rate of injury hospitalization among children less than 19 years 321.5 251.0 N/A NPM 10: Rate of death for 0-14 year olds due to motor vehicle crashes 4.9 3.0 9.2 National Outcome Measure 6: Child Death Rate(ages 1- 14) 21.7 20.3 N/A Page 2 of 6 Attachment P PERFORMANCE MEASURE CHECKLIST-PART II MCH MEASURES Priority Need .a e p� C o Explanation or Description 3 s• ppN a m °� w °d x a For ," Xi°• CC « .E e ' '° a u w E : Z t Checked Boxes z . 7 DC C M -0 O s e W G e z `a SPM 5: The percent of children in public schools with access to health education and to care through school based health 7.6 8.75 N/A centers NPM 13: Percent of children without insurance N/A 12.9 . 15.0 0.0 NPM 14: Percent of • Medicaid-eligible children receiving a Medicaid-paid N/A 84.7 93.0 N/A service INFANT HEALTH MEASURES NPM 15: Percent of Very Low Birth Weight live births 1.3 1.0 0.9 NPM 17:Percent of very low birth weight infants delivered at Level III • hospitals 71.0 75.0 90.0 State Outcome Measure 1: Low Birth Weight Rate 8.7 7.5 5.0 Page 3 of 6 Attachment P . PERFORMANCE MEASURE CHECKLIST-PART II MCH MEASURES a Priority Need .« t E E G CI 8 Explanation or Description N ap a ec °� m V r ?+ t a For o u y u W V a a '� 47 bb' .�' t7 u « o ° ° o f U R1 v o o d e k z a Checked Boxes a z z National Outcome Measure 1: Infant mortality rate 6.2 5.7 4.5 National Outcome Measure 3:Neonatal Mortality rate 4.2 3.9 2.9 National Outcome Measure 2: Black/White infant mortality ratio 2.9 1.9 N/A National Outcome Measure 4: Post neonatal Mortality rate 2.0 1.8 1.2 ORAL HEALTH MEASURES 1"New Oral Health Measure: Percent with caries experience 61.6 N/A 42.0 NPM 9: Patent of third graders with protective sealants 29.3 35.0 50.0 Page 4 of 6 Attachment P PERFORMANCE MEASURE CHECKLIST-PART II MCH MEASURES T ., Priority Need 9 a O O Explanation or Description „° El a m °d ... V � d . t 'fie For o u p� °�' r • r '0 u w a o $ x .a. P7 M a ra s °u `a9 z a 4 Checked Boxes z .7a" � DOg 0 .< O z �+ z z 2"New Oral Health Measure: Percent with 26.3 N/A 21.0 untreated decay SPM 6(Old SPM 8): Percent of Medicaid- eligible children receiving dental care 28.3 27.0 57.0 PERINATAL HEALTH MEASURES SPM 2: The percent of births that are unintended 39.2 36.0 30.0 NPM 18: Percent of infants whose mothers received first trimester prenatal care 79.1 85.0 90.0 • SPM 9(Old SPM 13: women with inadequate weight gain during pregnancy 23.5 20.0 N/A NPM 11: Percent of mothers breastfeeding at • hospital discharge 83.5 87.0 75.0 Page 5 of 6 Attachment P . PERFORMANCE MEASURE CHECKLIST-PART H MCH MEASURES C Priori Need a o • a �� ;, Explanation or Description p M e i 54 'oQ v N a�, i ,. v I ti n For to `+ ea o b' a~i A V 'C d e o w ca A ,a A L 2 0 a Checked Boxes z Z � X1 a" O O ..=0Oz ' to, z �' z National Outcome Measure 5: Perinatal Mortality rate 10.1 8.0 4.5 • Page 6 of 6 Attachment Q MATERNAL AM)CHILD HEALTH(MCH) LOCAL MCH PLAN FY06—October 1,2005—September 30,2006 DUE DATE: On or Before May 1,2005 The Local MCH Plan is part of a planning,implementation and evaluation process that is associated with the receipt of State and Federal funds for MCH activities in local district/county health departments at the local level. The information in this document provides guidance for the development of the Local MCH Plan due on or before May 1.2005. Please put the following information at the beginning of the report or on a cover page: 1. Title the Report:"Local MCH Plan for FY06" 2. Agency Name 3. Contact Person 4. Contact's Telephone Number 5. A Listing of the Topical Areas for Which the Goals and Objectives Are Written for example: "Reduce Low Birth Weight—Adequate Weight Gain" "Reduce Child Injury—Car Seats and Booster Seats" 'Improved Perinatal Outcomes—First Trimester Care" "Increase Breastfeeding Initiation" Please submit the Local MCH Plan for Federal FY 06 for the period of October 1,2005 through September 30, 2006,via e-mail to the state MCH office,no later than 5:00 P.M. on May 1,2005 to: Ian Reimer—E-mail Address: jan.reimerPstate.co.us Page 1 of 6 Local MCH Plan for FY 06 In the Local MCH Plan the district/county public health agency is asked to assess and prioritize the health status needs of the Perinatal Population,the Mild and Adolescent Population and the Children with Special Health Care Needs Population(CSHCN)and to identify how the MCH funds will be used to address the priority needs. Quantitative and qualitative data gathered at the state and local levels should be used in assessing health status needs. The re ources available in the community to meet the needs should also be assessed and considered in establishing ih;;priorities to be addressed with the MCH funding. Local public health agencies are encouraged to collaborate with public and private partners in the development of the Maternal and Child Health Plans. It is the intention of MCH federal and state fimded agencies to decrease,over time,the provision of basic health services to individuals using MCH monies and to increase enabling,population-based and infrastructure building activities. The contractor's decision to provide,or not provide,direct patient care services should be based on an assessment of the capacity of the community's public and private providers to meet the direct health care needs of its'perinatal and child/adolescent populations and with the approval of the State. Local decisions about how to use MCH funds must also take into account whether the activities to be implemented are likely to improve the MCH Performance Measures in the entire county or district and not just within a small group of individuals enrolled in a program within the agency. Colorado has identified ten MCH priorities to be addressed with MCH Block Grant funding. The services or activities provided under the MCH funding should be responsive to one or more of the priorities. There is no ranking of the tin priorities. They are as follows: o Reduce teen pregnancy and unintended pregnancy in women of all ages. o Improve perinatal outcomes. o Reduce child and adolescent morbidity and increase health and safety in childcare settings. o Reduce overweight among children and adolescents,addressing physical activity and nutritional habits. o Improve efforts to reduce unintentional and intentional injury, addressing motor vehicle crashes,suicide, child abuse and other violence. o Improve immunization rates for all children. o Increase access to health care(including behavioral health care). o Improve state and local infrastructure by increasing capacity to analyze data,carry out evaluations,develop quality standards, and assure availability of services to all children,including children with special health care needs. o Reduce substance abuse(alcohol,.tobacco,and drugs). o Improve oral health and access to oral health care. Page 2 of 6 A. Statement of Need: For the Statement of Need Section of your MCH Plan,complete the Performance Measure Checklist to assess and present the priority needs for which your agency will use the MCH funding for all three MCH populations. B. Operational Plans for Perinatal and Child/Adolescent populations:. (The Operational Plan and its attachments will become an attachment to the FY06 MCH-HCP Contract) The Operational Plan section shall describe the activities or services to be carried out,under the funding provided by this contractual agreement. These services and activities shall be designed to address unmet or emerging health care needs of the community. These services and activities may include the provision of direct health care services;information and referral services;follow up services;case management services; injury or disease prevention activities;or health promotion activities. These services and activities may also include projects designed to build the Contractor's or the local community's infrastructure,whichever is appropriate,for effective health status improvement These infrastructure-building activities may include the creation of a community planning structure to develop needed health care resources or carrying out further needs assessment The services or activities chosen by the Contractor shall be"Best Practice"or "Evidence-Based"approaches or a promising approach,as identified by a review of the applicable literature and consultation with experts. The Operational Plan section shall present reasonable,measurable and time-framed objectives, activities that will accomplish the objectives,methods to measure progress in completing the activities(process evaluation)and methods to evaluate if the objectives are met(outcome evaluation). The Contractor may select from templates of objectives and activities prepared by the State,if such prepared templates address needs identified as priorities for the Contractor's community in the Statement of Need Section. The objectives and activities of the prepared templates shall be adapted to be reasonable and appropriate for the needs and capacity of the agency. C. Using the MCH Performance Measures Checklist for the Statement of Need The checklist is made up of the performance and outcome measures by which the State MCH program reports to the federal Maternal and Child Health Bureau each year. There are a few additional measures on the checklist. They include original performance measures that are no longer reported to the MCH Bureau if we have been able to continue to track than and some new oral health measures that now have county- level data Complete the cover page at the beginning of the report by providing the following information: I. Title the Report: "Local MCH Plan for FY 06 2. Agency Name 3. Contact Person 4. Contact's Telephone Number 5. A Listing of the Topical Areas for Which the Templates are Selected or Agency-Written Goal and Objective Templates are Provided Page 3 of 6 Step-By-Step Instructions: The measures are grouped by CSHCN Measures, Adolescent Health Measures,Child Health Measures, Infant Health Measures,Oral Health Measures and Perinatal Health Measures. The first seven measures,on the first two pages,of the checklist are the measures that address the Children with Special Health Care Needs(CSHCN)Goals. The Program will still need to complete and submit the HERMAN Document. The CSHCN measures are all nationally set as the measures for the goals for CSHCN programs. It is given,then,that these measures are for priority needs,so local programs will not hay.:to decide whether each is a priority or not. 1. CSHCN Programs will complete the CSHCN Checklist as part of the Statement of Need and submit it with the HERMAN document to their HCP Program Consultant. Follow steps A, B,C& D in Attachment Y, "HERMAN Document Instructions for MCH/CSHCN Plan for FY06"to complete ALL the requirements for the Statement of Need. 2. To complete the Checklist,check the appropriate box under the Priority Need section to explain if and how that measure will be addressed. A rank column is provided just for the CSHCN measures. Local programs are asked to rank the six(6)measures from one(I)to six(6),to indicate the relative priority that they are giving the measures. (One would be the highest rank) 3. In the Explanation Box,provide a brief explanation of what the check mark means. After the CSHCN Section the measures on the Checklist are in the same order in which they are presented in each county's"Maternal and Child County Profile". The checklists have been pre-populated with the data that is provided in the county profiles,beginning with the teen fertility data. You will want to refer to the 2005 County Profiles for your county or counties,which will be provided by the state. Refer to the Profiles,also, for a description of the source of information for the data and how the rates that are reported were determined. The"Trends in MCH Performance Measures"document for each county is also included. These documents were prepared in 2003, after four years of county level data for the MCH Performance Measures had been collected. They analyze your agency's performance for each measure for which county-level data are available relative to the state as a whole and relative to the state goal for 2005 and the HP2010 goal,if applicable. To complete the next section of the checklist: 1. Decide if this measure indicates this is a priority need. Refer to the"Trends in MCH Performance Measures"for the county or counties in your jurisdiction. It will tell you which measures are "close to the goal","far from the goal"or"at some distance from the goal". Any of these designations would mean this is a priority need. 2. For the measures that show a priority need, check one of the boxes under the Priority Need Heading to show if you will be using MCH funds to address that need,if you are using other hinds to address that need;if other agencies in your community are addressing the need;or,if you are not addressing it because there are no funds or there is no agency or community support of addressing that need. It may be appropriate to check more than one box. 3. For the measures that show the need is not a priority for your agency because the goal is already met for that county, simply check under the'Not a Priority Need"Heading. 4 If it is not a priority need,but your agency has determined that you need to continue to use MCH funds in order to maintain the good status that the measure reflects,check under the Need to Maintain Current Effort heading. 