Minnesota Department of Health. Request for Proposals

Transcription

1 Minnesota Department of Health Request for Proposals Health Care Homes: Community Care Team Grants June 1, 2011 June 30, 2012 Published: April 15, 2011 Due Date: May 16,

2 Topics/Sections Health Care Homes: Community Care Team Table of Contents Page Introduction 3 Background Information about Health Care Homes and Community Care Teams 3 Program Goals: Health Care Homes Community Care Teams 4 Eligibility Requirements to Apply 4 Duration of Funding 4 Available Funding 4 Questions 4 Funding Restrictions 5 Application Requirements 5 Review Process 6 Evaluation Requirements 6 Grant Application and Program Summary 8 Project Narrative Instructions 9 Proposal Evaluation 12 Required Forms Page Form A: Application Face Sheet with Instructions 14 Form B: Project Implementation Plan 16 Form C: Budget Justification Sheet with instructions 18 Form D: Budget Summary Sheet 20 Form E: Accounting System and Financial Capability Questionnaire (If applicable) 21 Appendices Appendix A: Minnesota Statute 256B Appendix B: Minnesota Rules Health Care Home Rules 26 Appendix C: Sample MN Department of Health Grant Agreement 56 Page 2

3 Health Care Homes: Community Care Team Grant Introduction This document provides the forms and instruction you will need to complete the Health Care Homes: Community Care Teams Grant application. It is suggested that you review this document completely before you begin to write your application, including the Criteria for Grant Review provided at the end of each grant component: Applicant Experience and Capacity; Project Plan; and Budget. You will find copies of the HCH statute (M.S.456B.0751) and rule ( ) included in the Appendices. Other materials to assist you in completing this application are available on the HCH website - including answers to Frequently Asked Questions about this grant. The Minnesota Department of Health will provide consultation and guidance during the application process. For any questions related to this RFP, or for assistance please contact Marie Maes-Voreis Marie.maes-voreis@state.mn.us or by phone at or TTY line: (MDH s main phone line). MDH will host one optional conference call to answer questions: Thursday, April 21, 2011, 1:00-2:00 p.m. More details on this conference call are posted on the HCH website noted above. Questions and responses from the conference will be posted on the website noted above. Background Information about Health Care Homes and Community Care Teams A "health care home," also called a "medical home," is an approach to primary care in which primary care providers, families and patients work in partnership to improve health outcomes and quality of life for individuals with chronic health conditions and disabilities. The development of health care homes in Minnesota is part of the ground-breaking health reform legislation passed in May The legislation includes payment to primary care providers for partnering with patients and families to provide coordinated care and services. In order to qualify for reimbursement for care coordination activities primary care providers and clinics are required to meet a set of standards around access and communication, population-based registries, care coordination, care planning, and quality improvement. One of the primary principles of health care homes is the delivery of patient and family centered care. Care that is patient centered is holistic; recognizing that a person s health is determined by physical, psychosocial, and environmental factors. In alignment with patient and family centered care HCH recertification standard Subj. 6 B requires primary care practices to identify and work with community-based organizations and public health resources such as disability and aging services, social services, transportation services, school-based services, and home health care services to facilitate the availability of appropriate resources for participants. The intent of the rule is that certified HCH providers and clinics take a proactive approach to planning and partnering with community resources to ensure that their patients have access to needed resources and services. 3

4 Providing the level of care required by the state s HCH certification standards can be more challenging for small to medium sized rural clinics and those serving low income populations such as the safety net clinics. Shared support networks such as community care teams are one way smaller practices can pool their resources to partner with community agencies to support healthy management of a community population. The foundation of the Community Care Team is patient and family centered care that meets patients and family s needs by coordinating seamlessly with a broad range of health and community service providers. The Community Care Team is a multidisciplinary team that partners with primary care offices (certified health care homes), the hospital, and existing health and social service organizations. The goal is to provide citizens with the support they need for well-coordinated preventive health services and coordinated linkages to available social and economic support services. The Community Care Team is flexible in terms of staffing, design, scheduling and site of operation, resulting in a cost-effective, core community resource which minimizes barriers and provides the individualized support that patients need in their efforts to live as fully and productively as possible. Community care teams have been utilized effectively in other states to extend the work of primary care practices. North Carolina utilizes a community team model called Community Care Networks to bring together physicians, hospitals, social service agencies, county public health departments, and other key community leaders to increase access to health and community services with the overarching goal of improving population health. In Vermont community health teams are established in hospital service areas among NCQA certified medical homes. Services offered by community health teams include individual care coordination, health and wellness coaching, behavioral counseling, improved access and communication, and assistance in connecting patients to social and economic support services. Program Goals: HCH Community Care Team The goal is to design, document, and implement a Community Care Team that addresses community priorities, care coordination, transitions management, effective use of resources, and engages in collaborative activities with certified health care homes. The Community Care Team will work together to provide outcomes oriented care such that services will be guided by the principle of optimizing clinical outcomes for community members to meet the goals of the Institute for Health Improvement s triple aim: improved health outcomes, enhanced patient experience, and reduced costs / improved value. Eligibility Requirements to Apply Eligible applicants include community-based nonprofit and for-profit organizations and government entities or Tribal Government, clinics and hospitals, community health or public health organization and institutes of higher education. Duration of Funding MDH anticipates that it will enter into a grant agreement (i.e. contract) with the grantee from the period of June 1, 2011 through June 30, The funding is for 13 months. Available Funding The MDH expects to award 3-4 grants of $100,000-$150,000 per contract. 4

