ࡱ> c \bjbj ff>r!!o!o!o!D!!!3",_%T!-C/(k/k/k/"889T9,HJJJJJJ$!`n)o!98""899n!!k/k/4>>>9v!8k/o!k/H>9H>>īW!k/ .:Ȱ`4<(7:7H7o!099>99999nn<&99999997999999999 :  NC DHHS Notice of Funding Availability Reporting Form  DHHS Division/Office issuing this notice: Office of Rural Health Date of this notice: November 5, 2019 Grant Applications will be accepted beginning November 5, 2019 Deadline to Receive Applications: January 15, 2020 Working Title of the funding program: Community Health Grants Purpose: Description of function of the program and reason why it was created: Safety net organizations are facing increasing demand for access to services in communities across our state. The current opioid crisis, behavioral health needs, integrated patient care, ensuring the health of children and families, and the use of telehealth strategies to improve access and sustainability are among the many issues facing safety net providers. Collaboration among providers in the counties and regions of our state is a key component to address these issues. The Community Health Grant RFA will look for cooperation and collaboration among county and regional partners as part of the application process. These grant funds, supported through the North Carolina General Assembly, are for assuring access to primary and preventive care to meet the health needs of our states most vulnerable populations. Strengthening the safety net through increased levels of collaboration and integration of services and organizations to more effectively meet the needs of those served is also an important purpose of this grant. Primary care safety net organizations who care for underserved and medically indigent patients in the state are eligible to apply for this funding to pay for patient care through encounter-based reimbursement (Track A) or through reimbursement for eligible expenses (Track B). Telehealth services and equipment are eligible expenses in both tracks. Applicants must select ONE track. Track A: Encounter based reimbursement. Payment per patient encounter for low-income, uninsured and underinsured residents, who do not have health care coverage or access to primary health care services. Visits are reimbursable for medically necessary, on-site, face-to-face provider encounters. Face-to-face encounters may also include telehealth patient encounters with a provider. NOTE - Per the Free Clinics Federal Tort Claims Act (FTCA) Program Policy Guide, grant funding that applies to reimbursement, payment, or compensation for the delivery of health services to patients falls within the statutory prohibition, while grant funding that is not intended for or applied to this purpose does not. Free clinics who are FTCA recipients that choose a per encounter reimbursement methodology may void their FTCA liability protection. Track B: Reimbursement for eligible expenses. Payment may include salary/fringe for clinical staff, medical/office supplies and equipment and capital expenses, including equipment for telehealth services. Technical Assistance: Webinar: November 15, 2019 11:30 a.m. 12:30 p.m. Link:  HYPERLINK "https://zoom.us/webinar/register/WN_Yr0KGxrSQUG3QZppUlDJjA" https://zoom.us/webinar/register/WN_Yr0KGxrSQUG3QZppUlDJjA Funding Availability: Funding requests will depend on money awarded for program use. It is anticipated that the SFY 2021 Year One grant awards will be quite competitive. Approximately twenty grants will be awarded this year. Maximum Award Amount: Applicants may request up to a maximum of $150,000 for 12 months of funding. Proposed Project Period or Contract Term State Fiscal Year 2021: July 1, 2020 June 30, 2021 Eligibility: All primary care safety net organizations that provide direct primary and preventive care and serve as a medical home are eligible to apply. This includes: R Federally qualified health centers and look-alikes (FQHCs), R Free and charitable clinics, R Health departments, R Hospital-owned primary care clinics, R Rural health centers, R School-based and school-linked health centers, R AHEC clinics R Other non-profit community organizations that provide direct primary and preventive patient care to low-income, uninsured, underinsured and medically vulnerable populations. The Office of Rural Health encourages new applicants. Those applicants without a current Community Health Grant (entering Year 2 and Year 3) will receive an additional ten (10) points. Eligible organizations that provide direct primary and preventive care may use these funds to support any of the following: telehealth patient care, community health workers, health promotion, health maintenance, health counseling, disease prevention, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (care coordination/care management by a primary care entity, behavioral health, oral health, womens health, maternal and child health that supports health care services in a primary care setting), collaborative community-based whole person-centered health care delivery models. The Department and ORH work to advance the health, safety and well-being of all North Carolinians in collaboration with a wide array of partners and stakeholders. In its Strategic Plan, 2019-2021,  HYPERLINK "https://files.nc.gov/ncdhhs/NCDHHS-Strategic-Plan-2019-2021-WEB.pdf" https://files.nc.gov/ncdhhs/NCDHHS-Strategic-Plan-2019-2021-WEB.pdf, the Department focuses on and encourages collaboration among community partners in integrating physical health and behavioral health services, increasing community awareness and prevention of drug overdose and death, and the importance of healthy children and families. All applicants are encouraged to consider such collaborations. When describing collaborative relationships, outline specific partnerships within the community and their role in the partnership. If applicants in communities with multiple safety net organizations cannot show collaborative relationships, please address the barriers that exist to developing these relationships. Access to health care can be a problem for patients in a remote area. It may be difficult to get to a hospital quickly in an emergency or patients may be required to travel long distances to get routine checkups and screenings. Additional points may be added to applications from communities with a low ratio of providers per population. As a condition of receiving a grant award, successful applicants must: Submit a monthly expense report in a specified format for reimbursement Submit performance reports quarterly or biannually throughout the grant term Use an electronic financial software application (EXCEL spreadsheets are not acceptable formats) Document collaborations among safety net and social support organizations specifying distinct roles of each organization and designated fiscal responsibilities. Connect to NC HealthConnex To meet the states mandate, a provider is connected when its clinical and demographic information are being sent to NC HealthConnex at least twice