5. Provide a BRIEF explanation or description of the situation to explain the checked boxes. Page 4 of 6 D. Using the Templates for the Operational Plan Yon may select state-prepared model goals,objective and activities,choosing as many as are appropriate for the amount of MCH block grant funds you will be receiving.You may use a combination of state- prepared models and agency-developed goals and objectives. Please note that not all performance measures have models developed. Step-by-Step Instructions: 1. For the CSHCN Operational Plan, follow Steps E,F,&G in Attachment Y, 'HERMAN Document Instructions for MCH/CSHCN Plan for FY06". 2. For the MCH Operational Plan for the Child and Adolescent and the Perinatal populations, complete the Cover Page for the Operational Plan for 2005-2006. Choose templates that address priority needs as presented in the Statement of Need Section, and for which you checked that you plan to use MCH funding. 3. For state-prepared model goals and objectives: a. Fill in the appropriate target(the percent or rate to be achieved)that is realistic for your agency and community. b. Choose from the listed activities and follow the sequence of the activities as presented in the template. Select only what is realistic for your agency for the year. For example,if analyzing the need is all that can be accomplished on that objective in a year's time,then select only those activities. Fill in the level of activities,i.e.the number of meetings or number of individuals to be served, etc.,adapting the level to what will be needed to accomplish the objective that you have set. You may also want to add or adapt an activity that is determined to be more appropriate for your community based on past results or best and/or promising practice literature research. Note: It is likely that you will use the same objectives for a number of years,but the activities or level of activities to address the objectives are likely to change annually. 4. For Agency-developed objectives and activities: a. You may choose to use the MCH grant funds for other objectives to meet priority needs of the maternal-child populations in your community or to use other approaches than those outlined in the prepared templates by writing objectives and activities of your own. b. If you choose to do this,you should explain: • what priority need the objective(s)is addressing, • what data or information you used to determine that this is a priority need,and, • what information or experience you used to choose the activities or approach to accomplish the objective. This information may be presented in a paragraph or two preceding the agency-developed objective. Page 5 of 6 c. You should use the same standard table format as that used for the pre-written objective templates. A blank copy of the standard table format is referenced in the Scope of Work as Attachment R,on page 4 of•,and is to be used in presenting any agency-determined objectives. The objectives should be measurable and time-framed;the activities should be ones that will accomplish the objective;there should be process measures that are the ways you will check to see if you are completing the activities;and,outcome evaluation measures that are how you will evaluate whether the objective has been accomplished E. Please submit the Local MCH Plan for FY 06 for the period of October 1,2005 through September 30, 2006,via e-mail to the state MCH office,no later than 5:00 P.M. on May 1,2005 to: Jan Reimer—E-mail Address:ianseimerPstate.co.us Revised June 2,2004 J:We®1CON[RACTSWY 0NdCH-RCP Combined Centrum\Anad.man Q-Instructions for PY06 Local MCH Pim doc Page 6 of 6 Attachment R SAMPLE STANDARD TABLE FORMAT FOR LOCAL MCH PLAN Page 1 of 2 Goal 1: Objective 1: Outcome Evaluation: Outcome/Prcgress: Activities: Process Evaluation: 1.1 1.2 1.3 1.4 Paget of2 HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS(HCP) Attachment S SUGGESTED CHILDREN WITH SPECIAL HEALTH CARE NEED ACTIVITIES TO FULFILL REQUIREMENTS FOR MCH LOCAL HEALTH CONTRACTS AND COUNTY PRELIMINARY AND STRATEGIC PLANS As of October 1,2003 The following suggested strategies are offered as guidance to local public health agencies in defining how current or new services fit within the core public health functions. The Maternal and Child Health contract between local agencies and Colorado Department of Public Health and Environment(CDPHE)requires needs assessment of local communities. Local public health staff is currently doing many of the following activities. The CDPHE Health Care Program for Children with Special Needs(HCP)and Public Health Nursing consultant staff will provide technical assistance,as needed in assisting local public health agencies to define which of these—or other activities—are most appropriate for addressing the needs of children with chronic illnesses and disabilities. 1. Direct Services 1.1 Seek out funding resources and work with specialty providers to establish alternative funding sources for families. 1.2 Work with health providers so that they appropriately refer families to state and local resources that can fund or discount specialty medical care services. 1.3 Offer access to SELECT specialty care through HCP Specialty Clinic program. However no direct payment for services is available through HCP. 2. Enabling Services 2.1. Conduct an initial interview with a defined population(NICU,SSI,etc.)of new families to help than determine their need for information,referral and/or care coordination using a standard tool such as the"Family Status Profile"form. 2.2. Assist families who have insurance coverage,including private insurance,CHP+and Medicaid and those in managed care plans,to understand their benefits and their disenrollment and grievance procedures. 2.3. Refer families to agencies and services for which they are eligible and assist them with the registration or application process,e.g.,WIC,CHP+,Baby Care/lCids Care,Medicaid,SSI,Part C,Voc Rehab, Mental Health,etc. Follow-up with the family to assure the family was able to make the suggested contacts. 2.4. Determine the status of primary care and immunizations and make appropriate referrals. Work in collaboration with the EPSDT outreach worker if the child is on Medicaid to assure that EPSDT benefits have been explained and an EPSDT screen has been completed and billed. 2.5. Initiate or participate in the development of a Care Plan,IFSP(Individual Family Service Plan),or IEP(Individual Educational Plan)with the family and medical home when it has been determined that a family would benefit from care coordination. This includes a statement of the family's strengths and needs as identified by the family and strategies for enhancing the child's Page 1 of 5 development Include a statement of major outcomes to be achieved by the child and family. State the criteria,procedures and time lines. Document periodic statements of progress towards meeting family goals and the need for modifications or revisions. The process for the development of a care plan, IFSP,or LEP should include all the disciplines involved with the child's care,i.e.,medical home, audiologist,CHIP therapist,social worker,family advocate,OT/PT,dietitian,speech therapist,etc. 2.6. Follow-up with family according to plans written on care plan,IFS?,or IEP. Should HCP staff have no direct role in the IFS!'or IEP,or are not doing care coordination,assure that a contact with each family is made at least once a year to assure that the child and family are receiving necessary services and that the family is aware of community resources available to them 2.7. Make home visits when appropriate. (Situations might include complex medical or surgical conditions or when resources or help can be provided relating to the home environment) 2.8. ..Work in concert with the EPSDT outreach worker to review monthly listing of SSI recipients and Contact SSI families to assure that health care needs are being met If there are needs which HCP can meet,assure that children are enrolled in the program. 2.9. Meet periodically with staff from local agencies such as social services,representatives from the Community Centered Board,mental health and special education services from local schools to collaborate around services to individual children and their families. 2.10. Work with the older children and their families to facilitate transition from pediatric services to adult health care services. (To begin at about age 12 years.) 2.11. Work with NICU Consortium contacts in hospitals to identify needs of newborns as the child prepares to leave the hospital to return to the community. Make contact with other community resources as needed. 2.12. Design and maintain a clinic structure including identifying and scheduling clinic providers,facilities, and equipment Set clinic dates. Seek referrals by contacting local doctors,Child Find,interagency councils,and Community Center Boards to inform them of the clinics. Distribute the local HCP clinic schedule to appropriate agehcies and individuals. 2.13. Organize,schedule and staff each clinic using guidelines provided in the HCP Procedure Manual. Obtains a HCP application on each child scheduled for clinic and a consent for service signed by the parent or legal guardian. Provide the clinician with Medicaid and private insurance billing information and collect clinic support fees. 2.14. Complete a Clinic Encounter Form for each clinic patient After each clinic submit Encounter Forms, a copy of the attendance list(schedule)and the dictation to the assigned Regional Office. 2.15. Assure that families have transportation to each clinic and that appropriate and competent interpretation services are available. 2.16. Depending on the complexity of the child's condition and the needs of the family,appropriate team members shall attend,when available,and participate in the HCP Specialty clinics. 2.17. Evaluate the clinic caseload,waiting list and summaries yearly to determine the number and type of specialty clinics needed. Report findings to the Regional Office Team Leader and State Nursing Consultant Page 2 of 5 2.18. Identify existing primary health care and specialty providers and support resources including translation,transportation and respite care. 3. Population-based Services 3.1. Promote public health services available to children,i.e.,HCP,WIC,EPSDT,and Immunization,by using local media,posters and attendance at health fairs,etc. 12. Develop and maintain liaisons with the local community resources to maintain open communication, to promote the services of HCP and other services available to children with special needs,and to establish a network for working together to eliminate gaps or duplication of services and supports. 3.3. Assure that HCP staff is knowledgeable in Early Childhood Connections(Part C of IDEA),IFSPs, Service Coordination,Procedural Safeguards and eligibility criteria. 3.4. Assure that HCP staff is knowledgeable in the eligibility criteria and referral procedures for Medicaid, SSI,Children's Medical Waiver 200,Children's Home Care Based Services Waiver(Katie Beckett- Model 200 Waiver),and EPSDT. Assure that EPSDT case managers are knowledgeable about HCP services. 3.5. Assure that training opportunities are provided to staff on cultural competency and family-centered care. 3.6. Establish or maintain interagency collaboration through periodic meetings with representatives of the local human services agencies,the Community Center Board,the mental health agency and special education services from the school district to understand their services,to learn about their eligibility criteria,and to provide them with information about HCP and other resources within the local community. 3.7. Participate in the community's early child identification process as an active member of the community team. This participation could include assigning staff time to directly participate in a community sponsored identification process or coordinating the agency's services such as EPSDT, RCP and WIC,with other efforts so as to provide on-going systems of early identification for children 0-21 years. 4. Infrastructure-building Services 4.1. Know the numbers of children in the counties served by the agency and be able to estimate the number of children with special health care needs. Know the target population of children who could potentially benefit from HCP services and the actual number of children currently registered with HCP. Analyze large discrepancies between target and actual caseloads. 4.2. Know and analyze the numbers of children enrolled on HCP for care coordination only. Page 3 of 5 4.3. Coordinate and/or participate in conducting a community needs assessment with public and private agencies,organizations,providers and parents which identifies problems or voids within the service delivery system for children with special health care needs,defines the problems and determines the services or changes necessary to meet the identified needs. Elements involved in this process include: 4.3.1. involvement in tracking and data collection efforts of the community concerning the number of children with special health needs,the types of services needed,the types of services available,the accessibility of services,the quality of the services,whether the services are culturally competent and family centered,and a method to receive customer feedback about the services. 