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PRIMARY HEALTH CARE-COMMUNITY HEALTH CENTER REQUEST FOR PROPOSAL
State Form 52633 (R/2-07)

INDIANA STATE DEPARTMENT OF HEALTH (ISDH) Office of Primary Care (OPC) - Community Health Centers (CHC)

Form approved by State Board of Accounts, 2007

Page 1: Application Face Page
INDIANA STATE FISCAL YEAR 2008 FY 2008 Amount Requested: $ FY 2007 Amount Received: $

Legal Agency /Organization Name:

Street

City

ZIP Code

Phone

Fax

E-Mail Address

Name of Agency Contact Person

Title of Contact Person

E-Mail Address

Proposed Service Area (City, Counties): Please Check All that Apply: Private Nonprofit Medically Underserved Area Medically Underserved Population Health Professional Shortage Area Dental HPSA Teaching Facility NEW APPLICANT (not currently funded) Federally Qualified Health Center Federally Qualified Health Center Look Alike Rural Health Clinic University Affiliated School Based Only School Based and Community Health Center Prenatal Care Pediatric Care Post Partum Care Newborn Care Family Planning Adult Care

Signature of Project Director (type name)

Phone

Signature of Board President/Chairperson (type name)

Phone

Signature of Project Medical Director (type name)

Phone

CEO/Official Custodian of Funds (type name)

Phone

(Optional) Signature of Local Health Officer (type name)

Date signed or notified

Signature of person authorized to make legal and contractual agreements for the applicant agency (type name) Are you registered with the Secretary of State? Yes

Title

Date

No

State Form 52633 (R/2-07)

1 of 44

Table of Contents ­ RFP FORMS Application Face Page .......................................................Page Table of Contents..............................................................Page Project Information............................................................Page Sources of Funding............................................................Page Form A ­ Proposed Expenditures for State Fiscal Year 2008 ...........Page Form A-2 ­ Sample Budget Narrative......................................Page Form B ­ Program Expansions...............................................Page Form C ­ Personnel............................................................Page Form D ­ Professional Licenses.............................................Page Form E ­ Board Members.....................................................Page Form F ­ Monthly Report Totals Calendar Years 2004, 2005, 2006....Page Form G ­ ISDH Priorities.....................................................Page Form H ­ Program Narrative..................................................Page Form I ­ Sliding Fee Schedule...............................................Page Appendix A ­ Performance Measures......................................Page Appendix B ­ CHC Requirements Checklist..............................Page Comments for Reviewers.....................................................Page

State Form 52633 (R/2-07)

2

Page 3 -Project Information
Name and address of all clinic locations. Name all clinic sites Name of Clinic Manager Phone Number County Address of clinic site Supported by ISDH-OPC Funds
Yes No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

State Form 52633 (R/2-07)

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Page 4 ­Sources of Funding
List all sources of funding including other ISDH Programs (e.g. OPC, Maternal Child Health Care Services, Newborn Screening, Preparedness, HIV/AIDS, WIC, etc.). Fiscal Year (FY) 2004-2005
Source of Funding (Agency) Amount of Funding

FY 2005-2006
Source of Funding (Agency) Amount of Funding

FY 2006-2007
Source of Funding (Agency) Amount of Funding

What year did the applicant organization begin receiving ISDH-OPC Community Health Center Funding? Amount: $

State Form 52633 (R/2-07)

4

Form A Proposed Expenditures for State Fiscal Year 2008
Applicant Agency: 12-Month Budget Period: From July 1, 2007 to June 30, 2008
Total Project Costs Matching Funds Percent of CHC Request from total Budget

Category

CHC Request

A. TOTAL PERSONNEL

Salaries Fringes

B. OPERATING EXPENSES Contractual Services Equipment Consumable Supplies Pharmaceuticals Travel Rent and Utilities Communications Professional Staff CEU/CMEs Professional Staff Trainings ISDH Priorities (non-clinical) ­ Form G Only Related Items Other Expenditures SUBTOTAL B TOTAL

State Form 52633 (R/2-07)

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Form A-2 - Sample Budget Narrative
This sample budget narrative is provided as a general outline. Providing additional information and detail is recommended to fully describe your proposal. Please mark pages A-2; A-2-a; A-2-b; A-2-c, etc.