daily. For further information, please see the HIEA website:  HYPERLINK "https://hiea.nc.gov" https://hiea.nc.gov How to Apply: Applicants must submit the following documents electronically through the electronic survey. Organizational Information and Signature Sheet Organizational Profile Summary of Evaluation Criteria and Baseline Data Grant Narrative Budget Deadline for Submission: Grant applications must be received electronically by the Office of Rural Health by January 15, 2020. Only electronic applications will be accepted. Access to the electronic application is a two-step process: You must submit your organization name and contact information through the following link which opens November 5, 2019 and closes on January 10, 2020:  HYPERLINK "https://ncruralhealth.az1.qualtrics.com/jfe/form/SV_9EOuz19FgoPhiXr" \t "_blank" https://ncruralhealth.az1.qualtrics.com/jfe/form/SV_9EOuz19FgoPhiXr You will need to submit your contact information no later than January 10th. After January 10th you will not be able to receive a personalized link to submit an application. Once you submit your contact information in the link above, you will receive an email with a personalized link specific to your organization. The link in the e-mail will give you access to the electronic application. The application closes January 15, 2019. How to Obtain Further Information: Funding Agency Contact/Inquiry Information: Ginny Ingram at  HYPERLINK "mailto:ginny.ingram@dhhs.nc.gov" ginny.ingram@dhhs.nc.gov or 919-527-6457 For assistance with the link: Contact Johnathan McEachin,  HYPERLINK "mailto:Johnathan.McEachin@dhhs.nc.gov" Johnathan.McEachin@dhhs.nc.gov or 919-527-6468; Lola Omolodun,  HYPERLINK "mailto:lola.omolodun@dhhs.nc.gov" lola.omolodun@dhhs.nc.gov or 919-527-6453 SectionDescriptionGeneral Information RFA Title: Community Health Grants SFY 2021 Opening Date: 11/1/2019 Closing Date: 1/15/2020 Funding Agency Name: Office of Rural Health Funding Agency Address: 311 Ashe Avenue, Raleigh, NC, 27606 Funding Agency Contact/Inquiry Information: Ginny Ingram, 919-527-6457,  HYPERLINK "mailto:ginny.ingram@dhhs.nc.gov" ginny.ingram@dhhs.nc.gov Webinar: November 15, 2019 11:30 a.m. 12:30 p.m. Link:  HYPERLINK "https://zoom.us/webinar/register/WN_Yr0KGxrSQUG3QZppUlDJjA" https://zoom.us/webinar/register/WN_Yr0KGxrSQUG3QZppUlDJjA Submission Instruction: Grant applications must be received via email to the Office of Rural Health by January 15, 2020 Only electronic copies through the process listed below: You must submit your organization name and contact information through the following link which opens November 5, 2019 and closes on January 10, 2020:  HYPERLINK "https://ncruralhealth.az1.qualtrics.com/jfe/form/SV_9EOuz19FgoPhiXr" \t "_blank" https://ncruralhealth.az1.qualtrics.com/jfe/form/SV_9EOuz19FgoPhiXr You will need to submit your contact information no later than January 10th. After January 10th you will not be able to receive a personalized link to submit an application. Once you submit your contact information to the link above, you will receive an email with a personalized link specific to your organization. The link in the e-mail will give you access to the electronic application. The application closes January 15, 2019. Once you submit your contact information, you will receive an email with a link specific to your email address and your organization. This link will give you access to the electronic application. The application closes January 15, 2019. Applicants may request and receive up to a maximum $150,000 per year for this grant. Proposed Project Period or Contract Term: State Fiscal Year: July 1, 2020 June 30, 2021 Incomplete applications and applications not completed in accordance with the following instructions will not be reviewed. Questions regarding the grant application may be directed to Ginny Ingram at  HYPERLINK "mailto:ginny.ingram@dhhs.nc.gov" ginny.ingram@dhhs.nc.gov or 919-527-6457 RFA Description Eligibility The purpose of grants awarded under this program is to assure access to primary and preventive care for vulnerable, underserved and medically indigent patients in the state. Primary care* is defined as that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern. There are providers of healthcare other than physicians who render some primary care services. Such providers may include nurse practitioners, physician assistants, and some other healthcare providers. *American Association of Family Practice: http:www.aafp.org Grants will be awarded on a competitive basis to safety net organizations that: (i) provide primary and preventative medical services to uninsured or medically indigent patients and (ii) serve as a medical home to these vulnerable populations, in order to accomplish any of the following purposes: a. Increase access to primary care and preventative health services for these vulnerable populations in existing primary care locations. b. Establish primary care and preventative health services in counties where no such services exist to assist these vulnerable populations. c. Create new services, sustain existing service levels, or augment existing services provided to these vulnerable populations, including primary care and preventative health services, dental, pharmacy, and behavioral health services when integrated into the medical home. d. Increase primary care capacity to serve these vulnerable populations, including enhancing or replacing facilities, equipment, or technologies necessary to participate in the exchange of data and tools to monitor and improve the quality of care provided. Primary care safety net organizations are eligible to apply for this funding to pay for patient care through encounter-based reimbursement (Track A) or through reimbursement for eligible expenses (Track B). Applicants must select ONE track. Track A: Encounter based reimbursement. Payment per patient encounter for low income, uninsured and underinsured residents, who do not have health care coverage or access to primary health care services. Visits are reimbursable for medically necessary, on-site, face-to-face provider encounters. Face-to-face encounters may also include telehealth patient encounters with a provider. NOTE - Per the Free Clinics Federal Tort Claims Act (FTCA) Program Policy Guide, grant funding that applies to reimbursement, payment, or compensation for the delivery of health services to patients falls within the statutory prohibition, while grant funding that is not intended for or applied to this purpose does not. Free clinics who are FTCA recipients that choose a per encounter reimbursement methodology may void their FTCA liability protection. Track B: Reimbursement for eligible expenses. Payment may include salary/fringe for clinical staff, medical/office supplies and equipment, equipment related to providing telehealth services, and capital expenses. Indirect costs are not eligible. All primary care safety net organizations