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HomeMy WebLinkAboutC04-236 Colorado Department of Public Health and Environment-~ 1 DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIIZONMENT PREVENTION SERVICES DIVISION DEPARTMENT OR AGENCY NUMBER FLA CONTRACT ROUTING NUMBER 05-00220 INTERGOVERNMENTAL CONTRACT (Mixed Funds) This Contract is made this 23RD day of JUNE, 2004, by and between: the state of Colorado, acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIItONMENT, whose address or principal place of busu less is 4300 Cherry Creek Drive South, Denver, Colorado 80246, hereinafter referred to as "the State"; and, BO~.RD OF COUNTY COMMISSIONERS OF EAGLE COUNTY (apolitical subdivision of the state of Cola rado whose address or principal place of business is 500 Broadway, Eagle, Colorado 81631, for the use and benefit of the Eagle County Health & Human Services, whose address or principal place of business is 551 Bro~cdwav, Eagle, Colorado 81631, hereinafter referred to as "the Contractor". WHEREAS, pursuant to section 25-1.5-101 (j) (I), C.RS., as amended, the General Assembly ofthe state of Colc rado has declared that the state `has, in addition to all other powers and duties imposed upon it bylaw, the pow~;rs and duties to disseminate public health information." WH EREA5, section 25-1.5-101 (r), C.R.S., as am~ded, states that the state can, "operate and maintain a program for c hildren with disabilities to provide and expedite provision of health caze services to children who have cong enital birth defects or who aze the victims of burns or trauma or children who have acquired disabilities". WHEREAS, section 25-1-709 (IO (a), C.RS., as amended, further states that "[t]he program and services of regic anal health departments shall include to the greatest extent possible, but not be limited to personal health serve ces, including: maternal and child health services; program for children with disabilities". WHEREAS, to accomplish its statutory duties, the State has determined that public health services are desirable in the (:ontractor's region. WH EREA5, the United State Department of Health and Human Services ("HHS"), through the Maternal and Child Hea] th Services Block Grant (MCH) has awarded the State Title V federal funds under Notice of Grant Award ("NGA) number B04MC02394-01-00 (See, Catalog of Federal Domestic Assistance ("CFDA") number 93.994 . WHEREAS, the State's Prevention Services Division (PSD) is chazged with the administration of funds from the Title V MCH Block Grant to improve the health and well being of the maternal and child/adolescent populations throe igh assessing population needs, influencing health policy, engaging in strategic planning and coordinating/implementingbwt practices and evidenced-based programs; WH EREA5, the authority for the administration of the Title V MCH Block Grant, including the maternal, child and children with special health caze needs resides in Title V of the Social Security Act, §§ 501-509; Page 1 of 18 WHEREAS, each state that receives MCH funds from the HHS must demonstrate to the HHS that it has served three (3) distinct population groups with the MCH funds; WHEREAS, the three (3) distinct population groups are: "the perinatal population", which is defined to include women of childbearing age, pregnant women, and mothers; the "child and youth population", which is defined to include infants, children, and adolescents from birth through age twenty (20); and, the "children with special health care needs population" (CSHCI~, which is defined as those children who have, or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally, WHEREAS, the State has formulated a comprehensive statewide plan to carry out a Maternal and Child Health Program, funded by Title V MCH dollazs. WHEREAS, as pazt of the comprehensive plan, it is the express intent of the state to support local public health agencies in contributing to a coordinated, efficient statewide program which focuses on specific MCH performance measures set by the MCH state and Federal agencies; WHEREAS, local public health agencies, working in partnership with other community organizations, facilitate the development and enhancement of community-based systems of care for the maternal, and child population; WHEREAS, the goal of these systems is to ensure that all families have access to direct Gaze services, as well as, enabling and populations-based services that address the issues and health problems delineated in the MCH performance measures; WHEREAS, as of the made date of this Contract, the State has a currently valid Group II purchasing delegation agreement with the division of finance and procurement within the Colorado Department of Personnel and Administration; WHEREAS, section 29-1-203, C.R.S., as amended, encourages governments to make the most efficient and effective use of their powers and responsibilities by cooperating and contracting with each other to the fullest extent possible to provide any function, service, or facility lawfully authorized to each of the cooperating or contracting entities; WHEREAS, all state of Colorado contracts with its political subdivisions are exempt from the state of Colorado's personnel rules and procurement code; WHEREAS, as to the State, authority exists in the Law and Funds have been budgeted, appropriated, and otherwise made available, and a sufficient uncommitted balance thereof remains available for subsequent encumbering and payment of this Contract in Fund Number 100, Organizational Unit Code 6520, 6810 and 6830, Appropriation Code 581, 606, 611, and 665, and Object Code 5120, under Contract Encumbrance Number PO FLA MCH0500220; WHEREAS, as to the State, authority exists in the Law and Funds have been budgeted, appropriated, and otherwise made available, and a sufficient uncommitted balance thereof remains available for subsequent encumbering and payment in Fund Number 100, Organizational Unit Code 6810, Appropriation Code 609 and Object Code 5120 under Contract encumbrance number PO FLA HCPO5000001 for the Traumatic Brain Injury Services; and, WHEREAS, all required approvals, cleazances, and coordination have been accomplished from and with all appropriate agencies. Page 2 of 18 NOW THEREFORE, in consideration of their mutual promises to each, stated below, the parties hereto agree as follows: A. EFFECTIVE DATE AND TERM. The proposed effective date of this Contract is October 1.2004. However, in accordance with section 24-30-202(1), C.RS., as amended, this Contract is not valid until it has been approved by the State Controller, or an authorized designee thereof. The Contractor is not authorized to, and shall not, commence performance under this Contract until this Contract has been approved by the State Controller. The State shall have no financial obligation to the Contractor whatsoever for any work or services or, any costs or expenses, incurred by the Contractor prior to the effective date of this Contract» If the State Controller approves this Contract on or before its proposed effective date, then the Contractor shall commence performance under this Contract on the proposed effective date. If the State Controller approves this Contract after its proposed effective date, then the Contractor shall only commence performance under this Contract on that later date. The initial term of this Contract shall commence on the effective date of this Contract and continue through and including September 30, 2005, unless sooner terminated by the parties pursuant to the terms and conditions of this Contract. Unless expressly modified by the Contract, the total term of this Contract, including all automatic renewals, bilateral options to renew, and extensions, may not exceed that period of time authorized in the original procurement method used to select the Contractor. B. DUTIES AND OBLIGATIONS OF THE CONTRACTOR. The Contractor, in accordance with the terms and conditions of this Contract, shall perform and complete, in a timely and satisfactory manner, all work items described in the "Scope of Work", which is incorporated herein by this reference, made a part hereof and attached hereto as "Attachment A". 2. Title V, S~tion 504 (b) (6). Title V funds may not be used to pay for any item or service (other than an emergea~cy item or service) furnished by an individual or ~tity convicted of a criminal offense under the Medicare or any State health care program (i. e., Medicaid, Maternal and Child Health, or Social Services Block Grant Programs). 3. The Contractor agrees to provide services to all Program participants and employees in a smoke-free environment in accordance with Public Law 103-227, also known as "the Pro-Childran Act of 1994", (Act). Public Law 103-227 requires that smoking not be permitted m any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regulazly for the provision of health, day care, eazly childhood development s~'vices, education or library services to children under the age of 18, if the services are fimded by Federal programs either directly or through State or Local governments, by Federal grant, contract, loan, or loan guazantee. The law also applies to children's services that are provided in indoor facilities that aze constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable Federal funds is Medicaze or Medicaid; or facilities where WIC coupons aze redeemed. Failure to comply with the provision of Public Law 103-227 may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. By signing this Contract, the Contractor certifies that the Contractor will comply with the requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision of services for children as defined by the Act. The Contractor agrees that it will require that the language of the Act be included in any subcontracts which contain provisions for children's services and that all contractors shall sign and agree accordingly. Page 3 of 18 4. The Contractor certifies, to the best of its knowledge and belief, that no federally appropriated funds have been paid or will be paid by or on behalf of the Contractor, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of this Contract, and the extension, continuation, renewal, amendment, or modification of this Contract, or any grant, loan, or other cooperative agreement that utilizes Federal fiords. If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, Member of Congress, an officer or employee of Congress in connection with this Contract, or any other grant, loan, or other cooperative agreement, then the Contractor shall complete and submit Standard Form - LLL, "Disclosure Form to Report Lobbying" in accordance with its instructions. The Contractor shall require that the language of this certification be included in the awazd documents for subawazds at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipi~ts shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or metered into. This certification is a prerequisite for making or metering into this transaction imposed by section 1352, title 31, U. S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. The Contractor will not chazge for services those individuals of families at or below the official poverty guidelines, updated periodically in the Federal Register by the U. S. Department of Health and Human Services under the authority of 42 U.S.C. 9902(2), in accordance with Title V, Section 501 (1) (B) and Section 505 (5) (D). The 100 percent of poverty gross income guideline for farm or non-farm families is currently at $9,310 for a family of 1, $12,490 for a family of 2; $15,670 for a family of 3; $18,850 for a family of 4; $22,030 for a family of 5; $25,210 for a family of 6; $28,390 for a family of 7; and $31,570 for a family of 8. For families of more than eight, add $3,180 for each additional member. (The same increment applies to smaller family sizes also.) If any charges are imposed for services to clients who are above the 100% of poverty level, such charges must be on a sliding scale which takes into account the client's family size, income and resources. These charges and the sliding fee scale must be made available to the general public and to all clients and must be based on the agency's usual and customary cost for the service. Clients must understand they will not be denied services for inability to pay any of the sliding fee charges. 6. The Contractor shall protect the confidentiality of all applicant or recipient records and other materials that are maintained in accordance with this Contract. Except for purposes directly connected with the administration of this Contract, no information about or obtained from, any applicant or recipient shall be disclosed in a form identifiable with the applicant or recipient without the prior written consent of the applicant or recipient, or the parent or legal guardian of a minor applicant or recipient with the exception of information protected by Colorado statute as it applies to confidentiality for adolescent services in which case the adolescent minor and not the pazent or legal guardian must provide consent or, as otherwise properly ordered by a court of competent jurisdiction. The Contractor shall have written policies governing the access to, and duplication and dissemination of, all such information. The Contractor shall advise its employees, agents, servants, and subcontractors, if any, that they are subject to these confidentiality requirements. Page 4 of 18 Contractor shall ensure that the provisions of Section 601 of Title VI ofthe Civil Rights Act of 1964 are carved out. That Act states that "no person in the United States shall on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance." The Office of Civil Rights has concluded that it is the responsibility of any program which is a recipient of funds from the Department of Health and Human Services to ensure that clients who do not speak or understand English well, be provided interpretation services to ensure that the service provider and the client can communicate effectively. The Contractor shall have policies and procedures to ensure that interpretation services aze available for clients with Limited English Proficiency and will advise such clients that an interpreter will be provided for them. If a client has their own interpreter, they shall be advised that the Contractor will provide an interpreter if the client so chooses. 8. The services or activities under this Contract may be carried out by the Contractor itself, or through subcontracts with other providers or, through collaborative partnerships with other communitypartners. The State authorizes the Contractor to subcontract some, or all, ofthe services that are to be performed under this Contract. However, a subcontractor is subject to all of the terms and conditions of this Contract. Additionally, the Contractor remains ultimately responsible for the timely and satisfactory completion of all work performed by any subcontractor(s) under this Contract. ofthe Contractor desires to subcontract some, or all, ofthe services that aze to be performed under this Contract, the Contractor shall obtain the prior, express, written consent ofthe State before entering into any subcontract. C. DUTIES AND OBLIGATIONS OF THE STATE. In consideration of those services satisfactorily and timely performed by the Contractor under this Contract, the State shall cause to be paid by HCP to the Contractor a sum not to exceed THIRTEEN THOUSAND SIX HUNDRED TWENTY-TWO DOLLARS, ($23,622.00) for the initial term of this Contract, the State shall cause to be paid by the State Genetics Implementation Grant to the Contractor a sum not to exceed TWO THOUSAND EIGHT HUNDRED FIFTY- EIGHTDOLLARS. ($2,858.00) for the initial term of this Contract, and the State shall cause to be paid by MCH to the Contractor a sum not to exceed THREE THOUSAND TWO HUNDRED FORTY-EIGHT DOLLARS, ($3,248.00) for the initial term of this Contract, for a total financial obligation of NINETEEN THOUSAND SEVEN HUNDRED TWENTY-EIGHT DOLLARS, ($19,728.00). Of the total financial obligation referenced above, TWELVE THOUSAND TWO HUNDRED THIRTY-SIX DOLLARS, ($12,236.00) are identified as attributable to a funding source ofthe United States government and, SEVEN THOUSAND FOUR HUNDRED NINETY-TWO DOLLARS, ($7,492.00) are identified as attributable to a funding source ofthe state of Colorado. Page 5 of 18 Payments under this Contract shall be a combined monthly payment with a portion of each payment from the HCP, State Genetics hnplementation Grant and MCH funds and are subject to verification by the State that the Contractor has fully and satisfactorily complied with the terms and conditions of this Contract. Monthly reimbursements under this Contract for the period of October 1, 2004 through September 30, 2005 shall be paid to the Contractor by the State based upon one-twelfth (1/12) ofthe total financial obligation referenced above in first paragraph of C. 1., or ONE THOUSAND SIX HUNDRED FORTY-FOUR DOLLARS, ($1,644.00) for each of the twelve (12) months of the initial term of this Contract. The total cumulative reimbursements may not exceed the total financial obligation of the State for this Contract period. 