REVENUE: REVENUE TOTAL: SALARIES: PERSONNEL: (Break out by Position) FRINGE BENEFITS: (Itemize each segment of Fringe Benefits) PERSONNEL & FRINGE TOTAL: TRAVEL: Itemize travel for patient care (home visits, patients' transportation vouchers, gas cards, cab rides, etc.) TOTAL: EQUIPMENT: New purchases, repairs or maintenance costs. EQUIPMENT (The following line items and dollar amounts are illustrative only. You may delete samples when you type in your info.): 4 Exam Tables (4 @ $3,000) 1 Medical X-Ray (1 @ $17,800) 4 Dental Units (4 @ $ 4,500) 4 Dental Chairs (4 @ $4,000) 1 Dental X-Ray (1 @ $10,200) 8 Stools (8 @ $250) 20 Hand pieces (20 @ $600) 1 Developing Unit (1 @ $2,000) 8 PCs and related software (8 @ 3,500) TOTAL ALL EQUIPMENT SUPPLIES: Office & Printing Supplies $ _________ per encounter Medical & Dental Records $ _________ per encounter Medical Supplies $ _________ per encounter Pharmacy Supplies including Drugs Average per number of Prescriptions X-ray supplies Average per number of X-rays Laboratory supplies per average number of procedures Building and Maintenance Supplies per number of sites TOTAL: SUPPLIES
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CONTRACTUAL (Please describe with enough detail to justify the costs.) Patient Care Contracts Outside Reference Lab XYZ Company for any tests that cannot be performed in-house (Average number of procedures X Average Cost) Outside Contract Pharmacies (describe) (Average number of prescriptions X Average Cost) OB/GYN Contract with ABC Company (Average number of Patients served X Average Cost) Ophthalmologist with RST Company (Average number of patients @ Average Cost) Temporary Nursing Coverage (Average number of days @ Average Costs) Subtotal: Patient Care Contracts Non-Patient Contracts Housekeeping Services with LMN Company Number of sites Security Services with DEF Company for Number of hours per site Computer Maintenance Contract Landscaping Services Subtotal: Non-Patient Contracts TOTAL: CONTRACTUAL OTHER: Payroll Processing Services Audit Services with JKL Company Legal Fees with WXY Company fee per hour Association Dues Building Contents Insurance Telephone Service Answering Services Postage Utilities Rent (describe per site) Marketing/Outreach Educational materials Any special taxes (describe) Technical Assistance TOTAL: OTHER BUDGET TOTAL:

State Form 52633 (R/2-07)

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Form B ­ Personnel
List personnel for each clinic site.

* List the number of hours considered Full Time Equivalent (FTE) by applicant:
NAME AND POSITION/TITLE SITE/CLINIC LOCATION SITE/CLINIC HOURS OPEN FOR PATIENT CARE ANNUAL SALARY NUMBER OF MONTHS FOR BUDGET PERCENTAGE TIME TOTAL FUNDS REQUESTED

(1) $ Clinical - MDs
On ­ site Number of hours:

(2)

(3) %

(4) $

Clinical

Consultant

On Call

Clinical

On ­ site Number of hours :

Consultant

On Call

Clinical

On ­ site Number of hours:

Consultant

On Call

Clinical

On ­ site Number of hours:

Consultant

On Call

Clinical

On ­ site Number of hours:

Consultant

On Call

Clinical

On ­ site Number of hours:

Consultant

On Call

Clinical

On ­ site Number of hours:

Consultant

On Call

Clinical

On ­ site Number of hours:

Consultant

On Call

Clinical

On ­ site Number of hours:

Consultant

On Call

Clinical

On ­ site Number of hours:

Consultant

On Call

Clinical

On ­ site Number of hours:

Consultant

On Call

State Form 52633 (R/2-07)

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Form B-2- Personnel (continued)
List clinical personnel for each clinic site.
NAME AND POSITION/ TITLE TYPE OF CLINICIAN (NP, RN, LPN, CMA, DDS, etc.) SITE LOCATION ANNUAL SALARY NUMBER OF MONTHS FOR BUDGET PERCENTAGE TIME TOTAL FUNDS REQUESTED

