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Home My WebLink About20002486.tiff RESOLUTION RE: APPROVE TASK ORDER FOR HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with a Task Order for the Health Care Program for Children with Special Needs between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and the Colorado Department of Public Health and Environment, commencing October 1, 2000, and ending September 30, 2001, with further terms and conditions being as stated in said task order, and WHEREAS, after review, the Board deems it advisable to approve said task order, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Task Order for the Health Care Program for Children with Special Needs between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and the Colorado Department of Public Health and Environment be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said task order. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 16th day of October, A.D., 2000, nunc pro tunc, October 1, 2000. BOARD OF COUNTY COMMISSIONERS I_,// 4t4 WE C UNTY O ATTEST: lace �1 Barbara . irkmeyer, Chair Weld County Clerk to A = .''1'�%��'.� �©, �, M. J G i e, Pro-Tem BY: .iii wf%_ �r ►' l� �� /`�Deputy Clerk to the Board -t / r e . Baxter ROV D AS TO�RTA: Dale . Hall fLunty Attorn �` 1✓� li Glenn Vaad 2000-2486 HL0027 Department or Agency Name COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Department or Agency Number FAA Contract Routing Number 01-00797 TASK ORDER This TASK ORDER is made this 1" day of October, 2000,by and between:the State of Colorado,for the use and benefit of the COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT whose address or principal place of business is 4300 Cherry Creek Drive South,Denver,Colorado 80246,hereinafter referred to as"the State";and,the BOARD OF COUNTY COMMISSIONERS OF WELD COUNTY(a political subdivision of the state of Colorado),whose address or principal place of business is 915 10th Street,3rd Floor, Greeley,Colorado 80631 for the use and benefit of the.Weld County Department of Public Health and Environment),whose address or principal place of business is 1555 North 17th Avenue,Greeley,Colorado 80631,hereinafter referred to as"the Contractor". FACTUAL RECITALS Section 29-1-201,9 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,and to this end all State contracts with its political subdivisions are exempt from the State's personnel rules and the State procurement code. The State has formulated a comprehensive State plan,with associated budgets,relative to the State's programs and services which allocates funds to local health agencies in order to provide certain purchased services to the people of Colorado. This funding is to be allocated through task order contracts with local health agencies. The State,in order:to carry out its lawful powers,duties,and responsibilities under Section 25-1- 107(1)aa C.R.S.,as amended;and,to effectively utilize legislative appropriations made and provided therefore,in coordination with like powers,duties,and responsibilities of the Contractor,has determined that public health services are desirable in Weld County,Colorado. The authority for the Colorado Health Care Program for Children with Special Needs(HCP)also resides in Title V of the Social Security Act, §§501-509. The State,through the Health Care Program for Children with Special Needs has a mandate to provide core public health services for eligible children with special health care needs. The State and the Contractor mutually agree to facilitate the development of community-based systems of care for children with special needs to ensure that all families have access to services in their communities in order for children to attain their optimum growth and development. The State shall contract with the Contractor to provide comprehensive,multi-disciplinary care coordination and diagnostic and treatment services for uninsured and under- insured children with chronic physical medical conditions. The Contractor shall authorize treatment services within the guidelines,policies and procedures of HCP. 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 Page 1 of9 available for subsequent encumbering and payment in Fund Number(s) 100,Organizational Unit Code(s)FAA, Appropriation Code(s)611,Program Code(s)6810,and Object Code(s)5420 under Master Contract Routing Number 00-00008. All required approvals,clearances,and coordination have been accomplished from and with all appropriate agencies. NOW THEREFORE,in consideration of their mutual promises to each other,stated below,the parties hereto agree as follows: A. PERIOD OF PERFORMANCE AND CONTRACT TERMINATION. The effective date of this Task Order is October 1,2000,or on the date this Task Order is approved by the State Controller,whichever is later. The term of this Task Order shall commence on October 1,2000,and continue through and including September 30,2001 unless sooner terminated by the parties pursuant to the terms and conditions of the Master Contract. 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"Statement of Work",which is incorporated herein by this reference,made a part hereof and attached hereto as"Attachment A". C. COMPENSATION. In accordance with the budget set forth in"Attachment B"attached hereto,the State shall cause to be paid to the Contractor an amount not to exceed ONE HUNDRED FIFTY-SEVEN THOUSAND TWO HUNDRED EIGHT DOLLARS AND ZERO CENTS,($157,208.00)under this Task Order. Of this total amount,ONE HUNDRED FIFTY-SEVEN THOUSAND TWO HUNDRED EIGHT DOLLARS AND ZERO CENTS,($157,208.00)are identified as attributable to a funding source of the federal government and,ZERO DOLLARS($0.00)are identified as attributable to a funding source of the state of Colorado. Expenditures shall be in accordance with those items identified in the budget. To receive compensation under this Task Order,the Contractor must submit a"Task Order Reimbursement Statement"within sixty(60)calendar days of the end of the billing period for which services were rendered. A sample Task Order Reimbursement Statement is incorporated herein by this reference,made a part hereof,and attached hereto as"Attachment C". All Task Order Reimbursement Statements:must reference the related Master Contract by its contract routing number and this Task Order's contract routing number;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. Reimbursement under this Task Order,and any renewal or extension hereof,shall be made to the Contractor on a monthly basis. Accordingly,the Contractor shall be paid one twelfth(1/12)of the State's financial obligation under this Task Order each month for the first eleven(11)months. The final payment for the initial term of this Task Order,and any renewal or extension hereof, is contingent upon the State's timely receipt of the"Year-End Expenditure Report"from the Contractor in the form attached hereto as "Attachment A-6",for the Task Order term and the signed submission of"Attachment D","Task Order Duties and Obligations Certification Form". Page 2 of 9 The State will reimburse the Contractor for actual indirect costs up to the Family and Community Health Services Division's maximum of twenty percent(20%)when the Contractor's indirect rate is based on Direct Costs,or twenty-two percent(22%)when the Contractor's indirect rate is based on Salary Only or Salary and Fringe Costs. D. PAYMENT MECHANISM. Payments under this Task Order shall be made either through the Electronic Payment System or,upon the Contractor's monthly submission of duplicate invoices requesting reimbursement for those services provided in the previous month. Reimbursement statements shall be sent to: Terry de Leon Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South,Denver,CO 80246 FCHSD-HCP-A4 E. ADDITIONAL PROVISIONS. 1. 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 HCP Regional Office staff for care coordination of children with special health care needs to support activities of the HCP Regional Office on behalf of children with special health care needs. These revenues shall result from future care coordination reimbursements from Medicaid and Colorado Child Health Plan Plus (CCHP+)HMO providers. 5. The State will not accrue any liability for non-payment of care coordination fees by HMO providers. The State will facilitate negotiations with the Contractor during collection efforts, however timely notification by the Contractor to both the State and HMO providers will be essential. Page 3 of 9 6. The Contractor shall retain and use all HCP medical specialty clinic revenues generated by the HCP Regional Office to support HCP clinic activities such as: clinic supplies,clinic equipment, clinic furniture,or parent/professional stipends. 7. The Contractor agrees that any charges for attendance and services at HCP medical specialty clinics sponsored by the Program must conform to the"Sliding Fee Schedule for HCP Clinics, "Attachment E"and any subsequent amendments thereto. 8. Contractor shall ensure financial support for the HCP Regional Office team leader to attend two (2)State meetings and the HCP Discipline Regional Coordinators(Audiology,CO-Hear,Nursing, Nutrition,OT/PT,and Speech),Social Work Providers and Parent Consultants to attend required State and regional meetings. 