HomeMy WebLinkAbout20152861.tiff RESOLUTION
RE: APPROVE TASK ORDER CONTRACT AMENDMENT#1 FOR MATERNAL AND CHILD
HEALTH (MCH) 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 #1
for the Maternal and Child Health (MCH) Program between the County of Weld, State of Colorado,
by and through the Board of County Commissioners of Weld County, on behalf of the Department ,
of Public Health and Environment, and the Colorado Department of Public Health and
Environment, commencing October 1, 2015, and ending September 30, 2016, with further terms
and conditions being as stated in said task order contract amendment, and
WHEREAS, after review, the Board deems it advisable to approve said task order contract
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#1 for the Maternal and Child Health
(MCH) Program between the County of Weld, State of Colorado, by and through the Board of
County Commissioners of Weld County, on behalf of the 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 contract amendment.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 26th day of August, A.D., 2015.
BOARD OF COUNTY COMMISSIONERS
� WELD COUNTY, COLORADO
� ATTEST: �„Q2� G: .J�C,lto:� �� � �
, arbara Kirkmey r, Chair
Weld County Clerk the Board
IEI� CUSED
• Freeman, Pro-Tem
B
D puty Clerk to the Boar �
� P. Conway --
� / EDAS ORM: ���� , %f y � -�
� � "��- Julie A. ozad
.
t Attorney -,-,-� G' ' `z�ft�'-��,'
Steve Moreno
Date of signature: / /
/� 2015-2861
L C f�L (`�l�('����3C HL0047
Memorandum
TO: Esther Gesick, Clerk to the Board
t'l2 COUNTY FROM: Skye Turchado
Department of Public Health & Environment
DATE: August 24, 2015
SUBJECT: Routing Request—BOCC Agenda
The following documents have been approved for placement on the Board's meeting agenda
for the Board's final approval and the Chair's signature. We would like to have these items
placed on the Board's agenda for Wednesday, August 26, 2015.
NEW BUSINESS:
3 Original(s): FY15-16 Maternal and Child Health (MCH)Amendment for Task Orders#1
3 Original(s): REVISED FY15-16 Local Planning and Support aka Per Capita Amendment for
Task Orders#1
Original(s):
_ Original(s):
CONSENT AGENDA:
Original(s):
Original(s):
Original(s):
Original(s):
Once signed by the Chair, please return the original, signed documents to my attention.
If you have any questions, or if you require anything further in this regard, please '* me know. I
can be reached at Extension 2102 or via email.
2015-2861
As always, thank you for all of your help with processing our paperwork with the Board.
tALODA'l
I
�.� 1861 .��. Memorandum
��
���. � ,,
�.�,,.►�� TO: Barbara Kirkmeyer, Chair
v��-- N T Y Board of County Commissioners
GO �
FROM: Mark E. Wallace, MD, MPH,
Executive Director
Department of Public Health & Environment
DATE: August 24, 2015
SUBJECT: Continuation Task Order Contract for the
Maternal and Child Health (MCH) Program
FY15-16
Enclosed for Board review and approval is an Amendment for Task Orders #1 between the Board of County
Commissioners of Weld County on behalf of the Weld County Department of Public Health and Environment
("WCDPHE") and the Colorado Department of Public Health and Environment ("CDPHE") for the Maternal and
Child Health (MCH) Program. The original task order represented a two year term from October 1, 2014,through
September 30, 2016. This amendment represents total funding for the second year renewal period and will not
exceed $319,054 for the period October 1, 2015,through September 30, 2016. The MCH program encompasses
four separate and distinct programs as described below.
Early Childhood Obesity Prevention
In 2013, 26.5% of Colorado children ages 2 to 14 were overweight or obese. Among Hispanic children, the
prevalence of overweight or obesity was 36.6%. Childhood obesity increases the risk of developing a variety of
health problems in adolescence, and later in life. The Weld County Five-Year Community Health Improvement
Plan identified obesity prevention as a top priority area to be addressed. The goal for the strategies addressed
in the Early Childhood Obesity Prevention Action Plan is to focus closely upon the maternal and child population
and be a voice for maternal and early childhood health in existing partnerships and efforts. Objectives include
the Breastfeeding Friendly Business Initiative, training childcare professionals to implement obesity prevention
best practices, and community wide consistent messaging.
Health Care Program for Children with Special Needs (HCP): Care Coordination
The HCP program provides services to Weld County children and youth with special health care needs from birth
to age 21, who have, or are at risk for, physical, developmental, behavioral or emotional conditions. There are
no financial or diagnostic criteria; services are provided at no cost to the family. The HCP program provides
information and resources, individual care coordination/case management, access to primary and specialty
care, and referral to community resources. This program also facilitates the development and enhancement of
community-based systems of care for children and youth with special health care needs. Services provided will
include interagency collaboration, consultation, and community involvement.
Health Care Program for Children with Special Needs (HCP�: Medical Home
HCP identified the need for a high level stakeholder committee to address barriers to a Medical Home approach
for addressing medical needs of the "resource-challenged" children and families of Weld County. HCP initiated
the Weld Child Resource Consortium (WCRC) in February 2013. Our three-year plan for this consortium
composed of representatives from 22 Greeley/Weld agencies who will continue in 2015-2016 to explore
opportunities to eliminate barriers to the Medical Home approach. The consortium has completed a
comprehensive resource guide which supports medical home access to all types of health care for children in
Weld County. In 2016 we will begin the implementation phase for closing the referral/feedback loop between
care providers. The consortium will work closely with our Regional Care Collaborative to determine optimal
case management options for children with Medicaid. Leadership of the consortium will be transitioned to
other members to best serve all children and youth within the medical home neighborhood of Weld County.
Adolescent Health & Injury Prevention
This program's focus is directed to the Teen Motor Vehicle Safety program and the successful program of DRIVE
SMART Weld County to help meet the goal of decreasing deaths and injuries from motor vehicle crashes among
adolescents aged 14-19. The program will support and expand the DRIVE SMART Weld County community
traffic safety coalition, increase knowledge of graduated driver's license laws and willingness to issue citations
among law enforcement personnel, provide safe teen driving programs to students at Weld County high schools,
and provide classes for parents and teens about graduated driver's licensing laws (GDL).
This continuation contract was approved for placement on the agenda by the Board via pass-around dated
August 21, 2015
I recommend approval of this Maternal and Child Health (MCH) Continuation Task Order Contract with CDPHE.