2. In addition to the budget referenced in paragraph C. 1. above for the initial term of this Contract, the Contractor shall be reimbursed by HCP t'or traumatic brain injury services for a sum not to exceed Eight Hundred Fifty Dollars ($850,001 per child upon receipt of an invoice. Payment pursuant to this Contract for the Traumatic Brain Injury Services shall be made as earned, in whole or in part, from available Federal and State funds encumbered in an amount not to exceed ONE HUNDRED ELEVEN THOUSAND THREE AUNDRED FIFTY DOLLARS ($111,350.00) Statewide for Federal Fiscal Year 2005 (October 1, 2004 throueh and including September 30, 2005). Of this total financial obligation, ZERO DOLLARS, ($0.00) are identified as attributable to a funding source of the federal government and, ONE HUNDRED ELEVEN THOUSAND THREE HUNDRED FIFTY DOLLARS ($111,350.00) are identified as attributable to a funding source of the state of Colorado. The liability of the State, at any time, for such payments shall be limited to the unencumbered remaining balance of such funds. If there is a reduction in the total funds appropriated for the purposes of this Contract, then the State, in its sole discretion, may proportionately reduce the funding for this Contract or terminate this Contract in its entirety. 3. Payments under this Contract shall be made either through the State's Electronic Fund Transfer system or, upon the Contractor's periodic submission of a "Contract Reimbursement Statement". Reimbursement under this Contract, and any renewal or extension hereof, shall be wade to the Contractor on a monthly basis. Accordingly, the Contractor shall be paid one twelfth (I/12) of the State's financial obligation under this Contract each month for the first eleven (11) months. The final or twelfth (12a') payment for the initial term of this Contract, and any renewal or extension hereof, is contingent upon the State's timely receipt of a Final Expenditure Report from the Contractor utilizing the "Application Budget and Final Expenditure Report" form incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment B". The Contractor shall submit one Final Expenditure Reports on the "Application Budget and Final Expenditure Report" for the MCH, HCP, and Genetics funds combined. The final payment is also contingent upon the State's timely receipt of the signed submission of the "Core Public Health Services Expenditure Report" form, incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment C". The State shall reimburse the Contractor for actual indirect costs up to the Prevention Services Division's maximum of twenty-five percent (25%) when the Contractor's indirect rate is based on Direct Costs, twenty-seven percent (27%) when the Contractor's indirect rate is based on Salary Only, or thirty percent (30%) when the Contractor's indirect rate is based on Salary and Fringe where no other duect costs are charged. Page 6 of 18 6. The State HCP Office shall assure the HCP Regional Office provides technical assistance and that the technical assistance is coordinated with the Public Health Nursing Consultant in the Office of Local Liaison at the State. The State is responsible to ensure that the program planning, evaluation, and monitoring requirements as described in this Contract and the Attachments are met by the Contractor. To fulfill these responsibilities, the State has the right to make site visits and schedule any other meetings at the Contractor's location. 8. The state may allocate more or less funds available on this contract using a Funding Letter substantially equivalent to "Attachment D" and bearing the approval of the State Controller or his designee. The funding letter shall not be deemed valid until it shall have been approved bythe State Controller or his designee. The Funding Letter shall be used strictly to increase or decrease Federal funds only. If both State and Federal funds are being increased and/or decreased at the same time then the contract modification method found in pazagraph C. 9. below shall be used. Contract Renewal, Extension, and Moditication. The State, with the concurrence of the Contractor, may prospectively renew or extend the term of this Contract, or increase or decrease the amount payable under this Contract through a "Limited Amendment" that is substantially similaz to the sample form Limited Amendment that is incorporated herein by this reference and identified as "Attachment E". To be effective, this Limited Amendment must be signed by the State and the Contractor, and be approved bythe State Controller or an authorized delegate thereof. The parties understand that this Limited Amendment shall be used only for the following: A. To increase or decrease the level of funding during the current term of the Original Contract due to an increase or decrease in the amount of goods and/or level of services being provided based upon the existing Scope of Work and/or established pricing and/or established Budget/pricing; B. To revise specifications within the current Scope of Work and/or Budget that increase/decreasethe level of funding during the current term of the Original Contract; C. To renew or extend the term of the contract with appropriate changes in the amount of funding that results in a new total fmancial obligation of the State based upon: a. the same Scope of Work and pricing, or b. revised specifications to the previously defined Scope of Work. D. To make changes to the specifications to the original Scope of Work, project management/manager identification, notice address or notification personnel, or the period of performance, that result in `4~o cost" changes to the Budget. Upon proper execution and approval, this Limited Amendment shall become a formal amendment to this Contract. 10. Other Contract Modifications. If either the State or the Contractor desires to modify the terms and conditions of this Contract other than as provided for in pazagraph C. 8 and C. 9. above, then the parties shall execute a standazd written amendment to this Contract initiated by the State. The standard written amendment must be executed and approved in accordance with all applicable laws and rules by all necessary parties including the State Controller or delegate. Page 7 of 18 D. GENERAL PROVISIONS. Because this Contract involves the expenditure of federal, state, or private funds, this Contract is subject to, and contingent upon, the continued availability of those funds for payment pursuant to the terms and conditions of this Contract. If those funds, or any part thereof, become unavailable as determined by the State, than the State may immediately terminate this Contract. The parties warrant that each possesses actual, legal authority to enter into this Contract. The parties further warrant that each has taken all actions required by its applicable law, procedures, rules, or bylaw to exercise that authority, and to lawfully authorize its undersigned signatory to execute this Contract and bind that party to its terms. The person or persons signing this Contract, or any attachments or amendments hereto, also warrant(s) that such person(s) possess(es) actual, legal authority to execute this Contract, and any attachments or amendm~ts hereto, on behalf of that party. The Contractor is a `public entity' within the meaning of the Colorado Governmental Immunity Act (CGIA), section 24-10-101, et seg•, C.RS., as amended. Therefore, at all times during the initial term of this Contract, and any renewals or extensions hereof, the Contractor shall maintain such liability insurance, by commercial policy or self-insurance, as is necessary to meet its liabilities under the CGIA. Ifrequested bythe State, the Contractor shall provide the State with written proof of such insurance coverage. 4. The Contractor certifies that, as of the effective date of this Contract, it has currently in effect all required licenses, certifications, approvals, insurance, permits, etc., if any, that aze necessary to properly perform the services and/or deliver the products specified in this Contract. The Contractor also warrants that it shall maintain all required licenses, certifications, approvals, insurance, permits, etc., if any, that aze necessary to properly perform this Contract, without reimbursement by the State or other adjustment in the Contract price. Additionally, all employees or subcontractors of the Contractor performing services under this Contract shall hold, and maintain in effect, all required licenses, certifications, approvals, insurance, permits, etc., if any, that aze necessary to perform their duties and obligations under this Contract. Any revocation, withdrawal or nonrenewal of any required licenses, certifications, approvals, insurance, permits, etc., if any, that aze necessary for the Contractor, or its employees and subcontractors, to properly perform its duties and obligations under this Contract shall be grounds for termination of this Contract by the State for default without further liability to the State. If this Contract involves federal funds, or compliance is otherwise federally mandated, then the Contractor shall comply with the requirements of the following: A. Office of Management and Budget Circulazs A-Z1, A-87, A-102, A-110, or A-122, as applicable; B. the "Hatch Act" (5 U.S.C. 1501-1508) and Public Law 95-454, Section 4728. These federal statutes declare that federal funds cannot be used for partisan political purposes of any kind by any person or organization involved in the administration of federally- assisted programs; C. the "Davis-Bacon Act" (40 U.S.C. 276A-276A-5). This federal Act requires that all laborers and mechanics employed by contractors or subcontractors to work on construction projects financed by federal assistance must be paid wages not less than those established for the locality of the project by the Secretary of Labor; Page 8 of 18 D. 42 U.S.C. 6101 et sue, 42 U.S.C. 20004, 29 U.S.C. 794. These federal Acts mandate that no person shall, on the grounds of race, color, national origin, age, or disability, be excluded from participation in or be subjected to discrimination in any program or activity funded, in whole or in part, by federal funds; E. the "Americans with Disabilities Act" (Public Law 101-336; 42 U.S.C. 12101, 12102, 12111-12117,12131-12134,12141-12150,12161-12165,12181-12189,12201- 12213 and 47 U.S.C. 225 and 47 U.S.C. 611); F. if the Contractor is acquiring an interest in real property and displacing households or businesses in the performance of this Contract, then the Contractor is in compliance with the "Uniform Relocation Assistance and Real Property Acquisition Policies Act", as amended, (Public Law 91-646, as amended, and Public Law 100-17, 101 Stat. 246 - 256); G. when applicable, the Contractor shall comply with the provisions of the "Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments" (Common Rule); and, H. Section 2101 ofthe Federal Acquisition Streamlining Act of 1994, Public Law 103-355, which prohibits the use of federal money to lobby the legislative body of a political subdivision of a State. 6. If this Contract involves federal funds, or compliance is otherwise federally mandated, then by signing and submitting this Contract, the Contractor affirmatively avers that: A. the Contractor is in compliance with the requirements of the "Drug-Free Workplace Act" (Public Law 100-690 Title V, Subtitle D, 41 U.S.C. 701 et seq.); B. the Contractor is not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency, the Contractor shall to comply with all applicable regulations pursuant to Executive Order 12549, including, Debarment and Suspension and Participants' Responsibilities, 29 C.F.R 98.510 (1990); and, C. the Contractor shall comply with all applicable regulations pursuant to Section 319 of Public Law 101-121, Guidance for New Restrictions on Lobbying, including, Certification and Disclosure, 29 C.F.R 93.110 (1990). 7. To be considered for payment, billings for payments pursuant to this Contract must be received within a reasonable time after the period for which payment is requested; but in no event no later than sixty (60) cal~dar days after the relevant performance period has passed. Final billings under this Contract must be received by the State within a reasonable time after the expiration or termination of this Contract; but in no event no later than sixty (60) calendar days from the effective expiration or termination date of this Contract. Unless otherwise provided for in this Contract, "Local Match" shall be included on all billing statements, in the column provided therefore, as required by the funding source. 9. The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless approved in writing by the appropriate federal agency. Page 9 of 18 10. In accordance with Office of Management and Budget (OMB) Circular A-133 (Audits of States, Local Governments, and Non-Profit Organizations), if the Contractor receives federal funds from any source, including State pass through monies, in an aggregate amount in excess of $300,000.00 (June 24, 1997), in a State fiscal yeaz (July 1 through Jane 30), then the Contractor shall have an annual audit performed by an independent certified public accountant which meets the requirements of OMB Circular A-133. If the Contractor is required to submit an annual indirect cost proposal to the State for review and approval, then the Contractor's auditor shall audit the proposal in accordance with the requirements of OMB Circulars A-21 (Cost Principles for Educational Institutions), A-87 (Cost Principles for State, Local and Tribal Governments), or A- 122 (Cost Principles for Non-Profit Organizations), whichever is applicable. The Contractor shall furnish one (1) copy of the audit report(s) to the State=s Accounting Office within thirty (30) calendaz days of issuance; but in no event later than nine (9) months after the end of the Contractor's fiscal year. If (an) instance(s) ofnoncompliance with federal laws and regulations occurs, then the Contractor shall take all appropriate corrective action(s) within six (6) months of the issuance of (a) report(s). 11. The Contractor shall grant to the State, or its authorized agents, access to the records and financial statements of the Contractor that directly relate to its performance under this Contract. The Contractor shall retain all such records and financial statements for a period of six (6) years after the date of issuance of a final audit report. This requirement is in addition to any other audit requirements contained in other paragraphs of this Contract. 