HomeMy WebLinkAbout20171656.tiffRESOLUTION
RE: APPROVE TASK ORDER CONTRACT AMENDMENT #2 FOR WISEWOMAN
PROGRAM UNDER THE WOMEN'S WELLNESS CONNECTION PROGRAM AND
AUTHORIZE CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Task Order Contract Amendment #2
for the WISEWOMAN (Well -Integrated Screening and Evaluation for WOMan Across the Nation)
Program under the Women's Wellness Connection Program between the County of Weld, State
of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of
the Weld County Department of Public Health and Environment, and the Colorado Department of
Public Health and Environment, commencing upon execution of signature, and ending
February 28, 2019, with further terms and conditions being as stated in said amendment, and
WHEREAS, after review, the Board deems it advisable to approve said amendment, a
copy of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Task Order Contract Amendment #2 for the WISEWOMAN (Well -
Integrated Screening and Evaluation for WOMan Across the Nation) Program under the Women's
Wellness Connection Program between the County of Weld, State of Colorado, by and through
the Board of County Commissioners of Weld County, on behalf of the Weld County Department
of Public Health and Environment, and the Colorado Department of Public Health and
Environment, be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said amendment.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 31st day of May , A.D., 2017.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST: ddrAvv � j•(A,
Weld County Clerk to the Board
Steve Moreno , Pro-Tem
can P. Conway
Attorney
Date of signature: CD ( I',3 I (1
CC t-{1. CST/CST/TG(mw)
gf8(11
rbara Kirkmeyer
2017-1656
HL0049
(DAbad (tb 4<<coc
Memorandum
TO: Julie A. Cozad, Chair
Board of County Commissioners
FROM: Mark E. Wallace, MD, MPH
Executive Director
Department of Public Health & Environment
DATE: May 24, 2017
SUBJECT: FY17-18 Women's Wellness Connection
WISEWOMAN Continuation Contract
Amendment #2
For the Board's review and approval is the FY17-18 Women's Wellness Connection WISEWOMAN
Continuation Contract Amendment #2 between the Colorado Department of Public Health and
Environment ("CDPHE") and the Board of County Commissioners for the County of Weld, State
of Colorado, on behalf of the Weld County Department of Public Health and Environment
("WCDPHE").
The purpose and mission of the Well -Integrated Screening and Evaluation for WOMen Across the
Nation (WISEWOMAN) program is to provide cardiovascular screenings, risk reduction
counseling, referrals, lifestyle change programs and other healthy behavior support options to
improve control of hypertension and other cardiovascular disease risk factors to women. Eligible
recipients of this program must reside in Colorado, be uninsured or underinsured and enroll in
the Women's Wellness Connection (WWC) program. Furthermore, WWC clients must meet age,
income, and lawful presence requirements to participate in the program
The purpose of this contract amendment is twofold: 1) to extend the period of performance of
the original contract's current term by eighteen (18) months, changing the current ending date
from August 31, 2017, to February 28, 2019, and 2) provide funding of $16,300 for the fiscal year
of July 1, 2017, through June 30, 2018, all of which is federal funding.
This contract amendment was approved for placement on the Board's agenda via pass -around
dated May 23, 2017. I recommend approval of this continuation contract with CDPHE for the
Women's Wellness Connection WISEWOMAN program.
2017-1656
5(31
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
F LA-HSCB
DEPARTMENT OR AGENCY NUMBER
FAAA
TASK ORDER AMENDMENT ROUTING NUMBER
18-100917
To Original Task Order Routing Number
15-77061
TASK ORDER AMENDMENT #2
This Task Order Amendment is made this 7th day of May, 2017, by and between the State of Colorado, acting by and
through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, whose address or principal place of
business is 4300 Cherry Creek Drive South, Denver, Colorado 80246, hereinafter referred to as the "State"; and,
BOARD OF COUNTY COMMISSIONERS OF WELD COUNTY, (a political subdivision of the state of
Colorado) for the use and benefit of the Weld County Department of Public Health and Environment, whose
address or principal place of business is 1555 North 1711 Avenue, Greeley, Colorado 80631, hereinafter referred to
as the "Contractor".
FACTUAL RECITALS
The parties entered into a Master Contract dated January 17, 2012, with contract routing number 13 FAA 00051.
Pursuant to the terms and conditions of the Master Contract the parties entered into a Task Order Contract dated
February 12, 2015, with encumbrance number CT FHLA2015000000000757, and task order contract routing number
15 FHLA 77061, hereafter referred to as the "Original Task Order Contract", whereby the Contractor was to
provide to the State the following:
Provide cardiovascular screenings, risk reduction counseling, referrals, lifestyle programs and other healthy
behavior support options to improve control of hypertension and other cardiovascular disease risk factors to
women residing in Colorado who are uninsured or underinsured and are enrolled in the Women's Wellness
Connection program who meet the share age, income and lawful presence requirements
Changes were required to extend for an additional term of eighteen months and to modify Exhibit A, Additional
Provisions, in the Original Task Order Contract.