9. Contractor shall use the HCP Discipline Regional Coordinators'funding exclusively to support those contractors or staff. 10. 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. 11. 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 Contract,and the extension,continuation, renewal,amendment,or modification of this Task Order Contract,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 Page 4 of 9 connection with this Task Order Contract,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. 12. Title V,Section 504(b)(6).Tide V funds may not be used to pay for any item or service(other than an emergency item or service)furnished by an individual or entity convicted of a criminal offense under the Medicare or any State health care program(i.e.,Medicaid,Maternal and Child Health,Colorado Child Health Plan Plus(CHP+),or Social Services Block Grant programs). 13. The Contractor shall protect the confidentiality of all applicant or recipient records and other materials that are maintained in accordance with this Task Order Contract. Except for purposes directly connected with the administration of this Program,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 a minor's parent or guardian or as otherwise properly ordered by a court of competent jurisdiction. The Contractor shall have written policies governing access to,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 confidentialities. 14. Contractor shall ensure that the provisions of Section 601 of Title VI of the Civil Rights Act of 1964 are carried out. That Act states that"no person in the United States shall on the ground of race,color,or national origin,be excluded from participation in,be denied the benefits of,or be subjected to discrimination under any program or actively receiving Federal fmancial 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. 15. The Contractor shall: A. Inform potentially eligible recipients that the"Colorado Baby Care/Kid's Care Program" (CBC/KCP)exists and that potentially eligible recipients should apply for coverage under that program through the local county department of Social Services. Potentially Page 5 of 9 eligible recipients are pregnant women,up to two months postpartum,and children up to 6 years of age,who are reasonably believed to meet CBC/KCP family fmancial requirements; B. Inform the potential recipient that CBC/KCP may be a potential source of payment for their child's care; C. Inform the potential recipient that in order to receive continuing coverage under CBC/KCP they be encouraged to complete an application fully as soon as possible (CBC/KCP allows for up to 60 days of presumptive eligibility for pregnant women who are registered with Medicaid.);and D. Obtain from Medicaid and have present at their facility current information regarding eligibility and services under CBC/KCP. 16. 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; IL Supplemental appropriations,or non-appropriated federal funding changes resulting in an increase or decrease in the amounts originally budgeted and available for the purposes of this Task Order; I. Closure of programs and/or termination of related contracts or task orders; Page 6 of 9 J. Delay or difficulty in implementing new programs or services;and, K. Other special circumstances as deemed appropriate by the State. Upon proper execution and approval,the Task Order Change Order Letter shall become an amendment to this Task Order. Except for the General and Special Provisions of the Master Contract,the Task Order Change Order Letter shall supersede this Task Order in the event of a conflict between the two. It is expressly understood and agreed to by the parties that the task order change order letter process may be used only for increased or decreased levels of funding, corresponding adjustments to service or program levels,and any related budget line items. Any other changes to this Task Order,other than those authorized by the task order renewal letter process describedbelow,shall be made by a formal amendment to this Task Order executed in accordance with the Fiscal Rules of the State of Colorado. If the Contractor agrees to and accepts the proposed change,then the Contractor shall execute and return the Task Order Change Order Letter to the State by the date indicated in the Task Order Change Order Letter. If the Contractor does not agree to and accept the proposed change,or fails to timely return the partially executed Task Order Change Order Letter by the date indicated in the Task Order Change Order Letter,then the State may,upon written notice to the Contractor, terminate this Task Order twenty(20)calendar days after the return date indicated in the Task Order Change Order Letter has passed. The written notice shall specify the effective date of termination of this Task Order. In the event of termination under this clause,the parties shall not be relieved of their respective duties and obligations under this Task Order until the effective date of termination has occurred. 17. The State may renew this Task Order through a"Task Order Renewal Letter". A sample Task Order Renewal Letter is incorporated herein by this reference,made a part hereof,and attached hereto as"Attachment G". To be effective,the Task Order Renewal Letter must be:signed by the State and the Contractor;and,approved by the State Controller or an authorized designee thereof Additionally,the Task Order Renewal Letter shall include the following information: A. Identification of the related Master Contract by its contract number and this Task Order by its contract routing number,and the affected Task Order 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 Renewal Letter shall not be valid until approved by the State Controller or such assistant as he may designate. Upon proper execution and approval,the Task Order Renewal Letter shall become an amendment to this Contract. Except for the General and Special Provisions of this Master Contract, the Task Order Renewal Letter shall supersede this Task Order in the event of a conflict between the two. Page 7 of 9 It is expressly understood and agreed to by the parties that the task order contract renewal letter process may be used only to:renew this Task Order;increase or decrease levels of funding related to that renewal;make corresponding adjustments to service or program levels,and,adjust any related budget line items. Any other changes to this Task Order,other than those authorized by the change order letter process described above,shall be made by a formal amendment to this Task Order executed in accordance with the Fiscal Rules of the State of Colorado. If the Contractor agrees to and accepts the proposed renewal term,then the Contractor shall execute and return the Task Order Renewal Letter to the State by the date indicated in the Task Order Renewal Letter. If the Contractor does not agree to and accept the proposed renewal term, or fails to timely return the partially executed Task Order Renewal Letter by the date indicated in the Task Order Renewal Letter,then the State may,upon written notice to the Contractor, terminate this Task Order twenty(20)calendar days after the return date indicated in the Task Order Renewal Letter has passed. 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. 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 8 of 9 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 ubdivision of the state of Colorado) By: By: arbara J.Kirkm yer For the Executi a Director Chair (10/16/2000) Colorado De rtment of FEIN:84-6000813 Public Health and Environment If Corporal' ,Town/Ci oun ,or Equivalent:PROGRAM APPROVAL: ATTEST(Affi�21 l llda� By: to 1861 By: / .,, • � IY QiiMl� . •3.'4*1''�TF r; •7 eo ; ♦ .I6iE6E Deputy Clerk to t11 % t7%:"`"� APPROVALS: COLORADO DEPARTMENT OF LAW COLORADO DEPARTMENT OF PERSONNEL OFFICE OF THE ATTORNEY GENERAL OFFICE OF THE STATE CONTROLLER Ken Salazar,Attorney en ral Arthur L.Barnhart,State Controller By: • By: WELD COUNTY DEPARTMENT OF PUBLIC C HHE�ALT�H^A D NVIRONMENT BY:LI \W t\ Mark E. Wallace, D, MPH-Director Page 9 of 9 Attachment A HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS(HCP) STATEMENT OF WORK I. Under this Contract,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 children with special health care needs as described and defined in"Attachment A-1","Core public Health Services Delivered by MCH Agencies". Local public health agencies are required to assess the needs and develop the plan for services for the children with special health care needs(CSHCN)population at the same time that the needs of the perinatal population and the child and adolescent population are assessed and the MCH plans are developed. 2. Contractor shall perform in accordance with the HCP Performance Measures,which is attached hereto as "Attachment A-2". 4. On or before January 15,2002,for October 1,2000 through September 30,2001 and on or before January 15,2003 for October 1,2001 through September 30,2002,the Contractor shall submit a"Year End Progress Report"to the State,following the format attached hereto as"Attachment A-3",or a similar format. 