that provide direct primary and preventive care and serve as a medical home are eligible to apply. This includes: R Federally qualified health centers and look-alikes (FQHCs), R Free and charitable clinics, R Health departments, R Hospital-owned primary care clinics, R Rural health centers, R School-based and school-linked health centers, R AHEC clinics R Other non-profit community organizations that provide direct primary and preventive patient care to low income, uninsured, underinsured and medically vulnerable populations. The Office of Rural Health encourages new applicants. Those applicants without a current Community Health Grant (entering Year 2 and Year 3) will receive an additional ten (10) points. Eligible organizations that provide direct primary and preventive care may also use these funds to support any of the following: telehealth patient care, community health workers, health promotion, health maintenance, health counseling, disease prevention, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (care coordination/care management by a primary care entity, behavioral health, oral health, womens health, maternal and child health that supports health care services in a primary care setting), collaborative community-based whole person-centered health care delivery models. Note that under Session Law 2015-241, each provider of Medicaid and state-funded services will be required to connect to the NC HIE (now called NC HealthConnex) to receive state funds. Allowable CostsTrack A: Patient visits are reimbursable for medically necessary, on-site, face-to-face provider encounters at $100 per visit. Face-to-face visits may include telehealth patient sessions with a provider. NOTE - Per the Free Clinics Federal Tort Claims Act (FTCA) Program Policy Guide, grant funding that applies to reimbursement, payment, or compensation for the delivery of health services to patients falls within the statutory prohibition, while grant funding that is not intended for or applied to this purpose does not. Free clinics who are FTCA recipients that choose a per encounter reimbursement methodology may void their FTCA liability protection. Track B: Reimbursement for eligible expenses. Payment may include salary/fringe for clinical staff, medical/office supplies and equipment, equipment related to providing telehealth services and capital expenses. Indirect costs are not eligible. Note: Grant recipients shall not use these funds to do any of the following: (1) Enhance or increase compensation or other benefits for personnel, administrators, directors, consultants, or any other persons receiving funds for program administration. (2) Supplant existing funds, including federal funds traditionally received by federally qualified community health centers. However, grant funds may be used to supplement existing programs that serve the purposes described in subsection (a) of this section. (3) Finance or satisfy any existing debt. Track A and B applicants may request and receive up to a maximum of $150,000 per year for this grant funding. Proposed Project Period or Contract Term: State Fiscal Year: 7/1/2020 6/30/2021Other Contractor Requirements for successful award recipientsIn addition to the contents within this RFA, the contractor shall also adhere to the following: Submit Performance Reports (quarterly and as requested) Submit Monthly Expenditure Reports (MERs) to request reimbursement (due by the 10th of each month) Utilize an electronic financial software application (Excel is not an acceptable format) Document collaborations among safety net and social support organizations specifying the distinct roles of each entity and designated fiscal contribution.  SFY 2021 Community Health Grants ORGANIZATION INFORMATION & SIGNATURE SHEET Organization Name:Organization EIN: Organization NPI (if applicable):DUNS (if applicable):Mailing Address:Organization Fiscal Year:Organization Type: (check one) ( FQHC ( Free and Charitable Clinic ( Health Department ( AHEC Program ( Critical Access Hospital ( Rural Health Clinic ( SBHC ( Small/Rural Hospital ( Other (specify):Do you provide primary care*? ( Yes ( No Does this request include technology (computers, software, hardware or IT related services)? ( Yes ( No *Primary care is defined as that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern. There are providers of health care other than physicians who render some primary care services. Such providers may include nurse practitioners, physician assistants and some other health care providers. American Association of Family Practice: http://www.aafp.org Total Amount of Grant Request: $Primary County Served (where the grant will be utilized):Other Counties Served (if applicable):  Grant Contact Person: Email: Phone Number: Fax Number: Finance Contact PersonEmail:Phone Number:Print Signatory Name:Signature Date:Title:Email:Phone Number: SFY 2021 Community Health Grants Organizational Profile Number of Service Delivery Sites (locations): ________________ Total FTEs (full time equivalent) of Staff Employed in the organization (at the site(s) where the grant will be utilized: ________________ (please refer to Appendix A for instructions on calculating number of FTEs) Patient Insurance Status in your Organization: Enter the number of unduplicated patients, by category, who are projected to be served during the project period at the site where the grant will be utilized. Enter a projected baseline value as of July 1, 2020, in Column A; an estimated target value for the total number of patients who will be served by June 30, 2021 in Column B; and the projected net additional patients served in Column C for each insurance type. Column A Projected Baseline Served as of 07/01/2020Column B Projected Target Served as of 06/30/2021Column C Projected Net Additional Patients Served Col B minus Col ANone/Uninsured Patients Medicaid Childrens Health Insurance Program (CHIP)Medicare (including duals)Other Public Insurance (e.g. Tricare)Private Insurance (e.g. BCBS)Total Unduplicated Patients Served (sum of above) SFY 2021 Community Health Grants Organizational Profile ______________________________________________________________________________________ Patients by Race and Ethnicity: Enter the number of unduplicated patients by Race & Latino Ethnicity that you currently serve (a baseline value as of July 1, 2020). Only include patients at the site(s) where the grant will be utilized. Please use line g if race is not reported. Use column C if race is reported but ethnicity is not. RaceColumn A Hispanic/ LatinoColumn B Non-Hispanic/ LatinoColumn C Unreported/ Refused to Report EthnicityAmerican Indian / Alaska NativeAsianBlack/African AmericanNative Hawaiian / Other Pacific IslanderWhiteMore than one raceUnreported / Refused to report race Does your practice collect data on individual patients social risk factors or social determinants of health? ( Yes ( No, but in planning stages to collect this