The State promises to increase the amount of funds to be paid to the Contractor by Sixteen Thousand Three Hundred
Dollars ($16,300.00) during the current term of the Original Task Order Contract
NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree as
follows:
I . Consideration for this Contract Amendment to the Original Task Order Contract consists of the payments and
services that shall be made pursuant to this Contract Amendment, and promises and agreements herein set
forth.
2. It is expressly agreed to by the parties that this Contract Amendment is supplemental to the Original Task
Order Contract, contract routing number 15 FHLA 77061, as amended by Grant Funding Change Letter I,
routing number 16 FHLA 80204, Grant Funding Change Letter 2, routing number 16 FHLA 81529, Contract
Amendment I routing number 16 FHLA 87648, Grant Funding Change Letter 3 routing number 17 FHLA
89789, and Option Letter I routing number 17 FHLA 97673, collectively referred to herein as the Original
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ao/7- /6g ---G (3)
Task Order Contract, which is by this reference incorporated herein. All terms, conditions, and provisions
thereof, unless specifically modified herein, are to apply to this Contract Amendment as though they were
expressly rewritten, incorporated, and included herein.
3. It is expressly agreed to by the parties that the Original Task Order Contract is and shall be modified, altered,
and changed in the following respects only:
A. This Contract Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract. The
revised Additional Provisions of the Original Task Order Contract, are incorporated herein by this
reference and identified as Exhibit D.
I . Due to the extent of the revisions the Additional Provisions, Exhibit A, are hereby replaced
in their entirety with Exhibit D.
2. The following attachments are hereby deleted:
a. Attachment A -I, Grant Funding Change Letter
b. Attachment A-2, Option Letter
3. The following exhibits are hereby added:
a. Exhibit G, Sample Option Letter
B. The period of performance of the current term is hereby extended by eighteen (18) months,
changing the current ending date from August 31, 2017 to February 28, 2019. The revised period of
performance is March 1, 2015 through and including February 28, 2019.
1. This Contract Amendment is for the fiscal year of July 1, 2017, through and including June
30, 2018. The maximum amount payable by the State for the work to be performed by the
Contractor from July I, 2017 through June 30, 2018 is Sixteen Thousand Three Hundred
Dollars ($16,300.00) for an amended total contract financial obligation of the State of
Seventy Five Thousand Eight Hundred Five Dollars ($75,805.00).
a. Of the increased amount of Sixteen Thousand Three Hundred Dollars
($16,300.00) for the fiscal year Zero Dollars ($0.00) is attributable to a State of
Colorado funding source.
b. Of the increased amount of Sixteen Thousand Three Hundred Dollars
($16,300.00) for the fiscal year Sixteen Thousand Three Hundred Dollars
($16,300.00) is attributable to United States Government funding source (see Catalog
of Federal Domestic Assistance (CFDA) number 93.094). The amended total
contract financial obligation attributable to United States Government funding
source (see Catalog of Federal Domestic Assistance (CFDA) number 93.094) is
Seventy Five Thousand Eight Hundred Five Dollars ($75,805.00).
The modified specifications to the original Statement of Work and Budget of the Original Task
Order Contract, are incorporated herein by this reference and identified as Exhibits E and F,
respectively.
The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original
Task Order Contract are reaffirmed.
4. The Effective Date of this Task Order Contract Amendment is July 1, 2017, or upon approval of the State
Controller, or an authorized delegate thereof, whichever is later.
5. Except for the General Provisions and Special Provisions of the Original Task Order Contract, in the event of
any conflict, inconsistency, variance, or contradiction between the terms and provisions of this Contract
Amendment and any of the terms and provisions of the Original Task Order Contract, the terms and provisions
of this Contract Amendment shall in all respects supersede, govern, and control. The Special Provisions shall
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l8FIILA100917_AMD2.docx ver 18.5.17
Y
always control over other provisions of the Original Task Order Contract or any subsequent amendments
thereto. The representations in the Special Provisions to the Original Task Order Contract concerning the
absence of personal interest of state of Colorado employees are presently reaffirmed.
6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR ARE
CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND
OTHERWISE MADE AVAILABLE.
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I8FHI.A100917 AMD2.docxver 18.5.17
SIGNATURE PAGE
Contract Routing Number: 18 FHL.1 100917
THE PARTIES HERETO HAVE EXECUTED THIS TASK ORDER AMENDMENT
Each person signing this Task Order Amendment represents and warrants that he or she is duly authorized to execute this Task Order Amendment and to
bind the party authorizing his or her signature.