5. On or before December 1,2001,the contractor shall submit a fmal fiscal expenditure report,reporting actual expenditures and in-kind contributions and signed by a certified official,following the format attached hereto as"Attachment A-4" 6. On or before May 15,2001,the Contractor shall submit an annual MCH plan for federal fiscal year 2001- 2002(October 1,2001 through September 30,2002). A sample format,which the Contractor may use,is attached as"Attachment A-5". The Contractor shall also submit to the State,for review and approval,a Budget Estimate Form for the plan using"Attachment A-6,Section II". 7. Contractor shall engage in defined core public health activities designed to enhance the health status of children with special health care needs. Using the"Suggested Children with Special Health Care Need Activities",attached hereto as"Attachment A-7",which is incorporated herein by this reference and made a part hereof,as guidance and an assessment of community needs,these activities may include direct or enabling services,population-based activities and infrastructure building activities as described in "Attachment A-1","Core Public Health Services Delivered by MCH Agencies". 8. The Contractor will serve State recipients and recipient families who are determined to be eligible for Program services. Recipients served will be children residing or whose families have residence in Weld County. 9. The Weld HCP Regional Office shall work cooperatively with the public health nurses(PHNs)from Weld County. Page 1 of 2 10. The HCP Discipline Regional Coordinators funded through this contract shall serve State recipients who reside or whose families have residence in the counties as defined below: A. The Audiology Regional Coordinator shall serve Weld County. B. The OT/PT Regional Coordinator shall serve Weld County. C. The Speech Regional Coordinator shall serve Weld County. Page 2 of 2 Attachment A-1 CORE PUBLIC HEALTH SERVICES • DELIVERED BY MCH AGENCIES DIRECT • HEALTH CARE SERVICES: (GAP FILLING) Examples: • Basic Health Services, and Health Services for CSHCN ENABLING SERVICES: Examples: Transportation,Translation,Outreach, Respite Care,Health Education,Family Support Services,Purchase of Health Insurance, Case Management,Coordination with Medicaid, WIC,and Education POPULATION-BASED SERVICES: Examples: Newborn Screening,Lead Screening,Immunization, Sudden Infant Death Syndrome Counseling,Oral Health, Injury Prevention,Nutrition and Outreach/Public Education INFRASTRUCTURE BUILDING SERVICES: Examples: Needs Assessment,Evaluation,Planning,Policy Development, Coordination,Quality Assurance,Standards Development,Monitoring, Training,Applied Research.Systems of Care,and Information Systems MCHBroscH 10/10191 Page 1 of 2 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 1,2000 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 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 defmed 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 defmed 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. 1:\CLERICAL\CONTRACT\WORD\ROsWY01\Tack Orders\Attachment A-I-Page 2-Definitions.doc(09/28/00)SM/pw Page 2 of 2 Attachment A-2 HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS(HCP) PERFORMANCE MEASURES FOR THE HCP REGIONAL OFFICE CONTRACTS FOR FY 2001 The Performance Measures below are minimum requirements for Regional Offices in accepting Maternal Child Health(MCH)and State funds through the Health Care Program for Children with Special Needs(HCP). The "Suggested Children with Special Health Care Need Activities",Attachment A-7 of the Statement of Work,serve as guidance for communities defining optional indicators for local actions on behalf of children with special health care needs. A. The definition of children with special health care needs includes the following: 1. For the purpose of planning: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.) 2. For the purpose of enrollment into HCP Full Service Benefits:Continued use of the much more limited definition covering chronic,physical medical conditions as defined in the HCP Manual. B. Performance Measures: 1. Direct Services 1.1 Implement the program for HCP Full Service Benefits for eligible children according to the time lines, policies and procedures described in the HCP Policy & Procedure and IRIS Manuals. 1.2 Utilize the HCP Regional Office Discipline Coordinators to assist other regional office staff in the following activities as defmed in the HCP Manual: 1)assure "medical necessity"of OT, PT, speech, nutrition, CHIP and DME benefits(including hearing aids), 2) identify appropriate HCP full service benefit and providers,and 3)coordinate these benefits with the school districts,Part C,private insurance,Medicaid,and CHP+,as appropriate. 1.3 Conduct an annual patient chart audit on the lesser of 10% of the caseload or 50 patient records of children enrolled for HCP Full Service Benefits according to procedures defmed in the HCP Policy&Procedure and IRIS Manuals and include audit report results in the HCP Contract Performance Report due to the state by September 30,2001. 1.4 Assess and document the need for care coordination for children enrolled for HCP Full Service Benefits using the acuity scale, as defined in the HCP Care Coordination Booklet (see footnote(a)). 2. Enabling Services 2.1 Assist families who have children with special needs in applying to Medicaid,CHP+and SSI. 2.2 Assure appropriate multidisciplinary staffmg of care coordination services,for developing Care Coordination Plans and to begin to address not only the medical needs and resources, Page 1 of 4 but also the mental health care needs and family support needs of the children and families enrolled for HCP Full Service Benefits. 2.3 Collaborate with the Part C Coordinator or IFSP Team,and/or parent(s)to identify families Service Coordinator. Explain and determine role of HCP, with Part C Coordinator,IFSP Team and Families,for children registered with HCP and Part C. Attendance of at least one HCP Team member at the Part C Service Coordination Core Training is encouraged. 3. Population-Based Services 3.1 Assure that the Audiology Regional Coordinators work with hospital staff to assure that at least 85% of all newborns are screened before hospital discharge by ensuring: 1) the newborn hearing screening equipment and guidelines are understood and in place in each birthing hospital in the service area,2)that recommended procedures for children who fail the hearing screening are followed in each hospital, and 3) that local audiologists, pediatricians and hospital staff are educated on the importance of early identification and intervention as well as the community resources available to the professional and to families. 3.2 Use reports from the Colorado Infant Hearing Data Management System to follow up with families,as appropriate. 4. Infrastructure and Capacity Building 4.1 Complete and submit the HCP Contract Performance Report by September 30,2001. 4.2 Each regional office team will consist of staff, either as Fit, contractor, or shared with another regional office, which includes the following core disciplines: nursing,nutrition, audiology, early intervention specialist for hearing loss, speech, occupational or physical therapy,social work,parent or family advocate. To the extent possible,it is desirable to hire or contract with professionals who are also working in other care systems or community programs,e.g.,mental health,school district,community health center,community center board,Part C. In addition,specialists in community assessment,planning and evaluation, and epidemiology are highly encouraged to become part of the team. Multidisciplinary team members will assist in assessing needs and facilitating efforts to coordinate community health and support services for children with special health care needs. 4.3 The HCP Regional Office Team Leader and each State Discipline Consultant,will determine and document,in writing,which priorities from the discipline's Scope of Work,included in the HCP Policy&Procedure Manual,will be accomplished during each contract period for the Social Work Service Provider, Parent Consultant, and each Regional Discipline Coordinator(audiology,Co-Hear,nutrition,OT/PT,and speech). 4.4 When Discipline Regional Coordinators are shared with other HCP regional offices, the appropriate Regional Office Team Leaders, state discipline consultants, and regional coordinators will meet together at least annually to discuss issues,concerns,and satisfaction with the contractor before renewing the contract. 4.5 HCP Regional Office Team Leaders will attend two meetings together with the State HCP staff. Discipline staff will attend specified Regional Office Team meetings or conference calls and will attend at least two State meetings or conference calls per year of all the coordinators for that discipline,as convened by the State Discipline Consultants. And will ensure that a minimum of one staff member attends the bi-monthly HCP conference calls. Page 2 of 4 4.6 Ensure all IRIS users attend IRIS Training and meet the"FY2001 Standards for Usage of the IRIS I(Version 3.0)System"(revised 08/25/00),attached as Attachment A-2-a. Ensure a minimum of one staff member attends the bi-monthly IRIS conference calls. 