12. Unless otherwise provided for in this Contract, for all contracts with terms longer than three (3) months, the Contractor shall submit a written progress report specifying the progress made for each activity identified in this Contract. These progress reports shall be submitted in accordance with any applicable procedures developed and prescribed by the State. The preparation of progress reports in a timely manner is the responsibility of the Contractor. If the Contractor fails to comply with this provision, then the failure: may result in a delay of payment of funds; or, termination of this Contract. 13. The Contractor shall maintain a complete file of all records, documents, communications, and other materials that directly relate to this Contract. These materials shall be sufficient to properly reflect all direct and indirect costs of labor, materials, equipment, supplies, and services, and other costs of whatever nature for which a contract payment was made. These records shall be maintained according to generally accepted accounting principles and shall be easily separable from other records of the Contractor. Copies of all such records, documents, communications, and other materials shall be the property of the State and shall be maintained by the Contractor, in a central location as custodian for the State, on behalf of the State, for a period of six (6) years from the date of final payment under this Contract, or for such fiuther period as may be necessary to resolve any pending matters, including, but not limited to, audits performed by the federal government. Page 10 of 18 14. The Contractor authorizes the State, or its authorized agents or designees, to perform audits or make inspections of those records that directly relate to its performance under this Contract. Audits and inspections may be made at any reasonable time during the term of this Contract and for a period of three (3) after the termination or expiration date of this Contract. The Contractor shall permit the State, or any other duly authorized governmental agent or agency, to monitor all activities conducted by the Contractor pursuant to the terms of this Contract. Monitoring may include, but is not limited to: internal evaluation procedures, examination ofprogram data, special analyses, on-site checks, formal audit examinations, or any other reasonable procedures. All monitoring shall be performed by the State in a manner that does not unduly interfere with the work of the Contractor. 15. Subject to the Public (Open) Records Act, section 24-72-101, et sue, C.RS., as amended, if the Contractor obtains access to any records, files, or other information of the State in connection with, or during the performance of this Contract, then the Contractor shall keep alt such records, files, or other information confidential and shall comply with all laws and regulations concerning the confidentiality of alt such records, files, or information to the same extent as such laws and regulations apply to the State. Any breach of confidentiality by the Contractor, or third party agents of the Contractor, shall constitute good cause for the State to cancel this Contract, without liability to the State. Any State waiver of an alleged breach of confidentiality by the Contractor, or third party agents of the Contractor, does not constitute a waiver of any subsequent breach by the Contractor, or third party agents of the Contractor. 16. Unless otherwise provided for in this Contract, or in a written amendment executed and approved pursuant to Piscal Rules of the state of Colorado, all material, information, data, computes software, documentation, studies, and evaluations produced in the performance of this Contract for which the State has made a payment under this Contract are the sole property of the State. 17. If any copyrightable material is produced under this Contract, then the State, and any applicable federal funding entity, shall have a paid in full, irrevocable, royalty free, and non-exclusive license to reproduce, publish, or otherwise use, and authorize others to use, the copyrightable material for any purpose authorized by the Copyright Law of the United States as now or hereinafter enacted. Upon the written request of the State, the Contractor shall provide the State with three (3) copies of all such copyrightable material. 18. If required by the terms and conditions of a federal or state grant, the Contractor shall obtain the prior approval of the State and all necessary third parties prior to publishing any materials produced under this Contract. If required by the terms and conditions of a federal or state grant, the Contractar shall also credit the State and all necessary third parties with assisting in the publication of any materials produced under this Contract. Page 11 of 18 19. If this Contract is in the nature of personaUpurchased services, then the State reserves the right to inspect services provided under this Contract at all reasonable times and places during the term of this Contract. "Services", as used in this clause, includes services performed or written work performed in the performance of services. If any of the services do not conform with the terms of this Contract, then the State may require the Contractor to perform the services again in conformity with the teens of this Contract, with no additional compensation to the Contractor for the reperformed services. When defects in the quality or quantity of the services cannot be corrected by reperformance, then the State may: require the Contractor to take all necessary action(s) to rnsure that the future performance conforms to the terms of the Contract; and, equitably reduce the payments due to the Contractor under this Contract to reflect the reduced value of the services performed by the Contractor. These remedies in no way limit the other remedies available to the State as set forth in this Contract. 20. If, through any cause attributable to the action(s) or inactions) of the Contractor, the Contractor: fails to fulfill, in a timely and proper manner, its duties and obligations under this Contract; or, violates any of the agreements, covenants, provisions, stipulations, or terms of this Contract, then the State shall thereupon have the right to cancel this Contract, in whole or in part, for cause by giving written notice thereof to the Contractor. The written notice shall be given to the Contractor no less than thirty (30) calendaz days before the proposed cancellation date and shall afford the Contractor the opportunity to cure the default or state why cancellation is otherwise inappropriate. If this Contract is cancelled for default, then all finished or unfinished data, documents, drawings, evaluations, hazdwaze, maps, models, negatives, photographs, reports, softwaze, studies, surveys, or any other material, medium or information, however constituted, which has been or is to be produced or prepared by the Contractor ands this Contract shall, at the option of the State, become the property of the State. The Contractor shall be entitled to receive just and equitable compensation for any services or supplies delivered to, and accepted by, the State. If applicable, the Contractor shall return any unearned advance payment it received under this Contract to the State. Notwithstanding the above, the Contractor is not relieved of liability to the State for any damages sustained by the State because of the breach of this Contract by the Contractor. The State may withhold any payment due to the Contractor under this Contract to mitigate the damages of the State until such time as the exact amount of those damages is determined. If, after canceling this Contract for default, it is determined for any reason that the Contractor was not in default, or that the action(s) or inactions) of the Contractor was excusable, then such cancellation shall be treated as a termination for convenience, and the respective rights and obligations of the parties shall be the same as if this Contract had been t~rninated for convenience as described below. Page 12 of 18 21. The State may, when the interests of the State so require, terminate this Contract, in whole or in part, for the convenience of the State. The State shall give written notice oftermination to the Contractor. The written notice shall specify the part(s) of the Contract terminated. The written notice shall be given to the Contractor no less than thirty (30) calendar days before the effective date of termination. If this Contract is terminated for convenience, then all finished or unfinished data, documents, drawings, evaluations, hardware, maps, models, negatives, photographs, reports, software, studies, surveys, or any other material, medium or information, however constituted, which has been or is to be produced or prepared by the Contractor under this Contract shall, at the option of the State, become the property of the State. The Contractor shall be entitled to receive just and equitable compensation for any services or supplies delivered to, and accepted by, the State. If applicable, the Contractor shall return any unearned advance payment it received under this Contract to the State. This paragraph in no way implies that a party has breached this Contract by the exercise of this paragraph. If this Contract is terminated by the State as provided for herein, then the Contractor shall be paid an amount equal to the percentage of services actually performed for, or goods actually delivered to, the State, less any payments already made by the State to the Contractor for those services or goods. However, if less than sixty percent (60%) of the services or goods covered by this Contract have been performed or delivered as of the effective date of termination, then the Contractor shall also be reimbursed (in addition to the above payment) for that portion of those actual "out-of-pocket" expenses (not otherwise reimbursed under this Contract) incurred by the Contractor during the tam of this Contract that are directly attributable to the uncompleted portion of the services, or the undelivered portion of the goods, covered by this Contract. In no event shall reimbursement ands this clause exceed the total financial obligation of the State to the Contractor under this Contract. If this Contract is canceled for default because of a material breach of this Contract by the Contractor, then the above provisions for cancellation for default shall apply. 22. Neither the Contractor nor the State shall be liable to the other for any delay in, or failure of performance of, any covenant or promise contained in this Contract to the extent that the delay or failure is caused by a supervening cause. As used in this Contract, "supervening cause" is defined to mean: an act of God, fire, explosion, action of the elements, strike, interruption of transportation, rationing, court action, illegality, unusually severe weather, war, or any other cause which is beyond the control of the affected party and which, by the exorcise of reasonable diligence, could not have been prevented by the affected party. A delay or failure to perform that is caused by a supervening cause shall not constitute a material breach of this Contract or give rise to any liability for damages therefor ands this Contract. 23. The enforcement of the terms and conditions of this Contract, and all rights of action related to that enforcement, shall be strictly reserved to the State and the Contractor. Nothing contained in this Contract shall give rise to, or allow, any claim or right of action whatsoever to or by any third person. Nothing contained in this Contract shall be construed as a waive of any provision of the Colorado Governmental Immunity Act, section 24-10-101 et sea., C.RS., as amended. Any person or entity, other than the State or the Contractor, who may receive services or benefits under this Contract shall be deemed an incidental beneficiary only. 24. To the extent that this Contract maybe executed and performance of the obligations of the parties maybe accomplished within the intent of this Contract, the terms of this Contract are severable. If any term or provision of this Contract is declared invalid by a court of competent jurisdiction, or becomes inoperative for any other reason, then that invalidity or failure shall not affect the validity of any other term or provision of this Contract. Page 13 of 18 25. The waiver of a breach of a term or provision of this Contract shall not be constrned as a waiver of a breach of any other t~'m or provision of this Contract or, as a waiver of a breach of the same term or provision upon subsequent breach. 26. If this Contract is in the nature of personaUpurchased services, then, except for accounts receivable, the rights, duties, and obligations of the Contractor shall not be assigned, delegated, or otherwise transferred, except with the prior, express, written consent of the State. 27. Unless otherwise provided for in this Contract, this Contract shall inure to the benefit of, and be binding upon, the parties hereto and their respective successors and assigns. 28. Unless otherwise provided for in this Contract, the Contractor shall notify the State, within five (5) working days after being served with a summons, complaint, or other pleading in any case that involves any services provided under this Contract and which has been filed in any federal or state court or administrative agency. The Contractor shall deliver copies of any documents that it was served with to the State within five working (5) days of the date of service. 29. This Contract is subject to such modifications as may be required by changes in applicable federal or state law, or federal or state implementing rules, regulations, or procedures of that federal or state law. Any required modification(s) shall be automatically incorporated into, and be made a part of, this Contract as of the effective date of the change as if that change was fully set forth herein. Except as provided above, no modification of this Contract shall be effective unless that modification is agreed to in writing by both parties in the form of a written ~nendment to this Contract that has been previously executed and approved in accordance with the Fiscal Rules of the state of Colorado. 30. Unless otherwise provided for in this Contract, all terms and conditions of this Contract, and the attachments or exhibits hereto, that may require continued performance or compliance beyond the termination or expiration date of this Contract shall survive that termination or expiration date and shall be enforceable as provided for herein. 31. Unless otherwise provided for in this Contract, no term or condition of this Contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections, or other provisions of the Colorado Governmental Immunity Act (CGIA), section 24- 10-101, et sue, C.RS., as amended. Liability for claims for injuries to persons or property arising out of the alleged negligence of the State or the Contractor, their departments, institutions, agencies, boards, officials, and employees is controlled and limited by the provisions of section 24-10-101 et seq., C.RS., as amended. 32. The captions and headings used in this Contract aze for identification only, and shall be disregarded in any construction of the terms, provisions, and conditions of this Contract. 33. The exclusive venue for any action related to this Contract shall be in the City and County of Denver, Colorado. Page 14 of 18 34. All attachments or exhibits to this Contract are incorporated herein by this reference and made a part hereof as if fully set forth herein. In the event of any conflict or inconsistency between the terms of this Contract and those of any attachment or exhibit to this Contract, the terms and conditions of this Contract shall control. 35. This Contract is the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall have any force or effect whatsoever, unless embodied herein in writing. No subsequent novation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied in a written amendment to this Contract executed and approved in accordance with applicable law. E. SPECIAL PROVISIONS. 