CONTRACTOR STATE OF COLORADO
BOARD OF COUNTY COMMISSIONERS OF John W. Hickenlooper, Governor
WELD COUNTY
By:
for the use and benefit of the
Weld County Department of
Public Health and Environment
(a political subdivision of the state of Colorado)
Julie A. Cozad
Print Name of Authorized Individual
Chair
Signature oAut orii-d Individual
MAY 3 1 2097
Date
PROGRAM APPROVAL
Colorado Department of Public Health and Environment
Signature of Authorized CD
By:
By:
Colorado Department of Public Health and
Environment
Larry Wolk, MD, MSPH, Executive Director and
Chief Medical Officer
rYkcJ/N-1A-
Lisa McGovern
Purchasing and Contracting Section Director. CDPIIE
(Jeg
LEGAL REVIEW
Cynthia H. Coffman Attorney General
HE Program Approver Signature — Senior Assist Attorney General
Date
In accordance with §24-30-202 C.R.S., this Task Order Amendment is not valid until signed and dated below by the State
Controller or an authorized delegate.
By:
STATE CONTROLLER
bert Jaro , CPA, MBA, JD
Effective Date:
I8FH1,A 100917_AMD2 docx
CDPHE Delegate
&/!3/1
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EXHIBIT D
ADDITIONAL PROVISIONS
To Task Order Contract Dated 02/12/2015 CMS Task Order Routing Number 18 FHLA 100917
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified
above.
I . This Contract contains federal funds (see Catalog of Federal Domestic Assistance (CFDA) number 93.094).
2. The United States Department of Health and Human Services ("USDHHS"), through the Centers for
Disease Control and Prevention ("CDC") has awarded as of 09/13/2016 anticipated federal funds of
$2,638,537.00 under Notice of Cooperative Agreement Award, hereinafter "NCAA", number
6 NU58DP004850-04-01, to perform the following — WELL INTEGRATED SCREENING AND
EVALUATION FOR WOMEN ACROSS THE NATION
If the underlying Award authorizes the State to pay all allowable and allocable expenses of a Contractor as
of the Effective Date of that Award, then the State shall reimburse the Contractor for any allowable and
allocable expenses of the Contractor that have been incurred by the Contractor since the proposed Effective
Date of this Task Order Contract. If the underlying Award does not authorize the State to pay all allowable
and allocable expenses of a Contractor as of the Effective Date of that Award, then the State shall only
reimburse the Contractor for those allowable and allocable expenses of the Contractor that are incurred by
the Contractor on or after the Effective Date of this Task Order Contract, with such effective date being the
later of the date specified in this Task Order Contract or the date the Task Order Contract is signed by the
State Controller or delegee.
3. To receive compensation for screening services under this Task Order Contract, the Contractor shall
provide cardiovascular screening, follow-up, referral and healthy behavior support options to eligible
clients during the term of this Task Order Contract. The Contractor shall also provide WISEWOMAN-
approved follow up and referral services to women who meet the criteria in accordance with this Statement
of Work. The Contractor shall be paid in accordance with rates as outlined in the WISEWOMAN Bundled
Payment System.
Data entered into eCaST is the basis for calculating reimbursement for each client screened. To be
considered for payment, all WISEWOMAN services must be entered into eCaST within thirty (30) days of
service being performed. Breast and cervical cancer screening cases that exceed sixty (60) calendar days in
screening length and negatively affect the program's Performance Measures may or may not be reimbursed
at the discretion of the State. Contractors shall only be paid for cases that meet eligibility, performance and
data requirements. Reimbursement is determined by the outcome of the case.
The Contractor shall be paid in accordance with rates as outlined in the WISEWOMAN Bundled Payment
System. This document is incorporated and made part of this Contract by reference and is available on the
following WISEWOMAN website under "Billing and Reimbursement" at
https://www.colorado.gov/cdphe/wisewoman-provider-resources. Rates may be revised or updated during
the period this statement of work is in effect. Detailed reimbursement policies can be found in the
WISEWOMAN Colorado Program Manual in the "Reimbursement" section on the following
WISEWOMAN website: https://www.colorado.gov/cdphe/wisewoman-provider-resources, incorporated
and made part of the Task Order Contract by reference.
To receive compensation for non-eCaST purchases under the Task Order Contract, the Contractor shall
submit a signed Monthly CDPHE Reimbursement Invoice Form. This form is accessible from the CDPHE
internet website https://www.colorado.gov/pacific/cdphe/standardized-invoice-form-and-links and is
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EXHIBIT D
incorporated and made part of this Task Order Contract by reference. CDPHE will provide technical
assistance in accessing and completing the form. The CDPHE Reimbursement Invoice Form and
Expenditure Details page must be submitted no later than forty-five (45) calendar days after the end of the
billing period for which services were rendered. Expenditures shall be in accordance with this Statement of
Work and Budget.