information ( No, not planning to collect this information If yes, what type of tool does your practice use? Accountable Health Communities Screening Tools  HYPERLINK "https://innovation.cms.gov/Files/worksheets/ahcm-screeningtool.pdf" https://innovation.cms.gov/Files/worksheets/ahcm-screeningtool.pdf Upstream Risks Screening Tool and Guide  HYPERLINK "https://www.aamc.org/system/files/c/2/442878-chahandout1.pdf" https://www.aamc.org/system/files/c/2/442878-chahandout1.pdf IHELLP (Income, Housing, Education, Legal Status, Literacy, and Personal Safety)  HYPERLINK "https://www.aap.org/en-us/Documents/IHELLPPocketCard.pdf" https://www.aap.org/en-us/Documents/IHELLPPocketCard.pdf Recommend Social and Behavioral Domains for EHRs Health Leads USA recommended screening tool  HYPERLINK "https://healthleadsusa.org/wp-content/uploads/2016/07/Health-Leads-Screening-Toolkit-July-2016.pdf" https://healthleadsusa.org/wp-content/uploads/2016/07/Health-Leads-Screening-Toolkit-July-2016.pdf PRAPARE (Protocol for Responding to and Assessing Patients Assets, Risks and Experiences)  HYPERLINK "http://www.nachc.org/research-and-data/prapare/" http://www.nachc.org/research-and-data/prapare/ WE-CARE Survey (Well-child care visit, Evaluation, Community resources, Advocacy, Referral, Education)  HYPERLINK "https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/Screening-Tools.aspx" https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/Screening-Tools.aspx WellRx Health Leads Screening Toolkit NC DHHS Screening Questions THRIVE (Tool for Health and Resilience In Vulnerable Environments)  HYPERLINK "https://www.preventioninstitute.org/tools/thrive-tool-health-resilience-vulnerable-environments" https://www.preventioninstitute.org/tools/thrive-tool-health-resilience-vulnerable-environments Hunger VitalSign  HYPERLINK "http://academicdepartments.musc.edu/ohp/SFSP/FINAL-Hunger-Vital-Sign-2-pager1.pdf" http://academicdepartments.musc.edu/ohp/SFSP/FINAL-Hunger-Vital-Sign-2-pager1.pdf iScreen Social Screening Questionnaire  HYPERLINK "http://pediatrics.aappublications.org/content/pediatrics/suppl/2014/10/29/peds.2014-1439.DCSupplemental/peds.2014-1439SupplementaryData.pdf" http://pediatrics.aappublications.org/content/pediatrics/suppl/2014/10/29/peds.2014-1439.DCSupplemental/peds.2014-1439SupplementaryData.pdf  HYPERLINK "http://pediatrics.aappublications.org/content/134/6/e1611" http://pediatrics.aappublications.org/content/134/6/e1611 The EveryONE Project (by the American Academy of Family Physicians AAFP)  HYPERLINK "https://www.aafp.org/dam/AAFP/documents/patient_care/everyone_project/sdoh-guide.pdf" https://www.aafp.org/dam/AAFP/documents/patient_care/everyone_project/sdoh-guide.pdf Other, please describe: _______________________ We do not use a standardized assessment Please list any additional funding received from Office of Rural Health (if applicable). Community Health Grant: Amount: _____________ Medication Assistance Plan: ________________ Medical Access Plan (MAP) Funding: Amount: _______________ North Carolina Farmworker: Amount: ___________________ None FY 2021 Community Health Grants Application Grant Narrative Overview of Organization ____________ _________ 10 Points Provide a brief description of your organization (750-character limit; character limit is inclusive of space and punctuation) What have you achieved in the past year to advance your mission and improve your organizations capacity? (750-character limit; character limit is inclusive of space and punctuation) Do you provide comprehensive primary care services (e.g., preventive, primary, and/or acute) at your location? q Yes q No If yes, approximately how many hours per week do you offer these services? o 1-10 hours/week o 11-20 hours/week o 21-30 hours/week o 31-40 hours/week o 41-50 hours/week o >50 hours/week Describe how your organization serves as a medical home. A medical home can include school-based health centers, public health departments that provide maternal and child health, as well as free and charitable clinics that provide primary and preventive care. PCMH is encouraged, but not required. (500-character limit) Do you provide prenatal care and/or delivery services? q Yes q No If yes, approximately how many hours per week do you offer these services? o 1-10 hours/week o 11-20 hours/week o 21-30 hours/week o 31-40 hours/week o 41-50 hours/week o >50 hours/week Do you provide dental services? q Yes q No If yes, approximately how many hours per week do you offer these services? o 1-10 hours/week o 11-20 hours/week o 21-30 hours/week o 31-40 hours/week o 41-50 hours/week o >50 hours/week Do you provide behavioral health services (e.g., mental health or substance abuse services)? q No Yes. Comprehensive services q Yes. Limited, such as screening, brief intervention, and referral into treatment If yes, approximately how many hours per week do you offer these services? o 1-10 hours/week o 11-20 hours/week o 21-30 hours/week o 31-40 hours/week o 41-50 hours/week o >50 hours/week Do you provide specialty services (e.g., endocrinology, gastroenterology, neurology, or cardiology)? q Yes q No If yes, approximately how many hours per week do you offer these services? o 1-10 hours/week o 11-20 hours/week o 21-30 hours/week o 31-40 hours/week o 41-50 hours/week o >50 hours/week Does your clinic provide well woman care? q Yes q No If yes, approximately how many hours per week do you offer these services? o 1-10 hours/week o 11-20 hours/week o 21-30 hours/week o 31-40 hours/week o 41-50 hours/week o >50 hours/week Does your clinic provide primary care for children? q Yes q No If yes, approximately how many hours per week do you offer these services? o 1-10 hours/week o 11-20 hours/week o 21-30 hours/week o 31-40 hours/week o 41-50 hours/week o >50 hours/week Does your clinic have the capacity to accept new patients? q Yes q No If no, is there a waiting list? _________________ What is the average length of time for a new patient to be seen by a provider? __________ Is your organization currently connected to NC HealthConnex (formerly the NC Health Information Exchange)? Which Electronic Health Record software do you use to connect? Community Need_______________________________________________________________ 20 Points Describe the population served by this grant proposal (8,000-character limit, inclusive of spaces and punctuation). Why are grant funds needed? Include the populations healthcare needs, service area needs, information on the incidence of poverty in the targeted community, and other pertinent demographic data that support the necessity for grant funding and how these funds will directly meet the needs of the community. Will this grant align with the Community Needs Assessment? Provide citations/reference sources for all community demographics and health-status data. Please refrain from using bullets or tables in your essay. Project Description and Improved Access to Care____________________________________20 