1. CONTROLLER'S APPROVAL. CRS 24-30-202 (1) This contract shall not be deemed valid until it has been approved by the Controller of the State of Colorado or such assistant as he may designate. 2. FUND AVAII,ABILITY. CRS 24-30.202 (5.5) Financial obligations of the State of Colorado payable after the current fiscal year are contingent upon funds for that purpose being appropriated, budgeted, and otherwise made available. 3. INDEMNIFICATION. To the extent authorized bylaw, the contractor shall indemnify, save, and hold harmless the State against any and all claims, damages, liability and court awards inclndmg costs, expenses, and attorney fees incurred as a result of any act or omission by the Contractor, or its employees, agents, subcontractors, or assignees pursuant to the tams of this contract. No term or condition ofthis contract shall be construed or interpreted as a waive, express or implied, of any of the immunities, rights, benefits, protection, or other provisions for the parties, of the Colorado Governmental Immunity Act, CRS 24-10.101, et seq., or the federal tort claims act, 28 U.S.C. 2671 et seq., as applicable as now or hereafter amended. Page 15 of 18 4. INDEPENDENT CONTRACTOR. 4 CCR 801-2 THE CONTRACTOR SHALL PERFORM ITS DUTIES HEREUNDER AS AN INDEPENDENT CONTRACTOR AND NOT AS AN EMPLOYEE. NEITHER THE CONTRACTOR NOR ANY AGENT OR EMPLOYEE OF THE CONTRACTOR SHALL BE OR SHALL BE DEEMED TO BE AN AGENT OR EMPLOYEE OF THE STATE. CONTRACTOR SHALL PAY WHEN DUE ALL REQUIRED EMPLOYMENT TAXES AND INCOME TAX AND LOCAL HEAD TAX ON ANY MONIES PAID BY THE STATE PURSUANT TO THIS CONTRACT. CONTRACTOR ACKNOWLEDGES THAT THE CONTRACTOR AND ITS EMPLOYEES ARE NOT ENTITLED TO UNEMPLOYMENT INSURANCE BENEFITS UNLESS THE CONTRACTOR OR THIRD PARTY PROVIDES SUCH COVERAGE AND THAT THE STATE DOES NOT PAY FOR OR OTHERWISE PROVIDE SUCH COVERAGE. CONTRACTOR SHALL HAVE NO AUTHORIZATION, EXPRESS OR IMPLIED, TO BIND THE STATE TO ANY AGREEMENTS, LIABILITY, OR UNDERSTANDING EXCEPT AS EXPRESSLY SET FORTH HEREIN. CONTRACTOR SHALL PROVIDE AND KEEP IN FORCE WORKERS' COMPENSATION (AND PROVIDE PROOF OF SUCH INSURANCE WHEN REQUESTED BY THE STATE) AND UNEMPLOYMENT COMPENSATION INSURANCE IN THE AMOUNTS REQUIRED BY LAW, AND SHALL BE SOLELY RESPONSIBLE FOR THE ACTS OF THE CONTRACTOR, ITS EMPLOYEES AND AGENTS. 5. NON-DISCRIMINATION. The contractor agrees to comply with the letter and the spirit of all applicable state and federal laws respecting discrimination and unfair employment practices. 6. CHOICE OF LAW. The laws of the State of Colorado and roles and regulations issued pursuant thereto shall be applied in the interpretation, execution, and enforcement of this contract. Any provision of this contract, whether or not incorporated herein by reference, which provides for arbitration by any extra judicial body or person or which is otherwise in conflict with said laws, roles, and regulations shall be considered null and void. Nothing contained in any provision incorporated herein by reference which purports to negate this or any other special provision in whole or in part shall be valid or enforceable or available in any action at law whether by way of complaint, defense, or otherwise. Any provision rendered null and void by the operation of this provision will not invalidate the remainder of this contract to the extent that the contract is capable of execution. At all times during the performance of this contract, the Contractor shall strictly adhere to all applicable federal and State laws, rules, and regulations that have been or may hereafter be established. 7. SOFTWARE PIRACY PROHIBITION GOVERNOR'S EXECUTIVE ORDER. No State or other public funds payable under this Contract shall be used for the acquisition, operation or mamteriance of computer software in violation of United States copyright laws or applicable licensing restrictions. The Contractor hereby certifies that, for the term of this Contract and any extensions, the Contractor has in place appropriate systems and controls to prevent such improper use of public funds. If the State determines that the Contractor is in violation of this paragraph, the State may exercise any remedy available at law or equity or under this Contract, including, without limitation, immediate termination of the Contract and any remedy consistent with. United States copyright laws or applicable licensing restrictions. Page 16 of 18 8. EMPLOYEE FINANCTA.I. INTEREST. CRS 24-18-ZOl & CRS 24-50-507 The signatories aver that to their l~owledge, no employee of the State of Colorado has any personal or beneficial interest whatsoever in the service or property described herein. Page 17 of 18 IN WITNESS WHEREOF, the parties hereto have executed this Contract on the day first above written. CONTRACTOR: BOARD OF COUNTY COMMISSIONERS OF EAGLE COUNTY (apolitical subdivision of the state of Colorado) for the use and benefit of the Eagle County Nursing Service By: Name: T~~~srj ~~ , 7-d ti'p' Title: Chair FEIN: 84-6000762 Date: ~ 2 7'O STATE: STATE OF COLORADO Bill Owens, Governor By: For th ecutive Director DEPARTMENT OF PUBLIC HEALTH AND E ENT Date: (Seal) ATTEST: ~~41`~E oG Z f~- ~ By: C'~~~( ~ 90 ity, City and Co tO~ti tY~ ntY~ District, or Town Clerk or Equivalent PROGRAM APPROVAL: a, ~ APPROVALS: COLORADO DEPARTMENT OF LAW OFFICE OF THE ATTORNEY GENERAL Ken Salazar, Attorney General By: l--~C~ Date: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve ail state contracts. This contract is not valid until the State Controller, or sach assistant as he may delegate, has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not be obligated to pay for the goods and/or services provided. STATE CONTROLLER: Leslie M. 5henefelt Date: \ L~ ~~ Revised: 09/08/03 Page 18 of 18 CONTRACT Scope of Work Attachment A Under this Contract, a local public health agency, such as the Contractor shall provide the core public health services on behalf of the prenatal population, the child and adolescent population, and the children with special health care needs as described and defined in "Attachment F", "Core Public Health Services Delivered by MCH Agencies", which is incorporated herein by this reference, made a part hereof, and attached hereto. A. Maternal and Child Health (MCH) The Contractor shall provide leadership, in coordination with public and private community partners to: 1. Contribute to the accomplishment of the State's priorities, performance measures, and outcome measures, as identified in "Attachment G", which is incorporated herein by this reference, made apart hereof, and attached hereto; 2. Work with public and private community partners to plan for the development and maintenance of resources that assure access to direct caze and services for vulnerable women, children, and adolescents, such as those who are low-income, uninsured, underinsured, or who live in rural or underserved azeas or who are from ethnic or cultural minority communities and may experience language or cultural barriers to services; 3. Facilitate outreach and enrollment efforts, including having information and applications an site, to increase enrollment of eligible children and adolescents, including those with special health care needs, in Medicaid (Colorado Baby CaretKid's Care Program) or Colorado Child Health Plan Plus+ (CCHP); and 4. Refer families participating in any and all programs in its agency such as WIC, EPSDT, Immunization Clinics, Family Planning, HCP, etc. to appropriate enabling and direct Gaze service programs in the community. All pregnant women in need ofresources for prenatal medical caze shall be provided with information about programs such as Prenatal Plus, WIC, etc., as needed. The Contractor shall provide all individuals seeking reproductive health services: with information about pregnancy planning, the consequences of unintended pregnancies, and, referrals to comprehensive family planning services. Include the maternal and child health population in the five year community health assessment written for the State's Office of Local Liaison. 6. Include one or moxe MCH objectives in the "Annual Community Health Plan", submitted to the State's Office of Local Liaison. Page 1 of 5 B. Health Care Program for Children with Special Needs (HCP) Contractor shall engage in defined core public health activities designed to enhance the health status of children with special health care needs. The "Suggested Children with Special Health Care Need Activities", attached hereto as "Attachment H", which is incorporated herein by this reference and made a part hereof, may be used if appropriate as guidance. These activities may include direct or enablmg services, population based activities and infrastructure building activities as described in "Attachment F", "Core Public Health Services Delivered by MCH Agencies". The Contractor shall contribute to Western Slope HCP Regional Office's Plan for Children with Special Health Care Needs (CSHCN), which shall be carried out in federal fiscal year 2004 - 2005 (October 1, 2004 through September 30, 2005). The Western Slope HCP Regional Office Plan is designed to: contribute to the accomplishment of the MCH 6 Core Outcomes and Performance Measures, as id~tified in "Attachment I", incorporated herein, by this reference, made a part hereof. Contributions shall consist of, but are not limited to, completing requests from the HCP Regional Office to provide county specific data related to resources and needs of the population of CSHCN and participation in trainings or other learning activities sponsored by the State Genetics Implementation Grant in order to support families and local providers in understanding and accessing recommended follow up. 3. The Contractor shall work collaborativelywith the state's delegated HCP Regional Office staff for: orientation and framing of new staff, as needed; consultation on HCP policies and procedures; consultation and technical assistance on community systems building efforts and community needs assessment activities, as needed; consultation, monitoring and oversight on documentation in IRI5; and for ensuring adequate and timely communication with the HCP Regional Office multidisciplinary team and by meeting as least once annually all together for amulti-county team meeting. 4. Contractor shall ensure that all IRIS users attend IRIS Training and meet the "Nursing Services Standards for Usage of IRIS II", and any subsequent amendments thereof, attached hereto as "Attachment J", incorporated herein, by this reference, made a part hereof. HCP Regional Offices shall assist in assuring this training. 5. Contractor shall implement the "IRIS II Security Policy and Procedures", and any subsequent amendments thereof, attached hereto as "Attachment K, incorporated herein by this reference, made a part hereof. 6. The IRIS System, as provided by HCP, shall be used to document the contractor's core public health services that support meeting the MCH 6 Outcomes for CSHCN. 7. Contractor's "Five-Year Community Health Assessment Report", which is referenced within the County Nursing Service contract Scope of Work, shall include county's population of CSHCN. The assessment report shall include information regarding the MCH 6 Core Outcomes for CSHCN. Copy of the current Five Year Community Health Assessment Report shall be sent to State's delegated HCP Regional Office Team Leader. In addition, a copy of the county's "Annual Community Health Plan" shall be sent to State's delegated HCP RO Team Leader by January 30, 2005. Page 2 of 5 8. The Contractor shall serve families who are determined to fall under the MCH definition. of CSHCN: "Children with special health care needs are those who have or are at riskfor a chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children generally." (Developed by the Federal Bureau of Maternal Child Health in 1995.) Recipients served shall be children residing or whose families have residence in Eagle County. 9. If the Contractor has agreed to provide Traumatic Brain Injury services under this Contract, then the Contractor shall provide care coordination for families who have children with Traumatic Brain Injury (TBI) through the TBI Trust Fund Pilot Project as part of the HCP multi-county region in accordance with the following process: A. The Care Coordinator shall receive notification from the HCP Multi-County Regional Office (HCP RO) ofreferrals and provide care coordination for up to one (1) year for each child. B. The Laze Coordinator shall contact the family to setup an appointment to develop a care coordination plan. C. The Care Coordinator shall develop a care coordination plan, that is reasonable to accomplish within one (1) year, by reviewing the needs described on the TBI Trust Fund application and asking the family to describe their priority wants or needs. D. The Care Coordmator shall complete the HCP Care Coordination Plan Form, sign the plan and obtain a signature from the family. E. The Care Coordinator shall utilize the HCP RO multi-disciplinary team for care coordination assistance. F. Upon obtaining a signed care coordination plan, the Care Coordinator shall send an invoice in the amount of Eieht Hundred ~ftv Dollars ($850.00) p~ child to: Rasa Eglite Prevention Services Division Colorado Department of Public Health and Environment PSD-HCP-A4 4300 Cherry Creek Drive South Denver, CO 80246 G. The Caze Coordinator shall implement the care coordination plan. H. The Care Coordinator shall enter, or request assistance from the HCP RO to enter, demographic information, registration, status, referrals, concerns, and encounters into the IRIS Database to document care coordination plan, activities, and outcomes. I. The Care Coordinator shall have care coordination plans available for Audit purposes. The Care Coordinator shall provide the state family satisfaction survey to the families that received care coordination at the end of the one-yeaz period and encourage them to respond. Page 3 of 5 K. The Care Coordinator shall use the "HCP Policy and Procedures for Care Coordination Services for Children and Youth with Traumatic Brain Injury", incorporated herein, by this reference, attached hereto as "Attachment L", for documentation of services on the IRIS database and maintaining client records. L. The Contractor and Caze Coordinator shall comply with any and all local agency HIPAA regulations; take all appropriate steps to maintain client confidentiality; and obtain any necessary written permissions or agreements for data analysis or disclosure of protected health information, in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations, including, but not limited to, authorizations, data use agreements, business associate agreements, as necessary. Failure to comply with any applicable provision of HIPAA shall constitute a breach of this Contract. 10. The Contractor shall retain and use all HCP Specialty Clinic revenues generated by the contractor to support HCP clinic activities such as: clinic supplies, clinic equipment, clinic furniture, or pazent/professional stipends. 11. The Contractor agrees that any charges for attendance and services at HCP Specialty Clinics sponsored by the Program must conform to the "Sliding Fee Schedule for HCP Clinics, "Attachment M" and any subsequent amendments thereto, attached hereto, incorporated herein by this reference, made a part hereof. 