4.3.2. Awareness of and collaboration with other community agencies and projects regarding data that is being collected and use of the data to most effectively enhance the community service system for children with special needs. • 4.3.3. Establishment of mechanisms to include strong family participation in the development of all assessments. 4.3.4. Coordination with other agencies and organizations to jointly survey the community including families,providers and human service agencies and development of a process to provide feedback to those who participated in the answering of the surveys. 4.4. Provide assessment reports to the community. 4.5. Coordinate and/or participate in the community planning process to develop policies goals and objectives based on the community needs assessment 4.6. Develop local networks and partnerships with other communityresource agencies to determine policies to support the development of comprehensive,community-based systems of care including identification,assessment,intervention and referral services for children with special health care needs. 4.7. Develop referral and follow-up care systems using available resources such as Colorado Responds To Children With Special Needs(CRCSN),NICU Consortium,Universal Newborn Hearing Screening Programs,and hospital discharge planners,to identify children who may need support,care coordination and/or referral to community resources. 4.8. Establish a mechanism for including input from parents regarding current services,planning,policy development,implementation and evaluation of HCP paid service benefits as well as community/health services for all children with special health care needs. The process should include a means to provide feedback to families about decisions made in these areas. 4.9. Develop and maintain a system of parent support that includes: 4.9.1. Parent to parent support and/or support groups; 4.9.2. Internal practices that support advocacy for family needs and problem solving; 4.9.3. Information and education; 4.9.4. Linkages with community agencies to assure the availability and adequacy of resources to support the needs of families. Page 4 of 5 4.10. Assure that there is community parent representation from families who have children with special needs in the community service system efforts. (For example,attending meetings,contacting representatives,providing input into quality and quantity of local services.) 4.11. Participate actively in a community interagency council(ICC)by meeting regularly for the purpose of planning and policy development (These can be a formal or informal group of agencies,providers and parents who are interested in working together to discuss services ix children with special needs, to identify barriers and gaps in the service delivery system,to develop collaborative plans for removing the barriers and gaps including writing community-based grants for improvement of local systems. Revised June 17,2003 • JAPegreCOMRACTSIFY O MCWIfl Cmboed CmhactAiom s U.Suggested C47CN Activpo.doc - . Page 5 of 5 Attachment T MATERNAL AND CHILD HEALTH(MOT) CHILDREN WITH SPECIAL HEALTH CARE NEEDS(CSHCN) 6 CORE OUTCOMES AND PERFORMANCE MEASURES As of October 1,2003 Outcome#1: Families of children with special health care needs(CSHCN)will partner in decision making at all levels,and will be satisfied with the services they receive. I. Percent of families of CSHCN reporting satisfaction with the quality of:regular source of primary care, getting referrals and appointments for needed services,coordination between primary and specialty care overall services. 2. Percent of parents of CSHCN who report satisfaction with their level of involvementlmput in setting concerns and priorities to make decisions about their child's care plan. 3. Percent of parents of CSHCN who report knowing the steps to take when they are not satisfied with the services their child/family receives. 4. Nu:/. •er of parents of CSHCN who are supported financially for their involvement in state and local activities. 5. Number of parents of CSHCN who report that they are effective partners in policymaking at the state and local levels. Outcome#2:All children with special health care needs will receive coordinated ongoing comprehensive care within a medical home. 1. Percent of CSHCN with a regular source of primary medical care through a primary care provider. 2. Percent of CSHCN whose regular source of care communicates in a way that is clear and understandable to the family. 3. Percent of parents whose regular source of primary medical care identifies,discusses,and addresses the comprehensive needs of their child and family. 4. Percent of CSHCN whose regular source of primary medical care ensures age-appropriate well-child checks, including:vision,hearing,developmental,behavioral/mental health,oral health,newborn screening, immunizations. 5. Percent of parents of CSHCN who receive referrals and assistance from their regular source of primary medical care in accessing needed/desired services. Outcome#3:All families of children with special health care needs will have adequate private and/or public insurance to pay for the services they need. 1. Percent of CSHCN with insurance that covers costs of needed services,including:mental health,dental care,age-appropriate well-child checks,durable medical equipment,ancillary services,non-durable medical supplies, care coordination,prescriptions,specialty care,related therapies(e.g.,PT,OT,speech/language, audiology),in-home nursing. Page I of 3 2. Amount of out-of-pocket costs paid by families of CSHCN,including costs of mantal health,dental care, age-appropriate well-child checks,durable medical equipment,ancillary services,non-durable medical supplies,respite care,transportation,care coordination,prescriptions,specialty care,related therapies(e.g., PT,OT,speech/language,audiology),in-home nursing,home modifications,car/van modifications. 3. Percent of CSHCN who can choose the providers of their choice. 4. Percent of CSHCN whose insurance provides:timely approval for needed care,overall parental satisfaction, clear information,about coverage resources,and complaint procedures to providers and parents Outcome#4:All children will be screened early and continuously for special health care needs. 1. Percent of infants whose mothers began prenatal screening in the first trimester of pregnancy,for smoking, alcohol,drugs,tests for birth defects,11W,physical abuse. 2. Percent of infants and families being tracked for special health care needs and developmental delays. 3. Percent of children receiving age-appropriate well-child checks including:vision,hearing,developmental, behavioral,mental health,oral health,metabolic,and EPSDT(if implemented in state). 4. Percent of children receiving needed follow-up due to failed screening or risk factors:vision,hearing, developmental,behavioral,mental health,oral health,and metabolic. Outcome#5:Services for children with special health care needs and their families will be organized in ways that families can use them easily. 1. Percent of parents of CSHCN who have a single coordinated service plan that involves all providers and a lead service coordinator who communicates with the family. 1 Percent of parents of CSHCN who report that they are able to access comprehensive services for their child and family. 3. Percent of parents of CSHCN who have specialty care available in their region of the state. 4. The degree to which the state service system has an enrollment/eligibility process that links families of CSHCN(and their medical home)with a wide variety of public and private services and resources. 5. Number of private/public partnerships to provide community-based,comprehensive medical services for CSHCN,e.g., data sharing,contracts,MOM. Outcome#6:All youth with special health care needs(SHCN)will receive the services necessary to make • appropriate transitions to adult health care,work and independence. 1. Percent of youth with SHCN who by age 14 have a transition plan that addresses employment,transportation, housing,independent living,physical and mental health and necessary accommodations; and percent of youth with SHCN by age 16 have a transition plan that includes appropriate agencies as part of the transition planning team. 2. Percent of youth with SHCN whose regular source of primary medical care facilitates the transition from pediatric to adult providers. Page 2 of 3 3. Percent of adult health care providers who are prepared to save youth with SHCN. 4. Patent of youth who report satisfaction with the information and training they received to make informed decisions about their health care and other services. 5. Percent of youth with SHCN who receive necessary services/supports by age 21: Health insurance,Post- secondary education,Employment,Transportation,Housing,Personal care attendant, SSI, SSA-related work incentives, e.g. PASS, 1619 a&b. I\PenflcON1RAc-SPY OSMCH-HCP Coodmed Coot —:V.MCH CSHCN 6 Core 06&Pt doe • Page 3 of 3 Attachment U Health Care Program for Children with Special Needs(HCP) HCP Single County Regional Office Standards for Usage of IRIS II Data Entry 1. HCP Policies and Procedures will be followed as described in the HCP Policy and Procedure Manual, IRIS Help File, agency contract and training materials. II. Documentation of Activities I. Community Encounters will be entered to provide documentation of systems building and population based activities. (Community meetings, outreach,screening,training activities) 2. Person Referrals will be entered to document all referrals. Referral outcome will be entered for each referral. 3. Person Encounters will be entered to document person contact and person concerns. Care coordination will be entered when care coordination is being provided for specific concerns. 4. HCP Clinic data will be entered before clinic date on IRIS Clinic Schedule. Outcome will be entered after the clinic date for all HCP clinics. III Data entry for HCP Caseload on IRIS I. CSHCN Caseload on IRIS includes all CSHCN with whom agency staff have had person encounters and/or provided referrals within previous twelve months of the reporting period. 2. Each person receiving any level of care coordination services will have a Person Encounter entered showing a concern score. The concern score is determined by number of concerns with care coordination being provided by HCP staff. Concern outcome will be updated as needed or at least yearly. . 3. Person Referrals will be entered for all children receiving resource and referral services. 4. Data for all children receiving screening,assessment and/or consultation from a HCP Regional Coordinator will have person encounters,concerns,and/or person referrals with care coordination documented in IRIS. 5. A clinic visit is entered on clinic visit screen each time a person attends a HCP clinic. III. IRIS Security 1. The IRIS II Security Policy and Procedures will be followed. All new IRIS users and current staff and supervisors will sign the IRIS Security form and User Profile Form and submit to the state office as requested. IRIS passwords will be changed every sixty days along with the CITRIX password. Both passwords will be kept confidential and will not be shared. Page 1 of 2 IV. IRIS training 1. New HCP employees will complete the HCP Training CDs including security,multi-disciplinary training and program orientation. New IRIS users will complete IRIS training at the State HCP Office. The Regional HCP Office will provide IRIS training using the IRIS Train the Trainer materials when new users are not able to attend state training. New IRIS users will not be given IRIS access until both IRIS training and HCP Training CD have been completed: 2. New HCP Team Leaders and HO'Technicians will attend IRIS training in the State HCP Office unless local training is negotiated with the State Office. Revised June 4,2004 I:\Peg�CON7RACTSgFY 05\MCH-HCP Canbined Contract Single CamtNWeldWtecimnj U-IRIS Standards 05-Single Cty R(k.doc • Page 2 of 2 Attachment V Health Care Program for Children with Special Needs (HCP) IRIS II Security Policy, Procedures and Guidelines Security policy and procedures protect personal health information and IRIS data. The following IRIS security procedures are required for County Nursing Services,Health Departments and HCP Regional Offices: 1. IRIS Users(HCP Staff) a. IRIS users including current users,supervisors and new users will sign a Security and Secure Web User ID Form before a personal ID and password are assigned for access to CITRIX and the IRIS database. Users will sign a new security form as requested by State HCP Office. b. IRIS users will have a personal ID and password assigned by the State HCP Office after completing IRIS training. c. IRIS users will not allow new agency staff,another agency staff person, staff from another program or any person to have access or use their CITRIX/IRIS ID and password. d. New IRIS users will complete IRIS and security training as defined in the IRIS Standards. 