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
FHLA-MCH
DEPARTMENT OR AGENCY NUMBER
FAAA
CONTRACT ROUT[NG NUMBER
16 FHLA 82757
AMENDMENT FOR TASK ORDERS#1
This Amendment is made this 4th day of Au ust,2015,by and between the State of Colorado,acting by and
through the DEPARTMENT OF PUBL[C HEALTH AND ENVIRONMENT,whose address or principal pface
of business is 4300 Cherry Creek Drive South,Denver,Colorado 80246,hereinafter referred to as the"State";
and, Board of Countv Commissioners of Weld Countv(a political subdivision of the state of Colorado)whose
address or principal place of business is 915 10`h Street,Greelev,Colorado 80632-07�8,for the use and benefit
of the Weld Countv Deaartment of Public Health and Environment,whose address or principal place of
business is 1555 North 17`h Avenue,Greelev,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
July 15,2014,with encumbrance number CT FHLA2015000000000590,and contract routing number 15 FHLA
72161,collectively referred to herein as the"Original Task Order Contract,whereby the Contractor was to provide
to the State the following:
Develop,implement and evaluate evidence-based tiICH.action Plans,HCP Care Coordination services
and HCP Specialty Clinics
The State promises to pay the Contractor the sum of Three Hundred Nineteen Thousand Fiftv Four pollars,
($319,054.00)in exchange for the promise of the Contractor to continue to perform the work identified in the
Original Task Order Contract for the current term,ending on September 30,2016.
NOW THEREFORE, in consideration of their mutual promises to each other,stated below,the parties hereto agree
as follows:
l. Consideration for this Amendment to the Original Task Order Contract consists of the payments and
services that shall be made pursuant to this Amendment,and promises and agreements herein set forth.
2. It is expressly agreed to by the parties that this Amendment is supplemental to the Original Task Order
Contract,contract routing number 15 FHLA 72161,collectively referred to herein as the Original Contract,
which is by this reference incorporated herein. All terms,conditions,and provisions thereof, unless
specifically modified herein,are to apply to this Amendment as though they were expressly rewritten,
incorporated,andincluded 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
identified by contract routing number 15 FHLA 72161. This Amendment is for the current term
of October 1,2014,through and including September 30,2016. This Amendment modifies the
Original Task Order Contract by adding descriptive elements. The following provision
modifications are incorporated herein by this reference.
Page 1 of 6
Contract_Amendment_TaskOrder 01-2015
i. The foliowing information shafl be added as a supplement to page 1 of the Task Order
ContracC:
a Contractor DUNS: 075757955
b Classification: Subrecipient
ii. The following information shall be added as a supplement to Exhibit A,Additional
Provisions,of the Task Order Contract:
a This award does not include funds for Research and Development.
B. This Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified
by contract routing number 15 FHLA 72161. This Amendment is for the current term of
October 1,2014,through and including Seatember 30,2016. The maximum amount payable by
the State for the work to be performed by the Contractor during this current term is Three
Hundred Nineteen Thousand Fiftv Four pollars,($319,054.00)for an amended total financial
obligation of the State of Six Hundred Fortv Five Thousand Five Hundred Twentv Four
Dollars($645,524.00). This is an increase of Three Hundred Nineteen Thousand Fiftv Four
Dollars,($319,054.00)of the amount payable from the previous term.Of the maximum amount
for this current term One Hundred Seventv Four Thousand Four Hundred Seventeen
Dollars,($174,417.00)are attributable to a funding source of the State of Colorado and One
Hundred Fortv Four Thousand Six Hundred Thirtv Seven Dollars,($144,637.00)are
attributable to a funding source of the United States Government(see Catalog of Federal Domestic
Assistance(CFDA)number 93.994).Of the amended total financial obligation of the State
referenced above Three Hundred Twenty Four Thousand Three Hundred Seventv Five
Dollars and Ninetv Six Cents,($324,375.96)are attributable to a funding source of the State of
Colorado and Three Hundred Twentv One Thousand One Hundred Fortv Ei�ht Dollars Four
Cents,($321,148.04)are attributable to a funding source of the United States Government.
The revised Statement of Work is incorporated herein by this reference and identified as
"Revised Exhibit B". Revised Exhibit B is hereby modified to change FY15 to FY16,modify the
original dates to October 1,2015 through September 30,2016,and modify the original
deliverable due dates to October 31,2016. The revised Budget is incorporated herein by this
reference and identified as"Revised Exhibit C".
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 Amendment is October 1,2015,or upon approval of the State Controller,or an
authorized delegate thereof,whichever is later.
5. Except for the Special Provisions and other terms and conditions of the Master Contract and the General
Provisions of the Original Task Order Contract,in the event of any conflict, inconsistency,variance,or
contradiction between the terms and provisions of this Amendment and any of the terms and provisions of
the Original Task Order Contract,the terms and provisions of this Amendment shall in all respects
supersede,govern,and controL The Special Provisions and other terms and conditions of the Master
Contract shall always control over other provisions of the Original Task Order Contract or any subsequent
amendments thereto. The representations in the Special Provisions to the Master Contract concerning the
absence of personal interest of state of Colorado employees and the certifications in the Special Provisions
relating to illegal aliens are presently reaffirmed.
6. FINANC[AL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR
ARE CONT[NGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED,
AND OTHERWISE MADE AVA[LABLE.
Page 2 of 6
Contract_Amendment_TaskOrder_0 l-2015
Page 3 of 6
Contract_Amendment TaskOrder 01-2015
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Page 4 of 6
Contract Amendment TaskOrder_01-2015
IN WITNESS WHEREOF,the parties hereto have executed this Amendment on the day first above written.
* Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's
behalf and acknowledge that the State is relying on their representations to that effect.
CONTRACTOR: STATE:
Board of County Commissioners of Weld County STATE OF COLORADO
for the use and benefit of the Weld County John W.Hickenlooper,Governor
Department of Public Health and Environment
By:
Signature of uthorized Officer er For the Executive Director
DEPARTMENT OF PUBLIC HEALTH
AUG 2 6 2015 AND ENVIRONMENT
Date
Barbara Kirkmeyer
Print Name of Authorized Officer
Chair, Board of Weld
County Commissioners
Print Title of Authorized Officer
PROGRAM APPROVAL:
By:
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS§24-30-202 requires the State Controller to approve all State Contracts.This Contract is not valid until
signed and dated below by the State Controller or delegate.Contractor is not authorized to begin
performance until such time. If Contractor begins performing prior thereto,the State of Colorado is not
obligated to pay Contractor for such performance or for any goods and/or services provided hereunder.