5 Funding Restrictions Grant funds may be used to cover costs of personnel, consultants, supplies, grant-related travel, and other grant-related costs. Grant funds may not be used for direct clinical services or clinic operations, building alterations or renovations, construction, fund raising activities, political education or lobbying. There is no requirement for matching funds. Application Requirements Applications must be written in at least 12-point font with one-inch margins with a maximum of 15 pages. All pages must be numbered consecutively. One signed unbound original and 3 unbound copies of the complete application must be submitted. Applications must meet application deadline requirements. Late applications will not be reviewed. Applications must be complete and signed where noted. Faxed or ed applications will not be accepted. Incomplete applications will not be considered for review. The deadline for submission of proposals is May 16, To meet the deadline, proposals must: 1. Be hand delivered to the address below before 4:00 p.m., May 16, 2011; or 2. Arrive by mail, Fed Ex, or courier by 4:00 p.m., May 16, The complete application (one original unbound and three (3) unbound copies) should be sent to: Street Address (hand or courier delivery) US Postal Service Mailing Address Jan Jernell Minnesota Department of Health Community and Family Health Division Golden Rule Building 85 East Seventh Place, Suite 220 St. Paul, MN *Hand delivered proposals must be dropped off at the 2 nd floor reception desk of the Golden Rule Building Suite 220 Jan Jernell Minnesota Department of Health Community and Family Health Division P.O. Box St. Paul, MN Late applications, applications lost in transit by courier, faxed or ed applications will not be considered for review. Sending in a HCH: Community Care Team Grant application does not guarantee funding. Applications must meet all requirements listed in this packet, organizations must meet all eligibility requirements, and proposals must meet the criteria and requirements listed in this application. 5

6 Review Process Only complete applications, that meet the eligibility and application requirements, received on or before May 16, 2011 will be reviewed by a grant review committee according to the Criteria for Grant Review provided at the end of each component (Applicant Experience and Capacity; Project Plan; and Budget) as noted in the following pages. Reviewers will determine which applications best meet the criteria as outlined and should be recommended for funding. We anticipate that grant award decisions will be made by May 28, Applicants will be notified by letter whether or not their grant proposal was funded. MDH reserves the right to negotiate changes to budgets submitted. Grant agreements will be entered into with those organizations that are awarded grant funds. The anticipated effective date of the agreement is June 1, 2011, or the date, upon which all signatures are obtained prior to June 30, Grant agreements need to be fully executed by June 30, 2011 for funding to be available. Grant agreements will end on June 30, No work on grant activities can begin until a fully executed grant agreement is in place. Evaluation Requirements The evaluation of this program is a collaborative effort between MDH and the grantees. Below is an outline of MDH and grantee duties. The grantee will be required to report on a quarterly basis to MDH, in a format provided by MDH, including information on fiscal and programmatic performance and status. Evaluation responsibilities are outlined below. MDH will: Hold regular conference calls or meetings with the grantee. These calls/meetings will include monitoring of grantee activities and evaluating success towards reaching program goals. Provide grantees with technical assistance about how to conduct evaluation requirements outlined in the Project Narrative section of this RFP. Applicants/Grantees will: Participate in regular conference calls or quarterly meetings with MDH and Health Care Home Community Care Team planning staff. Participate in training activities or meetings developed for Health Care Homes or Community Care Teams. Complete status reports to MDH as agreed upon. Provide input into the development of the evaluation tools and activities. Develop a plan for process evaluation of this activity. Send one member of the community care team on a trip to Vermont to meet with the Vermont and North Carolina community care team members through a learning community sponsored by National Academy of State Health Policy (NASHP). Grantees should include $2,000 dollars for this two day trip in their overall budget. Provide a brief quarterly report of the community care team s current status, activities, learning, and challenges. Provide a final report that includes the following elements: Description of the Community Care Team s population and how community participation evolved throughout the pilot. 6

7 The Dissemination and Sustainability plans and lessons learned as described above. Summary of Community Care Team s evaluation activities. Prepare a presentation and present about this project at one meeting or conference to be determined jointly by grantee and HCH staff. 7