12. On or before December 1, 2004, the Contractor shall submit to the State for review and approval a "Final Expenditure Report" for federal fiscal year 2003-2004 (October 1, 2003, through September 30, 2004) HCP services. A sample format has previously been referenced in the Contract as "Attachment B", on Page 6 of 18, in the first paragraph of C. 4. The agency's Director or Authorized Representative shall sign the final expenditure report prior to submitting to the State. The final payment for the term of October 1, 2003, through September 30, 2004 is contingent upon the State's timely receipt of the fully completed and signed Final Expenditure Report, which shall be sent to: Aida Diaz Prevention Services Division Colorado Department of Public Health and Environment PSD-HCP-A4 4300 Cherry Creek Drive South Denver, CO 80246 13. On or before December 1, 2004, the Contractor shall submit to the State Section II of the "Core Public Health Services Expenditure Report" form showing the Contractor's actual budget allocations for the provision of services to the population of children with special health caze needs for the federal fiscal year 2003-2004 (October 1, 2003, through September 30, 2004). A sample format has previously been referenced in the Contract as "Attachment C", on Page 6 of 18, in the second paragraph of C. 4. The agency's Director or Authorized Representative shall sign the report prior to submitting to the State. The final payment for the term of October 1, 2003, through September 30, 2004 is contingent upon the State's timely receipt of the fully completed and signed Core Public Health Services Expenditure Report, which shall be sent to Aida Diaz, at the address provided in B. 12 above. Page 4 of 5 C. MCH and HCP: Contractor shall cooperate with the State and provide all requested records regarding recipients for whom services were provided under this Contract. 2. The Contractor shall cooperate with the State to ensure that the program planning, evaluation, and monitoring requirements as described in this Contract and the Attachments are met. This cooperation includes, but is not limited to participation in mutually agreed upon site visits at the Contractor's location. 3. Contractor shall retain and use all revenues generated by the individual MCH Programs for services in those programs. 4. Contractor is encouraged to attend regional teleconferences, meetings, and/or videoconference meetings, as appropriate, that the state may organize to address priority MCH/HCP needs, promote learning groups, increase skills asMCH/HCP practitioners and/or carry out state and local MCH planning activities. Page 5 of 5 Attachment B ' APPLICATION BUDGET AND EXPENDITURE REPORT FORM CONTRACTOR: FOR THE PERIOD: PROJECT: CHECK WHICH TYPE OF REPORT IS BEING SUBMITTED: BUDGET FINAL EXPENDITURE REPORT Annual # of Total SOURCE OF FUNDS Salary Rate months Bud et FTE Amount Re aired OTHER' Received from CDPHE PERSONAL SERVICES: ContractuaVFee for Service Supervising Personnel Fringe Benefits: Rate Total Personal Servkes S OPERATING EXPENSES(which are not part of indirect): TotalO ntin S s TRAVEL (in-state/Out-state) Total Travel S S Contractual Total Contractual S Total Direct Costs Personal Servkes+O entin +TnveNContnctua S ADMINISTRATIVE/INDIRECT COST Total AdministrativellndGed Costs S TOTAL PROJECT COST S S s 'Source of funding for "Other" (Match or fn-kind) I.e. Matema{ and Child Healtfi programs Locat/cou fundi $ State ca ita fundin $ Medicaid wi71 not be used to match 3 Patient fees $ Other list $ s a TOTAL S May the NON FEDERAL funds be used as match? YES NO Signature of Agency's Director or Authorized Representative Date Pape tof t a MATERNAL AND CHILD HEALTH CORE PUBLIC HEALTH SERVICES EXPENDITURE REPORT Attachment C CONTRACTOR: DUE DATE: December 1, 2004 (For The Period Of October 1, 2003 through September 30, 2004) Please provide actual numbers for how the funds were used in the period of Cktober 1, 2003 through September 30, 2004. MATERNAL AND CHILD HEALTH FUNDING REPORT FOR THE CORE PUBLIC HEALTH SERVICES SECTION I AMOUNT AND PERCENTAGE ALLOCATED TO: DOLLARS PERCENTAGE CHII,D HEALTH $ PERINATAL HEALTH $ TOTAL $ CHILD HEALTH PERCENTAGE ALLOCATED TO: DIRECT SERVICES ENABLING SERVICES POPULATION BASED SERVICES INFRASTRUCTURE BUII.DING Sl TOTAL PERINATAL HEALTH PERCENTAGE ALLOCATED TO: D11tECT SERVICES ENABLING SERVICES POPULATION BASED SERVICES INFRASTRUCTURE BUII.DING SERVIC SECTION II 100°l0 AMOUNT OF FUNDS ALOCATED TO CHILDREN WITH SPECIAL NEEDS $ CHILDREN WITH SPECIAL NEEDS PERCENTAGE ALLOCATED TO: DIRECT SERVICES ENABLING SERVICES POPULATION BASED SERVICES INFRASTRUCTURE BUILDING SERVICES 1 NOTE: Administrative costs can be allocated to each of the above categories as appropriate. Signature of Agency's Director or Authorized Representative Date Page 1 of 1 SAMPLE FUNDING LETTER Exhibit Date: State Fiscal Year: TO: (contractor's name here) SUBJECT: Funding Letter No. Attachment D In accordance with Paragraph of contract routing number ,between the State of Colorado Department of or Higher Ed Institution (aAency name) (division and (contractor's) covering the period of (contract start date) through (contract end date), the undersigned commits the following funds to the contract: The amount of funds available and specified in Paragraph is {increasedldecreased) by (~ amount of change) to a new total funds available of ($ ) to sates orders under the contract. Paragraph is hereby modified accordingly. This funding letter does not constitute an order for services under this contract. This funding letter is effective upon approval by the State Controller or such assistant as he may Designate. APPROVALS: State of Colorado: Bill Owens, Governor By: Date: _ For the Executive Director/College President Colorado Department of By: For Date: (Division) ALL CONTRACTS MUST BE APPROVi=D BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts. This contract is not valid until the State Controller, or such assistant as he may delegate, has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not be obligated-to pay far goods and/or services provided. State Controller Leslie M. Shenefelt By: Date: or Higher Ed institution Date Issued: February 10, 2003 DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT (ADD PROGRAM NAME HERE) DEPARTMENT OR AGENCY NUMBER *** CONTRACT ROUTING NUMBER ** ***** Attachment E LIlVHTED AMENDMENT #* This Limited Amendment is made this **** day of *********, 200*, by and between the State of Colorado, acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, whose address or principal place ofbnsiness is 4300 Cherrv Creek Drive South, Denver. Colorado 80246, hereinafter referred to as the "State"; and, LEGAL NAME OF ENTITY, (leeal tune of entity), whose address or principal place of business is Street Address. City, State & Zip Code, hereinafter referred to as the "Contractor". FACTUAL RECITALS The parties entered into a contract dated ******** **, ****, with contract encumbrance number PO *** **********, and contract routing number ** *** *****, whereby the Contractor was to provide to the State the following: [briefly describe what the Contractor was to do under the original contract -indent this paragraph] [Please choose one of the following four options and then delete this heading and the other three options not selected:] The State promises to [choose one and delete the other]increase/decrease the amount of funds to be paid to the Contractor by ********** Dollars, ($*.**) during the current term ofthe Original Contract in exchange for the promise of the Contractor to perform the [choose one and delete the other)increased/decreased work under the Original Contract. The State promises to pay the Contractor the sam of ********** Dollars. $*.** in exchange for the promise of the Contractor to continue to perform the work identified in the Original Contract for the r~ewal term of **** years/months, ending on ******** **, ****. The State promises to [choose one and delete the other]increaseldecreasetpe amount of funds to be paid to the Contractor by ********** Dollars, $(* **1 for the renewal term of **** [choose one and delete the other)years/months, ending on ******** **, ****, in exchange for the promise ofthe Contractor to perform the [choose one and delete the other]increased/decreased specifications to the Scope of Work described herein. The State hereby exercises a `~o cost" change to the [insert those that apply and delete those that don't)bndget, specifications within the Scope of Work, project managemenUmanagerideutification, notice address or notification personnel, or performance period within the [choose one and delete the other)cnrrent term of the Original Contract or renewal term of the Original Contract. NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree as follows: Consideration for this Iamited Amendment to the Original Contract consists of the payments and services that shall be made pursuant to this Limited Amendment, and promises and agreements herein set forth. It is expressly agreed to by the parties that this Limited Amendmea~t is supplemental to the original contract, contract routing numbea ** *** *****, (insert the following langaage here if previous amendment(s), change order(s), renewal(s) have been processed]as amended by [include all previous amendment(s), change order(s), renewal(s) and their routing numbers], [insert the following word here if previous amendment(s), change order(s), renewal(s) have been processed]collectivelyreferrwi to herein as the Original Contract, which is by this reference incorporated herein. All terms, conditions, and provisions thereof, ~mless specifically modified herein, are to apply to this Limited Amendment as though they were expressly rewritten, incorporated, and included herein. It is expressly agreed to by the parties that the Original Contract is and shall be modified, altered, and changed in the following respects only: A. [Use this paragraph when changes to the fending level of the Original Contract occur during the current term of the Original Contract]This Limited Amendment is issued pursuant to paragraph *~*. of the Original Contract identified by contract routing number ** *** ***** This Limited Amendment is for the current term of ********* **, ****, through and including ********* **, ****. The maximum amount payable by the State for the work to be performed by the Contractor dining this current term is (choose one and delete the other)increased/decreased by ********** Dollars, $*.** for an amended total financial obligation ofthe State of ********** DOLLARS, * ** . [delete any portion of this sentence that is not applicable]The revised specifications to the original Scope of Work and the revised Budget, if any, are incorporated herein by this reference and identified as "Attachment *" and "Attachment *". The first sentence in paragraph *~*. of the Original Contract is modified accordingly. All other teams and conditions of the Original Contract are reaffirmed. A. [Use this paragraph when the Original Contract will be renewed for another term]This Limited Amendment is issued pursuant to paragraph *_*. of the Original Contract identified by contract routing number ** *** *****. This Limited Amendment is for the renewal term of ********* **, ****, through andmcludmg ********* ** ****. Themaximum amount payable by the State for the work to be performed by the Contractor during this renewal term is ********** Dollars, $~ *.**) for an amended total financial obligation ofthe State of ********** DOLLARS. f$* **). This is an [choose one and delete the other]increaseldecrease of ********** Dollars. ($*.**) ofthe amount payable from the previous term. [delete any portion of this sentence that is not applicable]The revised specifications to the original Scope of Work and revised Budget, if any, for this renewal term are incorporated herein by this reference and identified as "Attachment *" and "Attachment *". The first sentence in paragraph *_*. of the Original Contract is modified accordingly. All other terms and conditions of the Original Contract are reaffirmed. A. [Use this paragraph when there are "no cost changes" to the Budget, the specifications within the orig'mal Scope of Work, allowable contract provisions as noted, or performance period.]This Limited Amendment is issued pursuant to paragraph *_*. of the Original Contract identified by contract rontingnumber ** *** *****. This Limited Amendment [choose those that apply and delete those that don't)modifies the Budget in [identify location in contract], modifies the specifications to the Scope of Work in [identify location in contractJ, modifies the project managemenUmanageradentification in [identify location in contract], modifies the notice address or notification personnel in [identify location in contract], modifies the period of performance in [identify location in contract] ofthe Original Contract. The revised [choose those that apply and delete those that don't]Budget, specifications to the original Scope of Work, project management/manager identification, notice address or notification personnel, or period of performance is incorporated herein by this reference and identified as "Attachment *". All other terms and conditions of the Original Contract are reaffirmed. The effective date ofthis Amendment is date, or upon approval ofthe State Controller, or an authorized delegate thereof, whichever is later. Page 2 of 4 Except for the General Provisions and Special Provisions of the Original Contract, in the event of any conflict, inconsistency, variance, or contradiction between the terms and provisions of this Amendment and any of the terms and provisions of the Original Contract, the terms and provisions of this Amendment shall in all respects sapeasede, govern, and control. The Special Provisions shall always control over other provisions ofthe Original Contract or any subsequent amendments thereto. The representations in the Special Provisions to the Original Contract concerning the absence of personal interest of state of Colorado employees is presently reaffirmed. 6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE C'.URRENT FISCAL YEAR ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND OTHERWISE MADE AVAILABLE. Page 3 of 4 IN WITNESS WHEREOF, the parties hereto have executed this Form Amendment on the day first above written. CONTRACTOR: [LEGAL NAME OF CONTRACTOR) (legal type of entity) By: Name: Title: FEIN: ATTEST: If the Contractor is a corporation ~. or governmental entity, then an attestation is required. (Seal, if available.) By: City, City and County, County, Special District, or Town Clerk or Equivalent Corporate Secretary or Equivalent STATE: STATE OF COLORADO Bill Owens, Governor By: For the Executive Director DEPARTMENT OF PUBLIC HEALTH AND ENVIItONMENT PROGRAM APPROVAL: By: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts. This limited amendment is not valid until the State Controller, or such assistant as he may delegate, has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not be obligated to pay for goods and/or services provided. STATE CONTROLLER Leslie M. Shenefelt By: Date: Form: LAT10-31-03GN Page 4 of 4 Attachment F CORE PUBLIC HEALTH SERVICES DELIVERED BY MCH AGENCIES DIRECT ' HEALTH CARE SERVICES: (OAP FILLING) / Examples: \ Basic Health Services, and Heahh Services for CSHCN ENABLING SERVICES: ~ Examples: Transportation, Translation, Outreach, Respite Care, Health Education, Family Support Services, Purchase of Health Insurance, Case Management, Coordination with Medicaid, WIC, and Education POPULATION-BASED SERVICES: Examples: Newborn Screening, Lead Screening, Immunization, Sudden Infant Death Syndrome Counseling, Oral Health, Injury Prevention, Nutrition and Outreach/Public Education INFRASTRUCTURE BUILDING SERVICES: Examples: Needs Assessment, Evaluation, Planning, PolicyDevelopment, Coordination, Quality Assurance, Standards Development, Monitoring, Training, Applied Research, Systems of Care, and Infomiatbn Systems MCHB/D9CH 10!20!97 Page 1 of 2 DEFINTTIONS OF THE FOUR TYPES OF SERVICES BY WHICH THE CORE PUBLIC HEALTH SERVICES ARE PROVIDED BY MATERNAL AND CHILD HEALTH PROGRAMS AS DEFINED BY THE MATERNAL AND CHILD HEALTH BUREAU As of October I, 2003 Direct Health Care Services Direct health care services aze defined as basic health services. Such services are generally delivered "one on one" between a health professional and a patient in an office, clinic or emergency room. Basic services include what most consider to be ordinary medical care, inpatient and outpatient medical services, allied health services, drags, laboratory testing, x ray services, dental care, and pharmaceutical products and services. State Title V programs may support services such as prenatal care, child health, school health and >amily plannuig by directly operating programs or by funding local providers. Direct health care services also include health care services for children with special needs. 