4.7 To ensure the central role of families as advisors and participants in policy-making activities and as documented in the HCP Contract Performance Tool Report. 4.7.1 Family members (see footnote (b)) participate on advisory committees or task forces and are offered training,mentoring and reimbursement,when appropriate. 4.7.2 Financial support(fmancial grants,technical assistance, travel and child care) is offered for parent activities or parent groups. 4.7.3 Family members are involved in in-service training of HCP staff and providers. 4.7.4 Family members are hired staff or consultants to the HCP regional office for their expertise as a family member. 4.7.5 Family members of diverse cultures, which represent the diversity of the community,are involved in all of the above activities. 5. For Multi-County Regional Offices 5.1 Orient and train new county staff assigned to HCP. 5.2 Meet at least once a year,individually with each county,to review their goals and objectives, the local chart audit,and the needs assessment, and to provide consultation and technical assistance around HCP policies for HCP full service benefits,care coordination,CHP+,HCP clinics,newborn hearing screening,parent involvement,and development of MCH Plans. 5.3 Convene at least one meeting annually of all regional office HCP team members including county nurses and discipline coordinators. 5.4 Summarize the MCH Plans from the county nursing agencies and submit a copy of the summary to the State Program Consultant by January 15, 2001 and report the Regional Office's responses, to the plans, in the Regional Office Contract Performance Report by September 30,2001. 5.5 Report on contract performance of the Delta/Las Animas-Huerfano/Otero County Contract by September 30,2001. 6. Negotiated Objectives in MCH Plan Page 3 of 4 Footnotes (a) • The Acuity Tool will be completed by Regional Offices who serve members of an HMO with whom HCP has a contract for care coordination. • The Acuity Tool will be completed by other Regional Offices pending training in the use of the Acuity Tool. • In addition to children enrolled for HCP Full Service Benefits,Regional Offices are encouraged to use the Acuity Tool for all children registered with HCP. (b) The family members referred to in this measure do not all need to be the HCP Parent Consultant. Different parents can be used for the different activities mentioned. J:\CLERICAL\CONTRACT1WORMROS\PY01\TASK ORDERS\WELD-ATTACHMENT A-2-RCVS RO PERFORMANCE MEASURES-FY2001.DOC(09/28/00)KW/pw Page 4 of 4 Attachment A-2-a HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS(HCP) FY2001 STANDARDS FOR USAGE OF THE IRIS I(VERSION 3.0)SYSTEM All items listed are required data elements unless indicated as optional (**=optional items). Registration A. Client,Household,Program completed within 3 days of receiving HCP application. B. Eligibility Calculator completed within 45 days of receiving application. 1. All children receiving paid services. 2. All children attending HCP clinics including those with status of"clinic fee". 3. Children who are receiving care coordination services paid by HMOs. 4. Children who are receiving care coordination who may not be diagnostically or fmancially eligible for HCP. Note:Acuity level will not be required until HCP provides state training to standardize how staff determines acuity level. II. Diagnosis Screen Diagnosis Screen is completed for all children who are registered with HCP. A note describing the child's medical condition is required at the time of registration in the note field of the Diagnosis Screen. HI.** Problem Screen (This is optional as problems or concerns can be entered on encounter screen when an encounter is added. In IRIS I the data field is named "Need") IV.** Referral Screen Document referrals to and from community agencies and/or services for all children registered with HCP. (This allows easier access for team members to view referrals versus looking in the child's hard copy chart. There will be reporting capability with IRIS II.) V.** Encounters(Chart) Encounters will be required in IRIS II. Regional offices are encouraged to use IRIS for encounters in preparation for IRIS II. Encounters include entering the encounter that documents the date,the staff,the type of visit,the reason,need,etc.,plus the narrative note. Making reference to a hard copy such as an assessment form or care plan can be an option for the narrative note. A hard copy in the child's chart is optional. Encounters are encouraged for the following: A. Initial contacts with children who are registered with HCP B. Yearly contacts C. Children attending HCP clinics D. "Problem solving"contacts with families or other providers E. Contacts with families or other providers regarding children who are receiving care coordination services. (Team stafngs or conferencing regarding care coordination activities.) F. F/U from visits,letters,applications,renewals,staffmgs,surgery,etc. VI. Services Screen Entering services,providers,and payers on IRIS are required for the following: A. All children receiving HCP paid services including children receiving nutrition,Home Intervention Program,speech,OT/PT,and social work services. B. All children receiving care coordination services paid by a third party such as CHP+,HMO,or Medicaid. C. Clinic patients with follow-up diagnostic studies or referrals to other specialist or providers. D. Home health services,lodging,and meals. Note: Primary and secondary payers are required. Page 1 of 2 VII.** Action Screen (Optional as will not convert to IRIS II.) VIII. Letters Using the HCP letters are required according to the Program's Policy and Procedures. (See IRIS Manual for description and recommended use.) Examples include the following letters: A. Renewal and renewal follow-up B. Care Coordination C. Orthodontia consultation and acceptance D. Additional paid services E. Medicaid F. CHP+and private insurance wraparound G. Clinic Fee H. Joint application for Medicaid and CHP+ I. SSI application J. Diagnostic Consultation K. HCP Welcome Letter L. Insufficient information on application or renewal M. Prior approval form IX.** Reports Reports are available for the Regional Office to help with caseload management,quality assurance,routine clerical activities,and program reporting. Use of reports are encouraged but not required. (Examples include:Duplicate Households, Open Caseload with Diagnosis, Mailing labels, Open Cases by Service Code Specific, Open Cases with Diagnostic or Financial Pending, Open Cases by Payer, Clients without Eligibility Calculator, Closed Cases, etc.) X. Ticklers Ticklers can be very helpful to remind staff of follow-up needed. Regional Offices are encouraged to use the following ticklers to manage caseload: A. Surgeries and prior authorization B. Diagnostic consultations C. Pending categories: 1. CHP+ 2. Medicaid 3. SSI D. Renewals E. Incomplete application or incomplete renewals F. Letters or phone calls requiring communication with families. XI. Weekly process for uploading and downloading data is required. Security procedures must be in place for all HCP staff who are IRIS users. Individual passwords for each HCP staff must be used and kept confidential. Regional offices must not add additional IRIS users without receiving security clearance from the state office. XII. HCP/Agency staff are required to attend a minimum of one IRIS training for both IRIS I and IRIS II before receiving security access. IRIS I training is provided as needed for employees or new staff using IRIS. IRIS II training will be scheduled for all IRIS users before IRIS II is implemented. Revised 08/25/00 J:\CLERICAL\CONTRACT\WORD\ROs\FY0l\Task Orders\Wcld-Attachment A-2-a-IRIS Standards 700.rtf(SBlpw) Page 2 of 2 Attachment A-3 MATERNAL AND CHILD HEALTH(MCH) OUTLINE FOR YEAR END PROGRESS REPORTS for Federal Fiscal Year 2000-2001 (October 1,2000 through September 30,2001) DUE JANUARY 15,2002 and for Federal Fiscal Year 2001-2002(October 1,2001 through September 30,2002) DUE JANUARY 15,2003 As of October 1,2000 Please put the agency name,contact person and telephone number at the beginning of the report or on a cover page. I. MCH Plan Progress Report A. Perinatal Population: 1. Restate the priority needs of the perinatal population for which the MCH funds were used. 2. For each priority need for which MCH funds were used: a. Restate the objective(s)which addressed that priority need; b. State if the objective was fully met,partially met,or not met; c. Describe what was accomplished,including summarizing important activities. B. Child and Adolescent Population: 1. Restate the priority needs of the child and adolescent population for which the MCH funds were used. 2. For each priority need for which MCH funds were used: a. Restate the objective(s),which addressed that priority need; b. State if the objective was fully met,partially met,or not met; c. Describe what was accomplished,including summarizing important activities. C. Children with Special Health Care Needs(CSHCN)Population: I. Restate the priority needs of the children with special health care needs population for which the CSHCN funds were used,through the contract with the Health Care Program for Children with Special Health Care Needs(HCP): 2. For each priority need for which the CSHCN funds were used: a. Restate the objective(s)which addressed that priority need; b. State if the objective was fully met,partially met,or not met; Page 1 of 5 c. Describe what was accomplished, including summarizing important activities. 