Points Describe the purpose of the grant and how funds will be used (8,000-character limit, inclusive of spaces and punctuation). Include proposed activities, timelines to implement grant activities, any project partners and their roles, and anticipated outcomes. The project description should be specific to how funds will meet the needs of the community discussed above. Please refrain from using bullets or tables in your essay. Project Evaluation and Return on Investment _ 30 Points Describe the process you will use to evaluate how the proposed use of funds affects the population and/or community need (8,000-character limit, including spaces). How will you evaluate your organizations influence on access to high-quality healthcare? Discuss potential factors that could negatively affect your organizations ability to reach your performance measure targets and describe how these factors might be mitigated. Explain why the proposed funding is a good use of State funds. Describe how you will use the mandatory performance measures to evaluate access to care and improvement of patient health outcomes. Please refrain from using bullets or tables in your essay. Collaboration ________________ __ 20 points The Department and ORH work to advance the health, safety and well-being of all North Carolinians in collaboration with a wide array of partners and stakeholders. Toward this goal, ORH encourages collaboration among community partners in integrating physical health and behavioral health services, increasing community awareness and prevention of drug overdose and death, and the importance of healthy children and families. Examples of collaboration (includes grants that are currently funded): Integrated physical health and behavioral health, such as medication assisted therapy for addiction patients; Integrated preventive oral health care for children; community family wellness programs in a primary care practice. Do you currently collaborate with partners in your community to improve health? (Yes or No). Partners can include safety net providers, primary care providers, allied health organizations, or agencies that address social determinants (transportation, food insecurity, personal safety and housing). R If yes then, How will these funds help in your collaborations (8,000-character limit, including spaces)? Describe, using a specific example, how your organization has built collaborative partnerships with other safety net organizations in your community. The example should include: 1) the names of each partner organization; 2) the purpose of the collaboration; 3) the outcome of the collaboration Make sure to document the collaborative roles among the safety net organizations in your example, specifying the distinct function of each organization and the designated fiscal contribution. Describe any unique or innovative community partnerships. Detail any barriers to collaboration. R If no then, What plans do you have to develop partnerships to address community health needs (8,000-character limit including spaces)? Include proposed partners, the purpose of the collaboration, and anticipated outcomes of the partnership. Note any barriers to collaborating with community partners and potential ways to address those barriers. Please refrain from using bullets or tables in your essay. Budget ____________________________________________________________________Required_ Track A: For encounter-based reimbursement: This is the only Budget requirement for Track A Complete the following statement: Number of encounters x $100 per encounter = $ [Total Amount of Grant Award] NOTE - Per the Free Clinics Federal Tort Claims Act (FTCA) Program Policy Guide, grant funding that applies to reimbursement, payment, or compensation for the delivery of health services to patients falls within the statutory prohibition, while grant funding that is not intended for or applied to this purpose does not. Free clinics who are FTCA recipients that choose a per encounter reimbursement methodology may void their FTCA liability protection. Budget ____________________________________________________________________Required_ Track B: Reimbursement for eligible expenses. Complete Budget Template attached. Line Item Budget and Budget Narrative General Instructions for Budget and Budget Narrative: Budget narratives must show calculations for all budget line items and must clearly justify/explain the need for these items. Calculations should be easy to follow/recreate. Each budgeted line item should explain: What is it? How many? How much? For what purpose? Do not add new line items to the budget. All budget expenses must fit into one of the line items listed in the budget template. Please use the guidelines below to place your project expense in the proper budget category. Project ExpensesDescriptionStaffingEmployee SalaryInclude separate descriptions of each position, including position title, name of staff person, position duties relative to project activities, & part/full-time status. Include the total annual salary for each staff person in the project. List only staff members that will work on project activities. Only include hours worked (regular and overtime). Do not include bonuses of any kind. Employee Fringe BenefitsInclude the employer part of health, dental & vision insurance, FICA (Social Security & Medicare tax) and 401k employer match. Indicate cost per category per staff person. Fringe shall not exceed 30% of total line item for salary allocated to the grant. Contracted StaffTemporary workers or subcontractor staff. Include hours to be worked and hourly rate.Facility ExpensesRentOffice space, program meeting spaceRented EquipmentRented or leased equipment, such as copier machine or phone systemUtilities (If not included in the rent)Gas/Electric/Water monthly expensesTelephone/InternetMonthly phone and/or internetSecuritySecurity services in the form of personnel such as security guard, retained by the Contractor. (Purchase of a security system belongs under Equipment Other).Repair and MaintenanceCustodial services or basic repair/maintenance not billed in the Professional Service Area line itemGeneral Supplies (Not Capital Equipment):Office SuppliesBusiness cards, printer ink, paper, etc.Medical SuppliesList out individual suppliesPatient Education MaterialsTraining manuals, handouts, one-pagers, information cards. List out specific materials.Postage and DeliveryOther Operating Expenses (Not Capital Equipment)TravelInclude purpose of travel (e.g. travel to visit patients, travel to conferences). Note that reimbursement should not exceed current State rates as defined by the NC Office of State Budget and Management.Staff DevelopmentConferences and conference registration, trainingsMarketing/Community AwarenessAdvertising, publications, PSAs, websites, and web materials. Marketing expenses shall not exceed 10% of the grant totalProfessional ServicesLegal services, IT