Scan the completed and signed CDPHE Reimbursement Invoice Form into an electronic document. Email
the scanned invoice with the Excel workbook containing the Expenditure Details page to the WWC Section
Manager via email at cdphe_wwc@state.co.us.
Final billings under the Task Order Contract must be received by the State within a reasonable time after
the expiration or termination of the Contract; but in any event no later than forty-five (45) calendar days
from the effective expiration or termination date of the Contract.
Unless otherwise provided for in the Task Order Contract, "Local Match", if any, shall be included on all
invoices as required by funding source.
The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless
approved in writing by the appropriate federal agency.
4. Time Limit For Acceptance Of Deliverables.
a. Evaluation Period. The State shall have fifteen (15) calendar days from the date a deliverable is
delivered to the State by the Contractor to evaluate that deliverable, except for those deliverables
that have a different time negotiated by the State and the Contractor.
b. Notice of Defect. If the State believes in good faith that a deliverable fails to meet the design
specifications for that particular deliverable, or is otherwise deficient, then the State shall notify
the Contractor of the failure or deficiencies, in writing, within fifteen (15) calendar days of: 1) the
date the deliverable is delivered to the State by the Contractor if the State is aware of the failure or
deficiency at the time of delivery; or 2) the date the State becomes aware of the failure or
deficiency. The above time frame shall apply to all deliverables except for those deliverables that
have a different time negotiated by the State and the Contractor in writing pursuant to the State's
fiscal rules.
c. Time to Correct Defect. Upon receipt of timely written notice of an objection to a completed
deliverable, the Contractor shall have a reasonable period of time, not to exceed thirty (30)
calendar days, to correct the noted deficiencies. If the Contractor fails to correct such deficiencies
within thirty (30) calendar days, the Contractor shall be in default of its obligations under this
Task Order Contract and the State, at its option, may elect to terminate this Task Order Contract or
the Master Contract and all Task Order Contracts entered into pursuant to the Master Contract.
5. Health Insurance Portability and Accountability Act (HIPAA) Business Associate Determination.
The State has determined that this Task Order Contract does not constitute a Business Associate
relationship under HIPAA.
6. This award does not include funds for Research and Development.
7. The Contractor shall request prior approval in writing from the WISE WOMAN Program Manager for any
modifications to the eCaST budget line item.
8. The Contractor shall request prior approval in writing from CDPHE for all modifications to the Statement
of Work/Work Plan or for any modification to the direct costs of supplies/operating and travel in excess of
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EXHIBIT D
twenty-five percent (25%) of the total budget for direct costs. Any request for modifications to the Budget
in excess of twenty-five percent (25%) of the total budget for direct costs shall be submitted to CDPHE at
least ninety (90) days prior to the end of the contract period and may require an amendment in accordance
with General Provisions, Section 5, Contract .1t/odifrcations, of this Task Order Contract.
9. 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 eighteen
(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.
10. The State of Colorado, specifically the Colorado Department of Public Health and Environment, shall be
the owner of all equipment as defined by Federal Accounting Standards Advisory Board (FASAB)
Generally Accepted Accounting Principles (GAAP) purchased under this Contract. At the end of the term
of this Task Order Contract, the State shall approve the disposition of all equipment.
Option to Increase or Decrease Quantities and Total Price
The State may increase or decrease the quantity of services described in Exhibit E based upon the rates
established in Exhibit F of the Task Order Contract. If the State exercises the option, it will provide written
notice to Contractor as least 1 day prior to the end of the current Contract term in a form substantially
equivalent to Exhibit G. Delivery/performance of the service shall continue at the same rates and terms. If
exercised, the provisions of the Option Letter shall become part of and be incorporated into the original
Task Order Contract.
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Contract_I'xhibit-1)_AdditionalProvisiu ns_'I'askOrdcr_0407I5
EXHIBIT E
STATEMENT OF WORK
To Original Contract Routing Number 15 FHLA 77061
Contract Amendment #2 Routing Number 18 FHLA 100917
These provisions are to be read and interpreted in conjunction with the provisions of the contract specified above.
I. Entity Name: Weld Department of Public Health and Environment
Term: PROJECT PERIOD: July 1, 2017 through February 28, 2019
PERIOD FOR COMPLETING ACTIVITIES: July 1, 2017 through December 31, 2018
11. Project Description:
This project serves to provide Women's Wellness Connection (WWC) participants with access to additional
preventive health services through the Well -Integrated Screening and Evaluation for WOMen Across the Nation
(WISEWOMAN) program. These medical services include cardiovascular health screening; health risk
assessments; risk reduction counseling; referrals for women with abnormal screening values to health care
providers for medical evaluation and management of condition(s); follow-up for uncontrolled hypertension;
linking participants to free or low-cost medication resources; and referrals to health coaching, approved lifestyle
programs and other healthy behavior support options.