STATE CONTROLLER
Rob t J,lros,CPA,MBA,JD
B It l ��
y: ,
Date: /2///5
Page 5 of 6
Contract Amendment TaskOrder 01-2015
49Z-045--a��/ '2 )
Maternal & Child Health Amendment for Task Orders #1
ATTEST: datrAest) 'ti BOARD OF COUNTY COMMISSIONERS
Weld Co ty Clerk to the B rd WELD COUNTY, COL RADO
BY:
Deputy Cle to the Board arbara Kirkmeyer, Chair G 2 6 2015
A " " aVLLA O UNDIN APPROVED AS TO SUBSTANCE:
Controller + Elected Official or Department ead
APPROVED AS TO FORM,, ' z� A/M
irector of General Services
my A ttorney •
02,0/5- i6)
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Page 6 of 6
Contract_Amendment TaskOrder 01-2015
Revised EXHIBIT B
STATEMEIYT OF WORK
To Task Order Dated 07/15/2014- Contract Routing Number 15 FHLA 72161
Contract Amendment# 1 Routin Number 16 FHLA 82757
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Agreement specified above.
L Project Description:
The Colorado Maternal and Child Health Program contracts with local public health agencies(LPHAs)to develop,
implement and evaluate evidence-based MCH Action Plans, HCP Care Coordination services,and HCP Specialty
Clinics. Contractors are responsible for contributing to the improvement of 10 state and 18 national MCH
performance measures and outcomes.
II. Definitions:
CDS—the state HCP-developed data system for documentation of Clinic Coordination,Care Coordination and
Information services for Children and Youth with Special Health Care Needs.
CRSCN-Colorado Responds to Children with. Special Needs
CYSHCN-Children and Youth with Special Health Care Needs
HCP-Program for Children and Youth with Special Health Care Needs
HCP Care Coordination—The state HCP-developed intervention model for providing care coordination for
families of children and youth with special health care needs.
HCP Consultants—The program staff for HCP who provide technical assistance,consultation and training on
HCP program components.
HCP Specialty Clinics—The state HCP-developed model for coordinating HCP specialty care.
LPHAs-Local Public Health Agencies
MCH -Maternal and Child Health
MCH Action Plans—Action Plans are work plans that Contractors select or develop to describe the goals,
objectives,key activities, persons responsible,and timelines of the MCH effort. Action Plans may be state-
developed and related to the MCH priorities or may be developed by the Contractor.
MCH Generalist Consultants—The primary MCH Program staff who monitor LPHAs' MCH contracts and who
provide technical assistance and consultation to Contractors on program development and implementation.
lIL Performance Requirements/Deliverables:
Contractor is required to notify its MCH Generalist Consultant within I S business days of any significant changes
to their MCH action plan or budget. Changes include,but are not limited to,the following: changes in staffing
including vacancies,changes in plan activities,agency changes or development that directly impact MCH
activities or plans,or community developments that directly impact MCH activities or plans.
Use of the term "partner"within the accompanying work plans connotes a collaboration relationship and not a
legal one unless otherwise specified.
A. Maternal and Child Health Pro�ram
I. The Contractor shall perform in accordance with the FY 16 Action Plans: Early Childhood Obesity
Prevention,referenced herein as Attachment B-1;and Teen Motor Vehicle Safety,referenced herein
as Attachment B-2.
2. The Contractor shall perform in accordance with the FY 16 MCH Guidelines and shall follow the policies,
procedures,and program expectations set forth in the FY16 MCH Guidelines.The FY16 MCH
Guidelines are incorporated and made part hereof by reference,and are located at
www.mchcolorado.or�.
Page I of 5
Exhibit B-Statement of Work
FEB2014
Revised EXHIBIT B
3. The MCH Guidelines are periodically updated and the Contractor will be notified by email when
updates/revisions are made.The Contractor is responsible for complying with any updates/revisions.
Revised MCH Guidelines will be posted to the MCH web site referenced in Il1.A.2.
4. The Contractor shall apply the public health approach throughout the process of developing,
implementing,and evaluating its MCH Action Plans in order to serve the MCH population in the
community. Brownson's evidence-based public health approach is described in the FY16 MCH
Guidelines and involves the following steps:
o Community assessment
o Quantify the issue
o Develop a concise statement of the issue
o Determine what is known through the scientific literature
o Develop/identify and prioritize program and policy options
o Develop an action plan and implement interventions
o Evaluate the program or policy
5. The Contractor shall contribute to the accomplishment of the MCH state priorities,and state and national
performance measures and outcomes that are outlined in the FY16 MCH Guidelines located at
www.mcl�colorado.orU.
6. The Contractor shall focus at least 30%of total MCH/HCP funds on MCH-priority action plans,
including the medical home priority.
7. The Contractor shall focus a majority of their effort and funding for each action plan on population-based
and infrastructure-building strategies from the MCH pyramid,per the review and approval by the state
MCH Program. Enabling services are allowable if they are evidence-based and enhance the population-
based and infrastructure-level work in the action plan. Enabling services should not comprise a majority
of the effort,with the exception of HCP Care Coordination.
For definitions of the different levels of the MCH Pyramid,see the FY 16 MCH Guidelines available
online on the MCH web site located at www.mchcolorado.ora.
8. The Contractor shall use evidence-based strategies or programs to address issues in the community. A
strategy or program is considered evidence-based if:
a. [t is based on a sound theoretical approach such as health behavior change theory or peer-
reviewed literature;
b. And/or if there is research or program evaluation data that supports the effectiveness of the
approach.
9. During the contract term,the Contractor shall follow the timelines identified in FY 16 action plans to
implement and evaluate work performed under the action plans.
10. The Contractor shall participate in and submit the following processes or reports, incorporated by
reference.These processes and reports, including instructions for completion and submission,are
available in the FY 16 MCH Guidelines located online on the MCH web site located at
www.mchcolorado.or��.
a. Progress check-in meetings(3)
MCH Generalist Consultants will conduct three progress check-in meetings with the Contractor
during the contract period in order to monitor the Contractor's progress on the FY 16 action plans
as well as to provide technical assistance and support during plan implementation. During the
progress check-ins,the Contractor and MCH Generalist Consultant use a standardized set of
questions to discuss the Contractor's progress and/or challenges of planning,implementing or
evaluating the MCH Action Plans and to review any relevant work products developed as part of
Page 2 of 5
Exhibit B-Statement of Worh
FEB2014
Revised EXHIBIT B
the plan,such as team charters,reports,community road maps,etc. The standardized questions
are available in a document entitled MCH Progress Call Guide on the MCH web site located at
www.mchcolorado.or:under Implementation and [nvoicing.