2. Enabling Services Enabling services aze defined as services that allow or provide for access to and the derivation ofbenefits from the array of basic health care services. Enabling services inchide transportation, translation, outreach, respite caze, health education, family support services, purchase ofhealth insmaiice, case management, and coordination of care. These kinds of services aze especially necessary for the low-income population which is disadvantaged, geographically or culturally isolated, and for those with special and complicated health needs. 3. Population-Based Services Population-based services aze defined as services which aze intended and available for the entire population, rather than for a selected group of individuals. Disease, prevention, health promotion and statewide outreach come under this heading. Oral health, injury prevention, nutrition and outreach and public education aze topics which also belong in this category. Population-based services aze generally available for women and children regardless of whether they receive caze in the public or private sector or whether or not they have health insurance. Infrastructure Building Services Infrastructiue building services aze defined as those services that are directed at improving and maintaining the health status of a population. Included among those services aze development and maintenance of health systems, standards, and guidelines, training, data, and planning. Needs assessment, evaluation, policy development, quality assurance, information systems, and applied research aze all contained within the infrashncture umbrella. H:\Conhacts\FY OS\MCH-HCP Combined CNS Ca~ntncts\Attacbmmt F -Page 2 - Pyramid I)efmitiona.doc Page 2 of 2 Attachment G MATERNAL AND CHII,D HEALTH (MCH) PRIORITIES, PERFORMANCE MEASURES, AND OUTCOME MEASURES As of Octoher 1, 2003 Colorado MCH Priorities 1. Reduce teen pregnancy and unintended pregnancy in women of all ages 2. Improve perinatal outcomes 3. Reduce child and adolescent morbidity and increase health and safety in child care settings 4. Reduce overweight among children and adolescents; addressing physical activity and nutritional habits 5. Improve efforts to reduce unintentional and intentional injury, addressing motor vehicle crashes, suicide, child abuse and other violence 6. Improve immunization rates for all children 7. Increase access to health care (including behavioral health care) 8. Improve state and local infrastrnctare by increasing capacity to analyze data, carry out evahiations, develop quality standards, and assure availability of services to all children, inchiding children with special health caze needs 9. Reduce substance abuse (alcohol, tobacco, and drugs) 10. Improve oral health and access to oral health care National Performance Measures 1. The percent of infants who are screened for conditions mandated by their State-sponsored newborn screening programs (e.g. phenylketonuria and hemoglobinopathies) and receive appropriate follow-up and referral as defined by their state 2. The percent of clii~dren with special health Gaze needs age 0 to 18 years whose families partner in decision making at all levels and aze satisfied with the services they receive 3. The percent of children with special health care needs age 0 to18 who receive coordinated, ongoing comprehensive care within a medical home 4. The percent of children with special health care needs age 0 to 18 whose Families have adequate private and/or public insurance to pay for the services they need 5. The percent of children with special health care needs age 0 to 18 whose families report the community-based service systems are organized so they can use them easily 6. The percent of youth with special health care needs who received the services necessary to make a transition to all aspects of adult life Page 1 of 3 7. The percent of children of 19 to 35 month olds who have received fall schedule of age appropriate immunizations against Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus, Pertussis, Hemophilus Influenza, and Hepatitis B 8. The rate ofbirth (per 1,000) for teenagers aged 15 through 17 yeazs 9. Percent of third grade children who have received protective sealants on at least one permanent molaz tooth 10. The rate of deaths to children aged 14 and younger caused by motor vehicle crashes per 100,000 children 11. Percentage ofmothers who breast feed their infants at hospital dischazge 12. Percentage ofnewborns who have been screened for hearing impairment before hospital dischazge 13. Percent of children without health insurance 14. Percent of potentially Medicaid-eligible children who have received a service paid by the Medicaid program 15. The percent of very low birth weight infants among all live births 16. The rate (per 100,000) of suicide deaths among youths 15 through 19 17. Percent of very low birth weight infants delivered at facilities for high-risk deliveries and neonates 18. Percent of infants born to pregnant women receiving prenatal care beginning in the first trimester State Performance Measures 1. The proportion of high school students reporting having drunk alcohol in the past month 2. The proportion of all pregnancies that aze unintended 3. The incidence of maltreatment of children younger than 18 (including physical abuse, sexual abuse, emotional abuse, and/or neglect) 4. The proportion of high school students reporting regnlaz use of tobacco products 5. The proportion of children and adolescents attending public schools who have access to reseazch-based health education and to basic preventive and primary, physical and behavioral health services through school-based health centers 6. The percent ofMedicaid-eligible children who receive dental services as part of their comprehensive services 7. The rate of homicides among teens 15-19 8. The proportion of WIC children who aze overweight 9. The percent of women with inadequate weight gain dining pregnancy 10. The rate of injury hospitalization among children 19 and younger Page 2 of 3 Nationally Choseu Outcome Measures 1. The infant mortality rate per 1,000 live births 2. The ratio of the black infant mortality rate to the white infant mortality rate 3. The neonatal mortality rate per 1,000 live births 4. The postneonatal mortality rate per 1,000 live births 5. The perinatal mortality rate per 1,000 live births State Chosen Outcome Measure 1. The low birth weight rate per 1,000 live births Revised Jaly 15, 2003 H:\Con4acis\FY OS\MCH-HCP Combined CN3 Con4acta\AttscLmmt 6 - MCH PriorBies and Ped'otmance Meas~nes 03-04.doc Page 3 of 3 HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS (HCP) SUGGESTED CHII.DREN WITH SPECIAL HEALTH CARE NEED ACTIVITIES TO FULFILL REQUIREMENTS FOR MCH LOCAL HEALTH CONTRACTS AND COUNTY PRELIMINARY AND STRATEGIC PLANS As of October 1, 2003 Attachment H The following suggested strategies aze offered as guidance to local public health agencies in defining how current or new services fit within the core public health fimctions. The Maternal and Child Health contract between local agencies and Colorado Department of Pablic Health and Environment (CDPHE) requires needs assessment of local communities. Local public health staff is currently doing many of the following activities. The CDPHE Health Care Program for Children with Special Needs (HCP) and Public Health Nursing consaltant staff will provide technical assistance, as needed in assisting local public health agencies to define which of these - or other activities -aze most appropriate for addressing the needs of children with chronic illnesses and disabilities. ~. Direct Services i.l Seek out fimding resources and work with specialty providers to establish alternative fimding sources for families. 1.2 Work with health providers so that they appropriately refer families to state and local resources that can fiord or discount specialty medical caze services. 1.3 Offer access to SELECT specialty care through HCP Specialty Clinic program. However no direct payment for services is available through HCP. 2. Enabling Services 2.1. Conduct an initial interview with a defined population (1~TICU, SSI, etc.) of new families to help them determuie their need for information, referral and/or caze coordination using a standard tool Bach as the "Family Status Profile" form. 2.2. Assist families who have insurance coverage, including private insurance, CHP+ and Medicaid and those in managed care plans, to understand their benefits and their disenrollmeiit and grievance procedures. 2.3. Refer families to agencies and services for which they aze eligible and assist them with the registration or application process, e.g., WIC, CHP+, Baby Caze/Kids Caze, Medicaid, SSI, Part C, Voc Rehab, Mental Health, etc. Follow-up with the family to assure the family was able to make the suggested contacts. 2.4. Determine the status ofprimary care and immunizations and make appropriate referrals. Work in collaboration with the EPSDT outreach worker if the child is on Medicaid to assure that EPSDT benefits have been explained and an EFSDT screen has been completed and billed. 2.5. hiitiate or participate in the development of a Care Plan, IFSP (Individual Family Service Plan), or IEP (Individual Educational Plan) with the family and medical home when it has been determined that a family would benefit from caze coordination. This includes a statement of the family's strengths and needs as identified by the family and strategies for enhancing the child's Page 1 of 5 development. Include a statement ofmalor outcomes to be achieved by the child and family. State the criteria, procedures and fume lines. Document periodic statements ofprogress towazds meeting family goals and the need for modifications or revisions. The process for the development of a Gaze plan, IFSP, or IEP should include all the disciplines involved with the child's care, i.e., medical home, audiologist, CHIP therapist, social worker, funny advocate, OT/PT, dietitian, speech therapist, etc. 2.6. Follow-up with family according to plans written on caze plan, IFSP, or IEP. Should HCP staff have no direct role in the IFSP or IEP, or aze not doing care coordination, assure that a contact with each family is made at least once a yeaz to assure that the child and family aze receiving necessary services and that the family is aware of community resources available to them 2.7. Make home visits when appropriate. (Situations might include complex medical or surgical conditions or when resources or help can be provided relating to the home environment.) 2.8. Work in concert with the EPSDT outreach worker to review monthly listing of SSI recipients and Contact SSI Families to assure that health care needs aze being met. If there aze needs which HCP can meet, assure that children aze enrolled in the program. 2.9. Meet periodically with staff from local agencies such as social services, representatives from the Community Centered Board, mental health and special education services from local schools to collaborate around services to individual children and their families. 2.10. Work with the older children and their families to facilitate transition from pediatric services to adult health care services. (To begin at about age 12 years.) 2.11. Work with NICU Consortium contacts in hospitals to identify needs ofnewborns as the child prepares to leave the hospital to retain to the community. Make contact with other community resources as needed. 2.12. Design and maintain a clinic structure inchiding identifying and scheduling clinic providers, facilities, and equipment. Set clinic dates. Seek referrals by contacting local doctors, Child Find, interagency councils, and Community Center Boards to inform them ofe clinics. Distn~bute the local HCP clinic schedule to appropriate agencies and individuals. 2.13. Organize, schedule and staff each clinic using guidelines provided in the HCP Procedure Manual. Obtains a HCP application on each child scheduled for clinic and a consent for service signed by the parent or legal guazdian. Provide the clinician with Medicaid and private insurance billing information and collect clinic support fees. 2.14. Complete a Clinic Encounter Form for each clinic patient. After each clinic submit Encounter Forms, a copy of the attendance list (schedule) and the dictation to the assigned Regional Office. 2.15. Assure that families have transportation to each clinic and that appropriate and competent interpretation services aze available. 2.16. Depending on the complexity of the child's condition and the needs of the family, appropriate team members shall attend, when available, and participate in the HCP Specially clinics. 2.17. Evaluate the clinic caseload, waiting list and summaries yearly to determine the number and type of specialty clinics needed. Report findings to the Regional Office Team Leader and State Nursing Consultant. Page 2 of 5 2.18. Identify existing primary health caze and specialty providers and support resources including translation, transportation and respite care. 3. Population-based Services 3.1. Promote public health services available to children, ie., HCP, WIC, EPSDT, and Immmiization, by using local media, posters and attendance at health fairs, etc. 3.2. Develop and maintain liaisons with the local community resources to maintain open communication, to promote the services of HCP and other services available to children with special needs, and to establish a network for working together to eliminate gaps or duplication of services and supports. 3.3. Assure that HCP staff is knowledgeable in Eazly Childhood Connections (Part C of IDEA), IFSPs, Service Coordination, Procedural Safeguards and eligibility criteria. 3.4. Assure that HCP staff is knowledgeable in the eligibility criteria and referral procedures for Medicaid, SSI, Children's Medical Waiver 200, Children's Home Caze Based Services Waiver (Katie Beckett - Mode1200 Waiver), and EPSDT. Assure that EPSDT case managers aze knowledgeable about HCP services. 3.5. Assare that training opportunities aze provided to staff on cultural competency and family-centered care. 3.6. Establish or maintain interagency collaboration through periodic meetings with representatives of the local human services agencies, the Community Center Board, the mental health agency and special education services from the school district to understand their services, to learn about their eligibility criteria, and to provide them with information about HCP and other resources within the local community. 3.7. Participate in the community's eazly child identification process as an active member of the community team This participation could inchide assigning staff time to directly participate in a community sponsored identification process or coordinating the agency's services Bach as EPSDT, HCP and WIC, with other efforts so as to provide on-going systems of eazly identification for children 0-21 years. 4. Infrastructure-building Services 4.1. Know the numbers of children in the counties served by the agency and be able to estimate the number of children with special health care needs. Know the target population of children who could potentially benefit from HCP services and the actual number of children currently registered with HCP. Analyze lazge discrepancies between tazget and actual caseloads. 