Program Purpose and Mission:
The purpose and mission of the WISEWOMAN program is to provide cardiovascular screenings, risk reduction
counseling, referrals, health coaching, lifestyle programs and other healthy behavior support options to improve
control of hypertension and other cardiovascular disease risk factors.
Beneficiaries:
Direct beneficiaries are women residing in Colorado who are uninsured or underinsured; who meet the age,
income and lawful presence requirements of both WWC and WISEWOMAN programs. Target populations
include women of diverse ethnic backgrounds, women living in geographically isolated and medically underserved
areas and women who have a high burden of cardiovascular disease.
III. Definitions:
I. Case Management- Case management services are provided to WISEWOMAN clients who have initial
abnormal or "alert" screening values for blood pressure or glucose or who have uncontrolled hypertension.
All women with alert values must receive these services to ensure access to the indicated medical care.
2. CDC: Centers for Disease Control and Prevention
3. DPP: Diabetes Prevention Program
4. eCaST: Colorado Department of Public Health and Environment's (CDPHE) Electronic Cancer
Surveillance Tracking data system
5. WISEWOMAN: Well -Integrated Screening and Evaluation for WOMen Across the Nation
6. WISEWOMAN Program: Ran by the Colorado Department of Public Health and Environment, Prevention
Services Division, WWC.
7. WWC: Women's Wellness Connection. The local name in Colorado for the National Breast and Cervical
Cancer Early Detection Program
IV. Work Plan:
Goal #1: Reduce the rate of cardiovascular disease risk in program eligible women in Colorado
Objective #1: No later than the expiration date of the Contract, women that meet WISEWOMAN eligibility
criteria are provided with cardiovascular screening services.
Primary
Activity #1
The Contractor shall perform cardiovascular screening services onsite at the Contractor's
place of business.
version_ Contract Statement of Work— Gxhibit R
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EXHIBIT E
Sub -Activities
#1
I. The Contractor shall provide medical evaluation and treatment to WISEWOMAN
clients with alert lab values.
2. The Contractor shall provide case management to WISEWOMAN clients with
abnormal screening values.
3. The Contractor shall provide referrals to medical care for WISEWOMAN clients with
abnormal screening values.
Primary
Activity #2
The Contractor shall provide face -to face risk reduction counseling onsite, at the
Contractor's place of business, at the time of their screening visit.
Objective #2: No later than the expiration date of the Contract, women that meet WISEWOMAN eligibility
criteria are offered healthy behavior support options.
Primary
Activity #1
The Contractor shall offer WISEWOMAN clients to the Diabetes Prevention Program
(DPP), Cooking Matters or to another comparable CDPHE approved lifestyle program,
either onsite or at another site.
Primary
Activity #2
The Contractor shall offer WISEWOMAN clients paid -for referrals to health coaching
services either onsite or to a CDPHE approved entity that provides health coaching.
Primary
Activity #3
The Contractor shall offer WISEWOMAN clients other referrals to other healthy behavior
support options such as other community based resources that support the woman's health
goals
Objective #3: No later than July 30, annually, WISEWOMAN data is entered into the eCaST data system.
Primary
Activity #1
The Contractor shall record WISEWOMAN qualifying procedures into the eCaST data
system on a monthly basis.
Objective #4: No later than the expiration date of the Contract, participate in the Baseline Screening
Assessment and Clinic Quality Improvement project.
Primary
Activity #1
The Contractor shall participate in the Baseline Screening Assessment and Clinic Quality
Improvement project by CDPHE related to breast, cervical, colorectal cancer and
cardiovascular screening rates.
Sub -Activities
#1
The Contractor shall participate in collection of baseline cardiovascular and cancer
screening data from Contractor's electronic health record.
1. The content of electronic documents located on CDPHE and non-CDPHE websites and
information contained on CDPHE and non-CDPHE websites may be updated
periodically during the Contract term. The Contractor shall monitor documents and
website content for updates and comply with all updates.
2. The Contractor shall comply with the WISEWOAI4,V Program Eligibility Criteria in the
WISEWOMAN Colorado Program Manual, found in the WISEWOMAN Provider
Resources page on the WISEWOMAN website. This document is incorporated and
made part of the Contract by reference and is available on the following website:
https://www.colorado.gov/pacific/sites/default/files/WISEWOMAN Manual.pdf
3. The Contractor shall comply with the lawful presence requirements for WWC.
a. Comply with Lawful Presence Requirements according to Colorado Department of
Revenue guidelines. This information is incorporated and made part of this Contract
by reference as is available at the following Department of Revenue website:
hitps://www.colorado.gov/pacific/dmv/identification-requirement-charts
b. Annually obtain a signed Lawful Presence Affidavit. The Contractor shall keep a
copy in the patient's medical record before services are rendered. This form is .
incorporated and made part of this Contract by reference and is available at the
WWC website on the Women's Wellness Connection Provider Resources page:
https://www.colorado.gov/pacific/cdphe/wwc-provider-resources; and
c. Attest by checking the Verified Legal Presence box in the electronic record in
eCaST.