8 Grant Application and Program Summary Eligibility for Grant Funds Individuals, Community Based Nonprofit Organizations, Clinics or Hospitals, and Institutes of Higher Education. Total Funds Available $550,000 for the 13 month grant cycle Maximum Grant Amount Approximately 3 to 4 grant awards of $100,000 to $150,000 Duration of Funding 6/1/2011 through 6/30/2012 Grant Purpose To design, document and implement 3-4 community care teams that have the capacity to engage in collaborative activities with certified health care homes. Application Requirements Applications must be written in at least 12-point font with one-inch margins. All pages must be numbered consecutively. One signed unbound original and 3 unbound copies of the complete application must be submitted. Applications must meet application deadline requirements. Late applications will not be reviewed. Applications must be complete and signed where noted. Order for Completed Application Face Sheet (Form A) Application Submission Description of Application Experience and Capacity Project Plan Project Implementation Plan (Form B) Project Budget Budget Justification Sheet with Instruction (Form C) Administrative Cost Questionnaire (Form D) Administrative Cost Allocation Worksheet (If applicable, Form E) Budget Summary Sheet (Form F) Accounting System Financial Capability Questionnaire (If applicable, Form G) Application Deadline All applications must be received by MDH no later than 4:00 p.m. on May 16, Faxed or ed applications will not be accepted. Late applications will not be considered for review. Applications Sent Mailing Address: Jan Jernell Minnesota Department of Health Community and Family Health Division P.O. Box St. Paul, MN Delivery Address: Jan Jernell Minnesota Department of Health Community and Family Health Division Golden Rule Building 85 East Seventh Place, Suite 220 St. Paul, MN Beginning Grant Agreement Date upon which all signatures to the agreement are Date obtained or June 1, 2011, whichever is later. Statutory Authority M.S.456B.0751 (see Appendix A) 8

9 Project Narrative Instructions Following are the minimum requirements of the Proposal Narrative. Applicants should place emphasis on completeness and clarity of content. Order of documents to be submitted: 1. Description of the Applicant Experience and Capacity. Keep this section to 3 or fewer pages. This section must describe: A brief history of the entity and any notable accomplishments. A brief description of experience of the applicant entity related to health care homes, health clinics, practice transformation, and health care reform. A brief overview of the capacity of the agency and specifically how it is prepared to accomplish the grant objectives. Skill and experience of the Project s lead staff (include CVs of lead staff in an appendix). Anticipated barriers and challenges in implementing this project and potential solutions. Criteria for Grant Review: The Agency Information section of the application will be reviewed and scored according to the following criteria (20 Points): Does the description give a clear picture of the history, structure, services provided, and clientele served by the agency? Does the agency have a successful history of providing proposed services? Does the agency have the capacity (infrastructure, facilities, staffing) to develop proposed community care team services? Does the agency have experience in working with multidisciplinary teams and community collaboration? Does the agency have a current relationship with a Health Care Home? What barriers does the agency anticipate and what are the identified potential solutions? 2. Project Plan Keep this section to 12 or fewer pages. Proposals must address in sufficient detail how the applicant would fulfill the expected outcomes and features set forth below. This section should detail how the Project would be carried out in an effective and efficient manner, including who would be involved, what resources are required, target dates for Project activities, and the timeframe for completion. This section must describe: A. The proposed community to be served by the Community Care Team 1) Describe the geographic area you will serve 2) Describe your target population(s). 3) Describe how you plan to involve the target population(s) either in programplanning or implementation. 4) Describe how the target population will know about your services 9

10 5) Describe the Health Care Home certification status for primary care practices/clinicians in the community (certified, in process, or under consideration). B. Description of priority issues that you propose to target with the Community Care Team and provide a goal and objective for each priority issue. C. Rationale for why the Community Care Team is a good fit for the specific community to be served. D. Members and Partners. Letters of support from each key partner are required to be included as attachments. 1) Proposed membership and infrastructure of the Community Care Team that includes participation by community primary care providers, one certified (or soon to be certified) health care home must participate, and will include team members with expertise in coordination of chronic conditions, health maintenance, and prevention to address the health of the community. The intent is to have a flexible locally designed team approach based on the needs of your population. 2) Proposed staffing and administrative structure for Community Care Team operations. This should be based on your specific proposal and where possible should build on existing community and public infrastructure and reflect the population s needs in your community. Describe how you will use existing staff, if additional training will be sought, and if additional staff members will be hired. 3) Proposal for a local oversight structure that emphasizes improved communication between Community Care Team partners and a clear understanding of services and referral structures. The Community Care Team must include at least two consumers from the community as part of their oversight structure. 4) If other agencies will help provide services or be involved in your proposal, describe who they are and describe their roles. 5) Describe how the Community Care Team will work together to implement a transitional care approach for patients who are hospitalized. The goal is to have a structured approach that streamlines, simplifies, and optimizes the opportunity for patients to engage in effective care coordination that is supported by the Community Care Team. 6) Describe how the Community Care Team will develop an infrastructure for patient care communication. While ideally this is an electronic communication structure, for the period of the grant this may not be possible and therefore is not required. Communication structures must be in place to prevent gaps in care and improve communication for consumer patient participants. E. Goals, Objectives, and Implementation Plan 1) For each component of the project plan listed above provide at least one goal and objective. 10