2. An agency supervisor will sign the security form for each HCP/IRIS user indicating the access level the staff person needs. Forms will be sent to the State HCP office to request a new ID and password for new staff or when duties change for current staff. A new ID and password will be issued based on the request of the supervisor and the discretion of the State HCP Office. Agency supervisors will not allow or request access for any staff that does not have the need to access HG'person specific data on IRIS. 3. Local Health Department,HCP Regional Office and Nursing Service agencies will have agency policies and procedures for IRIS security and confidentiality. All staff will be trained on the importance of security and confidentiality. 4. Agency supervisors will contact the State HCP office and request that an ID and password be expired when an IRIS user leaves the HCP Program or no longer needs IRIS access. IRIS Users will be deactivated if they have not signed onto IRIS within six months. Agency supervisors will notify the State HCP office to request a specific person's ID/password be disabled when a security breach is suspected. A new ID and/or password will be issued based on the request of the supervisor and the discretion of the State HCP Office. 5. Agency supervisors will supervise and monitor access to the IRIS Database. Agency supervisors will not allow sharing of IDs or passwords. 6. Agency supervisors will monitor/implement HCP policies and procedures for release of information and consent for clinic services including HIPAA disclosures as defined with local agency HIPAA policy. (The Health Insurance Portability and Accountability Act of 1996(HIPAA) 164.528 regarding accounting for disclosures.) 7. Security for IRIS access to Newborn Evaluation, Screening, and Tracking(NEST)data will be predefined with business rules and HCP Policies and Procedures. The agency will identify staff members that have a 'need to know"for public health information from the NEST database. Page I of 2 • • M , 8. The IRIS Security Policy and agency HIPAA procedures will be followed when providing care coordination for referrals and requests for follow-up from NEST data. 9. When an IRIS user forgets a personal password,they will call the IRIS Help Line or the State HO'office for assistance. The IRIS Help Line staff will re-set the personal password to a default password. The IRIS user v 4 immediately change the default password to a secure personal password as defined in training material. 10. Agency supervisors will require IRIS users to change their IRIS password every 60 days when the CITRIX password is changed. Passwords will be changed more frequently if it is suspected that the password has been compromised. Revised May 28, 2004 1•WegloACCHITRACTSTY O5\McH.ACP Combined CmfactWfedimey V-IRIS II Security Policy 05.doc • Page 2 of 2 Attachment W HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS(HCP) HERMAN DOCUMENT INSTRUCTIONS FOR HCP REGIONAL OFFICE MCH/CSHCN PLAN FOR FY06 FOR PERIOD OF: OCTOBER 1,2004 THROUGH SEPTEMBER 30,2005 DUE DATE: On or Before MAY 1,2005 As of May 24,2004 Please present the Statement of Need and the Operational Plan for Children with Special Health Care Needs(CSHCN) by following the instructions provided below to complete the appropriate parts of the HERMAN Document: A. Complete the cover page for the HERMAN Document that contains the following information: 1. Agency name 2. Date of report 3. Contact person for report 4. Contact's telephone number,and 5. Contact person's email B. Complete Sections A3 &A.4-Surveillance of Need for Performance Outcomes 1-7. This fulfills the first part of the Statement of Need for the MCH/CSHCN Plan for FY06. Follow the guidance in HERMAN for specific directions on data sets and IRIS reports to utilize- If IRIS reports are not available,then state"data not available"in your report C. Read Section B-Self-Assessment and Prioritization,for Performance Outcomes 1-6(NOTE:Outcome#7 does rag have a Section B). Review the information provided in A3 &A4,read the guidance section in B,and then complete the CSHCN Checklist. D. Send completed CSHCN Checklist as an attachment to HERMAN.This fulfills the second and last part of the Statement of Need for the MCH/CSHCN plan for FY06. E. Complete Section C-MCH Plan Activities and Evaluation Outcome Measures,for Performance Outcomes 1-7. Follow the steps below: 1. For Performance Outcomes 1,3-5,and 7 choose option A or B. • If you choose"A",then you have completed Section C for that Performance Outcome. Your operational plan for that Performance Outcome is that you will continue to fulfill the associated HCP contract performance measures at the same level. No template is submitted. • If you choose"B",you need to select from or modify the objectives supplied in the CSHCN templates or develop your own. Use the template format supplied by CDPHE. 2. For Performance Outcomes 2 and 6 there are no HCP Contract Performance Measures directly related to the Performance Measures. You need to select from or modify the objectives supplied in the CSHCN templates or develop your own.Use the template format 3. Send all completed templates as an attachment with HERMAN. This is your MCH/CSHCN Operational Plan. F. Save your newly named HERMAN document to your hard drive or a floppy disk. Page 1 of3 G. Submit your operational plan(templates),CSHCN Checklist,and HERMAN Document,via a-mail,for the period of October 1,2005 through September 30,2006,no later than 5:00 P.M.May 1,2005 to: Jan Reimer—E-mail Address:jan.reimer(a,state.co.us And Your State HCP Program Consultant(see next page for e-mail addresses) • Page 2 of 3 HCP PROGRAM CONSULTANTS AND THEIR REGIONAL OFFICE ASSIGNMENTS, E-MAIL ADDRESSES AND PHONE NUMBERS HCP PROGRAM PHONE NUMBERS& REGIONAL OFFICES CONSULTANT E-MAIL ADDRESSES Boulder HCP Regional Office Vickie Thomson 303-692-2458 vickie.thomson@state.co.us Denver HCP Regional Office Eileen Forlenza 303-692-2794 eileen.forlenzaO,state.co.us El Paso HCP Regional Office Steve Holloway 303-692-2327 stephen.holloway@state.co.us Jefferson HCP Regional Office Anne-Marie Braga 303-692-2362 -Broomfield Health Dept anne-maiie.braga@state.co.us Larimer HCP Regional Office Shirley Babler 303-692-2455 shirley.babler@state.co.us Northeast HCP Regional Office Lynn Bindel 303-692-2392 lymbindelastate.co.us Northwest HCP Regional Office Lynn Bindel 303-692-2392 lvnn.bindel@state.co.us Pueblo HCP Regional Office Steve Holloway 303-692-2327 stephen.holloway(a,state.co.us South Central HCP Regional Office Shirley Babler 303-692-2455 -Las Animas-Huerfano Health Dept shirlev.bablerO,state.co.us Southeast HCP Regional Office Eileen Forlenza 303-692-2794 elleertforlenza@state.co.us Southwest HCP Regional Office Anne-Marie Braga 303-692-2362 annemarie.braga(a,state.co.us Tri-County HCP Regional Office Charla Low 303-692-2423 charlalow@state.co.us Weld HCP Regional Office Lynn Bindel 303-692-2392 Ivnn.bindel@state.co.us Western Slope HCP Regional Office Karen Fehringer 303-692-2399 -Delta Health Dept. karen.fehring er@state.co.us Revised May 24,2004 1 We®•ODNTRACIgyyON.al-H(3 Combined CmtraRWbchmml Y•HERMAN Imhuc4m.duc Page 3 of 3 Attachment X Health Care Program for Children with Special Needs (HCP) Policy and Procedures Care Coordination Services for Children and Youth with Traumatic Brain Injury October 1, 2004 -September 30, 2005 Page 1of12 Health Care Program for Children with Special Needs (HCP) Policy and Procedures Care Coordination Services for Children and Youth with Traumatic Brain Injury October 1, 2004 -September 30, 2005 I. Overviewof Care Coordination Services For Children and Youth With Traumatic Brain Iniury(TB!) Traumatic Brain Injury Care Coordination is a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet individuals' needs, using communication and available resources to promote quality, cost effective outcomes. TBI Care Coordination operates with an underlying premise that when individuals reach their optimal level of wellness and functional capability, everyone benefits: the individual and family being served, their community support systems, the healthcare delivery system, and insurance carriers. The primary functions of TBI Care Coordination are: i) To maximize individual and family understanding and participation through education and support. ii) To advocate for individual wellness and autonomy through advocacy, communication and identification of service resources. iii) To optimize access to appropriate community services. iv) To integrate and coordinate service delivery by multiple sources and to prevent fragmentation of services. HCP Care Coordination Services for Traumatic Brain Injury follow HCP Policies and Procedures and are applied consistently by Care Coordinators in all HCP Regions of the state. • The term"individuaVfamily" refers to whoever has legal responsibility for the person receiving program services. This may be the parent of a minor, an emancipated youth, a guardian, a county department of social services, or another party having legal responsibility for the program participant. • Page 2 of 12 H.Training HCP Staff Regional/County HCP staff/care coordinators attend training before providing care coordination services and receiving funding for TBI Care Coordination. The State HCP office will keep records of HCP staff who have completed training for TBI Care Coordination. HCP staff must participate at required HCP TBI Care Coordination training or if unable to attend must complete the following steps before providing TBI Care Coordination: i) Read provided Power Point Presentation and Handouts ii) View HCP Training Video iii) Read the Brainstars Manual iv) Submit a completed Care Coordination Sample Plan to the Regional Office Team Leader and/or State Nursing Consultant. For review and approval. v) Discuss Questions/Concems with the HCP Regional Office Team Leader and/or State Nursing Consultant III. Eligibility and Referral Process 1. Eligibility-The Brain Injury Association of Colorado (BIAC)will perform client intake and determine eligibility for the Colorado Traumatic Brain Injury Program. Once the family is determined to be eligible the family is approved for a 12-month period of care coordination funded by the Colorado Traumatic Brain Injury Trust Fund. Eligible dates for a 12 month period beginning on the date the care coordination plan is signed. BIAC will refer eligible families/individuals under age 21 to the state HCP Office (CDPI{E) for care coordination services. Families/individuals seeking program services will contact BIAC directly to begin the application process through one of the following options: A) The family/individual contacts the Brain Injury Association of Colorado directly. B) Families/individuals contacts the state HCP office or the HCP Regional or County Nursing Agency. The HCP office informs the family/individual that the Brain Injury Association of Colorado will complete the application process and determine eligibility for program services. The HCP office provides contact information for BIAC to the family and family contacts BIAC. C) Family/individual contacts the state HCP office or the HCP Regional Office or County Nursing Agency. HCP contacts the Brain Injury Association of Colorado on behalf of the family/individual, and provides the family/individual's contact information so that the Brain Injury Association may contact the family/individual to begin the application process. HCP will notify BIAC within two (2) business days of its initial contact with the family/individual seeking services. Page 3 of 12 2. Referral Process A) BIAC refers eligible families/individuals under age 21 to State HCP office (CDPHE) for care coordination services. B) State HCP office forwards referrals to the appropriate Regional HCP Office. C) The Regional HCP Office forwards all referrals to the appropriate HCP County Nursing Agency. 3. Wait List-Program services are subject to available funding. If the demand and need for care coordination services exceeds the available funding, state HCP office will maintain a wait list of eligible persons. A) Wait list is maintained in order of the date of referral, and individuals shall receive program services on a first-come, first-served basis. B) Persons are also put on the waitlist when the demand is too great for an HCP regional or county nursing office's capacity. The HCP regional or county nursing office and the state HCP office referral manager determine HCP office capacity. C) The HCP office referral manager reviews active caseload and the number of new referrals received each month to determine if additional new referrals can be referred to Regional Offices. 