The MCH Generalist is responsible for scheduling the check-in with the Contractor.The format
(via phone or in person)of the check-in is at the discretion of the MCH Generalist Consultant
and will be communicated to the Contractor in advance. The MCH Generalist Consultant will
send a follow-up summary of the check-in meeting and will highlight any issues that require
follow-up.Three progress check-in meetings or phone calls will take place during the fiscal year.
The first check-in will occur in October,the second in January,and the last in the spring as part
of planning meetings focused on subsequent year activities.
b. MCH Annual Report on FY16 Action Plans
The FY 16 MCH Action Plan Annual Report is due October 31,2016 for the period of October
I,2015 to September 30,2016.The Contractor shall submit the completed report via email to
cdphe.psmchreports,c state.co.�is.
For annual reporting,update the following sections of the MCH priority-related action plans:
• Evaluation of Objective—provide a brief narrative on the progress of the objective,
including successes and challenges. Discuss how the strategy contributed to moving the
objective forward. [nclude assessment of"as measured by"indicators that correspond
to"criteria for success" in this section.
• Activity Monitorin�Plan Completion—comment if the activity was met or unmet.
For annual reporting,update the following sections of the"other"MCH action plans:
• Evaluation of Measure—provide the actual measure of progress for the
measure/indicator previously selected
• Evaluation of Objective—provide a brief narrative on the progress of the objective,
including successes and challenges. Discuss how the strategy contributed to moving the
objective forward.
• Activity Monitoring Plan Completion—comment if the activity was met or unmet.
• Sources of fundin�and support- provide the amount and source each of each outside
funding stream used to support the work completed. Provide the overall costs for the
program for the period, including CDPHE and outside funding support.
c. HCP Annual Report for FY16
The FY I 6 HCP Annual Report is due October 31,2016 for the period of October 1,2015 to
September 30,2016. The FY 16 HCP Annual Report Form will be available on the MCH web
site located at www.mchcolorado.or<�.The Contractor shall submit the completed report via
email to cdp.he.psmchreports,ustate.co.us.
�---
d. MCN Core Services Final Report for FY16
The Final Report for MCH Core Services should be reported on the MCH Budget form that will
be available on the MCH web site located at www.mchcolorado.or��.The report is due October
31,2016 for the period of October I,2015 to September 30,2016. The Contractor shall submit
the completed report via email to cdphe•psmchreports�state.co.us.
For each of the Contractor's FY 16 Planning Budgets,review the objectives and activities
included in the corresponding MCH Action Plan(s),report on the percentage of total budget
funds expended on the different levels of the MCH pyramid.
Page 3 of�
Exhibit B-Statement of Work
FEB2014
Revised EXHIBIT B
■ Direct Services
• Enabling Services
■ Population-based Approaches
■ Infrastructure Building Approaches
For the Contractor's FY 16 HCP Care Coordination Planning Budget,enter the actual number of
children and youth with special health care needs who received HCP Care Coordination services
with an action plan.Next enter the actual number of children who received information only.
(1. The Contractor shall develop or revise,according to the FY 16 MCH Guidelines,the Contractor's MCH
action plans and budgets for FY 16.
12. The Contractor shall notify the State of programmatic changes that might affect the viability,
effectiveness or productivity of the programs,including but not limited to:changes in personnel; physical
facilities in which services are provided; scope of services that deviates from those proposed by the
Contractor in the MCH action plans;and local interagency or political circumstances that might impact
the MCH Program.Notification shall be in writing within fifteen(15)business days of said change.
B. Children and Youth with Special Health Care Needs(CYSHCN)
l. The Contractor shall perform in accordance with the FY 16 HCP Policy and Guidelines and shall follow
the policies,procedures,and program expectations set forth in the FY16 HCP Policy and Guidelines.The
FY 16 HCP Policy and Guidelines are incorporated and made part hereof by reference,and are located on
the HCP web site located at www.hCpcolorado.or�.
2. The Contractor shall perform in accordance with the FY16 Action Plan: Reducing Barriers to a Medical
Home Approach,referenced herein as Attachment B-3.
3. The HCP Policy and Guidelines are periodically updated and the Contractor will be notified by email
when updates/revisions are made.The Contractor is responsible for complying with any
updates/revisions.Revised HCP Policy and Guidelines will be posted to the HCP web site referenced in
IILB.I.
4. The Contractor shall attend scheduled HCP Policy Advisory Committee(H-PAC)meetings,HCP Annual
Meetings,and quarterly scheduled activities for local HCP staff to promote learning and increase skills,
as organized by CDPHE HCP Program and as referenced in the FY16 HCP Policy and Guidelines.
5. The local HCP Coordinator shall provide orientation,technical assistance and ongoing training for other
HCP agency staff by referencing the HCP Policy and Guidelines,HCP training modules and other HCP
Resources available online on the HCP web site located at www.hcpco_lorado,�rg.
6. The Contractor shall engage families with CYSHCN and community family leaders to solicit consumer
feedback when serving the CYSHCN population by referencing the Reducing Barriers to a Medical
Home Approach resource document available online on the HCP web site located at
www,hcUcolorado.or7.
HCP Care Coordination
I. The Contractor shall provide HCP Care Coordination services using a medical home approach for
CYSHCN residing in the counties the agency is contracted to serve according to the FY 16 HCP Policy
and Guidelines.
2. The Contractor shall provide information and resources to families of CYSHCN in accordance with the
FY16 HCP Policy and Guidelines.
Page 4 of 5
Exhibit B-Statement of Work
FEB2014
Revised EXHIB[T B
3. The Contractor shall complete required data documentation in the CDS for HCP Care Coordination and
Information services according to the FY16 HCP Policy and Guidelines.
4. The Contractor shall participate in consultation,technical assistance,oversight and training by state HCP
staff on using the CDS for documentation of HCP Care Coordination services.