3. Please describe any mechanisms that are in place in your community for coordination of health services which are new since the report in January of last year. This would include coordination among providers of primary care,habilitative and rehabilitative service,or other specialty medical treatment services,mental health services and home health care. 4. Please describe any mechanisms that are in place in your community for coordination and service integration among programs serving children with special health care needs, including early intervention and special education,social services and family support services,which are new since the report in January of last year. II. Describe any important changes in administrative or organizational aspects of the program which affected service delivery during the twelve-month period. III. Describe any emerging issues regarding the perinatal population,child and adolescent population and/or the children with special health care needs population in your community. IV. Fill out Tables I and II as applicable and submit along with your report. V. Complete the Final Expenditure Report for Maternal and Child Health Programs for the MCH funded services for the Perinatal Population and for the Child and Adolescent Population. (Attachment F). Please submit five(5)copies of your report to: Carolyn Dodge,CPS,FCHSD-ADM A4 Family and Community Health Services Division Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver,CO 80246-1530 no later than 5:00 P.M.on Tuesday,January 15,2002 for the period October I,2000 through September 30,2001 and no later than 5:00 P.M.on Wednesday,January 15,2003 for the period October 1,2001 through September 30,2002 1:1CLERICAL\COMRACIIWOREAROs\FY0I\Task Orders\Weld-Anachmcnt A-3-Outline for Year End Progress Reponsdoc(09/25/00)SM/pw Page 2 of 5 Program Prepared by Telephone TABLE I (7 AR) NUMBER OF INDIVIDUALS SERVED (UNDUPLICATED) UNDER TITLE V By Class of Individuals and Health Coverage, FY 2000-2001* (1) (2) (3) (4) (5) (6) Number Number With Number Number Unduplicated Count by With Title XXI With Other With No Number Class of Individual Served Total Number' Medicaid' (CHIP)3 Insurance" Coverages Unknown Pregnant women,postpartum and deliveries6 Infants under age one(not elsewhere)' Children age 1-22 (not elsewhere)10 Children with special health care needs' Other individuals (not elsewhere)' Total MCH Population" Please take the Total Number shown in Column 1 for Children age 1-22 and estimate the number in each of the following age groups: Age 1-4: Age 5-9: Age 10-14: Age 15-19: Age 20-22: * October 1,2000 through September 30,2001 Page 3 of 5 Estimates (round numbers) are acceptable and are preferable to no data. Please estimate to the best of your ability. Be sure that Col. (2) + Col. (3) + Col. (4)+ Col. (5) + Col. (6) =Col. (1). If a person can be counted in more than one class in a year, select one class only in which to report them. If you cannot provide information on health coverage, show Col. (1) figures in Col. 6 (number unknown) as well. These data will be used at the state level to compile Colorado's Annual Form 7 AR in the MCH federally required Annual Report. If you need help call Sue Ricketts, Family and Community Health Services, Colorado Department of Public Health and Environment, (303) 692-2316. Include this table with the Final Progress Report due January 21, 2002, to Carolyn Dodge, CPS, FCHSD-ADM-A4, Colorado Department of Public Health and Environment,4300 Cherry Creek Drive South, Denver, CO 80246-1530. Footnotes for Table I (7 AR): 'Total number of individuals who received a direct service(in person or by phone) from the Title V program regardless of the primary source of coverage. 'Number of individuals in Column 1 whose primary source of coverage was Title XIX. 'Number of individuals in Column 1 whose primary source of coverage was Title XXI(Child Health Insurance Program). 'Number of individuals in Column 1 whose primary source of coverage was private insurance, including HMOs, PPOs, etc. 'Number of individuals in Column 1 for whom there was no payment. It will be assumed that the costs of care for these patients was wholly supported by Title V. 'Total number of pregnant (or postpartum)women who received any services provided or paid for in whole or in part by Title V. 'Total number of individuals under the age of 22 who received any services under the State plan for children with special health care needs provided or paid for in whole or in part by Title V. 'Total number of infants less than one who received any services provided or paid for in whole or in part by Title V. 'Total number of individuals (other than pregnant or postpartum women, infants, children age 1 through 21 or children with special health care needs) who received services provided or paid for in whole or in part by Title V. 10Total number of individuals ages 1 through 21 who received any services provided or paid for in whole or in part by Title V (excluding children with special health care needs or pregnant women through 21). "Total is the sum of the numbers shown for each of the classes of individuals (each class is mutually exclusive of every other class). Table I, 7/26/00 c:\123r3\mchapp02\6mo&fpr.doc is\sue\mchapp02\6mo&fpr.doc Page 4 of 5 Table II applies only to programs providing service to pregnant women and/or infants under the age of 1. Program Prepared by Telephone TABLE II (8 AR) NUMBER OF DELIVERIES AND INFANTS SERVED BY TITLE V UNDUPLICATED COUNT BY RACE AND ETHNICITY, FY 00-01* (1) (2) (3) (4) (5) (6) (7) (8) -r- Asian or Total All American Pacific Other& Total Total Races White Black Indian Islander Unknown Hispanic Non-Hispanic Total Pregnant Women served by program ' Total Infants served by program' * October 1, 2000 through September 30, 2001. 'Total number of pregnant/postpartum/delivery care women paid for in whole or in part by Title V. While the table title says deliveries,the number should include women who received prenatal care regardless of how their delivery was covered. 'Total infants under the age of 1 who received any services provided or paid for in whole or in part by Title V. The numbers in Column 1 should be the same as the numbers in Column 1 in Table I(7AR)! Estimates are acceptable and are preferable to no data. Please estimate to the best of your ability. Be sure that Col. (2)+Col. (3)+Col. (4)+Col.(5)+Col. (6)=Col.(1). Columns(7) and(8)must also equal Col. (1). These data will be used at the state level to compile Colorado's Annual Form 8 AR in the MCH federally required Annual Report. If you need help call Sue Ricketts,Family and Community Health Services, Colorado Department of Public Health and Environment, (303) 692-2316. Include this table with the Final Progress Report due January 21,2002, to Carolyn Dodge, CPS, FCHSD-ADM-A4, Colorado Department of Public Health and Environment,4300 Cherry Creek Drive South,Denver,CO 80222-1530. Table II Page 5 of 5 Attachment A-4 APPLICANT: PROJECT: Health Care Program for Children with Special Needs (HCP) ACTUAL EXPENDITURES: FOR THE PERIOD: OCTOBER 1,2000 through SEPTEMBER 30,2001 Annual Full Total Source of Funds Salary Time Amount *Applicant Requested Rate Equivalent Required and Other from CDPHE PERSONNEL EXPENSES: Fringe Benefit Rate and Expenses Total Personnel Expenses CONTRACTED SERVICES: Sub-total Contracted Services OPERATING EXPENSES: (include only costs not part of indirect) Sub-total Operating Expenses TRAVEL: Sub-total Travel Expenses EQUIPMENT: Sub-total Equipment Costs Administrative/Indirect Rate and Costs TOTAL PROJECT COSTS *Source of Funding for"Applicant and Other" State Percapita Funds pi $ Local/County Funds in $ Medicaid Funds $ Patient Fees $ Other $ Total Applicant and Other $ nl May these State Percapita funds be used to match Colorado's Maternal and Child Health Block Grant? YES NO ui May these Local/County funds be used to match Colorado's Maternal and Child Health Block Grant? YES NO Signature of Director or Authorized Representative Date c Vikskxcd`coumicstrequcsz.n is Attachment A-5 MATERNAL AND CHILD HEALTH(MCH) COUNTY MCH PLAN As of October 1,2000 The County MCH Plan asks the local public health agency to assess and prioritize the health status needs of the Perinatal Population,the Child 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. The Plan is to categorize the activities or services which will be used to address the needs by four types of services,i.e.direct care services,enabling services,population-based services or infrastructure-building activities as defined by the Maternal and Child Health Bureau in"Core Public Health Services Delivered by MCH Agencies". Quantitative and qualitative data gathered at the state and local levels should be used in assessing health status needs. The resources available in the community to meet the needs should also be assessed and considered in establishing the priorities to be addressed. Local public health agencies are encouraged to collaborate with public and private partners in the development of the Maternal and Child Health Plans. 