4. Referral Packet The referral packet includes the signed application from the Brain Injury Association of Colorado, documentation of diagnosis and any supporting eligibility information, signed informed consents, and signed subrogation form. A) BIAC sends referral packet for eligible persons to State HCP office referral manager B) Referral manager assures completeness of referral packet contents, including signatures. C) Referral manager forwards referral packet to the HCP regional or county office. D) Referral manager documents the referral in the state HCP TBI database. IV. Implementing Care Coordination Services 1. Assignment of Care Coordinators HCP solicits and considers the family/individual's preferences when assigning a Care Coordinator within the capacity of the HCP staff. Factors such as gender, age, culture, language, location, and hours of availability may be considered as part of this process. A) The HCP Regional and/or County Office assigns a Care Coordinator to the family/individual. B) Care Coordination assignments are documented in IRIS. Page 4 of 12 • . f • 2. Developing the Care Coordination Plan A) The HCP Care Coordinator and family/individual develop the care coordination plan together. The plan reflects the family/individual's own identification of service needs. The care coordination plan is not a clinical treatment plan and does not reflect clinical treatment goals or objectives. In selecting specific service providers, the Care Coordinator should assist the family/individual to choose from among available providers, taking into consideration any preferences the family/individual may have concerning the service providers. Factors such as gender, age, culture, language, location, pediatric specialty, experience with children with special needs and hours of availability may be considered as part of this process. The care coordination plan identifies financial assistance programs the family/individual is receiving, or may be eligible to apply for within the community or at the State or federal level. B) Document plan on"Health Care Program for Children with Special Needs (HCP) Care Coordination Child/Family Plan of Care" form provided by state HCP. Refer to figure #1. C) Each outcome/goal must have a documented expected date outcome/goal is to be achieved. D) Each outcome/goal must state specific actions/interventions in a logical sequence. E) For every action/intervention there must be documented an assigned responsible person. F) Evaluation of outcome goal status will be documented during and at the end of the 12 month period of care coordination services. 3. Signing the Care Coordination Plan The family/individual who receives program services must agree to the terms of the care coordination plan. A) Family/individual signs original agreed upon care coordination plan form B) HCP Care Coordinator signs and initials original care coordination form and gives copy of form to family/individual. C) Any additionally assigned HCP Care Coordinator that is involved in modifications or evaluation of the plan's status must initial and sign the original form Page 5 of 12 .. t 4. Approval of Care Coordination Plans The Regional HCP Office and/or State HCP Office reviews and provides consultation for new care coordination plans. A) Shortly after State HCP sends the referral packet to the HCP regional or county office, assigned State staff will contact that local office to provide consultation. B) HCP Regional and county offices keep a hard copy of completed and signed care coordination plans on file. C) State HCP office completes a follow up review of a monthly random sample of 25% of new care coordination plans. D) For ongoing consultation, as needed, local offices can contact State and/or Regional office personnel. 5. Duration of Care Coordination Services CDPHE shall provide the care coordination services included in the care coordination plan for a period of twelve (12) months from the date of signature on the completed care coordination plan. If DPHE and/or the family/individual determine that care coordination services are no longer necessary before the end of the twelve-month period, DPHE shall place the client on"inactive" status. If the family/individual requests and needs additional care coordination services after being placed on inactive status and before the end of the twelve-month period, DPHE shall place the client on "active" status and resume services to the family/individual. At the conclusion of the twelve-month period, DPHE shall close the individual's case. A family/individual may submit a new application for care coordination services to the Brain Injury Association of Colorado at any time. V. Client Records Upon completion and signing of a care coordination plan, the HCP regional or county office opens and maintains a client record for the individual receiving services. The client record includes the following: A) Application for benefits, documentation of eligibility, and signed client agreements and consent for release of medical records. (The Brain Injury Association of Colorado provides these documents, and they are included in the referral packet sent from the state HCP office.) B) The signed Care Coordination plan. C) Progress notes for each contact with the family/individual receiving services. Progress notes can be either hard copy written notes or can be documented in the IRIS database as client encounter notes. If the chart is needed for audit purposes, the IRIS encounters are printed and included in the chart. D) Completed satisfaction surveys from the client, the client's family, or other stakeholders. Page 6 of 12 E) Record of any client appeals and grievances, and responses to these appeals and grievances from the State HCP Office. Documentation for client appeals and grievances are entered in progress notes. See above. F) The client's Social Security Number which cross-checked for client identification. 1. Maintenance of Client Records The Regional, State and County HCP Offices maintain all client records in a locked and secure area following the HIPAA guidelines on security and confidentiality of all written or oral communications regarding the family/individual receiving benefits. Client records are available, on request,to any State or Federal agency with review and audit authority, specifically State and Regional HCP agencies and Department of Human Services (DHS). All client care coordination records are the property of DHS and shall be surrendered to DHS upon request. 2. Sharing Client Records/Care Coordination Information A) Health Insurance Portability and Accountability Act(HIPAA) HCP Regional and County Agencies shall comply with all applicable provisions of the Health Insurance Portability and Accountability Act of 1996. HCP staff and care coordinators follow County HIPAA policies and procedures for security and confidentiality. HCP staff provides County Privacy Practices during first contact with families. Disclosures of Personal Health Information are documented on approved County Disclosure Form. B) Consent/Authorization - The family/individual receiving care coordination benefits signs an HCP authorization to allow communication between County, State and Regional HCP Offices; all service providers listed in the care coordination plan and the State Department of Human Services (DHS). HCP Offices use their own agency's current HIPAA consent/authorization forms. C) Disclosure Tracking - The HCP County and Regional HCP Offices document any disclosures/sharing of the client's records on the agency's HIPAA disclosure form. D) Privacy Practice Policy- The HCP County and Regional HCP Offices provide the individual/families receiving services the current agency's HIPAA privacy practice policy. Page 7 of 12 VI. IRIS Documentation Specific TBI Care Coordination information is documented on IRIS by either the HCP regional or county office. The procedures are as follows: 1. Enter demographic information from the BIAC Application. (Program, Person and Household screens). 2. Enter time elapsed since injury. This information is available from the BIAC application and Household screens. This information is entered on the Program screen. 3. Enter"TBI Care Coordination" as the benefit type on benefit calculator. Enter the approved 12 month date range from the TBI application as eligibility dates. (Benefits Calculator) 4. "Active"status is automatically assigned by IRIS when the registration process, encounters and/or referrals are completed and entered. To change the child's status to"inactive", a new Benefits Calculator is added for"TBI CC Inactive". The ending date is changed to the date the status change is entered. 5. A "Welcome Letter for Care Coordination" is mailed to individual/family. IRIS generates an auto encounter to document the correspondence. (HCP Letter) 6. Enter client encounters to document all contacts with the individual/family. 7. New concerns are added as necessary with each encounter. (Concerns) 8. Progress notes are entered to document progress on the care coordination plan. See also Section III Client Records. (Client Encounter). 9. Enter all referrals to document the family's being referred to community resources, medical providers, etc. (Client Referral Screen). 10. Enter services the child is currently receiving when care coordination with HCP begins and services the family starts during care coordination with HCP. (Client Services Screen) 11. Change the benefit type and ending eligibility dates on the Benefits Calculator when the individual/family no longer needs HCP Care Coordination i.e. "Closed- moved from state". NOTE: Care Coordination Care Plan will be added to IRIS after July 1, 2004 and documentation will be entered in IRIS on the Care Plan Tab on the Client Chart. The care plan will be printed from IRIS as an IRIS Report and then signed by the family and the care coordinator. VII. Reimbursement for Care Coordination The fixed price for care coordination services reimbursement is $850 per client per year. The fixed price per person covers all of the care coordination services the client needs for a period of twelve (12) consecutive months after the care coordination plan is completed and signed. Services may be provided to an individual for up to one year. However, services shall be discontinued and the client placed on "inactive" status if the individual's need for care coordination services has been met prior to the end of 12 months, or if the individual no longer qualifies for services (e.g. he/she moves out of state). Page 8 of 12 . . , . Once a care coordination plan is signed, the care coordinator will send the HCP care coordination invoice(Provider) to Rasa Eglite with a check box assuring the plan is signed. Rasa will log the information and initiate payment process. VIII. Quality Assurance The State HCP Office, in collaboration with HCP regional and county offices, completes quality improvement activities on a yearly basis. State and Regional HCP ensures that all Care Coordinators are appropriately and consistently trained, apply the policies and procedures for care coordination services, and participate in audits of care coordination care plans, client records, IRIS documentation and . family satisfaction surveys. The State HCP office: A) Evaluates the outcomes of the care coordination services provided by determining whether the quality of clients' lives have been maintained or improved as a result of receiving services. B) Evaluates administrative processes, such as customer service, and response to appeals and grievances; and C) Uses results of quality improvement activities to plan and improve HCP care coordination services and administrative systems. State HCP documents its quality improvement efforts and makes information on quality improvement activities and results available to clients, families and other stakeholders. 1. Customer Satisfaction Surveys State HCP requests that families/individuals who receive program services complete a Customer Satisfaction Survey when an individual goes on "inactive status", and at the end of twelve months when the case is closed. HCP provides assurances to clients that their responses will be confidential. HCP uses the results of satisfaction surveys to evaluate the outcomes of the services provided and the administrative referral and documentation system A) HCP Regional or county office sends family the "Customer Satisfaction Survey'provided by State HCP office. B) Survey is sent out when family goes on "inactive status"and/or at end of 12-month service period. D) Regional and county office staff instructs family to complete survey and return to State HCP office. E) State HCP office compiles and shares survey data and results Page 9 of 12 2. Annual Quality Improvement Report State HCP submits an Annual Quality Improvement Report to Department of Human Services, September 30 each year. The Report includes: i) A quality improvement program description outlining the administrative structure and operation of the quality improvement program; ii) Results of the previous year's quality improvement activities iii) A work plan describing the planned activities on what? 3. Client Appeals and Grievance Process Regional and County HCP Agencies are familiar with and follow the HCP Grievance and Appeal process to ensure that familieS.receiving care coordination for TBI receive fair treatment and, support to enable them to advocate for appropriate and helpful care coordination services. Individuals who are eligible for services, and other individuals acting on behalf of eligible individuals, shall have a right to appeal decisions of HCP to deny, reduce, suspend or terminate program services. The HCP appeal/grievance process is a formal mechanism for providing feedback regarding the HCP administrative processes, as well as assuring consistency and fair treatment in policy implementation. A primary function of the grievance process is to provide HCP management feedback regarding policies. The process is an integral part of Quality Assurance and includes annual review of logs and other records, to identify patterns of dissatisfaction and recommend policy changes. Appeals and Grievances may address issues including but not limited to: i) quality of care coordination services provided by HCP ii) timeliness of care coordination services iii) dissatisfaction with a Care Coordinator or HCP staff