CRCSN
l. !f the contractor elects to receive CRCSN notifications on the FY16 HCP Care Coordination Planning
Form,the Contractor shall follow the CRCSN guidance set forth in the FY16 HCP Policy and Guidelines
including the entry of data into CDS.
HCP Saecialtv Clinics
l. The Contractor agrees to provide clinic coordination for regional HCP Specialty Clinics according to the
FY16 HCP Specialty Clinic Benchmarks,FY16 HCP Specialty Clinic Standards and FY16 HCP Policy
and Guidelines.
2. The Contractor shall provide clinic coordination using a medical home approach for all CYSHCN
attending HCP Specialty Clinics according to the FY l6 HCP Policy and Guidelines.
3. The Contractor shall participate in consultation,technical assistance,oversight and training by state HCP
staff on HCP Specialty Clinic Coordination and using CDS for documentation of HCP Specialty Clinic
services.
IV. Monitoring:
CDPHE's monitoring of this contract for compliance with performance requirements will be conducted
throughout the contract period by the Program's MCH Generalists and HCP Consultants. Methods used
will include review of documentation reflective of performance to include progress meetings,site visits,
invoices,and data reports. 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.
V. Resolution of Non-Compliance:
The Contractor will be notified in writing within 30 calendar days of discovery of a compliance issue.
Within 45 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 require an extension to the time line,the Contractor
must email a request to the MCH Unit Manager and receive approval of 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 Remedies section of the General Provisions of this
contract.
Page 5 of5
Exhibit B-Statement of Work
FEB2014
REVISED EXHIBIT C
�� COLORADO
Department o[Public
Hcaltk�&Lnvuonmeni
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Contract Routing # 16 FHLA 82757
FY 2016 Maternal and Child Health Planning Budget
Date Completed: July 21,2015
Agency Name Weld County Dept of Public Health&Environment Kelly Campbell,Health
Program Contact Name,Title, Communicaiton Supervisor
Phone and Email (970)304-6370 x2325
Budget Period October 1,2015-September 30,2016
kca m pbell @wel dgov.com
Identify the population Tan a Geiser,Director
Child and Adolescent(CA) V
for this budget Fiscal Contact Name,Title, Administrative Services
Identify all action plans Phone and Email tgeiser@co.weld.co.us
related to this budget Teen Motor Vehicle Safety(TMV) 970-304-6410 ext 2122
Expenditure Categories
Personal Services
Salaried Employees
Budget item Percent of Total Amount
supports SOW Gross or Time on Requested from
Position Title Description of Work (Yes/No) Annual Sala Frin e Pro'ect CDPHE
Primary MCH liaison;provides management of
Public Hlth MCH project deliverables,supervises MCH
Communication staff,directs work plan activities,monitors Yes $67,019.43 $26,090.66 15% $13,966.51
Supervisor grant expenditures,and is responsible for
reporting and evaluation of MCH program.
Public Hlth Oversees the higher level activities of CASH
Communication MGR worplan Yes 5g6,846.51 $33,80934 1% $1,205.55
Coordinate grant evaluation and data analysis.
Public Hlth Data Assist with stakeholder interviews,creation of
Specialist county specific fact sheets and development of Yes 588,138.97 $34,312.50 2% $2,449.02
community educational presentations.
Clerical support including data entry,copyting
and printing,inventory control,supply orders,
Office Technician IV meeting coordination,graphic design and Yes $42,488.23 $16,540.66 25% $14,757.22
social media/website designing and updating.
For all above listed employees:fringe includes
paid time off,workers comp insurance,
unemployment insurance,health insurance,
life insurance,EAP services,long-term
disability,and retirement.
Personal Services
Hourly Employees
Page 1 of 12
REVISED EXHIBIT C
�� COLORADO
De artment of Pubtic
Heatth b Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Contract Routing# 16 FHLA 82757
FY 2016 Maternal and Child Health Planning Budget
Date Completed: July 21,2015
Agency Name Weld County Dept of Public Health&Environment Kelly Campbell,Health
Program Contact Name,Title, Communicaiton Supervisor
Phone and Email (970)304-6370 x2325
Budget Period October 1,2015-September 30,2016 kcampbell@weldgov.com
Identify the population Tan a Geiser,Director
Child and Adolescent(CA) Y
for this budget Fiscal Contact Name,Title, Administrative Services
Identify all action plans Phone and Email tgeiser@co.weld.co.us
Teen Motor Vehicle Safety(TMV) 970-304-6410 ext 2122
related to this budget
Budget item Total#of Total Amount
supports SOW Hours on Requested from
Position Title Description of Work (Yes/No) Hourly Wage Hourly Fringe Project CDPHE
$0.00
Total Personal Services
(including fringe benefits) 532,37830
Supplies&Operating Expenses
Budget item Total Amount
supports SOW Requested from
Item Description of Item (Yes/No) Rate Quantity CDPHE
Supplies&Operating
Program postage-misc mailing to community partners Yes 53.00 1 53.00
Expenses
Total Supplies
&O eratin Ex enses 53.00
Travel
Budget item Total Amount
supports SOW Requested from
Item Description of Item (Yes/No) Rate Quantity CDPHE
Travel to meetings at various sites,and participate in various
Mileage Yes 50.555 8.5 $4.72
outreach opportunities.Mileage is reimbursed at$.555/mile.
Total Travel
$a.72
Contractual
Budget item Total Amount
supports SOW Requested from
Subcontractor Name Description of Item (Yes/No) Rate Quantity CDPHE
Public relations/Community Outreach professional to promote
programs,coordinate media campaigns,coordinate the
implementation of the Safe Teen Drivers Program at participating
Lyn Tausan high schools and assist with stakeholder and law enforcement Yes $25.00 6.5 $162.50
advocacy campaigns. Contractor will serve as the community
liason and media contact for DRIVE SMART Weld County.