11 2) Describe how you propose to meet your stated goals and objectives by providing proposed strategies related to each objective. 3) Describe the methods and criteria that will be used to measure whether the project goals and objectives have been achieved. 4) Outline the major tasks and deliverables, project milestones, and start and finish dates for key activities associated with program implementation and operation. (Implementation Plan) Required Plans. State commitment that the Community Care Team will work to develop the following plans during the grant cycle: o o Dissemination plan- description of the action steps taken to develop and implement the Community Care Team including, oversight structure, community partners, implementation planning and how the Community Care Team met its goals. This plan is to inform other communities about their lessons learned and the challenges and successes in creating a Community Care Team. Sustainability plan- development of a plan for identifying resources (including reimbursement for services provided) to support future activities of the Community Care Team after this grant has ended. Criteria for Grant Review: The Project Plan section of the application will be reviewed and scored according to the following criteria (65 points): Does the applicant clearly describe the community care team members and relationships, including patient involvement? Is there a Letter of Support from key members and/or partners? Are adequate resources allotted to provide administration? Does the applicant provide clear goals for each proposed component? Are the proposed Objectives for each component clearly described, measurable, and realistic? To what extent do the proposed indicators effectively measure the project s progress toward meeting their objectives? To what extent is the project likely to meet its objectives in the grant cycle? Overall, is the Implementation Plan sufficiently detailed, clear and easy to understand and does it demonstrate a clear relationship between the identified problem and the goals, objectives, and activities? Does the applicant provide a clear description of how they intend to serve the geographic area? Does the applicant clearly identify their target population(s) and how the Community Care Team is suited to that target population? Does the applicant clearly identify their priority issues and how the Community Care Team is suited to deal with those issues? Does the applicant clearly describe the local oversight structure? 3. Project Budget: Describe and explain the estimated costs. Identify any ancillary services to be provided that have associated costs, and the components essential to delivering quality services. Explain the proposed use of the grant funds. Include a budget narrative for each line item as noted. Be sure that the Budget Justification Sheet (Form C) provides sufficient detail to justify the total amount budgeted in each category. The program budget must be complete and reasonable, must link to the proposed program activities, and must specify how the amounts for each budget item were determined. Responders are encouraged to 11

12 apply for only the amount needed for their proposed programs. The selected applicant will not be guaranteed the entire amount requested. Budget Proposals will be judged on overall cost-effectiveness and efficient use of funds (meaning funds are being spent on direct costs versus administrative costs). Criteria for Grant Review: The Budget Summary and Budget Justification Section of the application will be reviewed and scored according to the following criteria (15 Points): PLEASE REVIEW THIS CRITERIA Are the Budget Summary Form and the Budget Justification Sheet complete? Do the amounts on Budget Summary Form match what is in the Budget Justification Sheet? Is the information contained in the Budget Justification Sheet consistent with what is proposed in the Project Narrative and Implementation Plan? Are the projected costs reasonable and sufficient to accomplish the proposed activity? Proposal Evaluation The factors and weighting for proposals are as follows: 1. Applicant Experience and Capacity 20% 2. Project Description, Implementation and Accountability Plan 65% 3. Budget, and Budget Justification 15% 12

13 Required Forms Required Forms: Form A: Application Face Sheet with Instructions Form B: Project Implementation Plan Form C: Budget Justification Sheet with Instructions Form D: Budget Summary Sheet Form E: Accounting System and Financial Capability Questionnaire (If applicable) 13

14 FORM A Application Face Sheet Health Care Homes Community Care Team Grant 1. Legal name and address of the applicant agency with which grant agreement would be executed 2. Minnesota Tax I.D. Number Federal Tax I.D. Number 3. Requested funding for the total grant period $ 4. Director of applicant agency Name, Title, and Address: Address: Telephone Number: ( ) FAX Number: ( ) 5. Fiscal management officer of applicant agency Name, Title and Address: Address: Telephone Number: ( ) FAX Number: ( ) 6. Operating agency (if different from number 1 above) Name, Title and Address: Address: Telephone Number: ( ) FAX Number: ( ) 7. Contact person for operating agency (if different from number 5 above) Name, Title and Address: Address: Telephone Number: ( ) FAX Number: ( 8. Contact person for further information on grant application Name, Title and Address: Address: Telephone Number: ( ) FAX Number: ( ) Certification I certify that the information contained herein is true and accurate to the best of my knowledge and that I submit this application on behalf of the applicant agency. Signature of Authorized Agent for Title Date Grant Agreement 14