related technical services, accounting, bookkeeping, payrollCapital EquipmentAny item purchased outright exceeding $500.00 is considered capital equipment and will be deducted from Year 2 and 3 grant award amounts  Evaluation Criteria Complete the mandatory performance measures required for all applicants. These measures will be reported monthly, quarterly, or biannually as indicated. Our performance measures are based off the measures in the Uniform Data System, a standardized reporting system that federally qualified health centers use to submit data. There have been some proposed changes for the 2020 year, however, the official manual has not been released. We do not anticipate the measures changing the outcomes they are requesting, the potential changes will only impact the way data is reported/requested. For each measure, you will need to include the following information: Data Source: where will you obtain the information you report for your performance measures? Collection Process and Calculation: what method will you use to collect the information? Collection Frequency: how often will you collect the information? Data Limitations: what may prevent you from obtaining data for your performance measures? Evaluation Criteria Evaluation Criteria for Primary and Preventive CareBaseline Values/Measures as of 07/01/2020Target to Be Reached by 06/30/2021This is a projected value This is a projected target REQUIRED: Output Measure Number of unduplicated patients served (Note: If you are utilizing grant funds for Dental and another service (General Care, Maternal, School Based) you will need to report patients served based on Dental only patients.)Measure TypeOutcomeData SourceCollection Process and CalculationCollection FrequencyBiannually (at six and 12 months)Data Limitations Community Health Grants: General Care Applicants Controlling High Blood Pressure: Percentage of patients 18-85 years old who had a diagnosis of Hypertension (overlapping the reporting period) and whose most recent Blood Pressure was adequately controlled (less than 140/90 mm Hg) during the reporting period. Note that this is a positive measure. For this measure, the higher the number of patients with controlled hypertension the better the performance on the measure. Source: HRSA Uniform Data System (UDS) 2019 p. 99; CMS eMeasure ID: CMS165v8; National Quality Forum#: eCQI indicates N/A (formerly 0018) This measure is calculated using the numerator and denominator defined below. Measure (Denominator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Patients 18-85 years of age who had a visit and diagnosis of essential hypertension (overlapping the reporting period)  Patients Excluded Patients with evidence of end-stage renal disease (ESRD), dialysis, or renal transplant before or during the contract period, patients with a diagnosis of pregnancy, patients in hospice care, patients 66 years of age and older who are living long term in an institutionfor more than 90 days during contract period and patients 66 years of age and older with advanced illness and frailty.Measure TypeOutcomeData SourceCollection Process and CalculationCollection FrequencyBiannually (at six and 12 months)Data Limitations Measure (Numerator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Patients 18-85 years old who had a diagnosis of hypertension and whose blood pressure at the most recent visit is adequately controlled during the reporting period. Adequate control is defined as systolic blood pressure lower than 140 mm Hg and diastolic blood pressure lower than 90 mm Hg. (Patients who have not had their blood pressure tested during the reporting period are not counted in the numerator.)  Measure TypeOutcomeData SourceCollection Process and CalculationCollection FrequencyBiannually (at six and 12 months)Data Limitations Community Health Grants: General Care Applicants Diabetes: Hemoglobin A1c Poor Control: Percentage of patients 18-75 years of age with diabetes who had hemoglobin HbA1c greater than 9.0 percent during the reporting period (or who had no test conducted during the reporting period). Note that this is a negative measure. For this measure, the lower the number of adult diabetics with poorly controlled diabetes, the better the performance on the measure. Also note that unlike the Hypertension measure, this measure calls for reporting on patients with diabetes regardless of when they were first diagnosed. Source: HRSA Uniform Data System (UDS) 2019 p.100; CMS eMeasure ID: CMS122v8; National Quality Forum#: eCQI indicates N/A (formerly 0059) This measure is calculated using the numerator and denominator defined below. Measure (Denominator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Patients 18-75 years of age with a medical visit during the reporting period who have a diagnosis of Type 1 or Type 2 diabetes. It does not matter if diabetes was treated, or is currently being treated, or when the diagnosis was made. The notation of diabetes may appear during or prior to the reporting period.  Patients Excluded Patients with Gestational diabetes, steriod-induced diabetes, diagnosis of secondary diabetes due to another condition, hospice care overlaps reporting period, patients 66 and older who are living long term in an institution for more than 90 days, patients 66 and older with advance illness and fraility because it is unlikley patients will benefit from the services being measured. Measure TypeOutcomeData SourceCollection Process and CalculationCollection FrequencyBiannually (at six and 12 months)Data LimitationsMeasure (Numerator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Patients 18-75 with a diagnosis of Type 1 and Type 2 diabetes (who meet the population above) who met one of the following criteria their most recent hemoglobin A1c level during the reporting period is greater than 9.0 percent OR they had no test conducted during the reporting period OR their test result is missing   Measure TypeOutcomeData SourceCollection Process and CalculationCollection FrequencyQuarterlyData LimitationsCommunity Health Grants: General Care Applicants Body Mass Index Screening and Follow -Up: Percentage of patients aged 18 years and older with a visit during the reporting period with a documented BMI during the most recent visit or within the previous twelve months AND with a BMI outside of normal parameters*, a follow-up plan is documented during the visit or during the previous twelve months of the current visit. * Normal parameters: Age 18 years and older BMI greater than or equal to 18.5 and less than 25 kg/m2 Note that this is a positive measure. For this measure, the higher the number of patients with a screening the better the performance on the measure. Source: HRSA Uniform Data System (UDS) 2019 p. 82; CMS eMeasure ID: CMS69v7; National Quality Forum#: 0421e This measure is calculated using the numerator and denominator defined below. Measure (Denominator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Patients who are 18 years of age or older with a medical visit during the reporting period   ExclusionsPatients who are pregnant, visits where the patient is receiving palliative care, refuses measurement of height and/or weight, is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patients health status.Measure TypeQuality / ProcessData SourceCollection Process and CalculationCollection FrequencyBiannually (at six and 12 months)Data Limitations Measure (Numerator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Patients (who meet the population above) with a documented BMI (not just height and weight) during their most recent visit or during the previous twelve months of the most recent visit, AND meet one of the following criteria: when the BMI is outside of normal parameters, a follow-up plan is documented during the visit or during the previous twelve months of the current visit OR the documented BMI is within normal parameters Normal Parameters: Age 18-64 years and BMI was greater than or equal to 18.5 and less than 25 Age 65 years and older and BMI was greater than or equal to 23 and less than 30  Measure TypeQuality (Process)Data SourceCollection Process and CalculationCollection FrequencyBiannually (at six and 12 months)Data Limitations Community Health Grants: General Care Applicants Tobacco Use and Screening: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND if identified as a tobacco user, received cessation counseling intervention Note that this is a positive measure. For this measure, the higher the number of patients with a screening the better the performance on the measure. This measure is meant to capture patients who are screened for tobacco use and offered cessation intervention if they are a tobacco user. A tobacco user who is screened and not offered cessation intervention would be included in the denominator but not included in the numerator. Source: HRSA Uniform Data System (UDS) 2019 p. 83; CMS eMeasure ID: CMS138v8; National Quality Forum#: 0028e This measure is calculated using the numerator and denominator defined below. Measure (Denominator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the reporting period  ExclusionsDocumentation of medical reasons for not screening for tobacco use (e.g., limited life expectancy, other medical reason)Measure TypeQuality (Process)Data SourceCollection Process and CalculationCollection FrequencyBiannually (at six and 12 months)Data Limitations Measure (Numerator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Patients (who meet the population above) who were screened for tobacco at least once in the last 24 months AND meet one of the following criteria: was identified as a tobacco user and received documented tobacco cessation intervention OR Not a tobacco user (Note that this measure is meant to capture patients who are screened for tobacco use and offered cessation intervention if they are a tobacco user. A tobacco user who is screened and not offered cessation intervention would not be included.)  Measure TypeQuality / ProcessData SourceCollection Process and CalculationCollection FrequencyBiannually (at six and 12 months)Data LimitationsSchool Based Health Center Applicants Weight Assessment and Counseling for Nutrition and Physical Activity: Percentage of patients 3 -18* years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period: height, weight, and body mass index (BMI) percentile documentation and counseling for nutrition and counseling for physical activity during the reporting period. Note that this is a positive measure. For this measure, the higher the number of patients with a screening the better the performance on the measure. Source: HRSA Uniform Data System (UDS) 2019 p. 81; CMS eMeasure ID: CMS155v8; National Quality Forum N/A (formerly #0024) *Note that the age cut-off used differs from the age cut-off used in the sources listed above. HRSA, CMS, and NQF use age 17 while ORH extends the age cut-off to 18 to allow for inclusion of 18 year old high school seniors. This measure is calculated using the numerator and denominator defined below. Measure (Denominator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Patients 3-18 years of age with at least one outpatient visit with a primary care physician (PCP) or an obstetrician/gynecologist (OB/GYN) during the reporting period  ExclusionsPatients who have a diagnosis of pregnancy or patients whose hospice care overlaps the reporting periodMeasure TypeQuality (Process)Data SourceCollection Process and CalculationCollection FrequencyBiannually (at six and 12 months) Data Limitations Measure (Numerator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Patients who had their BMI percentile (not just BMI or height and weight) documented during the reporting period AND who had documentation of counseling for nutrition AND who had documentation of counseling for physical activity during the reporting period. (Visit must be performed by a PCP or OB/GYN)   Measure TypeQuality (Process)Data SourceCollection Process and CalculationCollection FrequencyBiannually (at six and 12 months) Data Limitations School Based Health Center Applicants Tobacco Use and Help with Quitting Among Adolescents: Percentage of adolescents 12-20 years of age during the measurement year for whom tobacco use status was documented and, if identified as a tobacco user, received help with quitting. Note that this is a positive measure. For this measure, the higher the number of patients with a screening the better the performance on the measure. This measure is meant to capture adolescent patients who are screened for tobacco use and offered cessation intervention if they are a tobacco user. A tobacco user who is screened and not offered cessation counseling would be included in the denominator but not included in the numerator Source: National Quality Forum #2803 This measure is calculated using the numerator and denominator defined below. Measure (Denominator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Patients, age 12 -20 years, with a medical visit during the reporting period   Measure TypeQualityData SourceCollection Process and CalculationCollection FrequencyBiannually (at six and 12 months) Data LimitationsMeasure (Numerator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Patients age 12-20 years (who meet the population above) who meet one of the following criteria: Tobacco use status was documented and patient was not a tobacco user OR Tobacco use status was documented and patient was identified as a tobacco user and patient received cessation counseling* *Include those adolescents who use tobacco and are offered help with quitting but who refuse to accept help.   