Page 2 of 12
REVISED EXHIBIT C
�� COIORADO
De artment of Public
Health b Environment
PREVENTION SERVICES DIVISION- BUDGET WITH 1USTIFICATION FORM
Contract Routing# 16 FHLA 82757
FY 2016 Maternal and Child Health Planning Budget
Date Completed: July 21,2015
Agency Name Weld County Dept of Public Health&Environment Kelly Campbell,Health
Progrem Contact Name,Title, Communicaiton Supervisor
Phone and Email (970)304-6370 x2325
Budget Period October 1,2015-September 30,2016 kcampbell@weldgov.com
Identify the population Tan a Geiser,Director
Child and Adolescent(CA) Y
for this budget Fiscal Contact Name,Title, Administrative Services
Identify all action plans Phone and Email tgeiser@co.weld.co.us
related to this budget Teen Motor Vehicle Safety(TMV) 970-304-6410 ext 2122
Total Contractual $16z.5o
SUB-TOTAL BEFORE INDIRECT $32,548.52
Indirect
Total Amount
Item Description of Item Requested from
CDPHE
Negotiated Indirect cost The 2015 CDPHE Negotiated Indirect Rate for Health Communication,Education&Planning is 13.68%of TDC;
rate(Federal,State,or Weld County will use the FY16 negotiated rate once it has been finalized with the State $4,452.49
CDPHE)
Indirect rate(other):
Indirect(modified or
additional base)
Totallndirect Sq,a52.a9
TOTAL AMOUNT REQUESTED FROM CDPHE $37,001
Core Services
What percentage of funding from the budget total is allocated to work at each level of the MCH HCP CARE COORDINATION ONLY
pyramid7
What is the estimated number of children/youth with special health
Direct Services care needs who will receive HCP Care Coordination services in FY15?
Enabling Services
Public Health Services 100%#with an HCP Care Coordination Action Plan:
Total to equal 100% 100%#who will receive information only:
Page 3 of 12
REVISED EXHIBIT C
.�
COLORADO
� Department of Public
Health b Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Contract Routing# 16 FHLA 82757
FY 2016 Maternal and Child Health Planning Budget
Date Completed: July 21,2015
Eric Aako,MS MCHES Health
Agency Name Weld County Dept of Public Health&Environment Education,Communications,and
Program Contact Name,Title,
Planning Division Director
Budget Period October 1,2015-September 30,2016 Phone and Email
eaakko@co.weld.co.us
970.304.6470 x.2380
Identify the papulation Women of reproductive age and infants/children Tanya Geiser,Director
for this budget birth to age 5 Fiscal Contact Name,Title, Administrative Services
[dentify all action plans Phone and Email tgeiser@co.weld.co.us
Early Childhood Obesity Prevention 970-304-6410 ext 2122
related to this budget
Expenditure Categories
Personal Services
Salaried Employees
Budget item Percent of Total Amount
supports SOW Gross or Time on Requested from
Position Title Description of Work (Yes/No) Annual Sala Fri� e Project CDPHE
Public Hlth Plans,Coordinates,and Implements Weld
Communication Spec II ECOP Action Plan Yes $58,009.49 522,583.09 93% $74,951.09
Public Hlth
Supervises day-to-day activities of the ECOP
Communication grant and workplan Yes $67,019.43 $26,090.66 2% 51,862.20
Supervisor
Public Hlth Oversees the higher level adivities of the ECOP
Communication MGR work lan Yes $86,846.51 $33,809.34 1% $1,206.55
Public health Data Coordinates ECOP workplan grant evaluation
Specialist and related data analysis Yes $88,138.97 $34,312.50 2% $2,449.02
For all above listed employees:fringe includes
paid time off,workers comp insurance,
unemployment insurance,health insurance,
life insurance,EAP services,long-term
disability,and retirement.
Personal Services
Hourly Employees
Budget item Total#of Total Amount
supports SOW Hours on Requested from
Position Title Description of Work (Yes/No) Hourly Wage Hourly Fringe Project CDPHE
Total Personal Services
(including fringe benefits) $80,468.86
Supplies&Opereting Expenses
Budget item Total Amount
Item Description of Item supports SOW Rate Quantity Requested from
(Yes/No) CDPHE
Supplies&Operating posta e-misc mailin for ECOP ro ram Yes
g g p g $1.00 6 $6.00
Expenses
Page 4 of 12
REVISED EXHIBIT C
�� , �OLORADO
Department of Public
Health b Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Contract Routing# 16 FHLA 82757
FY 2016 Maternal and Child Health Planning Budget
Date Completed: July 21,2015
Agency Name Weld County Dept of Public Health&Environment Eric Aako,MS MCHES Health
Program Contact Name,Title,
Education,Communications,and
Planning Division Director
Budget Period October 1,2015-September 30,2016 Phone and Email
eaakko@co.weld.co.us
970.304.6470 x.2380
Identify the population Women of reproductive age and infants/children Tanya Geiser,Director
for this budget birth to age 5 Fiscal Contact Name,Title, Administrative Services
Identify all action plans Phone and Email tgeiser@co.weld.co.us
Early Childhood Obesity Prevention 970-304-6410 ext 2122
related to this budget
Total Supplies
&O eratin Ex enses 56.00
Trevel
Budget item Total Amount
supports SOW Requested from
Item Description of Item (Yes/No) Rate Quantity CDPHE
Travel to meetings at various sites,and participate in various
Mileage Yes $0.555 26 $14.43
outreach opportunities.Mileage is reimbursed at$.555/mile.
Total Travel
$ia.a3
Contractual
Budget item Total Amount
supports SOW Requested from
Subcontractor Name Description of Item (Yes/No) Rate Quantity CDPHE
LINE NOT OPEN
Total Contractual $o.00
SUB-TOTAL BEFORE INDIRECT
$80,489.29
Indirect
Total Amount
Requested from
Item Description of Item CDPHE
Negotiated Indirect cost The 2015 CDPHE Negotiated Indirect Rate for Health Communication,Education&Planning is 13.68%of TDC;
rate(Federal,State,or Weld County will use the FY16 negotiated rate once it has been finalized with the State $11,010.71
CDPHE
Indirect rate(other�:
Indirect(modified or
additional base
TotalIndirect $11,010.71
Page 5 of 12
REVISED EXHIBIT C
ICOLORADO
�• I Department of Public
Health b Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Contract Routing# 16 FHLA 82757
FY 2016 Maternal and Child Health Planning Budget
Date Completed: July 21.2015
Eric Aako,MS MCHES Health
Agency Name Weld County Dept of Public Health&Environment
Program Contact Name,Title, Education,Communications,and
Phone and Email Planning Division Director
Budget Period October 1,2015-September 30,2016 eaakko@co.weld.co.us
970.304.6470 x.2380
Identify the population Women of reproductive age and infants/children Tanya Geiser,Oirector
for this budget birth to age 5 Fiscal Contact Name,Title, Administrative Services
Identify all action plans Phone and Email igeiser@co.weld.co.us
Early Childhood Obesity Prevention 970-304-6410 ext 2122
related to this budget
TOTAL AMOUNT REQUESTED FROM CDPHE $g1,500
Core Services
What percentage of funding from the budget total is allocated to work at each level of the MCH HCP CARE COORDINATION ONLY
pyramid?