4.2. Know and analyze the numbers of children enrolled on HCP for care coordination only. Page 3 of 5 4.3. Coordinate and/or participate in conducting a community needs assessment with public and private agencies, organizations, providers and parents which identifies problems or voids within the service delivery system for children with special health care needs, defines the problems and determines the services or changes necessary to meet the identified needs. Elements involved in this process include: 4.3.1. Involvement in tracking and data collection efforts of the community concerning the number of children with special health needs, the types of services needed, the types of services available, the accessibility of services, the quality of the services, whether the services aze culturally competent and family centered, and a method to receive castomer feedback about the services. 4.3.2. Awazeness of and collaboration with other community agencies and projects regarding data that is being collected and use of the data to most effectively enhance the community service system for children with special needs. 4.3.3. Establishment of mechanisms to include strong family participation in the development of all assessments. 4.3.4. Coordination with other agencies and organizations to jointly survey the community including families, providers and human service agencies and development of a process to provide feedback to those who participated in the answering of the surveys. 4.4. Provide assessment reports to the community. 4.5. Coordinate and/or participate in the community planning process to develop policies goals and objectives based on the community needs assessment. 4.6. Develop local networks and partnerships with other community resource agencies to determine policies to support the development of comprehensive, community-based systems of care including identification, assessment, intervention and referral services for children with special health caze needs. 4.7. Develop referral and follow-up care systems using available resources such as Colorado Responds To Children With Special Needs (CRCSN), NICU Consortium, Universal Newborn Hearing Screening Programs, and hospital discharge planners, to identify children who may need support, care coordination and/or referral to community resources. 4.8. Establish a mechanism for including input from pazents regarding current services, planning, policy development, implementation and evahiation of HCP paid service benefits as well as community/health services for all children with special health care needs. The process should include a means to provide feedback to families about decisions made in these areas. 4.9. Develop and maintain a system ofpazent support that includes: 4.9.1. Parent to parent support and/or support groups; 4.9.2. Internal practices that support advocacy for family needs and problem solving; 4.9.3. Information and education; 4.9.4. Linkages with community agencies to assmre the availability and adequacy of resources to support the needs of families. Page 4 of 5 4.10. Assare that there is community parent representation from families who have chddren with special needs in the community service system efforts. (For example, attending meetings, contacting representatives, providing input into quality and quantity oflocal services.) 4.11. Participate actively in a community interagency cotinci~ (ICC) by meeting regularly for the purpose of planning and policy development. (These can be a formal or informal group of agencies, providers and parents who aze interested in working together to discuss services for children with special needs, to identify basit~s and gaps in the service delivery system, to develop collaborative plans for removing the bamers and gaps including writing commmnity-based grants for imprave~ment of local systems. Revised June 17, 2003 H:\Conhacts\PY OSMCIi-HCP Combined CN3 Conhacfs\AMacbmmt H -Suggested CSHCN Activitiea.doc Page 5 of S Attachment I MATERNAL AND CHII.D HEALTH (MCH) CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN) 6 CORE OUTCOMES AND PERFORMANCE MEASURES As of October 1, 2003 Outcome #1: Families of children with special health care needs (CSHCN) will partner in decision making at all levels, and will be satisfied with the services they receive. 1. Percent of families of CSHCN reporting satisfaction with the quality of: regular source ofprimary Gaze, getting referrals and appointments for needed services, coordination between primary and specialty care overall services. 2. Percent of pazents of CSHCN who report satisfaction with their level of involvement/input in setting concerns and priorities to make decisions about their chfid's care plan. 3. Percent of pazea-ts of CSHCN who report ]mowing the steps to take when they are not satisfied with the services their child/family receives. 4. Number of parents of CSHCN who aze supported financially for their involvement in state and local activities. 5. Number of parents of CSHCN who report that they aze effective partners in policymaking at the state and local levels. Outcome #2: All children with special health care needs will receive coordinated ongoing comprehensive care within a medical home. 1. Percent of CSHCN with a regular source of primary medical Gaze through a primary care providex. 2. Percent of CSHCN whose regular source of caze communicates in a way that is clear and understandable to the family. 3. Percent ofpazents whose regular source ofprimary medical Gaze identifies, discusses, and addresses the comprehensive needs of their child and family. 4. Percent of CSHCN whose regalaz source of primary medical care ensures age-appropriate well-child checks, including: vision, hearing, developmental, behavioraUmeutal health, oral health, newborn screening, immunizations. 5. Percent of paz~ts of CSHCN who receive referrals and assistance from their regular source of primary medical care in accessing needed/desired services. Outcome #3: All families of children with special health care needs will have adequate private and/or public insurance to pay for the services they need. Percent of CSHCN with insurance that covers costs of needed services, including: mental health, dental care, age-appropriate well-child checks, durable medical equipment, ancillary services, non-durable medical supplies, care coordination, prescriptions, specialty care, related therapies (e.g., PT, OT, speech/language, audiology), in home nursing. Page 1 of 3 2. Amount of out-of-pocket costs paid by families of CSHCN, includmg costs of: mental health, dual care, age-appropriate well-child checks, durable medical equipment, ancillary services, non-durable medical supplies, respite care, transportation, care coordination, prescriptions, specialty Gaze, related therapies (e.g., PT, OT, speech/language, audiology), in-home nursing, home modifications, caz/van modifications. Percent of CSHCN who can choose the providers of their choice. 4. Percent of CSHCN whose insarance provides: timely approval for needed caze, overall parental satisfaction, cleaz information, about coverage resources, and complaint procedures to providers and parents. Outcome #4: All children will be screened early and continuously for special health care needs. 1. Percent of infants whose mothers began prenatal screening in the first trimester of pregnancy, for smoking, alcohol, drugs, tests for birth defects, HW, physical abase. 2. Percent of infants and families being tracked for special health care needs and developmental delays. Percent of children receiving age-appropriate well-child checks including: vision, hearing, developmental, behavioral, mental health, oral health, metabolic, and EPSDT (if implemented in state). 4. Percent of children receiving needed follow up due to failed screening or risk factors: vision, hearing, developmental, behavioral, mental health, oral health, and metabolic. Outcome #5: Services for children with special health care needs and their families will be organized in ways that families can use them easily. 1. Percent of paz~-ts of CSHCN who have a single coordinated service plan that involves all providers and a lead service coordinator who communicates with the family. 2. Percent of pazents of CSHCN who report that they are able to access comprehensive services for their ch>7d and family. 3. Percent of parents of CSHCN who have specialty caze available in their region of the state. 4. The degree to which the state service system has an enrollment/eligibility process that links families of CSHCN (and their medical home) with a wide variety of public and private services and resources. 5. Number ofprivate/pnblicpartnerships to provide community based, compr~ensive medical services for CSHCN, e.g., data sharing, contracts, MOAs. Ontcowe #6: All youth with special health care needs (SHC1V) will receive the services necessary to make appropriate transitions to adult health care, work and independence. Percent of youth with SHCN who by age 14 have a transition plan that addresses employment, transportation, housing, independent living, physical and mental health and necessary accommodations; and percent of youth with SHCN by age 16 have a transition plan that includes appropriate agencies as part of the transition planning team. 2. Percent of youth with SHCN whose regular source of primary medical care facilitates the transition from pediatric to adult providers. Page 2 of 3 Percent of adult health care providers who are prepared to serve youth with SHCN. Percent of youth who report satisfaction with the information and framing they received to make informed decisions about their health care and other services. 5. Percent of youth with SHCN who receive necessary services/supports by age 21: Health insurance, Post- secondary education, Employment, Transportation, Housing, Personal care attendant, SSI, SSA-related work incentives, e.g. PASS, 1619 a & b. H:~Conhacts~FY OS~MCH-HCP Combined CN3 Conhaeffi~Alfachmmt I - MCIi CSHCN 6 Cole OCs & PMs.doc Page 3 of 3 Attachment J Health Care Program for Children with Special Needs (HCP) HCP Large Narsing Services Standards for Usage of IItIS II I. Data Entry Agency will use the HCP Regional Office for consultation and technical assistance for all IRIS data entry, IRIS training, and IRIS users security approval. 2. HCP Policies and Procedures will be followed as described in the HCP Policy and Procedure Manual, IRIS Help File, HCP County Contract and IRIS Training Materials. II. Documentation of Activities Community Encounters will be entered to provide documentation of systems building and population based activities. (Community meetings, outreach, screening, training activities) 2. Person Referrals will be entered to document all referrals. Referral outcome will be entered for each referral. Person Encounters will be entered to document person contact and person concerns. Care coordination will be entered when care coordination is being provided for specific concerns. 4. HCP Clinic data will be entered before clinic date on IRIS Clinic Schedule. Outcome will be entered after the clinic date for all HCP clinics. (Only for counties providing HCP Clinics). III. Data entry for HCP Caseload on IRIS 1. CSHCN County Caseload on IRIS includes all CSHCN with whom agency staff have had person encounters and/or provided referrals within previous twelve months of the reporting period. 2. Each person receiving any level of care coordination services will have a Person Encounter entered showing a concern score. The concern score is determined by number of concerns with care coordination being provided by HCP staff. Concern outcome will be updated as needed or at least yearly. 3. Person Referrals will be entered for all children receiving resource and referral services. 4. A clinic visit is entered on clinic visit screen each time a person attends a HCP clinic. III. IRIS Security The IRIS II Security Policy and Procedures will be followed. All new IRIS users and current staff and supervisors will sign the IRIS Security form and Secure Web User ID Form and submit to the state office as requested. IRIS passwords will be changed every sixty days along with the CITRIX password. Both passwords will be kept confidential and will not be shared. IV. IRIS Training 1. New HCP employees will complete the HCP Training CDs including security, multi-disciplinary training and program orientation. New IRIS users will complete IRIS training at the State HCP Office. The Regional HCP Office will provide IRIS training using the IRIS Train the Trainer materials when new users are not able to attend state training. New IRIS users will not be given IRIS access until both IRIS training and HCP Training CD have been completed. Revised June 7, 2004 H \Ccsrt:ads\FY OS\MCA HCP Canbined CNS ContradsWtactunent J - Large NS ConntyIRIS Standards OS.doc Attachment K Health Care Program for Children with Special Needs (HCP) IRIS II Security Policy, Procedures and Guidelines Security policy and procedures protect personal health information and IRIS data. The following IRIS security procedures are required for County Nursing Services, Health Departments and HCP Regional Offices: IRiS Users (HCP Stall) a. IRIS users including current users, supervisors and new users will sign a Security and Secure Web User ID Form before a personal ID and password are assigned for access to CITRIX and the IRIS database. Users will sign a new security form as requested by State HCP Office. b. IRIS users will have a personal ID and password assigned by the State HCP Office after completing IRIS training. c. IRIS users will not allow new agency staff, another agency staff person, staff from another program or any person to have access or use their CITRIX/IRIS ID and password. d. New IRIS users will complete IRIS and security training as defined in the IRIS Standards. 2. An agency supervisor will sign the security form for each HCP/IRIS user indicating the access level the staffperson needs. Forms will be sent to the State HCP office to request a new ID and password for new staff or when duties change for current staff Anew ID and password will be issued based on the request of the supervisor and the discretion of the State HCP Office. Agency supervisors will not allow or request access for any staff that does not have the need to access HCP person specific data on IRIS. 3. Local Health Department, HCP Regional Office and Nursing Service agencies will have agency policies and procedures for IRIS security and confidentiality. All staff will be trained on the importance of security and confidentiality. 4. Agency supervisors will contact the State HCP office and request that an ID and password be expired when an IRIS user leaves the HCP Program or no longer needs IRIS access. IRIS Users will be deactivated if they have not signed onto IRIS within six months. Agency supervisors will notify the State HCP office to request a specific person's ID/password be disabled when a security breach is suspected. A new IDand/or password will be issued based on the request of the supervisor and the discretion of the State HCP Office. 5. Agency supervisors will supervise and monitor access to the IRIS Database. Agency supervisors will not allow sharing of IDs or passwords. 6. Agency supervisors will monitor/implement HCP policies and procedures for release of information and consent for clinic services including HIPAA disclosures as defined with local agency HIPAA policy. (The Health Insurance Portability and Accountability Act of 1996 (HIPAA) 164.528 regarding accounting for disclosures.) 7. Security for IRIS access to Newborn Evaluation, Screening, and Tracking (NEST) data will be predefined with business rules and HCP Policies and Procedures. The agency will identify staffmembers that have a `heed to Imow" for public health information from the NEST database. Page 1 of 2 The IRIS Security Policy and agency HIPAA procedures will be followed whew providing care coordination for referrals and requests for follow up from NEST data. 9. When an IRIS uses forgets a personal password, they will call the IRIS Help Line or the State HCP office for assistance. The IRIS Help Linestaffwill re-set the personal password to a default password. The IltIS user will immediately change the default password to a secure personal password as defined in training material. 