15 (FORM A) Application Face Sheet Instructions Please type or print all items on the Application Face Sheet. 1. Applicant agency Legal name of the agency authorized to enter into a grant contract with the Minnesota Department of Health 2. Applicant agency s Minnesota and Federal Tax I.D. number 3. Requested funding for the total grant period Amount the applicant agency is requesting in grant funding for the grant period (June 1, June 30, 2012). 4. Director of the applicant agency Person responsible for directing the applicant agency. 5. Fiscal Management Officer of applicant agency The chief fiscal officer for applicant agency who would have primary responsibility for grant agreement and grant funds expenditure and reporting. 6. Operating Agency Complete only if other than the applicant agency listed in number 1 above. 7. Contact Person for Operating Agency Person who may be contacted concerning questions about implementation of this proposed program. Complete only if different from the individual listed in number Contact person for Further Information Person who may be contacted for detailed information concerning the application, or the proposed program. 9. Signature of Director of Applicant Agency Provide original signature of the Director of the applicant agency and the date of signature. 15

16 Community Care Team Implementation Plan Goal: Form B OBJECTIVES ACTIVITIES TRACKING METHODS MILESTONES/TIMELINES 16

17 Budget Summary and Justification Narratives and Forms C, D, E, Minnesota Department of Health Community Care Team Grant The Budget Section of the application is composed of a total of three (3) possible forms: i. Budget Justification Sheet (Form C) ii. Budget Summary Sheet (Form D) iii. Accounting System and Financial Capability Questionnaire (If applicable, Form E) Complete the Budget Justification Sheet (Form C) for your grant program. The grant period will be from June 1, 2011 through June 30, The Budget Justification Sheet will provide the details of your expenses and a brief description of how they support your proposed grant activity. (The full description of the purpose of each grant-funded position and the necessity of budgeted items should appear in your Project Narrative.) The Budget Summary Sheet (Form D) is where you will provide the total expenses for the proposal. The Accounting System and Financial Capability Questionnaire (Form E) is only required for non-profit, private colleges and tribal colleges to complete. If your organization is part of the MnSCU or University of MN system, it is not necessary to complete Form E. 17

18 FORM C Budget Justification Sheet Community Care Team Grant Applicant Agency: Contact Person: Phone Number: Address: Budget Period: June 1, 20 to June 30, 20 Revision # (MDH use only) Salary and Fringe Benefits: For each proposed funded position, list the title, the full time equivalent, the expected rate of pay, and the total amount you expect to pay the position. Budget Justification: REQUESTED DOLLARS Total Salary and Fringe: Contractual Services: List the services you expect to contract out, the contractor s or consultant s name, whether the contractor is non-profit or for-profit, the length of time the services will be provided and the total amount you expect to pay. Supplies and travel should be included, if applicable. Itemize equipment rented or leased for the project. Budget Justification: REQUESTED DOLLARS Travel: Total Contractual Services: Send one member of the community care team on a trip to Vermont to meet with the Vermont and North Carolina community care team members through a learning community sponsored by National Academy of State Health Policy (NASHP). Grantees should include $2,000 dollars for this two day trip in their overall budget. REQUESTED DOLLARS Explain your expected travel costs, including mileage, hotel and meals. If project staff will travel, itemize the costs, frequency and the nature of the travel. Budget Justification: Total Travel: Supplies and Expenses: Briefly explain the expected costs for items and services you will purchase to run your program. Include telephone expenses that are part of your proposal. Estimate postage if it is part of the project. List any printing and copying costs necessary for the project (other than occasional copying on an office copy machine). List office and program supplies and expendable equipment such as training materials, curriculum and software. Generally supplies include items that are consumed during the course of the project participant transportation, participant training and other direct costs as needed. REQUESTED DOLLARS 18

19 Budget Justification: Total Supplies and Expenses: Other Expenses: Briefly describe any expenses that do not fit in any other category. An example is staff training, which can be charged to the grant at a rate not to exceed $250. Budget Justification: REQUESTED DOLLARS Other Expenses Total: SUBTOTAL (Enter subtotal of expenses from all previous categories): Subtotal: Evaluation: 10% of grant expenses must be included in the budget for evaluation costs. Multiply the amount of the Subtotal by 10% and enter here. It is not necessary to include any information on evaluation procedures. Evaluation: REQUESTED DOLLARS DIRECT COST TOTAL (Subtotal + Evaluation): Direct Cost Total: Administrative Costs: Administrative costs are defined as costs that represent the expenses of doing business that are not easily identified with a particular grant, contract, project, function, or activity but are necessary for the general operation of the organization and the conduct of activities it performs. Examples of such expenses include accounting, administration, and costs to operate and maintain facilities. REQUESTED DOLLARS Administrative cost rate is GRANT FUNDS TOTAL: Administrative Total: 19

20 FORM D Budget Summary Sheet Community Care Team Grant Applicant Agency: Contact Person for further information: Phone: address: Grant Funds Requested Budget by Line Item Total Dollars Salaries and Fringe $0.00 Contractual Services $0.00 Travel Expenses $0.00 Supplies and Expenses* $0.00 Other Expenses $0.00 Sub Total 0.00 *Includes telephone, postage, print, copy, rent, and equipment under $5, % Evaluation $0.00 Direct Cost Total (Subtotal + Evaluation) $0.00 Administrative Costs (Refer to Form C) $0.00 GRANT FUNDS TOTAL $