4. The Contractor shall complete the WWC. WISEWO,1Ll. I,V Combined Consent, Patient
version, Contract Statement of Work — Exhibit B
December 2015
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EXHIBIT E
Standards
and
Requirements
Information and Risk Reduction Counseling and Referral forms. These forms are
incorporated and made part of this Statement of Work by reference and are available in
the WISEWOMAN Provider Resources page on the WISEWOMAN website.
5. The Contractor shall perform cardiovascular screening services in accordance with the
WISEWOM4V Service Delivery Flow Diagram and clinical and program guidelines in
the WISEWOMAN Colorado Program Manual.
6. The Contractor shall use as a guideline the published alert values, disease values, flow
chart, clinical guidelines and risk reduction counseling as described in the
WISEWOMAN Colorado Program Manual.
7. The Contractor shall provide face-to-face risk reduction counseling in accordance with
the WISEWOrt4A!V Service Delivery Flow Diagram and the WISEWOMAN Colorado
Program Manual.
8. The Contractor shall provide all women, with alert lab values, medical evaluation and
treatment immediately or within seven (7) days of the alert measurement, in accordance
with national standards of care and the judgment of the Contractor's Medical Director.
9. The Contractor shall provide all women, with alert level blood pressure or laboratory
alert values, referrals for medical evaluation and management of condition(s) if not
currently being treated.
10. The Contractor shall provide all women, with uncontrolled hypertension, case
management and other appropriate follow-up.
11. The Contractor shall follow the guidelines and comply with the requirements for case
management of WISEWOMAN clients stated in the WISEWOMAN Colorado Program
Manual.
a. Clinical aspects of case management shall be overseen by a Registered Nurse,
Physician Assistant or Physician licensed and in good standing to provide healthcare
in the state of Colorado.
b. Case management shall begin from the first abnormal result through referral to
additional medical follow-up or evaluation.
12. The Contractor shall have a Medical Director to develop and implement medical
protocols to cover situations not addressed by WISEWOMAN national guidelines.
13. The Contractor shall refer all women to free or low-cost medication resources, if
needed.
14. The Contractor shall have an established referral process for abnormal findings.
15. The Contractor shall provide services referenced on the Current Procedural Technology
(CPT) Code List directly or through a subcontractor agreement and is available in the
WISEWOMAN Provider Resources page on the WISEWOMAN website.
16. If the Contractor is a CDC recognized Diabetes Prevention Program (DPP) site, or
pending recognition, then DPP services may be provided by the Contractor.
17. For services that may not be provided onsite, including the DPP services, the Contractor
shall maintain a network of subcontractors. Contractor shall forward a copy of the fully
executed Memorandum of Understanding or other binding contractual agreement to the
WISEWOMAN Program within 15 calendar days of execution.
a. Subcontracts shall be secured with local providers to the extent possible.
b. Services performed by subcontractors shall be agreed upon in writing through the use
of a binding contract which includes the period of service.
version: Contract Statement of Work — Exhibit B
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EXHIBIT E
c. This agreement shall cover referral of eligible clients for services in accordance with
WISEWOMAN guidelines in the WISEWOMAN Colorado Program Manual; utilize
approved reimbursement rates; obtain written monthly feedback on client
participation; access and barriers to participation; and date and length of DPP
classes/sessions.
Standards
and
Requirements
18. The Contractor shall comply with requirements stated in the most current national
clinical, diet and lifestyle guidelines as outlined in the WISEWOMAN Colorado
Program Manual.
19. At least one (1) representative from the Contractor and/or its network provider sites shall
attend all required meetings, conference calls or trainings hosted by the WISEWOMAN
Program. This attendance can be achieved by participating at the time of the event or by
reviewing a recorded version at a later time.
20. It is expected that if a Contractor enrolls a client in WISEWOMAN and provides initial
cardiovascular screening services, the same Contractor shall be responsible for entering
all data in eCaST and assuring that clinically appropriate follow-up care is completed
through case management services and healthy behavior support options.
21. When corresponding with the WISEWOMAN Program, Contractor shall use all privacy
and security measures to protect the client's personal health information.
Accepted forms of communication include:
a. Unencrypted email conversations using the eCaST identification number;
b. Mail or fax clearly marked "Confidential" and using the eCaST identification
number;
c. HIPAA compliant files transmitted via secure File Transfer Protocol (FTP) sites; and
d. Secure encrypted email.
22. The Contractor shall enter the most recent WISEWOMAN client data into the eCaST
system by the 15th of each month in preparation for the monthly billing run.