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 ten priorities. They are as follows: 1. Reduce teen pregnancy and unintended pregnancy in women of all ages. 2. Improve perinatal outcomes. 3. Reduce child and adolescent morbidity. 4. Increase health and safety in child care settings. 5. Improve efforts to reduce unintentional and intentional injury,addressing motor vehicle crashes, suicide,child abuse and other violence. 6. Improve immunization rates for all children. 7. Increase access to health care(including behavioral health care). 8. Improve state and local infrastructure by increasing capacity to analyze data,carry out evaluations,develop quality standards,and assure availability of services to all children,including children with special health care needs. 9. Reduce substance abuse(alcohol,tobacco,and drugs). 10. Improve oral health and access to oral health care. Please present the Statement of Need and the Plan for children with special health care needs using the following format: I. CHILDREN WITH SPECIAL HEALTH CARE NEEDS POPULATION A. Statement of Need-What are the priority needs of the Children with Special Health Care Needs population in the County or District,based on an assessment of the health status needs and of the resources to address the needs? 1. Health and related service needs-What information about the health and related service needs of the children with special health care needs in your county or district were used to select the priority needs? 2. Resources to address the health and related service needs-What are the resources of the public health agency and of other agencies in the community which address the health and related service needs of children with special health care needs in your community? Page 1 of 3 a. Direct Care Service Needs-What are the resources in the community which provide direct health care services for the children who have conditions or illnesses which are diagnostically eligible for direct care payment by the Health Care Program for Children with Special Health Care Needs? Are there gaps or unmet needs in such direct care services? Are there issues of availability and accessibility? b. Enabling Services-What are the resources in the community which provide enabling services, i.e. transportation,interpretation and translation,outreach, health education,family support services,case management and service coordination with other related services? Are there gaps or unmet needs? c. Population-Based Service Needs—What are the resources which provide population-based services for children with special health care needs in the community,i.e.newborn hearing screening or vision screening services? d. Infrastructure-Building Services or Activity Needs—What infrastructure- building services,resources or activities are needed to promote the development of community-based systems of services for children with special health care needs and their families? Present information regarding the need for activities such as planning activities,needs assessments,program evaluation,policy development,program coordination,quality assurance activities,standards development,monitoring,training,research,developing systems of care and related services,or development of information systems. 3. Unmet or continuing needs-Considering the health and related service needs and the resources which address the needs that were identified above,what are the continuing or unmet needs for direct care,enabling,population-based and/or infrastructure building services? B. Children with Special Health Care Needs Plan 1. Priority Needs for use of CSHCN funds-Considering the unmet or continuing needs identified in the Statement of Need(Section A),what are the priority needs of the children with special health care needs population for which CSHCN funding under the contract with the Health Care Program for Children with Special Needs(HCP)will be used? Explain your rationale for selecting these needs to be the ones addressed with the CSHCN funds. 2. Operational Plan-Objectives,Activities,Monitoring and Evaluating Need Restate each of the needs that will be addressed with CSHCN funding Objective State the objective or objectives(one to four objectives suggested)that will address this need. All objectives should be reasonable,specific, time-framed and measurable. Activities Describe the specific activities that will be carried out to achieve each objective. Include"Best Practice"or"Evidence-Based"interventions or activities whenever possible. Categorize the activities according to the level or type of service being carried out(i.e.,direct health care, enabling,population-based,or infrastructure-building). Page 2 of 3 Monitoring Describe your methods of monitoring to assure quantity of service (numbers of clients and services)and quality of service(measured through use of protocols,chart audits,policy procedure manuals,etc.). Infrastructure-building activities or services may be monitored by tracking the completion of planned activities or whether benchmarks have been realized or protocols or policy procedures put in place. Evaluation Describe your methods of evaluation the effectiveness of your activities in addressing the identified need. J\CLERICAL\CONTRACTWORMROs\FY01\Task thaws\Weld-Attachment A-5-County MCH Plwn.doc(09/28/00)SM/pw Page 3 of 3 Attachment A-6 BUDGET ESTIMATE FORM FOR THE PERIOD: CONTRACTOR: MATERNAL AND CHILD HEALTH REPORTING FOR THE CORE PUBLIC HEALTH SERVICES INCLUDING CHILD HEALTH, PERINATAL HEALTH AND CHILDREN WITH SPECIAL NEEDS PROGRAMS Section I Based on your county plan, please estimate the following based on your MCH funding formula contract amount DOLLARS PERCENTAGE AMOUNT AND PERCENTAGE ALLOCATED TO: 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. h:lmchreprtNursing. wb2 Attachment A-7 HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS(HCP) 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 1,2000 The following suggested strategies are offered as guidance to local public health agencies in defming 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 The policies establishing which diagnosis or conditions will be covered by the Colorado Health Care program for Children with Special Needs(HCP)are set at the state level and the funding and payment for the direct personal specialty care services is administered at the state. Therefore,it is not necessary to establish a plan for direct care provision at the county level. 2. Enabling Services 2.1. Conduct an initial interview with a defined population(NICU,SSI,etc.)of new families to help them determine their need for information,referral and/or care coordination using a standard tool such as the"Family Status Profile" form,attached hereto as Attachment A-7-a 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,(WIC,CEP+,Baby Care/Kids Care,Medicaid,SSI,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 or IFSP(Individual Family Service Plan) with the family 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 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 or IFSP should include all the disciplines involved with the child's care, i.e.,audiologist,CHIP therapist,social worker,family advocate, OT/PT,dietitian,speech therapist,etc. Page 1 of 4 2.6. Follow-up with family according to plans written on Care Plan or IFSP. Should HCP staff have no direct role in the IFSP 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. Designs and maintains a clinic structure including identifying and scheduling clinic providers, facilities,and equipment. Sets clinic dates. Seeks referrals by contacting local doctors,Child Find,interagency councils,and Community Center Boards to inform them of the clinics. Distribute the local RCP clinic schedule to appropriate agencies and individuals. 2.13. Organizes,schedules and staffs each clinic using guidelines provided in the HCP Procedure Manual. Obtains a HCP Registration on each child scheduled for clinic and a consent for service signed by the parent or legal guardian. Provides the clinician with Medicaid and private insurance billing information and collects clinic fees from over-income families who do not have health insurance. 2.14. Completes a Clinic Encounter Form for each clinic patient.After each clinic submits Encounter Forms,a copy of the attendance list(schedule)and the dictation to the assigned Regional Office. 2.15. Assures 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 will attend and participate in the multi-county clinics. 2.17. Evaluates the clinic caseload,waiting list and summaries yearly to determine the number and type of specialty clinics needed. Reports findings to the Regional Office Team Leader. 