10. Agency supervisors will require IRI5 users to change their IRIS password every 60 days when the CITRIX password is changed. Passwords will be changed more frequently if it is suspected that the password has been compromised. Revised May 28, 2004 H:~Conhacte~FY OS~MCLi HCP Canbined GNS Cmtracts~Atte~diment R- IRiS II Sec~xity Policy OS - CNS doc Page 2 of 2 ...' Attachment L Health Care Program for Children with Special Needs (HCP) Policy and Procedures Care Coordination Services for Children and Youth with Traumatic Brain Injury October 1, 2004 -September 30, 2005 Page 1 of 12 Health Care Program for Children with Special Needs (HCP) Policy and Procedures Care Coordination Services for Children and Youth with Traumatic Brain Injury October 1, 2004 -September 30, 2005 I.Overviewof Care Coordination Services For Children and Youth With Traumatic Brain Iniury (TBD Traumatic Brain Injury Care Coordination is a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet individuals' needs, using communication and available resources to promote quality, cost effective outcomes. TBI Care Coordination operates with an underlying premise that when individuals reach their optimal level of wellness and functional capability, everyone benefits: the individual and family being served, their community support systems, the healthcaze delivery system, and insurance carriers. The primary functions of TBI Caze Coordination aze: i) To maximize individual and family understanding and participation through education and support. ii) To advocate for individual wellness and autonomy through advocacy, communication and identification of service resources. iii) To optimize access to appropriate community services. iv) To integrate and coordinate service delivery by multiple sources and to prevent fragmentation of services. HCP Care Coordination Services for Traumatic Brain Injury follow HCP Policies and Procedures and are applied consistently by Care Coordinators in all HCP Regions of the state. The term "individuaUfamily" refers to whoever has legal responsibility for the person receiving program services. This may be the parent of a minor, an emancipated youth, a guardian, a county department of social services, or another party having legal responsibility for the program participant. Page 2 of 12 II. Training HCP Staff RegionaUCounty HCP staff/care coordinators attend training before providing care coordination services and receiving funding for TBI Care Coordination. The State HCP office will keep records of HCP staff who have completed training for TBI Care Coordination. HCP staff must participate at required HCP TBI Care Coordination training or if unable to attend must complete the following steps before providing TBI Care Coordination: i) Read provided Power Point Presentation and Handouts ii) View HCP Training Video iii} Read the Brainstars Manual iv) Submit a completed Care Coordination Sample Plan to the Regional Office Team Leader and/or State Nursing Consultant. For review and approval. v) Discuss QuestionslConcerns with the HCP Regional Office Team Leader and/or State Nursing Consultant III. Elil~'bitity and Referral Process 1. Eligibility -The Brain Injury Association of Colorado (BIAC) will perform client intake and determine eligibility for the Colorado Traumatic Brain Injury Program Once the family is determined to be eligible the family is approved for a 12-month period of care coordination funded by the Colorado Traumatic Brain Injury Trust Fund. Eligible dates fora 12 month period beginning on the date the care coordination plan is signed. BIAC will refer eligible families/individuals under age 21 to the state HCP Office (CDPHE) for care coordination services. Families/individuals seeking program services will contact BIAC directly to begin the application process through one of the following options: A) The family/individual contacts the Brain Injury Association of Colorado directly. B) Families/individuals contacts the state HCP office or the HCP Regional or County Nursing Agency. The HCP office informs the family/individual that the Brain Injury Association of Colorado will complete the application process and determine eligibility for program services. The HCP office provides contact information for BIAC to the family and family contacts BIAC. C) Family/individual contacts the state HCP office or the HCP Regional Office or County Nursing Agency. HCP contacts the Brain Injury Association of Colorado on behalf of the family/individual, and provides the family/individual's contact information so that the Brain Injury Association may contact the family/individual to begin the application process. HCP will notify BIAC within two (2) business days of its initial contact with the family/individual seeking services. Page 3 of 12 r 2. Referral Process A) BIAC refers eligible families/individuals under age 2I to State HCP office (CDPHE) for care coordination services. B) State HCP office forwards referrals to the appropriate Regional HCP Office. C) The Regional HCP Office forwards all referrals to the appropriate HCP County Nursing Agency. 3. Wait List -Program services are subject to available funding. If the demand and need for care coordination services exceeds the available funding, state HCP office will maintain a wait list of eligible persons. A) Wait list is maintained in order of the date of referral, and individuals shall receive program services on a first-come, first-served basis. B) Persons are also put on the waitlist when the demand is too great for an HCP regional or county nursing office's capacity. The HCP regional or county nursing office and the state HCP office referral manager determine HCP office capacity. C) The HCP office referral manager reviews active caseload and the number of new referrals received each month to determine if additional new referrals can be referred to Regional Offices. 4. Referral Packet The referral packet includes the signed application from the Brain Injury Association of Colorado, documentation of diagnosis and any supporting eligibility information, signed informed consents, and signed subrogation form A) BIAC sends referral packet for eligible persons to State HCP office referral manager B) Referral manager assures completeness of referral packet contents, including signatures. C) Referral manager forwards referral packet to the HCP regional or county office. D) Referral manager documents the referral in the state HCP TBI database. 1V. Implementing Care Coordination Services 1. Assignment of Care Coordinators HCP solicits and considers the family/individual's preferences when assigning a Care Coordinator within the capacity of the HCP staff. Factors such as gender, age, culture, language, location, and hours of availability may be considered as part of this process. A) The HCP Regional and/or County Office assigns a Care Coordinator to the family/individual. B) Care Coordination assignments are documented in IRIS. Page 4 of 12 2. Developing the Care Coordmahon Plan A) The HCP Care Coordinator and family/individual develop the Gaze coordination plan together. The plan reflects the family/individual's own identification of service needs. The care coordination plan is not a clinical treatment plan and does not reflect clinical treatment goals or objectives. In selecting specific service providers, the Care Coordinator should assist the family/individual to choose from among available providers, taking into consideration any preferences the family/individual may have concerning the service providers. Factors such as gender, age, culture, language, location, pediatric specialty, experience with children with special needs and hours of availability may be considered as part of this process. The care coordination plan identifies financial assistance programs the family/individual is receiving, or may be eligible to apply for within the community or at the State or federal level. B) Document plan on "Health Care Program for Children with Special Needs (HCP) Care Coordination Child/Family Plan of Caze" form provided by state HCP. Refer to figure #1. C) Each outcome/goal must have a documented expected date outcome/goal is to be achieved. D) Each outcome/goal must state specific actions/interventions in a logical sequence. E) For every action/intervention there must be documented an assigned responsible person. F) Evaluation of outcome goal status will be documented during and at the end of the 12 month period of care coordination services. 3. Signing the Care Coordination Plan The family/individual who receives program services must agree to the terms of the care coordination plan. A) Family/individual signs original agreed upon care coordination plan form B) HCP Care Coordinator signs and initials original care coordination form and gives copy of form to family/individual. C) Any additionally assigned HCP Care Coordinator that is involved in modifications or evaluation of the plan's status must initial and sign the original form Page 5 of 12 4. Approval of Care Coordination Plans The Regional HCP Office and/or State HCP Office reviews and provides consultation for new care coordination plans. A) Shortly after State HCP sends the referral packet to the HCP regional or county office, assigned State staff will contact that local office to provide consultation. B) HCP Regional and county offices keep a hard copy of completed and signed care coordination plans on file. C) State HCP office completes a follow up review of a monthly random sample of 25% of new care coordination plans. D) For ongoing consultation, as needed, local offices can contact State and/or Regional office personnel. 5. Duration of Care Coordination Services CDPHE shall provide the care coordination services included in the care coordination plan for a period of twelve (12) months from the date of signature on the completed care coordination plan. If DPHE and/or the family/individual determine that care coordination services are no longer necessary before the end of the twelve-month period, DPHE shall place the client on "inactive" status. If the family/individual requests and needs additional care coordination services after being placed on inactive status and before the end of the twelve-month period, DPHE shall place the client on "active" status and resume services to the family/individual. At the conclusion of the twelve-month period, DPHE shall close the individual's case. A family/individual may submit a new application for care coordination services to the Brain Injury Association of Colorado at any time. V. Client Records Upon completion and signing of a care coordination plan, the HCP regional or county office opens and maintains a client record for the individual receiving services. The client record includes the following: A) Application for benefits, documentation of eligibility, and signed client agreements and consent for release of medical records. (The Brain Injury Association of Colorado provides these documents, and they are included in the referral packet sent from the state HCP office.) B) The signed Care Coordination plan. C) Progress notes for each contact with the family/individual receiving services. Progress notes can be either hard copy written notes or can be documented in the IRIS database as client encounter notes. If the chart is needed for audit purposes, the IRIS encounters are printed and included in the chart. D) Completed satisfaction surveys from the client, the client's family, or other stakeholders. Page 6 of 12 E} Record of any client appeals and grievances, and responses to these appeals and grievances from the State HCP Office. Documentation for client appeals and grievances are entered in progress notes. See above. F) The client's Social Security Number which cross-checked for client identification. 1. Maintenance of Client Records The Regional, State and County HCP Offices maintain all client records in a locked and secure area following the HIPAA guidelines on security and confidentiality of all written or oral communications regazding the family/individual receiving benefits. Client records are available, on request, to any State or Federal agency with review and audit authority, specifically State and Regional HCP agencies and Department of Human Services (DHS). All client care coordination records are the property of DHS and shall be surrendered to DHS upon request. 2. Sharing Client Records/Care Coordination Information A) Health Insurance Portability and Accountability Act (HIPAA) HCP Regional and County Agencies shall comply with all applicable provisions of the Health Insurance Portability and Accountability Act of 1996. HCP staff and caze coordinators follow County HIPAA policies and procedures for security and confidentiality. HCP staff provides County Privacy Practices during first contact with families. Disclosures of Personal Health Information are documented on approved County Disclosure Form B) Consent/Authorization -The family/individual receiving care coordination benefits signs an HCP authorization to allow communication between County, State and Regional HCP Offices; all service providers listed in the care coordination plan and the State Department of Human Services (DHS}. HCP Offices use their own agency's current HIPAA consent/authorization forms. C) Disclosure Tracking -The HCP County and Regional HCP Offices document any disclosures/sharing of the client's records on the agency's HIPAA disclosure form. D) Privacy Practice Policy -The HCP County and Regional HCP Offices provide the individuaUfamilies receiving services the current agency's HIPAA privacy practice policy. Page 7 of Z2 w t ~ - ry r r ~` B. Pediatric Clinics Children attending an HCP Pediatric Clinic: i. Upon referral from the child's PCP requesting a diagnostic evaluation and/or continuing consultation from the pediatrician, the child maybe seen in the HCP Pediatric Clinic. 2. Families not on Medicaid will be charged a clinic support fee. (HCP is providing access for these families, but not paying for services to children.) 3. Family pays all labs and x-rays ordered out of clinic. Revised August 11, 2003 J:~iCPCOMMC~~ 04~COUN'IYNS~ATTACHM@ITS -LARGE COUNIISSIATTACHbffi4T H - CLRdIC 3I]DING FSB SCHHDULBDOC Page 2 of 2 STATE OF COLORADO Bill Owens, Governor Douglas H. Benevento, Executive Director Dedicated to protecting and improving the health and environment of the people of Colorado 4300 Cherry Creek Dr. S. Denver, Colorado 80246-1530 Phone (303)692-2000 TDD L+ne (303) 691-7700 Located in Glendale, Colorado http://www. cdphe.state.co. us Laboratory Services Division 8100 Lowry Blvd, Denver, Colorado 80230-6928 (303)692-3090 Prevention Services Division Oftice of Maternal and Child Health Telephone: 303-692-2370; FAX: 303-782-5576 November 2, 2004 Kathleen Forinash, Director Eagle County Health and Human Services P.O. Box 6b0 Eagle, Colorado 81631 RE: MCHIHCP Contract Contract Routing Number OS FLA 00220 Dear Ms. Forinash: ~~~.~ NOV 4 5 2004 of ~ ~O~o mow,, . ~.~ ;N~~~ ~ p~ *~~» ~ ~s ~ 1876 ~` Colorado Department of Public Health and Environment HEALTH & HUMAN SERVICES Enclosed please find a fully executed copy of the above referenced Contract for your files. This Contract covers the period from October 8, 2004, the date the State Controller or delegate signed the Contract, through and including September 30, 2005. If you have any questions regarding the MCH portion of the Contract or the attachments please contact Sally Merrow at 303-692-2391 or sall~merrownnstate.co.us. However, should you have questions regarding the HCP portion of the Contract or its attachments please contact Charla Low at 303-692-2423 or charla:low_cr,state _co,us. Yo(u~rs very truly, /~G/ ~~ Ms. Peggy Becker MCH Contract Coordinator 303-692-2404 pe;?~v.b ecker~state. co. us Enclosure cc: Sally Metrow, MCH Fiscal Officer Charla Low, HCP Fiscal Officer