iv) accessibility of HCP Care Coordinator or HCP staff v) availability of HCP Care Coordinator or HCP staff The HCP Director has overall responsibility for assuring the HCP Appeal Grievance Process protects the family and/or individual rights. This activity is administered through the Quality Assurance Committee. The assigned State HCP staff person is responsible for the thy-to-thy operation of this process, including accepting the complaints, researching and documenting the issues, coordinating follow-up and calling the QA Committee as needed. The QA Committee will review the reports for all appeals and grievances during the past 12 months during the yearly quality assurance review. Page 10 of 12 . • ,I . HCP Appeal and Grievance Process A) Provide to families/individuals the Appeal and Grievance policies and procedures as part of the care coordination planning process. The care coordinator will describe the procedures and give the family a copy of the written procedures when the care coordination plan is signed. The HCP state office will provide these written procedures to all local HCP offices. B) Regional, County and/or State HCP Office become aware of families/individuals and other person's dissatisfaction with a decision to deny, reduce, suspend or terminate services and/or request to access Appeal and Grievance process. C) County/Regional HCP office documents the issues, and follows up with the appropriate Regional/County HCP staff/Care Coordinator to resolve the problem. D) The Regional/County HCP office staff then contacts the family and explains how the issue is being addressed. Within 10 calendar days. The Regional/County HCP staff provides the family with the written appeal/grievance process and explains the next steps (See E, F below) if they are not satisfied with the resolution. E) Family remains dissatisfied and/or wishes to proceed with Appeal and Grievance Process. Regional/County HCP Office assists the family to call the State HCP Office and/or calls the State HCP Office on the family's behalf. State HCP requires that the family put the complaint in writing within ninety(90) calendar days from the date of the follow- up call? The State HCP Office staff contacts both the Regional/County HCP Office staff and the family to discuss possible solutions to the family's complaint. F) If the State HCP Office staff assigned to cover all appeal/grievance calls and the family cannot come to resolution, the Quality Assurance HCP State Committee meets within thirty(30) calendar days of the family's letter received date. The committee includes the HCP Director. The decision of the special committee is final. The care coordinator and family can attend the meeting to testify. G) The State HCP office will document the process by maintaining the following information for each complaint: date received complainant name, address, and phone number area coordinator name and agency description of the complaint action taken including documentation of phone calls, meetings, etc. resolution date resolved This will be documented in the state project referral database. Page l l of 12 M ' Contact Information Brain Injury Association of Colorado (MAC) 4200 W. Conejos Place, Suite 524 Denver, CO 80204 Phone: 303-355-9969 800-955-2443 FAX: 303-355-9968 www.biacolorado.org Rasa Eglite,HCP TBI Referral Manager • Health Care Program for Children with Special Needs (HCP) PSD—HCP A4 Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, CO 80426-1530 Phone: 303-692-2411 800-886-7689 (ext. 2411) FAX: 303-753-9249 rasa.eglite@state.co.us nPcggzACa RAcrSPy 05VMCH-HCP Combined CmYadWtaduavd Z-TBI CC Policies and Procedures 5-14-04.dac Page 12 of 12 . , EXHIBIT A HIPAA BUSINESS ASSOCIATE Memorandum of Understanding The parties to this Business Associate Memorandum of Understanding ("MOU") are the Colorado Department of Public Health and Environment ("State" or"Department") and the Board of County Commissioners of Weld County ("Contractor," or "Associate"). This MOU is effective as of October 1, 2004 or the compliance date of the Privacy Rule (defined below), whichever first occurs (the "MOU Effective Date"). RECITALS A. The Department is a business associate of the Colorado Department of Human Services ("Covered Entity" or "CE") and as such must comply with applicable requirements Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. § 1320d- 3120d- 8 ("HIPAA"), which requires that if the Department subcontracts any covered function and discloses protected health information to a subcontractor, the Department must enter into a business associate agreement with such a subcontractor. B. The Department wishes to disclose certain information to Associate pursuant to the terms of.:re Contract, some of which may constitute Protected Health Information ("PHI") (defined below). C. Department and Associate intend to protect the privacy and provide for the security of PHI disclosed to Associate pursuant to the Contract in compliance with the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. § 1320d — 1320d-8 ("HIPAA") and its implementing regulations thereunder by the U.S. Department of Health and Human Services (the "Privacy Rule") and other applicable laws, as amended. D. As part of the HIPAA regulations, the Privacy Rule requires the Department to enter into a contract containing specific requirements with Associate prior to the disclosure of PHI, as set forth in, but not limited to, Title 45, Sections 160.103, 164.502(e) and 164 504(e) of the Code of Federal Regulations ("C.F.R.") and contained in this MOU. E. Authority exists in the Law and Funds have been budgeted, appropriated, and otherwise made available, and a sufficient uncommitted balance thereof remains available for subsequent encumbering and payment of this Contract in Fund Number 100, Organizational Unit Code 6520 and 6810, Appropriation Code 581, 606 and 611, and Object Code 5120, under Contract Encumbrance Number PO FLA MCH0500203. F Authority exists in the Law and Funds have been budgeted, appropriated, and othenvise made available, and a sufficient uncommitted balance thereof remains available for subsequent encumbering and payment in Fund Number 100, Organizational Unit Code 6810, Appropriation Code 609 and Object Code 5120 under contract encumbrance number PO FLA HCP05000001 for Traumatic Brain Injury Services. Page I of 10 G. Required approval, clearance and coordination have been accomplished from and with appropriate agencies. The parties agree as follows: 1. Definitions. a. Except as otherwise defined herein, capitalized terms in this MOU shall have the definitions set forth in the HIPAA Privacy Rule at 45 C.F.R. Parts 160 and 164, as amended. In the event of any conflict between the mandatory provisions of the Privacy Rule and the provisions of this MOU, the Privacy Rule shall control. Where the provisions of this MOU differ from those mandated by the Privacy Rule, but are nonetheless permitted by the Privacy Rule, the provisions of this MOU shall control. b. "Protected Health Information" or"PHI" means any information, whether oral or recorded in any form or medium: (i) that relates to the past, present or future physical or mental condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; and (ii) that identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual, and shall have the meaning given to such term under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.501 c. "Protected Information" shall mean PHI provided by CE to the Department or to Associate or created or received by Associate on CE's behalf To the extent Associate is a covered entity under HIPAA and creates or obtains its own PHI for treatment, payment and health care operations, Protected Information under this MOU does not include any PHI created or obtained by Associate as a covered entity and Associate shall follow its own policies and procedures for accounting, access and amendment of Associate's PHI. 2. Statement of Work and Responsibilities. The Scope of Work for purposes of this MOU is contained in the Task Order between the Department and Associate dated June 11, 2004. 3. Payment Amount and Billing Procedure. The consideration for Associate performing its obligations under Section 2 above, is set forth in the Task Order between the Department and Contractor dated June 11, 2004. 4. Term. The term of this MOU begins on the MOU Effective Date, as set forth in the opening paragraph of this MOU, and runs through and including September 30, 2005. Colorado MOU-Subcontracting Covered Functions Rev. 3/04 Page 2 of 10 . . II '1 5. Obligations of Associate. a. Permitted Uses. Associate shall not use Protected Information except for the purpose of performing Associate's obligations under and as permitted by the terms of this MOU. Further, Associate shall not use Protected Information in any manner that would constitute a violation of the Privacy Rule if so used by CE, except that Associate may use Protected Information: (i) for the proper management and administration of Associate; (ii) to carry out the legal responsibilities of Associate; or(iii) for Data Aggregation purposes for the Health Care Operations of CE. Additional provisions, if any, governing permitted uses of Protected Information are set forth in Attachment A-1. b. Permitted Disclosures. Associate shall not disclose Protected Information in any manner that would constitute a violation of the Privacy Rule if disclosed by CE, except that Associate may disclose Protected Information: (i) in a manner permitted pursuant to this MOU; (ii) for the proper management and administration of Associate; (iii) as required by law; (iv) for Data Aggregation purposes for the Health Care Operations of CE; or(v) to report violations of law to appropriate federal or state authorities, consistent with 45 C.F.R. Section 164.502(j)(1). To the extent that Associate discloses Protected Information to a third party, Associate must obtain, prime: to making any such disclosure:(i) reasonable assurances from such third party that such Protected Information will be held confidential as provided pursuant to this MOU and only disclosed as required by law or for the purposes for which it was disclosed to such third party; and (ii) an agreement from such third party to notify Associate within one business day of any breaches of confidentiality of the Protected Information, to the extent it has obtained knowledge of such breach. Additional provisions, if any, governing permitted disclosures of Protected Information are set forth in Attachment A-1. c. Appropriate Safeguards. Associate shall implement appropriate safeguards as are necessary to prevent the use or disclosure of Protected Information otherwise than as permitted by this MOU. Associate shall maintain a comprehensive written information privacy and security program that includes administrative, technical and physical safeguards appropriate to the size and complexity of the Associate's operations and the nature and scope of its activities. d. Reporting of Improper Use or Disclosure. Associate shall report to the Department in writing any use or disclosure of Protected Information other than as provided for by this MOU within three (3) business days of becoming aware of such use or disclosure. e. Associate's Agents. If Associate uses one or more subcontractors or agents to provide services under this MOU, and such subcontractors or agents receive or have access to Protected Information, each subcontractor or agent shall sign an agreement with Associate containing substantially the same provisions as this MOU and further identifying CE as a third party beneficiary with rights of enforcement and indemnification from such subcontractors or agents in the event of any violation of such subcontractor or agent agreement. Associate shall implement and maintain appropriate sanctions against agents and subcontractors that violate such restrictions and conditions and shall mitigate the effects of any such violation. Colorado MOU—Subcontracting Covered Functions Rev. 3/04 Page 3 of 10 . . f. Access to Protected Information. Associate shall make Protected Information maintained by Associate or its agents or subcontractors in Designated Record Sets available to the Department for inspection and copying within seven(7) business days of a request by the Department to enable CE to fulfill its obligations to permit individual access to PHI under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.524. g. Amendment of PHI. Within seven (7) business days of receipt of a request from the Department for an amendment of Protected Information or a record about an individual contained in a Designated Record Set, Associate or its agents or subcontractors shall make such Protected Information available to CE for amendment and incorporate any such amendment to enable CE to fulfill its obligations with respect to requests by individuals to amend their PHI under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.526. If any individual requests an amendment of Protected Information directly from Associate or its agents or subcontractors, Associate must notify the Department in writing within three (3) business days of the receipt of the request. Any denial of amendment of Protected Information maintained by Associate or its agents or subcontractors shall be the responsibility of CE. h. Accounting Rights. Within seven (7) business days of notice by the Department of a request for an accounting of disclosures of Protected Information, Associate and its agents or subcontractors shall make available to the Department the information required to provide an accounting of disclosures to enable CE to fulfill its obligations under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.528. As set forth in, and as limited by, 45 C.F.R. Section 164.528, Associate shall not provide an accounting to CE of disclosures: (i) to carry out treatment, payment or health care operations, as set forth in 45 C.F.R. Section 164.506; (ii) to individuals of Protected Information about them as set forth in 45 C.F.R. Section 164 502; (iii) pursuant to an authorization as provided in 45 C.F.R. Section 164.508; (iv) to persons involved in the individual's care or other notification purposes as set forth in 45 C.F.R. Section 164.510; (v) for national security or intelligence purposes as set forth in 45 C.F.R. Section 164.512(k)(2); (vi) to correctional institutions or law enforcement officials as set forth in 45 C.F.R. Section 164.512(k)(5); (vii) incident to a use or disclosure otherwise permitted by the Privacy Rule; (viii) as part of a limited data set under 45 C.F.R. Section 164.514(e); or (ix) disclosures prior to April 14, 2003.. Associate agrees to implement a process that allows for an accounting to be collected and maintained by Associate and its agents or subcontractors for at least six (6) years prior to the request, but not before the compliance date of the Privacy Rule. At a minimum, such information shall include: (i) the date of disclosure; (ii) the name of the entity or person who received Protected Information and, if known, the address of the entity or person; (iii) a brief description of Protected Information disclosed; and (iv) a brief statement of purpose of the disclosure that reasonably informs the individual of the basis for the disclosure, or a copy of the individual's authorization, or a copy of the written request for disclosure. In the event that the request for an accounting is delivered directly to Associate or its agents or subcontractors, Associate shall within five (5) business days of the receipt of the request forward it to the Department in writing. It shall be CE's responsibility to prepare and deliver any such accounting requested. Associate shall not disclose any Protected Information except as set forth in Section 5(b) of this MOU. Colorado MOU—Subcontracting Covered Functions Rev. 3/04 Page 4 of 10 i. Governmental Access to Records. Associate shall make its internal practices, books and records relating to the use and disclosure of Protected Information available to the Secretary of the U.S. Department of Health and Human Services (the "Secretary"), in a time and manner designated by the Secretary, for purposes of determining CE's compliance with the Privacy Rule. Associate shall provide to the Department a copy of any Protected Information that Associate provides to the Secretary concurrently with providing such Protected Information to the Secretary. j. Minimum Necessary. Associate (and its agents or subcontractors) shall only request, use and disclose the minimum amount of Protected Information necessary to accomplish the purpose of the request, use or disclosure, in accordance with the Minimum Necessary requirements of the Privacy Rule including, but not limited to, 45 C.F.R. Sections 164.502(6) and 164.514(d). k. Data Ownership. Associate acknowledges that Associate has no ownership rights with respect to the Protected Information. 1. Retention of Protected Information. Except as provided in Section 7(e) of this MOU, Associate and its subcontractors or agents shall retain all Protected Information throughout the term of this MOU and shall continue to maintain the information required under Section 5(h) of this MOU for a period of six (6) years after termination of the Contract. m. Notification of Breach. During the term of this MOU, Associate shall notify the Department within two business days of any suspected or actual breach of security, intrusion or unauthorized use or disclosure of PHI and/or any actual or suspected use or disclosure of data in violation of any applicable federal or state laws or regulations. Associate shall take (i) prompt corrective action to cure any such deficiencies and (ii) any action pertaining to such unauthorized disclosure required by applicable federal and state laws and regulations. n. Audits, Inspection and Enforcement. Within seven (7) business days of a written request by the Department, Associate and its agents or subcontractors shall allow the Department to conduct a reasonable inspection of the facilities, systems, books, records, agreements, policies and procedures relating to the use or disclosure of Protected Information pursuant to this MOU for the purpose of determining whether Associate has complied with this MOU; provided, however, that: (i) Associate and the Department shall mutually agree in advance upon the scope, timing and location of such an inspection; (ii) the Department shall protect the confidentiality of all confidential and proprietary information of Associate to which the Department has access during the course of such inspection; and (iii) the Department shall execute a nondisclosure agreement, upon terms mutually agreed upon by the parties, if requested by Associate. The fact that the Department inspects, or fails to inspect, or has the right to inspect, Associate's facilities, systems, books, records, agreements, policies and procedures does not relieve Associate of its responsibility to comply with this MOU, nor does the Department's (i) failure to detect or(ii) detection, but failure to notify Associate or require Associate's remediation of any unsatisfactory practices, constitute acceptance of such practice or a waiver of the Department's enforcement rights under this MOU. Colorado MOU-Subcontracting Covered Functions Rev. 3/04 Page 5 of 10 o. Safeguards During Transmission. Associate shall be responsible for using appropriate safeguards to maintain and ensure the confidentiality, privacy and security of Protected Information transmitted to CE pursuant to this MOU, in accordance with the standards and requirements of the Privacy Rule, until such Protected Information is received by the Department, and in accordance with any specifications set forth in Attachment A-1. p. Restrictions and Confidential Communications. Within seven (7) business days of notice by the Department of a restriction upon uses or disclosures or request for confidential communications pursuant to 45 C.F.R. 164.522, Associate will restrict the use or disclosure of an individual's Protected Information, provided Associate has agreed to such a restriction. Associate will not respond directly to an individual's requests to restrict the use or disclosure of Protected Information or to send all communication of Protected Information to an alternate address. Associate will refer such requests to the Department so that the Department can coordinate with the CE and prepare a timely response to the requesting individual and provide direction to Associate. 6. Obligations of the Department and CE. a. Safeguards During Transmission. The Department and CE shall be responsible for using appropriate safeguards to maintain and ensure the confidentiality, privacy and security of PHI transmitted to Associate pursuant to this MOU, in accordance with the standards and requirements of the Privacy Rule, until such PHI is received by Associate, and in accordance with any specifications set forth in Attachment A-1. b. Notice of Changes. The Department shall provide Associate with a copy of CE's notice of privacy practices produced in accordance with 45 C.F.R. Section 164.520, as well as any subsequent changes or limitation(s) to such notice, to the extent such changes or limitations may effect Associate's use or disclosure of Protected Information. The Department shall provide Associate with any changes in, or revocation of, permission to use or disclose Protected Information, to the extent it may affect Associate's permitted or required uses or disclosures. To the extent that it may affect Associate's permitted use or disclosure of PHI, the Department shall notify Associate of any restriction on the use or disclosure of Protected Information that CE has agreed to in accordance with 45 C.F.R. Section 164.522. CE may effectuate any and all such notices of de-identified information via posting on CE's web site. Associate shall review CE's designated web site for notice of changes to CE's HIPAA privacy policies and practices on the last day of each calendar quarter. 7. Termination. a. Without Cause. Either of the parties shall have the right to terminate this MOU by giving the other party twenty-one (21) calendar days notice. If notice is given, the MOU will terminate at the end of twenty-one (21) calendar days, and the liabilities of the parties hereunder for further performance of the terms of the MOU shall thereupon cease, but the parties shall not be released from duty to perform up to the date of termination. Colorado MOU-Subcontracting Covered Functions Rev. 3/04 Page 6 of 10 e • I , b. Material Breach. Any material breach by Associate of any provision of this MOU, as determined by the Department, shall be grounds for immediate termination of the Contract by the Department. Any dispute concerning the performance of this MOU which cannot be resolved at the divisional level shall be referred to superior departmental management staff designated by each department. Failing resolution at that level, disputes shall be presented to the executive directors of each department for resolution. Failing resolution by the executive directors, the dispute shall be submitted in writing by both parties to the State Controller, whose decision on the dispute shall be final. This dispute resolution mechanism is in addition to, and not in lieu of, any other reporting or other requirement of federal or state law concerning alleged privacy violations. c. Reasonable Steps to Cure Breach. If the Department knows of a pattern of activity or practice of Associate that constitutes a material breach or violation of the Associate's obligations under the provisions of this MOU or another arrangement and does not terminate this MOU pursuant to Section 7(a), then the Department shall take reasonable steps to cure such breach or end such violation, as applicable. If the Department's efforts to cure such breach or end such violation are unsuccessful, the Department shall either (i) terminate this MOU, if feasible :Jr (ii) if termination of this MOU is not feasible, the Department shall report Associate's breach or violation to the CE, the Colorado Attorney General's Office and to the Secretary of the U S. Department of Health and Human Services. Judicial or Administrative Proceedings. Either party may terminate this MOU, effective immediately, if(i) the other party is named as a defendant in a criminal proceeding for a violation of HIPAA, the HIPAA Regulations or other security or privacy laws or(ii) a finding or stipulation that the other party has violated any standard or requirement of HIPAA, the HIPAA Regulations or other security or privacy laws is made in any administrative or civil proceeding in which the party has been joined. e. Effect of Termination. (1) Except as provided in paragraph (2) of this subsection, upon termination of this MOU, for any reason, Associate shall return or destroy all Protected Information that Associate or its agents or subcontractors still maintain in any form, and shall retain no copies of such Protected Information. If Associate elects to destroy the PHI, Associate shall certify in writing to the Department that such PHI has been destroyed. (2) If Associate believes that returning or destroying the Protected Information is not feasible, Associate shall promptly provide the Department notice of the conditions making return or destruction infeasible. Upon mutual agreement of the Department and Associate that return or destruction of Protected Information is infeasible, Associate shall continue to extend the protections of Sections 5(a), 5(b), 5(c), 5(d) and 5(e) of this MOU to such information, and shall limit further use of such PHI to those purposes that make the return or destruction of such PHI infeasible. Colorado MOU-Subcontracting Covered Functions Rev. 3/04 Page 7 of 10 8. No Waiver of Immunity. No term or condition of this MOU shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protection, or other provisions of the Colorado Governmental Immunity Act, CRS 24-10-101 et seq. or the Federal Tort Claims Act, 28 U.S.C. 2671 et seq. as applicable, as now in effect or hereafter amended. 9. Defense. To the extent any legal action against either party is not covered by the Risk Management Fund or other authorized self-insurance fund for tort claims, each party shall defend itself at its own expense in any action by third parties. 