23. The Contractor's new data entry staff shall participate in WISEWOMAN eCaST
training within 30 calendar days of hire, unless otherwise approved by the
WISEWOMAN Program.
24. The Contractor shall identify and support key personnel assigned these roles: a
WISEWOMAN Coordinator, Clinical Liaison, eCaST Coordinator, eCaST data entry
staff, Agency Director, Contract Administrator, Signature Authority, Fiscal Payment
Coordinator, Fiscal Manager, Health Coach, and Case Manager(s).
25. The Contractor shall comply with the requirements stated in the Contacts Descriptions
document, which is available in the WISEWOMAN Provider Resources page of the
WISEWOMAN website.
26. The Contractor shall report all staff changes during the contract period to
WISEWOMAN Program within 15 calendar days. The Contractor shall use the .Igency
and Site Contacts Form or another WISEWOMAN-provided form.
27. The Contractor shall report all subcontractor changes during the contract period to the
WISEWOMAN Program within 15 calendar days of occurrence, via email to
WISEWOMAN Program Coordinator.
Expected
Results of
Activity(s)
Clients' complete cardiovascular screenings, risk reduction counseling and referrals, and
received needed treatment.
version: Contract Statement or Work — Exhibit H
December 2015
l8FI1LA 100917_Fx E.docx
Page 4ol5
0
EXHIBIT E
Measurement
of Expected
Results
WISEWOMAN Program will analyze data from eCaST to include the number of women
receiving cardiovascular screenings, risk reduction counseling, and referrals for lifestyle
programs .
Completion Date
Deliverables
1. The Contractor shall identify (an) eCaST user(s) responsible for
WISEWOMAN data entry in eCaST and submit a list of eCaST
user(s) via email to WISEWOMAN Program Coordinator.
No later than
7/15/2017
2. The Contractor shall submit key personnel contact information to
WISEWOMAN Program within 15 calendar days of the start of
the fully executed contract or start of term date, whichever is
later, via email to WISEWOMAN Program Coordinator.
No later than 15
calendar days of
change
V. Monitoring:
CDPHE's monitoring of this contract for compliance with performance requirements will be conducted throughout
the contract period by the WISEWOMAN Program Coordinator. Methods used will include a review of
documentation determined by CDPHE to be reflective of performance to include monthly check -in calls, All
Agencies Calls, eCaST data, site visits, and other fiscal and programmatic documentation as applicable. The
Contractor's performance will be evaluated at set intervals and communicated to the contractor. A Final
Contractor Performance Evaluation will be conducted at the end of the life of the contract.
VI. Resolution of Non -Compliance:
The Contractor will be notified in writing within 15 calendar days of discovery of a compliance issue. Within 30
calendar days of discovery, the Contractor and the State will collaborate, when appropriate, to determine the
action(s) necessary to rectify the compliance issue and determine when the action(s) must be completed. The
action(s) and time line for completion will be documented in writing and agreed to by both parties. If extenuating
circumstances arise that requires an extension to the time line, the Contractor must email a request to the
WISEWOMAN Section Manager and receive approval for a new due date. The State will oversee the
completion/implementation of the action(s) to ensure time lines are met and the issue(s) is resolved. If the
Contractor demonstrates inaction or disregard for the agreed upon compliance resolution plan, the State may
exercise its rights under the provisions of this contract.