2.18. Identify existing health care 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,Well Child,EPSDT,and Immunizations by using local media,posters and attendance at health fairs,etc. Page 2 of 4 3.2. Develop and maintain liaisons with the local community resources to maintain open communication,to promote the services of HCP and other services available to children with special needs,and to establish a network for working together to eliminate gaps or duplication of services and supports. 3.3. Assure that HCP staff is trained in Early Childhood Connections(Part C of IDEA)including the Colorado Interagency Coordinating Council Values Statements(see attached),IFSPs,Service Coordination,Procedural Safeguards and eligibility criteria. 3.4. Assure that HCP staff is trained 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 Well Child,EPSDT,HCP and WIC,with other efforts so as to provide on-going systems of early identification for children 0-21 years. 4. Infrastructure-building Services 4.1. Know the numbers of children in the counties served by the agency and be able to estimate the number of children with special health care needs. Know the target population of children who are potentially eligible for HCP paid service benefits 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. • 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. Page 3 of 4 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 community resource agencies to determine policies to support the development of comprehensive,community-based systems of care including identification,assessment,intervention and referral services for children with special health care needs. 4.7. Develop referral and follow-up care systems using available resources such as Colorado Responds To Children With Special Needs(CRCSN),NICU Consortium,Universal Newborn Hearing Screening Programs,and hospital discharge planners,to identify children who may need support, care coordination and/or referral to community resources. 4.8. Establish a mechanism for including input from parents regarding current services,planning, policy development,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. 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 for 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. I\CLERICAL\CONTRACTWORD\ROs\FY0 I\Task Orden\Weld-Attachment A-l-Suggested Activities.doc (07/18/00)KW/pw Page 4 of 4 Attachment A-7-a % Va COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT °a- HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS (HCP) FAMILY ASSESSMENT TOOL CURRENT FAMILY STATUS PROFILE Date Completed: Child's Name Date of Birth: Child's Address: County: Mother's Name: Father's Name: Legal Guardian's Name: Guardian's Employer: Home #: Work #: Message #: Completed by Signature Relationship Reviewed by R.N. Signature SUBJECTIVE DATA 1. How can we help you? 2. What are your concerns about your child's health issues? 3. Is your child visiting a doctor or clinic on a regular basis? 0 YES 0 NO If YES: Who is your child's regular doctor or care provider? How often does your child see his/her regular doctor or care provider? What medications and/or treatments has your child's doctor recommended? Are you able to get the medications and/or treatment your child needs? 0 YES 0 NO Have you had any difficulties getting your child's medicines? 0 YES 0 NO Have you had any problems getting the treatments that your doctor has recommended? 0 YES 0 NO Are your child's shots (immunizations) up-to-date? 0 YES 0 NO Do you have a copy of your child's shot records and could we have a copy? 0 YES 0 NO Page 1 of 4 4. What other people or organizations are involved in your child's care? 5. Is there anyone involved who is helping you to pull these people and services together? ❑ YES ❑ NO If YES, What is his or her name? and What is his or her relationship to you? 6. How do your child's needs affect you and your family? 7. What are your plans and hopes for your child? Long-term: Short-term: 8. What are your child's plans and hopes for him or herself? (if applicable) Long-term: Short-term: 9. What is being done to support your child and your family to be successful with those plans? 10. What do you see as strengths in your family? 11. We know that many times families have needs that are not necessarily medical, but make it difficult to care for their family. Do you or your family have any other issues that we can help you with, i.e., housing, food, clothing? 12 Are you able to get away from the house to do things for yourself if you need to? ❑ YES ❑ NO 13. Are you able to go to the doctor if you need to? ❑ YES ❑ NO 14. Are you and your family covered by Medicaid or health insurance? ❑ YES ❑ NO 15. Is there anything else we could assist you with? Page 2 of 4 OBJECTIVE DATA OBSERVED lif on-site interview conducted) use additional paper if needed ASSESSMENT FORM This form should only be used as a guide for assessment. Further studies are needed in order to quantify assessment guide and assess for validity and reliability. ASSESSMENT (place check mark in appropriate column of each question) Column A Column B Column C YES TO SOME NO DEGREE Family understands medical condition? Family following medical treatment plan including follow-up appointments? Community resources accessed? Care coordination in place? Goals set? Goals being pursued? Support systems in place? Family strengths identified? Child's needs are being met? Family's needs are being met? NOTES: 1. If all answers fall in Column A -- may only need to follow-up in one year or as needed. 2. If most answers fall in Column A, some answers in Column B or C - may need additional follow-up and/or referrals. 3. If all answers fall in Columns B and/or C -- will need further assessment and determination of why, and I.F.S.P. ASSESSMENT FINDINGS: Page 3 of 4 FOLLOW-UP PLAN (place check mark by appropriate items) Information given only (specify) 1. 2. 3. 4. DATE TIME Conference scheduled for I.F.S.P. development. / / Home Visit scheduled / / Clinic Appointment made / / Referral made to (document date referral made) Child Find / / School District / / Community Center Board / / Social Services / I W.I.C. / / Parent Support team / / Support Group / / EPSDT / / Medicaid / / Public Health Nurse / / Other (specify) / / / / / / Family does not want interventions, Follow-up / / Follow-up with family in one year or P.R.N. per HCP Standards. Other (specify) J:\CLERICAL\CONTRACT\WORD\ROS\FV01\TASK ORDERS\WELD-ATTACHMENT A-7-A-FAMILY ASSESSMENT TOOL.DOC(cr.08/13/93 rev.09/25/001pw Page 4 of 4 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, 2000 through SEPTEMBER 30, 2001 Funded by CDPHE HCP Weld County Regional Office: (1/12 payable monthly for October through August, _ September's payment contingent upon Annual Expenditure Report) 151,458 Sub-total HCP Weld County Regional Office: 151,458 HCP Regional Coordinators: (line item billing) Audiology 2,000 Travel for Colo. Academy of Audiology meeting 250 Occupational or Physical Therapy 2,500 Speech 1,000 Sub-total Regional Coordinators 5,750 Total HCP Weld County Regional Office 157,208 INVOICE NUMBER ATTACHMENT C TASK ORDER REIMBURSEMENT STATEMENT TO: Colorado Department of Public Health and Environment FROM: Health Care Program for Children with Special Needs (HCP) 4300 Cherry Creek Drive South FCHSD- HCP-A4 Denver, Colorado 80246-1530 FAX: ( 303 ) 782-5576 DATE OF EXPENDITURE: TYPE OF FROM: Final PROGRAM: Bill? FEDERAL ID TO: O Yes NUMBER: ❑ No 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 Notified of Reimbursement Amount Change? 0 Yes 0 No Initial: Attachment D COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS (HCP) TASK ORDER DUTIES AND OBLIGATIONS CERTIFICATION FORM TO: Colorado Department of Public Health and Environment Health Care Program for Children with Special Needs(HCP) 4300 Cherry Creek Drive South FCHSD-HCP-A4 Denver,Colorado 80246-1530 Telephone: (303)692-2370;FAX#:(303) 782-5576 FROM: TYPE OF PROGRAM: FEDERAL ID NUMBER: This is to certify that the"Duties and Obligations of the Contractor" have been performed per Task Order Contract Routing Number for the period of October 1,2000 through September 30,2001. SIGNATURES: Contractor or Authorized Designee Date HCP Regional Office Team Leader Date I hereby certify that all task order requirements have been met and final payment of$ for task order services for the period of October 1, 2000 through September 30,2001 is authorized. SIGNATURES: HCP Program Consultant Date HCP Program Director or Authorized Designee Date 1 CLERICALWONTRACT\WORD\ROS YO TASK ORDERSNTTACIIMENT D DUTIES&OBLIGATIONS CERTIFICATION.DOC (u 06/28/99 rcv 09/28/00) SMlpw • Attachment E COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS(HCP) SLIDING FEE SCHEDULE FOR HCP CLINICS The Health Care Program for Children with Special Needs(HCP)is committed to the Clinic System. We want to ensure that throughout Colorado families have access to the HCP Clinics. HCP has designed a Clinic Fee Schedule. The sliding fee schedule affects families without insurance and have an HCP financial rating above 133%Federal Poverty Guidelines(FPG). The clinic physician will always bill Medicaid and private insurance for all children who have Medicaid or private insurance benefits. This policy does not address the state-wide Developmental Evaluation Clinic System. HCP is billed by each Developmental Evaluation Clinic on a fee for service basis for children with HCP benefits. A. Hearing,Orthopedic,Pediatric Cardiology,Pediatric Neurology,Plastic,Rehabilitation,and Scoliosis Clinics 1. Clients with an HCP financial rating of 133%FPG will continue to receive: a. diagnostic evaluations(to include one follow up visit to interpret the results)at no cost to the family, b. continuing clinic visits at no cost to the family for children who are diagnostically eligible,and c. labs and X-rays at no cost to the family. 