10. Disclaimer. The Department makes no warranty or representation that compliance by Associate with this MOU, HIPAA or the HIPAA Regulations will be adequate or satisfactory for Associate's own purposes. Associate is solely responsible for all decisions made by Associate regarding the safeguarding of PHI. 11. Certification. To the extent that the Department determines an examination is necessary in order to comply with CE's legal obligations pursuant to HIPAA relating to certification of its security practices, the Department or its authorized agents or contractors, may, at the Department's expense, examine Associate's facilities, systems, procedures and records as may be necessary for such agents or contractors to certify to the Department the extent to which Associate's security safeguards comply with HIPAA, the HIPAA Regulations or this MOU. 12. Amendment. a. Amendment to Comply with Law. The parties acknowledge that state and federal laws relating to data security and privacy are rapidly evolving and that amendment of this MOU may be required to provide for procedures to ensure compliance with such developments. The parties specifically agree to take such action as is necessary to implement the standards and requirements of HIPAA, the Privacy Rule, the Final HIPAA Security regulations at 68 Fed. Reg. 8334 (Feb. 20, 2003), 45 C.F.R. § 164.314 and other applicable laws relating to the security or privacy of PHI. The parties understand and agree that the Department must receive satisfactory written assurance from Associate that Associate will adequately safeguard all Protected Information. Upon the request of either party, the other party agrees to promptly enter into negotiations concerning the terms of an amendment to this MOU embodying written assurances consistent with the standards and requirements of HIPAA, the Privacy Rule or other applicable laws. The Department may terminate the MOU upon thirty (30) days written notice in the event (i) Associate does not promptly enter into negotiations to amend this MOU when requested by the Department pursuant to this Section or(ii) Associate does not enter into an amendment to this MOU providing assurances regarding the safeguarding of PHI that CE, in its sole discretion, deems sufficient to satisfy the standards and requirements of HIPAA and the Privacy Rule. b. Amendment of Attachment A-1. Attachment A-1 may be modified or amended by mutual agreement of the parties in writing from time to time without formal amendment of this MOU. Colorado MOU-Subcontracting Covered Functions Rev. 3/04 Page 8 of 10 • 13. Assistance in Litigation or Administrative Proceedings. Associate shall make itself, and any subcontractors, employees or agents assisting Associate in the performance of its obligations under this MOU, available to the Department, at no cost to the Department up to a maximum of 30 hours, to testify as witnesses, or otherwise, in the event of litigation or administrative proceedings being commenced against the Department, CE, its directors, officers or employees based upon a claimed violation of HIPAA, the Privacy Rule or other laws relating to security and privacy of PHI, except where Associate or its subcontractor, employee or agent is a named adverse party. 14. No Third Party Beneficiaries. Nothing express or implied in this MOU is intended to confer, nor shall anything herein confer, upon any person other than the Department, CE, Associate and their respective successors or assigns, any rights, remedies, obligations or liabilities whatsoever. 15. Interpretation. This MOU shall be interpreted as broadly as necessary to implement and comply with HIPAA and the Privacy Rule. The parties agree that any ambiguity in this MOU shall be resolved in favor of a meaning that complies and is consistent with HIPAA and the Privacy Rule. 16. Survival of Certain Terms. Notwithstanding anything herein to the contrary, Associate's obligations under Section 7(d) ("Effect of Termination") and Section 14 ("No Third Party Beneficiaries") shall survive termination of this MOU and shall be enforceable by CE as provided herein in the event of such failure to perform or comply by the Associate. 17. Representatives and Notice. a. Representatives. For the purpose of this MOU, the individuals listed below are hereby designated as the parties' respective representatives. Either party may from time to time designate in writing new or substitute representatives. Colorado MOU—Subcontracting Covered Functions Rev. 3/04 Page 9 of 10 rt • b. Notices. All required notices shall be in writing and shall be hand delivered or given by certified or registered mail to the representatives at the addresses set forth below. State/Department Representative: Name: Kathy Watters Title: Director, Children and Youth with Special Health Care Needs Department and Division: Colorado Department of Public Health and Environment Prevention Services Division Address: 4300 Cherry Creek Drive South PSD-HCP-A4 Denver, Colorado 80246 Contractor/Business Associate Representative: Name: Judy Nero Title: Business Manager Department and Division: Weld County Department of Public Health and Environment Address: 1555 North 17th Avenue Greeley, CO 80631 18. Availability of Funds. Payment pursuant to this MOU, if in any part federally funded, is subject to and contingent upon the continuing availability of federal funds for the purposes hereof. If any of said federal funds become unavailable, as determined by the Department, either party may immediately terminate or seek to amend this MOU. 19. Audits. In addition to any other audit rights in this MOU, Associate shall permit the Department and any authorized federal agency to monitor and audit records and activities which are or have been undertaken pursuant to this MOU. 20. No Assignment. Except as otherwise provided, the duties and obligations of Associate shall not be assigned, delegated or subcontracted except with the express prior written consent of CE. Any subcontractors or agents used by BA to perform any services in connection with this MOU shall be subject to the requirements of this MOU. Colorado MOU—Subcontracting Covered Functions Rev.3/04 Page 10 of 10 4 ' D 1. ATTACHMENT A-1 This Attachment sets forth additional terms to the HIPAA Business Associate MOU dated October 1, 2004, between the Colorado Department of Public Health and Environment (CDPHE) and Board of County Commissioners of Weld County(Associate). This Attachment may be amended from time to time as provided in Section 12(b) of the MOU. 1. Additional Permitted Uses. In addition to those purposes set forth in Section 5(a) of the MOU, Associate may use Protected Information as follows: The Associate may disclose aggregate reports that conform to HIPAA de-identification definitions contained in HIPAA § 164.514 (b) (1)or(2). • 2. Additional Permitted Disclosures. In addition to those purposes set forth in Section 5(b) of the MOU, Associate may disclose Protected Information as follows: The Associate may disclose aggregate reports that conform to HIPAA de-identification definitions contained in HIPAA § 164.514 (b) (1) or(2). • 3. Suo untractor(s). The parties acknowledge that the following subcontractors or agents of Associate shall receive Protected Information in the course of assisting Associate in the performance of its obligations under the MOU: Associate's Health Care Program for Children with Special Needs discipline coordinator contractors. 4 Receipt. Associate's receipt of Protected Information pursuant to the MOU shall be deemed to occur as follows, and Associate's obligations under the MOU shall commence with respect to such PHI upon such receipt: Delivery of copies of eligibility applications including ICD-9 diagnosis and any other information that can be used in the treatment of the traumatic brain-injured child. This information may be in paper or electronic format. 5. Additional Restrictions on Use of Data. Associate shall comply with the following restrictions on the use and disclosure of Protected Information: N/A 6. Additional Terms. [This section may include specifications for disclosure format, method of transmission, use of an intermediary, use of digital signatures or PICT, authentication, additional security of privacy specifications, de-identification or re- identification of data and other additional terms.] The Associate will secure HIPAA- compliant authorization to allow disclosure of personally identifiable data to the CDPHE TBI Surveillance program. Authorization form to be used is attached as Attachment A-2 to the MOU. Page 1 of 1 * ` "` M• ATTACHENT A-2 r a; ; Health Care Program for Children with Special Needs(HCP) Telephone: (303)692-2370; FAX: (303)782-5576 Colorado Traumatic Brain Injury (TBI) Program AUTHORIZATION TO RELEASE PATIENT INFORMATION OBTAIN FROM: (Who is releasing the information?) RELEASE TO:(Who is receiving the information?) Colorado Department of Public Health and Environment Colorado Department of Public Health and Environment I health Care Program for Children with Special Needs(HCP) Injury Epidemiology Program PSD-HCP-A4 Traumatic Brain Injury Surveillance Project 4300 Cherry Creek Drive South PSD-IE-A4 Denver,CO 80246-1530 4300 Cherry Creek Drive South Denver,CO 80246-1530 SPECIFIC IDENTIFYING INFORMATION BEING REQUESTED: PATIENT NAME: ADDRESS: CITY COUNTY STATE ZIP DATE Ot u,...ti. GENDER(Circle): M F RACE(Optional) PERSON AUTHORIZED TO SIGN FOR PATIENT: RELATIONSHIP TO PATIENT: ADDRESS(Ifdinerent from patient's) DATE OF HOSPITALIZATION FOR TBI: HOSPITAL NAME: PURPOSE FOR DISCLOSURE: (What is the information to be used for?) Public health analysis. The Injury Epidemiology Program will group this information to describe children who received services, compare this group to all children hospitalized with TBI,and estimate the need for TBI services. I understand that signing this authorization is not a condition of receiving services. I understand that a copy or facsimile of this authorization is to be considered as valid as the original and that this authorization will expire 365 days from the date of signature. I also understand that I may revoke this authorization at any time and that I will be asked to sign the Revocation Section on the back of this form. I further understand that any action taken on this authorization piior to the rescinded date is legal and binding. I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes. Patient Signature Date/Time Person authorized to sign for patient Date/Time Address Relationship to Patient Phone City State Zip HCP Staff Signature/Title(if signed in person) Date/Time Page 1 of 2 REVOCATION SECTION 9 • ) I do hereby request that this authorization to disclose personal information of Name of Patient signed by on Name of person who signed Authorization Date of Signature be rescinded effective . I understand that any action taken on this (Date/Time) authorization prior to the rescinded date is legal and binding. Patient Signature Date/Time Person authorized to sign for patient Date/Time Address Relationship to Patient Phone City State Zip Witness Signature/Title Date/Time Page 2 of 2 a , ts Attachment V COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS(HCP) SLIDING FEE SCHEDULE FOR HCP CLINICS Effective October 1,2003 The Health Care Program for Children with Special Needs(HCP)is committed to the HCP Sponsored Specialty Clinics. We want to ensure that throughout Colorado families have access to specialty care. HCP has designed a Clinic Support Fee Schedule to offset the infrastructure cost of the clinics. The clinic physician will bill Medicaid and private insurance for all children who have Medicaid or private insurance benefits. This policy does not address the statewide Developmental Evaluation Clinic System. .A. Pediatric Audiology/Otology, Pediatric,Pediatric Orthopedic,Pediatric Cardiology, Pediatric Neurology,and Pediatric Rehabilitation Clinics 1. Clients on Medicaid will not be charged a clinic support fee. 2. Clients not on Medicaid: a. will be charged a clinic support fee for all clinic visits. The family will be assessed a: (I) $5 fee per visit for a rating of 133%FPL or less (2) $10 fee per visit fora rating of 134 to 185%FPL (3) $30 fee per visit for a rating of 186 to 211%FPL (4) $50 fee per visit fora rating of 212 to 399% FPL (5) $75 fee per visit for a rating of400 to 450% FPL (6) $100 fee per visit for a rating of 45 I% FPL or greater b. and will pay all labs and x-rays ordered out of clinic. 4. All clinic patienSmust be registered with HCP and complete a financial statement included in the HCP application. Families who choose not to complete the financial statement will be charged the maximum fee on the schedule per visit. 5. The clinic sites and ROs shall negotiate the percent each of them shall receive of the Clinic Support Fees collected from the families. The fees collected are to support HCP clinic activities such as: clinic supplies,clinic equipment,clinic furniture or parent/professional stipends. Records on the distribution of collected Clinic Support Fees shall be maintained according to HCP policy. Page 1 of 2 rr , . . B. Pediatric Clinics Children attending an HCP Pediatric Clinic: 1. Upon referral from the child's PCP requesting a diagnostic evaluation and/or continuing consultation from the pediatrician,the child may be seen in the HCP Pediatric Clinic. 2. Families not on Medicaid will be charged a clinic support fee. (HCP is providing access for these families,but not paying for services to children.) 3. Family pays all labs and x-rays ordered out of clinic. Revised July 28,2004 I\MCMCONTRACTS\FY 05\MCH-HCP COMBINEDVIDS-ROSSINGLE COUNTY\W ELDWTTACHMENTY-CLINIC SLIDING FEE SCHEDULE.DOC • Page 2 of 2 Hello