version: Contract Statement of Work— 1 xhibit B
December 2015
8FHLA 100917_Ex E.docx
Page 5 of 5
EXHIBIT F
CDPHE
!COLORADO
Department of Public
Health & Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Contract Routing # 18 FHLA 100917
Contractor Name
Weld County Department of Public Health and
Environment
Budget Period
07/01/2017 - 06/30/2018
Project Name
WISEWOMAN FY18 Award
Program Contact Name,
Title, Phone and Email
Keri Dennison, WISEWOMAN
Program Coordinator, 970-400-2315,
kdennison@co.weld.co.us
Fiscal Contact Name, Title,
Phone and Email
Tanya Geiser, Director, Admin
Services 970-400-2122
tgeiser@co.weld.co.us
Expenditure Categories
Personal Services
Salaried Employees
Position Title
Description of Work
Budget Item
Supports SOW
(Yes/No)
Gross or
Annual Salary
Fringe
Percent of
Time on
Project
Total Amount
Requested from
CDPHE
$0.00
Personal Services
Hourly Employees
Position Title
Description
Lion of Work
Budget Item
Supports SOW
(Yes/No)
Hourly Wage
Hourly
Fringe
Total # of
Hours on
Project
Total Amount
Requested from
CDPHE
$0.00
Total Personal Services
(including fringe benefits)
$0.00
Supplies & Operating Expenses
Item
Description of Item
Budget Item
Supports SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested from
CDPHE
Service Delivery
Billed in eCaST
Yes
$13,300.00
1
$13,300.00
Operating Supplies
Allowable purchase of supplies/operating listed on the WISEWOMAN
allowable purchase document on the WISEWOMAN website:
https://www.colorado.gov/cdphe/wisewoman-provider-resources
Yes
$1,275.00
1
$1,275.00
$0.00
Total Supplies
& Ooeratina Expenses
$14,575.00
Page 1 of 2
w
EXHIBIT F
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Contract Routing # 18 FHLA 100917
Contractor Name
Weld County Department of Public Health and
Environment
Budget Period
07/01/2017 - 06/30/2018
Project Name
WISEWOMAN FY18 Award
Program Contact Name,
Title, Phone and Email
Ken Dennison, WISEWOMAN
Program Coordinator, 970-400-2315,
kdennison@co.weld.co.us
Fiscal Contact Name, Title,
Phone and Email
Tanya Geiser, Director, Admin
Services 970-400-2122
tgeiser@co.weld.co.us
Travel
Item
Description of Item
Budget Item
Supports SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested from
CDPHE
Travel Costs
Allowable purchase of travel costs listed on the WISEWOMAN allowable
purchase document on the WISEWOMAN website:
https://www.colorado.gov/cdphe/wisewoman-provider-resources
Yes
$1,266.00
1
$1,266.00
$0.00
Total Travel
$1,266.00
Contractual
Subcontractor Name
Description of Item
Budget Item
Supports SOW
(Yes/No)
Rate
Quantity
Total Amount
Requested from
CDPHE
$0.00
Total Contractual
$0.00
SUB -TOTAL BEFORE INDIRECT
$15,841.00
Indirect
Item
Description of Item
Total Amount
Requested from
CDPHE
Federally -negotiated
indirect cost rate
CDPHE-approved indirect
cost rate
2017 indirect rate per CDPHE Indirect Cost Negotiation Agreement
$459.00
De minimis indirect cost
rate
Total Indirect
S459.00
A 4 %
Page 2 of 2
IV
EX
OPTION LETTER
Date:
State Fiscal Year:
Option Letter No.
CMS Routing #
CORE Encumbrance #
1) OPTIONS: Choose all applicable options listed
a. Option to renew only (for an additional term)
b. Change in the amount of goods within current
c. Change in amount of goods in conjunction
d. Level of service change within current term
e. Level of service change in conjunction with
f. Option to initiate next phase of a contract
2) REQUIRED PROVISIONS. All Option Letters
a. For use with Options 1(a -e): In accordance
in §1 and in §2 and delete the
term
with renewal for additional term
renewal for additional term
shall contain the appropriate provisions
with Section(s) of the
Name of Department or Higher
for an additional term beginning
in Section , AND/OR an
in Identify the Section, Schedule,
following: In accordance with
rest.
set forth below:
Original Contract routing number
Ed Institution , and Contractor's
Insert start date and ending on
increase/decrease in the amount of
Attachment, Exhibit etc.
Section(s) of the Original
of Department or Higher Ed
to initiate Phase indicate which
ending date at the cost/price
contract value is
New $ Amt to as consideration
Fiscal Year. The first
value including all previous
State Controller or
APPROVAL
Department of Public Health and
Environment
between the State of Colorado, Insert
Name, the State hereby exercises its option
Insert ending date at a cost/price specified
goods/services at the same rate(s) as specified
b. For use with Option 1(f), please use the
Contract routing number between the
Institution , and Contractor's Name, the State
Phase: 2, 3, 4, etc for the term beginning Insert
specified in Section
c. For use with all Options 1(a -f): The amount
State of Colorado, Insert Name
hereby exercises its option
start date and ending on Insert
of the current Fiscal Year
to a new contract value of Insert
for the current fiscal year indicate
accordingly. The total contract
$ Amt.
Letter is upon approval of the
PROGRAM
Colorado
By:
increased/decreased by $ amount of change
for services/goods ordered under the contract
sentence in Section is hereby modified
amendments, option letters, etc. is Insert New
3) Effective Date. The effective date of this Option
whichever is later.
STATE OF COLORADO
John W. Hickenlooper, Governor
Department of Public Health and Environment
By:
Lisa McGovern INSERT -Name of Authorized Individual
Purchasing and Contracting Section Director. CDPHE INSERT -Official Title of Authorized Individual
In accordance with
Name
Date Date
§24-30-202 C.R.S., this Contract is not valid until signed and dated below by the State Controller or an authorized
delegate.
STATE CONTROLLER
Robert Jaros, CPA, MBA, JD
By:
of Agency Delegate -Please delete if contract will be routed to OSC for approval.
Effective Date:
Contract Option Letter SAMPLE (2).docx ver 30.4.17 Page 1 il)f 1
Hello