2. Clients with an HCP financial rating of 134 to 159%FPG will receive: a. diagnostic evaluations(to include one follow up visit to interpret the results)at no cost to the family, b. labs and X-rays for the diagnostic evaluation at no cost to the family, c. continuing clinic visits for children who are diagnostically eligible at a fee for service. The family will be assessed a: (1) $10 fee per visit for a rating of 134 to 146%FPG (2) $20 fee per visit for a rating of 147 to 159%FPG and (3) labs and x-rays for the continuing clinic visits are the financial responsibility of the family. Page 1 of 2 3. Clients with a rating of 160%FPG and above: a. pay a fee for service for both diagnostic evaluations and continuing clinic visits. The family will be assessed a: (1) $30 fee per visit for a rating of 160 to 172%FPG (2) $40 fee per visit for a rating of 173 to 185%FPG (3) $50 fee per visit for a rating of 186 to 198%FPG (4) $60 fee per visit for a rating of 199 to 211%FPG (5) etc. - b. and pay all labs and x-rays ordered out of clinic. 4. All clinic patients must be registered with HCP and complete a financial statement. 5. HCP is recommending that the clinic sites keep the clinic 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. 13. Pediatric Clinics Children attending an HCP Pediatric Clinic without an HO'eligible diagnosis: 1. If the child's PCP requests continuing consultation from the pediatrician,the child may be seen in the HCP Pediatric Clinic and pay fee for service according to the established sliding fee. 2. Families with a financial rating of 133%FPG or below will be required to pay at the 134 to 146% FPG level. (HCP is providing access for these families,but not paying for services to children who are not diagnostically eligible.) 3. Family pays all labs and x-rays ordered out of clinic. C. Developmental Evaluation Clinics This policy does not address the state-wide Developmental Evaluation Clinic System. HCP is billed by each Developmental Evaluation Clinic on a fee for service basis for children with HCP benefits. 1.CLERICAL\CONTRACnWORD\NOS\FV01\TASK ORDERSUTTACHMENT E-CLINIC SLIDING FEE SCHEDULE.DOC (09/28/00)SM/pw Page 2 of 2 STATE OF COLORADO Bill Owens Governor COt. Jane E.Norton,Executive Director Dedicated to protecting and improving the health and environment of the people of Colorado * r. ., n * 4300 Cherry Creek Dr.S. Laboratory and Radiation Services Division Denver,Colorado 80246-1530 8100 Lowry Blvd. Phone(303)692-2000 Denver CO 80230-6928 �1876' TDD Line(303)691-7700 (303)692-3090 Colorado Department Located in Glendale,Colorado of Public Health http://www.cdphestate.co.us and Environment Health Care Program for Children with Special Needs(HCP) Telephone:(303)692-2370;FAX:(303)782-5576 [Date] Sample Task Order Change Order Letter Attachment F State Fiscal Year 19"-** - Task Order Change Order Letter Number" Task Order Change Order Letter Contract Routing Number**-***** (Master Contract Contract Routing Number**-*****) (Task Order Contract Routing Number**-*****) This Task Order Change Order Letter is issued pursuant to paragraph**of the Task Order with contract routing number**- *****and contract encumbrance number***********,(as amended by Task Order Change Order Letter**,contract routing number**-***** and/or Task Order Renewal Letter**,contract routing number**-*****,if any),hereinafter referred to as the"Original Task Order"(a copy of which is incorporated herein by this reference,made a part hereof,and attached hereto as"Attachment A")between the State of Colorado,Department of Public Health and Environment and Contractor's Legal Name. The parties agree that the maximum amount payable by the State for the eligible services referenced in paragraph**of the Original Task Order is increased/decreased by dollar amount DOLLARS,($*.**)for a new,total financial obligation of the State of dollar amount DOLLARS ($*.**). The revised work plan,which is attached hereto as"Attachment 1",and the revised budget,which is attached hereto as"Attachment 2",are incorporated herein by this reference and made a part hereof The first sentence in paragraph**of the Original Task Order is hereby modified accordingly. All other terms and conditions of the Original Task Order are hereby reaffirmed. This amendment to the Original Task Order is intended to be effective as of********* ** ****. However,in no event shall this amendment be deemed valid until it shall have been approved by the State Controller or such assistant as he may designate. Please sign,date,and return all**originals of this 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: By: Print Name: For the Executive Director Title: DEPARTMENT OF PUBLIC HEALTH FEIN: AND ENVIRONMENT Title: APPROVALS: STATE CONTROLLER: PROGRAM: By: By: Arthur L. Barnhart STATE OF COLORADO Bill Owens,Governor Jane E.Norton,Executive Director �� o�Dedicated to protecting and improving the health and environment of the people of Colorado «e 4 • 4300 Cherry Creek Dr.S. Laboratory and Radiation Services Division * • f-� ♦ . ., Denver,Colorado 80246-1530 8100 Lowry Blvd. • • y. Phone(303)692-2000 Denver CO 80230-6928 TDD Line(303)691-7700 (303)692-3090 Colorado Department Located in Glendale,Colorado of Public Health http://www.cdphe.srate.co.us and Environment Health Care Program for Children with Special Needs(HCP) Telephone:(303)692-2370;FAX:(303)782-5576 [Date] Sample Task Order Renewal Letter Attachment G State Fiscal Year 19"-**, - Task Order Renewal Letter Number**, Task Order Renewal Letter Contract Routug Number**-***** (Master Contract Contract Routing Number**-*****) (Task Order Contract Routing Number**-*****) This Task Order Renewal Letter is issued pursuant to paragraph**of the Task Order with contract routing number**- *****and contract encumbrance number*********** (as amended by Task Order Change Order Letter**,contract routing number**-***** and/or Task Order Renewal Letter",contract routing number**-*****,if any),hereinafter referred to as the"Original Task Order"(a copy of which is attached hereto and by this reference incorporated herein and made a part hereof)between the State of Colorado,Department of Public Health and Environment and Contractor's Legal Name. The parties agree that for the renewal term from*********** ****,through*********** ****,the maximum amount payable by the State for the eligible services referenced in paragraph**of the Original Task Order is increased/decreased by dollar amount DOLLARS,($*.**)for a new,total financial obligation of the State of dollar amount DOLLARS,($*.**). The revised work plan,which is attached hereto as"Attachment 1",and the revised budget, which is attached hereto as"Attachment 2",are incorporated herein by this reference and made a part hereof. The fust sentence in paragraph**of the Original Task Order is hereby modified accordingly. All other terms and conditions of the Original Task Order are hereby reaffirmed. This amendment to the Original Task Order is intended to be effective as of ********* ** ****. However,in no event shall this amendment be deemed valid until it shall have been approved by the State Controller or such assistant as he may designate. Please sign,date,and return all**originals of this 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: By: Print Name: For the Executive Director Title: DEPARTMENT OF PUBLIC HEALTH FEIN: AND ENVIRONMENT Title: APPROVALS: STATE CONTROLLER: PROGRAM: By: By: Arthur L. Barnhart Memorandum TO: Barbara J. Kirkmeyer, Chair,_ O Board of County Commissioners' • FROM: Mark E. Wallace, MD, MPH,Department of Public Health Director, COLORADO and Environment DATE: October 9, 2000 SUBJECT: Health Care Program for Children With Special Needs Task Order Enclosed for Board review and approval is the Health Care Program for Children with Special Needs task order between the Colorado Department of Public Health and Environment (CDPHE) and Weld County Department of Public Health and Environment (WCDPHE). This task order will authorize WCDPHE to provide case finding, community outreach, care coordination, clinic management, program management, parent and family involvement and support, and interagency collaboration to children and their families who are determined to be eligible for services. In return for these services, WCDPHE will be paid an amount not to exceed $157,208 for the time period October 1, 2000 through September 30, 2001. I recommend your approval of this task order. Enclosure Hello