21 FORM E (If Applicable) MDH Accounting System and Financial Capability Questionnaire* This form must be completed by applicants that are non-profit, educational institutions. However, if your institution of higher education is part of MnSCU or the University of Minnesota, it is not necessary to complete this form. No applicants will be excluded from receiving funding based solely on the answers to these questions. SECTION A: APPLICANT INFORMATION 1. Organization Name and Address 2.Employer 3.Number of Employees Identification Number Full Time: Part Time: (MM/DD/YYYY)? 5. Is the applicant affiliated with or managed by any other organizations (Ex. regional or national offices)? YES NO If Yes, provide details: 4. When did the applicant receive its 501(c)3 status? 6a. Total revenue in most recent accounting period (12 months). 5b. Does the applicant receive management or financial assistance from 6b. How many different funding sources any other organizations? YES NO If Yes, provide details: does the total revenue come from? 7. Does the applicant have written policies and procedures for the following business processes? a. Accounting Yes No Not Sure If yes please attach a copy of the table of contents b. Purchasing Yes No Not Sure If yes please attach a copy of the table of contents c. Payroll Yes No Not Sure If yes please attach a copy of the table of contents SECTION B: ACCOUNTING SYSTEM 1.Has a Federal or State Agency issued an official opinion regarding the adequacy of the applicants accounting system for the collection, identification and allocation of costs for grants Yes No Note: If a financial review occurred within the past three years, omit Questions 2 6 of this Section and 1-3 of Section C. a. If yes, provide the name and address of the reviewing agency: b. Attach a copy of the latest review and any subsequent documents. 2. Which of the following best describes the accounting system? Manual Automated Combination 3. Does the accounting system identify the deposits and expenditures of program funds for each and every grant separately? 4. If the applicant has multiple programs within a grant, does the accounting system record the expenditures for each and every program separately by budget line items? 5. Are time studies conducted for an employee(s) who receives funding from multiple sources? 6. Does the accounting system have a way to identify over spending of grant funds? SECTION C: FUND CONTROL Yes No Not Sure Yes No Not Sure Not Applicable Yes No Not Sure No Multiple Sources Yes No Not Sure 1. Is a separate bank account maintained for grant funds? Yes No Not Sure 2. If grant funds are mixed with other funds, can the grants expenses be easily identified? Yes No Not Sure 3. Are the officials of the organization bonded? Yes No Not Sure SECTION D: FINANCIAL STATEMENTS 1. Did an independent certified public accountant (CPA) ever examine the organization s financial statements? SECTION E: CERTIFICATION I certify that the above information is complete and correct to the best of my knowledge. Yes No Not Sure 1. Signature 2. Date / / 21

22 3. Title *This is the standard form to be used to determine the financial capacity of grant applicants. The creation and implementation of this form is in response to the best practices stated in the Office of Legislative Auditor s report State Grants to Nonprofit Organizations, January

23 Appendices Appendix A Minnesota Statute 256B.0751 Appendix B Minnesota Rules , Health Care Homes Rules Appendix C Sample MDH Grant Agreement 23

24 Minnesota Statute 256B Appendix A CHAPTER 358--S.F.No ARTICLE 2 HEALTH CARE HOMES Section 1. [256B.0751] HEALTH CARE HOMES. Subdivision 1. Definitions. (a) For purposes of sections 256B.0751 to 256B.0753, the following definitions apply. (b) "Commissioner" means the commissioner of human services. (c) "Commissioners" means the commissioner of humans services and the commissioner of health, acting jointly. (d) "Health plan company" has the meaning provided in section 62Q.01, subdivision 4. (e) "Personal clinician" means a physician licensed under chapter 147, a physician assistant registered and practicing under chapter 147A, or an advanced practice nurse licensed and registered to practice under chapter 148. (f) "State health care program" means the medical assistance, MinnesotaCare, and general assistance medical care programs. Subd. 2. Development and implementation of standards. (a) By July 1, 2009, the commissioners of health and human services shall develop and implement standards of Certification for health care homes for state health care programs. In developing these standards, the commissioners shall consider existing standards developed by national independent accrediting and medical home organizations. The standards developed by the commissioners must meet the following criteria: (1) emphasize, enhance, and encourage the use of primary care, and include the use of primary care physicians, advanced practice nurses, and physician assistants as personal clinicians; (2) focus on delivering high-quality, efficient, and effective health care services; (3) encourage patient-centered care, including active participation by the patient and family or a legal guardian, or a health care agent as defined in chapter 145C, as appropriate in decision making and care plan development, and providing care that is appropriate to the patient's race, ethnicity, and language; (4) provide patients with a consistent, ongoing contact with a personal clinician or team of clinical professionals to ensure continuous and appropriate care for the patient's condition; (5) ensure that health care homes develop and maintain appropriate comprehensive care plans for their patients with complex or chronic conditions, including an assessment of health risks and chronic conditions; (6) enable and encourage utilization of a range of qualified health care professionals, including dedicated care coordinators, in a manner that enables providers to practice to the fullest extent of their license; (7) focus initially on patients who have or are at risk of developing chronic health conditions; (8) incorporate measures of quality, resource use, cost of care, and patient experience; (9) ensure the use of health information technology and systematic follow-up, including the use of patient registries; and (10) encourage the use of scientifically based health care, patient decision-making aids that provide patients with information about treatment options and their associated benefits, risks, costs, and comparative outcomes, and other clinical decision support tools. (b) In developing these standards, the commissioners shall consult with national and local organizations working on health care home models, physicians, relevant state agencies, health plan companies, hospitals, other providers, patients, and patient advocates. The commissioners may satisfy this requirement by continuing the provider directed care coordination advisory committee. (c) For the purposes of developing and implementing these standards, the commissioners may use the expedited rulemaking process under section Subd. 3. Requirements for clinicians certified as health care homes. (a) A personal clinician or a primary care clinic may be certified as a health care home. If a primary care clinic is certified, all of the primary care clinic's clinicians must meet the criteria of a health care home. In order to be certified as a health care home, a clinician or clinic must meet the standards set by the commissioners in accordance with this section. Certification as a health care home is voluntary. In order to maintain their status as health care homes, clinicians or clinics must renew their Certification annually. (b) Clinicians or clinics certified as health care homes must offer their health care home services to all their patients with complex or chronic health 24