What is the estimated number of children/youth with special health
Direct Services care needs who will receive HCP Care Coordination services in FY15?
Enabling Services
Public Health Services 100%#with an HCP Care Coordination Action Plan:
Total to equal 100% 100%tt who will receive information only:
Page 6 of 12
REVISED EXHIBIT C
�� COLORADO
Depariment of Public
Heatih b Environment
PREVENTION SERVICES DNISION- BUDGET WITH JUSTIFICATION FORM
Contract Routing# 16 FHLA 82757
FY 2016 Maternal and Child Health Planning Budget
Date Completed: July 21,2015
Agency Name Weld County Dept of Public Health&Environment Debbie Drew,Interim Program
Progrem Contact Name,Title,Phone Manager
and Email ddrew@co.weld.co.us
Budget Ceriod October 1,2015-September 30,2016
970-304-6420 ext 2304
ldentify the population CYSHCN-Medical Home(MH) Tanya Geiser,Director
for this budget Fiscal Contact Name,Title,Phone and Administrative Services
Identify all action plans Email tgeiser@co.weld.co.us
Medical Home 970-304-6410 ext 2122
related to this budget
Expenditure Categories
Personal Services
Salaried Employees
Budget item Percent of Total Amount
supports S0W Gross or Time an Requested from
Position Title Description of Work (Yes/No) Annual Sala Frin e Pro'ect CDPHE
Provides oversight,facilitation,coordination of Medical yes $73,505.60 $28,615.73 9.90% $10,110.01
Home Project/WCRC. Actual MH program FTE is 9.9%.
Public Hlth Nurse
Supervisor
For all above listed employee:Fringe includes
medicare,unemployment,workers'compensation,
PERA,Life/AD&D insurance,health insurance,
accrual-vacation,accrual-holiday,accrual-sick.
Estimated at 38.93%
Personal Services
Hourly Employees
Budget item Total#of Total Amount
supports SOW Hours on Requested from
Position Title Description of Work (Yes/No) Hourly Wa e Hourl Frin e Pro'ect CDPHE
Total Personal Services
(including fringe benefits) $10,110.01
Supplies&Operating Expenses
Budget item Total Amount
supports S0W Requested from
Item Description of Item (Yes/No) Rate Quantity CDPHE
Supplies&Operating pro ram osta e-misc.mailin s to mmmunit artners. Yes
Expenses g P g g Y P �1.00 2 52.00
Total Supplies
&O eratin Ex enses $Z.00
Page 7 of 12
REVISED EXHIBIT C
�� COLORADO
Department of Public
Healih b Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Contract Routing # 16 FHLA 82757
FY 2016 Maternal and Child Health Planning Budget
Date Completed: July 21,2015
Agency Name Weld County Dept of Public Health&Environment Debbie Drew,Interim Program
Program Contact Name,Title,Phone Manager
and Email ddrew@co.weld.co.us
Budget Period October 1,2015-September 30,2016
970-304-6420 ext2304
Identify the population Tanya Geiser,Director
CYSHCN-Medical Home(MH)
for this budget Fiscal Contact Name,Title,Phone and Administrative Services
Identify all action plans Email tgeiser@co.weld.co.us
related to this budget Medical Home 970-304-6410 ext 2122
Travel
Budget item Total Amount
supports S0W Requested from
Item Description of Item (Yes/No) Rate Quantity CDPHE
Trevel to meetings at various sites,and participate in various outreach
Mileage-MH Program Staff
opportunities.Mileage is reimbursed at$.555/mile. Yes $0.555 66 $36.63
Total Travel
$36.63
Contractual
Budget item Total Amount
supports S0W Requested from
Subcontrector Name Description of Item (Yes/No) Rate Quantity CDPHE
$0.00
LINE N0T 0PEN
Total Contractual $o.00
SUB-TOTAL BEFORE INDIRECT $10,148.64
Indirect
Total Amou�t
Requested from
Item Description of Item CDPHE
Negotiated Indirect cost The 2015 CDPHE Negotiated Indirect Rate for Public Health Services is 13.84%of TDC; Weld County will use the FY16 negotiated
rate(Federal,State,or rate once it has been finalized with the State
CDPHE) $1,404.36
Indirect rate(other):
Indirect(modified or
additional base)
TotalIndirect $1,40a.36
TOTAL AMOUNT REQUESTED FROM CDPHE $11,553
Page 8 of 12
REVISED EXHIBIT C
�� COLORADO
Department of Public
Health b Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Contract Routing# 16 FHLA 82757
FY 2016 Maternal and Child Health Planning Budget
Date Completed: July 21,2015
Agency Name Weld County Dept of Public Health&Environment Debbie Drew,Interim Program
Progrem Contact Name,Title,Phone Manager
Budget Period October 1,2015-September 30,2016 and Email ddrew@co.weld.co.us
970-304-6420 ext 2304
Identify the population
CYSHCN-Medical Home(MH) Tanya Geiser,Director
for this budget fiscal Contact Name,Title.Phone and Administrative Services
Identify all action plans Email tgeiser@co.weld.co.us
related to this budget Medical Home 970-304-6410 ext 2122
Core Services
What percentage of funding from Lhe budget total is allocated to work at each level of the MCH HCP CARE COORDINATION ONLY
pyramid?
What is the estimated number of children/youth with special health care
Direct Services needs who will receive HCP Care Coordination services in FY15?