Data SourceCollection Process and CalculationCollection FrequencyBiannually (at six and 12 months) Data LimitationsSchool Based Health Center Applicants Screening for Clinical Depression and Follow Up Plan: Percentage of patients aged 12 years and older screened for clinical depression on the date of the visit or 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND, if screening is positive, for whom a follow-up plan is documented on the date of the positive screen. Note that this is a positive measure. For this measure, the higher the number of patients with a screening the better the performance on the measure. Source: HRSA Uniform Data System (UDS) 2019 p. 89; CMS eMeasure ID: CMS2v9; National Quality Forum #0418e This measure is calculated using the numerator and denominator defined below. Measure (Denominator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Patients 12 years and older with at least one medical visit in the reporting period.   ExclusionsPatients with an active diagnosis for depression or a diagnosis of bipolar disorder. Patient refuses to participate. Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient's health status. Situations where the patient's cognitive capacity, functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools. For example: certain court appointed cases or cases of delirium Note: Patients who are already participating in ongoing treatment for depression will not be included in the universe count. Measure TypeQualityData SourceCollection Process and CalculationCollection FrequencyBiannually (at six and 12 months) Data Limitations Measure (Numerator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Patients screened for clinical depression (who meet the population above) on the date of the visit or 14 days prior to the date of the encounter using an age-appropriate standardized tool AND meet one of the following criteria: Screened for depression and found to be negative for clinical depression OR Screened for clinical depression and found to be positive for clinical depression and a follow-up plan is documented on the date of the positive screen   Data SourceCollection Process and CalculationCollection FrequencyBiannually (at six and 12 months) Data Limitations Dental Clinic Applicants Primary Car)789:;c{{odoodXLX@4hh&h@65CJaJhG'Ohf5CJaJhG'Oh+)=5CJaJhG'Oh5CJaJhOP(h$CCJaJhOP(h$C5CJaJh$Ch$CCJOJQJ^J%jh$Ch$CCJOJQJU^J 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$$Ifa$gd'#(>A_bt#(t#(abcptwxy #(-.FPQRtw|hh36 h35hh35h3 h]h3 hh3hh3CJaJQab^UUUUU $Ifgd'kd$$IflF*m t0*6    44 laqpyt'bcpxvmm $Ifgd'kdQ$$Ifl0* t0*644 laqpyt'xyvmm $Ifgd'kd$$Ifl^0* t0*644 laqpyt'vmm $Ifgd'kd$$Ifl^0* t0*644 laqpyt'vmmm $Ifgd'kd:$$Ifl0* t0*644 laqpyt'vmm $Ifgd'kd݋$$Ifl0* t0*644 laqpyt'.Qvqqh\\ $$Ifa$gd' $Ifgd'gd3kd$$Ifl0* t0*644 laqpyt'QR6^U@3@ J$If^Jgd' & FJ$If^J`gd' $Ifgd'kd#$$IflF.*j\ t0*6    44 laqpyt'!#(6t !#(+,-.QRShtLTLULVLZLnLh$$h3CJaJh$$h3CJ\aJUh$$h35CJ\aJhh35CJaJhh3CJaJhh37hh35h3 hh3A ,>kdލ$$IflF.*j\ t0*6    44 laqpyt' $Ifgd' $$Ifa$gd' J$If^Jgd',-.QRmkd$$Ifl-0* t0*644 laqpyt' $Ifgd'RShvmmm $Ifgd'kd8$$Ifl0* t0*644 laqpyt'xoo $Ifgd'kdۏ$$Ifl0* t0*644 laqpyt'xoo $Ifgd'kdz$$Ifl0* t0*644 laqpyt'LLMMvqqqqqqqqqqqgd3kd$$Ifl0* t0*644 laqpyt' ies Prevention Intervention as Offered by Primary Care Providers, Including Dentists:Percentage of children, age 0-20 years, who received a fluoride varnish application during the reporting period. Note: Fluoride varnish can be offered by primary care providers, including dentists Source: HRSA Uniform Data System (UDS) 2020 p.TBD; CMS eMeasure ID: CMS74v90; National Quality Forum N/A; This measure is calculated using the numerator and denominator defined below. Measure (Denominator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Number of children, age 0-20 years old, who had a visit during the reporting period.   ExclusionsPatients whose hospice care overlaps the reporting periodMeasure TypeQuality / ProcessData SourceCollection Process and CalculationCollection FrequencyQuarterlyData Limitations Measure (Numerator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Children (who meet the population above) who received a fluoride varnish application during the reporting period.   ExclusionsChildren for whom all first permanent molars are non-sealable (i.e., molars are either decayed, filled, currently sealed or unerupted/missing)Measure TypeQuality / ProcessData SourceCollection Process and CalculationCollection FrequencyQuarterlyData Limitations Maternal Care Applicants Access to Prenatal Care: First Prenatal Visit in 1st Trimester: Percentage of prenatal care patients who entered prenatal care during their first trimester. Note that prenatal care is considered to have begun at the time the patient had her first visit with a physician or NP, PA, or CNM provider who inititates prenatal care with a complete prenatal exam. (Most women will have one or more interactions with the health center prior to that for their pregnancy test, other lab tests, dispensing vitamins, and/or taking a health history. These interactions do not count as the start of prenatal care.) Also note that in those rare instance where a woman receives prenatal care services for two separate pregnancies in the same reporting period, she is to be counted twice. Source: HRSA Uniform Data System (UDS) 2019 p. 76 This measure is calculated using the numerator and denominator defined below. Measure (Denominator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Total number of women (of any age) seen for prenatal care during the reporting period.  Measure TypeQuality (Process)Data SourceCollection Process and CalculationCollection FrequencyQuarterlyData Limitations Measure (Numerator)Baseline Value as of 07/01/2020Target to be reached by 06/30/2021Number of women beginning prenatal care at the health center, including referral provider or with another health center, during their first trimester.  Measure TypeQuality (Process)Data SourceCollection Process and CalculationCollection FrequencyQuarterlyData Limitations Appendix A: Table for proper conversion of hours to Full Time Equivalent (FTE) # of FTEsConversion Logic when staff sustained from grant >1.00 FTE Add 1.00 to fraction of part time. Example: if there is a part time staff working 10 hours a week in addition to one full time, that converts to 1.00+.25=1.25 FTE Hint: for staff working odd number of hours (e.g., 3 hours per week) round up to next level or, in this case, to 4 hours=.10FTE. 2 hours/week.05 FTE4 hours/week.10 FTE6 hours/week.15 FTE8 hours/week.20 FTE10 hours/week.25 FTE12 weeks/week.30 FTE14 hours/week.35 FTE16 hours/week.40 FTE18 hours/week.45 FTE20 hours/week.50 FTE22 weeks/week.55 FTE24 hours/week.60 FTE26 hours/week.65 FTE28 hours/week.70 FTE30 hours/week.75 FTE32 hours/week.80 FTE34 hours/week.85 FTE36 hours/week.90 FTE38 hours/week.95 FTE40 hours/week1.00 FTE     Office of Rural Health SFY 2020 Community Health Grant Program  PAGE \* MERGEFORMAT 6 Office of Rural Health SFY 2020 Community Health Grant Program  PAGE \* MERGEFORMAT 21 Summary of Request Provide a brief, one to two sentences, description of your request. 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