25 conditions who are interested in participation. (c) Health care homes must participate in the health care home collaborative established under subdivision 5. Subd. 4. Alternative models. Nothing in this section shall preclude the continued development of existing medical or health care home projects currently operating or under development by the commissioner of human services or preclude the commissioner Sec. 2. from establishing alternative models and payment mechanisms for persons who are enrolled in integrated Medicare and Medicaid programs under section 256B.69, subdivisions 23 and 28, are enrolled in managed care long-term care programs under section 256B.69, subdivision 6b, are dually eligible for Medicare and medical assistance, are in the waiting period for Medicare, or who have other primary coverage. Subd. 5. Health care home collaborative. By July 1, 2009, the commissioners shall establish a health care home collaborative to provide an opportunity for health care homes and state agencies to exchange information related to quality improvement and best practices. Subd. 6. Evaluation and continued development. (a) For continued Certification under this section, health care homes must meet process, outcome, and quality standards as developed and specified by the commissioners. The commissioners shall collect data from health care homes necessary for monitoring compliance with Certification standards and for evaluating the impact of health care homes on health care quality, cost, and outcomes. (b) The commissioners may contract with a private entity to perform an evaluation of the effectiveness of health care homes. Data collected under this subdivision is classified as nonpublic data under chapter 13. Subd. 7. Outreach. Beginning July 1, 2009, the commissioner shall encourage state health care program enrollees who have a complex or chronic condition to select a primary care clinic with clinicians who have been certified as health care homes. [256B.0752] HEALTH CARE HOME REPORTING REQUIREMENTS. Subdivision 1. Annual reports on implementation and administration. The commissioners shall report annually to the legislature on the implementation and administration of the health care home model for state health care program enrollees in the fee-for-service, managed care, and county-based purchasing sectors beginning December 15, 2009, and each December 15 thereafter. Subd. 2. Evaluation reports. The commissioners shall provide to the legislature Sec. 3. comprehensive evaluations of the health care home model three years and five years after implementation. The report must include: (1) the number of state health care program enrollees in health care homes and the number and characteristics of enrollees with complex or chronic conditions, identified by income, race, ethnicity, and language; (2) the number and geographic distribution of health care home providers; (3) the performance and quality of care of health care homes; (4) measures of preventive care; (5) health care home payment arrangements, and costs related to implementation and payment of care coordination fees; (6) the estimated impact of health care homes on health disparities; and (7) estimated savings from implementation of the health care home model for the fee-for-service, managed care, and countybased purchasing sectors. 25

26 Appendix B Health Care Homes Rule APPLICABILITY AND PURPOSE. 1.2 Subpart 1. Applicability. Parts to apply to an eligible provider 1.3 that is an applicant or is certified as a health care home. 1.4 Subp. 2. Purpose. Parts to establish the standards and 1.5 procedures for certification of health care homes. The purpose of the standards is to 1.6 require health care homes to deliver services that: 1.7 A. facilitate consistent and ongoing communication among the health care 1.8 home and the patient and family, and provide the patient with continuous access to the 1.9 patient's health care home; 1.10 B. use an electronic, searchable patient registry that enables the health care 1.11 home to manage health care services, provide appropriate follow-up, and identify gaps 1.12 in patient care; 1.13 C. include care coordination that focuses on patient and family-centered care; 1.14 D. include a care plan for selected patients with a chronic or complex condition, 1.15 involve the patient and, if appropriate, the patient's family in the care planning process; and 1.16 E. reflect continuous improvement in the quality of the patient's experience, the 1.17 patient's health outcomes, and the cost-effectiveness of services. 26