Enabling Services
Public Health Services 100%#with an HCP Care Coordination Action Plan:
Total to equal 100% 100%#who will receive information only:
Page 9 of 12
REVISED EXHIBIT C
�� COLORADO
Department of Public
Health b Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Co�tract Routing# 16 FHLA 82757
FY 2016 Maternal and Child Health Planning Budget
Date Completed: July 21,2015
Agency Name Weld County Dept of Public Health&Environment Amy Antuna RN,BSN,HCP
Program Contact Name,Title,Phone
Supervisor aantuna@co.weld.co.us
and Email
Budget Period October 1,2015-September 30,2016 970-304-6420 x2322
[dentify the population Tanya Geiser,Director
CYSHCN-HCP Care Coordination(CC)
for this budget Fiscal Contact Name,Title,Phone and Administrative Services
Identify all adion plans Email igeiser@co.weld.co.us
970-304-6410 ext2122
related to this budget
Expenditure Categories
Personal Services
Salaried Employees
Budget item Percent of Total Amount
supports SOW Gross or Time on Requested from
Position Title Description of Work (Yes/No� Annual Saia Frin e Pro'ect CDPHE
Provides direct oversight and supervision of HCP
care coodination program and staff,directs care
coordination activities,oversees HCP support group
activities,participates in HCP program outreach and
HCP Supervisor Yes $68,771.43 $26,772.71 45% 542,994.86
represents HCP on several community
groups/coalitions,responsible for reporting and
evaluation of HCP program. WCDPHE FTE is 1.0.
Actual HCP program FTE is.95.
Provides care coordination services[o HCP clients,
assists with HCP program outreach and attends HCP
Public Health Nurse Yes $59,784.11 $23,273.95 45% $37,376.12
community meetings. WCDPHE FTE is 1.0. Actual
HCP program FTE is 1.0.
Provides psychosocial care coordina[ion services to
HCP tlients,coordinates and fatilitates monthly HCP
Public Health Social Worker support group,HCP program outreach and Yes 563,130.17 $24,576.57 20% 517,541.34
represents HCP on several community
groups/coalitions. WCDPHE FTE is 1.0. Actual HCP
program FTE is.8.
Provides care coordination services to HCP clients,
assists with HCP program outreach and attends HCP Yes $58,375.54 $22,725.59 45% $36,495.50
Public Health Nurse
community meetings. WCDPHE FTE is.75. Actual
HCP program FTE is.5.
Page 10 of 12
REVISED EXHIBIT C
�� COLORADO
De artment of Publ�c
Health b Environment
PREVENTION SERVICES DIVISION- BUDGET WITH JUSTIFICA7ION FORM
Contract Routing# 16 FHLA 82757
FY 2016 Maternal and Child Health Planning Budget
Date Completed: July 21,2015
Agency Name Weld County Dept of Public Health&Environment Amy Antuna RN,BSN,HCP
Progrem Contact Name,Title,Phone
Supervisor aantuna@co.weld.co.us
Budget Period October 1,2015-September 30,2016 and Email
970-304-6420x2322
Identify the population Tanya Geiser,Director
CYSHCN-HCP Care Coordination(CC)
for this budget Fiscal Contact Name,7itle,Phone and Administrative Services
Identify all action plans Email tgeiser@co.weld.co.us
970-304-6410 ext2122
related to this budget
Administrative support to HCP team.
Responsibilities include interpretation and
translation,CDS data entry,EMR data entry,
OfficeTechnician Yes 535,609.03 513,862.59 42% 520,778.08
materials preparation,assists HCP staff with care
coordination activities,etc. WCDPHE FTE is 1.0.
Actual HCP program FTE is.8.
Provides oversight of HCP program and HCP staff,
Community Health participates in reporting and evaluation of HCP Yes 573,505.60 $28,615.73 2% 52,042.43
Manager program. WCDPHE FTE is 1.0. Actual HCP program
FTE is.02.
For All above listed employees:Fringe includes
medicare,unemployment,workers'compensation,
PERA,Life/AD&D insurance,health insurance,
accrual-vacation,accrual-holiday,accrual-sick.
Estimated at 38.93%
Personal Services
Hourly Employees
Budget item Total#of Total Amount
supports SOW Hours on Requested from
Position Title Description of Work (Yes/No) Hourl Wa e Hourl Frin e Pro'ect CDPHE
$0.00
Total Personal Services
(including fringe benefits) 5157,22833
Supplies&Operating Expenses
Budget item Total Amount
supports SOW Requested from
Item Description of Item (Yes/No) Rate Quantity CDPHE
Supplies&Operating Expenses Program office supplles Yes $4.50 1 $4.50
Total Supplies
&O eratin Ex enses $4.50
Trevel
Budget item Total Amount
supports SOW Requested from
Item Description of Item (Yes/No) Rate Quantity CDPHE
Page 11 of 12
REVISED EXHIBIT C
�� COLORADO
Department of Publlc
Heatih&Environment
PREVENTlON SERVICES DIVISION- BUDGET WITH JUSTIFICATION FORM
Contract Routing# 16 FHLA 82757
FY 2016 Maternal and Child Health Planning Budget
Date Completed: July 21,2015
Agency Name Weld County Dept of Public Health&Environment Amy Antuna RN,BSN,HCP
Program Contact Name,Title,Phone
Supervisor aantuna@to.weld.co.us
and Email
Budget Period October 1,2015-September 30,2016 970-304-6420 x2322
]dentify the population Tanya Geiser,Director
CYSHCN-HCP Care Coordination(CC)
for this budget Fiscal ConWct Name,Title,Phone and Administrative Services
Identify all action plans Email tgeiser@co.weld.co.us
970-304-6410 ext2122
related to this budget
MCH-HCP staff mileage to MCH/HCP meetings. Annual HCP team travel is Y25 $0.555 10 $5.55
reimbursed at$.555/mile.
Mileage
Total Travel
$5.55
Contractual
eudget item 7otal Amount
supports S0W Requested from
Subcontrettor Name Description of Item (Yes/No) Rate Quanti CDPHE
LINE N0T 0PEN 50.00
Total Contradual $o.00
SUB-TOTAL BEFORE 1NDIRECT $157,238.38
Indirect
Total Amount
Requested from
Item Description of Item CDPHE
Negotiated Indirect cost The 2015 CDPHE Negotiated Indirect Rate for Public Health Services is 13.84%of TDC; Weld County will use the FY16 negotiated
rate(Federal,State,or $21,761.62
rate once it has been finalized with the State
CDPHE)
Indirect rate(other):
Indirect(modified or
additional base)
TotalIndirect $21,761.62
TOTAL AMOUNT REQUESTED FROM CDPHE $179,000
Core Services
What percentage of funding from the budget total is allocated to work at each level of the MCH HCP CARE C00RDINATI0N 0NLY
pyramid�
What is the estimated number of children/youth with special health care
Direct Services needs who will receive HCP Care Coordination services in FY16?
Enabling5ervices 100%
PubliC Health ServiCes St with an HCP Care Coordination Action Plan: gp
Total to equal 100% 100%#who will receive information only: 300
Page 12 of 12
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