27 DEFINITIONS Subpart 1. Scope. The terms used in parts to have the 1.20 meanings given them in this part Subp. 2. Applicant. "Applicant" means an eligible provider that has applied for 1.22 certification or recertification under parts to Subp. 3. Care coordination. "Care coordination" means a team approach that 1.24 engages the participant, the personal clinician or local trade area clinician, and other 2.1 members of the health care home team to enhance the participant's well-being by 2.2 organizing timely access to resources and necessary care that results in continuity of 2.3 care and builds trust. 2.4 Subp. 4. Care coordination payment system. "Care coordination payment system" 2.5 means a system established under Minnesota Statutes, section 256B.0753, subdivision 1, 2.6 or 62U.03, paragraph (a), to compensate health care homes. 2.7 Subp. 5. Care coordinator. "Care coordinator" means a person who has primary 2.8 responsibility to organize and coordinate care with the participant in a health care home. 2.9 Subp. 6. Care plan. "Care plan" means an individualized written document, 2.10 including an electronic document, to guide a participant's care Subp. 7. Chronic condition. "Chronic condition" means a medical condition that 2.12 has lasted at least six months, can reasonably be expected to continue for at least six 2.13 months, or is likely to recur Subp. 8. Clinic. "Clinic" means an operational entity through which personal 27

28 2.15 clinicians or local trade area clinicians deliver health care services under a common set of 2.16 operating policies and procedures using shared staff for administration and support. The 2.17 operational entity may be a department or unit of a larger organization as long as it is a 2.18 recognizable subgroup Subp. 9. Commissioner. "Commissioner" means the commissioner of health Subp. 10. Commissioners. "Commissioners" means the commissioners of health 2.21 and human services Subp. 11. Complex condition. "Complex condition" means one or more medical 2.23 conditions that require treatment or interventions across a broad scope of medical, social, 2.24 or mental health services. 3.1 Subp. 12. Comprehensive care plan. "Comprehensive care plan" means the care 3.2 plan for a participant plus all available and relevant portions of any external care plans 3.3 created for that participant. 3.4 Subp. 13. Continuous. "Continuous" means 24 hours per day, seven days per week, days per year. 3.6 Subp. 14. Cost-effectiveness. "Cost-effectiveness" means the measure of a service 3.7 or medical treatment against a specified health care goal based on quality and cost, 3.8 including use of resources. 3.9 Subp. 15. Direct communication. "Direct communication" means an exchange 3.10 of information through the use of telephone, electronic mail, video conferencing, or 28

29 3.11 face-to-face contact without the use of an intermediary. For purposes of this definition, an 3.12 interpreter is not an intermediary Subp. 16. Eligible provider. "Eligible provider" means a personal clinician, local 3.14 trade area clinician, or clinic that provides primary care services Subp. 17. End-of-life care. "End-of-life care" means palliative and supportive 3.16 care and other services provided to terminally ill patients and their families to meet the 3.17 physical, nutritional, emotional, social, spiritual, cultural, and special needs experienced 3.18 during the final stages of illness, dying, and bereavement Subp. 18. Evidence-based guidelines. "Evidence-based guidelines" means clinical 3.20 practice guidelines that are recognized by the medical community for achieving positive 3.21 health outcomes and are based on scientific evidence and other authoritative sources, 3.22 such as clinical literature Subp. 19. External care plan. "External care plan" means a care plan created for a 3.24 participant by an entity outside of the health care home such as a school-based individual 3.25 education plan, a case management plan, a behavioral health plan, or a hospice plan. 4.1 Subp. 20. Family. 4.2 A. For a patient who is 18 years of age or older, "family" means: 4.3 (1) any person or persons identified by the patient as a family member; 4.4 (2) legal guardian according to appointment or acceptance under Minnesota 4.5 Statutes, sections to ; 29

30 4.6 (3) a health care agent as defined in Minnesota Statutes, section 145C.01, 4.7 subdivision 2; and 4.8 (4) a spouse. 4.9 B. For a patient who is under the age of 18, "family" means: 4.10 (1) the natural or adoptive parent or parents or a stepparent who live in 4.11 the home with the patient; 4.12 (2) a legal guardian according to appointment or acceptance under 4.13 Minnesota Statutes, sections 260C.325 or to ; 4.14 (3) any adult who lives with or provides care and support for the patient 4.15 when the patient's natural or adoptive parents or stepparents do not reside in the same 4.16 home as the patient; and 4.17 (4) a spouse Subp. 21. Health care home. "Health care home" means a clinic, personal clinician, 4.19 or local trade area clinician that is certified under parts to Subp. 22. Health care home learning collaborative or collaborative. A "health 4.21 care home learning collaborative" or "collaborative" means an organization established 4.22 under Minnesota Statutes, section 256B.0751, subdivision 5, in which health care home 4.23 team members and participants from different health care organizations work together in a 30