(1) (2) (3) $ % CHC Clinical Staff (NP, RN, LPN,CMA, DDS, RDH, and DA only)

(4) $

State Form 52633 (R/2-07)

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Form B-3- Personnel (continued) List subsequent pages B-4-; B-5-; B-6-, etc
List administrative personnel for each clinic site.
NAME AND POSITION/ TITLE SITE LOCATION ANNUAL SALARY NUMBER OF MONTHS FOR BUDGET PERCENTAGE TIME TOTAL FUNDS REQUESTED

(1) $ CHC Other Staff

(2)

(3) %

(4) $

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Form C - Professional Licenses List subsequent pages Form C-2; C-3; C-4; etc.
List staff with current professional licenses.

Name of staff person

Type of License

State Form 52633 (R/2-07)

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Form D - Board Members
Applicants must meet the community health center criterion of 30 percent consumer based Board.
Type of Board: Board of Directors Advisory Board

How often does the Board meet: When does the Board meet (day and time): Name Address Phone E-mail Profession CHC Consumer Yes or No Position on Board Board Position Term Length Years in Position

State Form 52633 (R/2-07)

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Form D-2- Board Members (continued)
Applicants must meet the community health center criterion of 30 percent consumer based Board.
Name Address Phone E-mail Profession CHC Consumer Yes or No Position on Board Board Position Term Length Years in Position

State Form 52633 (R/2-07)

13

Form E­ Monthly Report Totals for Calendar Year 2004
OMB No.: 0915-0285. Expiration Date: 06/30/2007

OFFICE OF PRIMARY CARE: State Funded Community Health Center Annual Report ­ Calendar Year 2004 Name of Center: Name of Preparer: City: Email:

Phone Number:

By Age

Total New Patients by Gender * M F

Existing Medical Patients Service of Provided Record

Dental Service Provided

White, Black, Hispanic American non non or Indian/Alaska Hispanic Hispanic Latino Native

Asian/Pacific Unreported/ Islander Refused to report

Birth-18 19-64 Over 65 Totals
Total Encounters this YEAR by payer source:

By Age

Medicaid

Hoosier Healthwise

Medicare

Private Insurance

Sliding Fee Scale

Birth ­ 18 19-64 Over 65 Total

Chronic Disease Patients Diabetes Cardiovascular Depression Asthma Other

New Diagnosis

Number of active patients this year

State Form 52633 (R/2-07)

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Form E -2 ­ Monthly Report Totals for Calendar Year 2005
OFFICE OF PRIMARY CARE: State Funded Community Health Center Annual Report ­ Calendar Year 2005 Name of Center: Name of Preparer: City: Email:

Phone Number:

By Age

Total New Patients by Gender * M F

Existing Medical Patients Service of Provided Record

Dental Service Provided

White, Black, Hispanic American non non or Indian/Alaska Hispanic Hispanic Latino Native

Asian/Pacific Unreported/ Islander Refused to report

Birth-18 19-64 Over 65 Totals
Total Encounters this YEAR by payer source:

By Age

Medicaid

Hoosier Healthwise

Medicare

Private Insurance

Sliding Fee Scale

Birth ­ 18 19-64 Over 65 Total

Chronic Disease Patients Diabetes Cardiovascular Depression Asthma Other

New Diagnosis

Number of active patients this year

State Form 52633 (R/2-07)

15

Form E-3 ­ Monthly Report Totals for Calendar Year 2006
OFFICE OF PRIMARY CARE: State Funded Community Health Center Annual Report ­ Calendar Year 2006 Name of Center: Name of Preparer: City: Email:

Phone Number:

By Age

Total New Patients by Gender * M F

Existing Medical Patients Service of Provided Record

Dental Service Provided

White, Black, Hispanic American non non or Indian/Alaska Hispanic Hispanic Latino Native

Asian/Pacific Unreported/ Islander Refused to report

Birth-18 19-64 Over 65 Totals
Total Encounters this YEAR by payer source:

By Age

Medicaid

Hoosier Healthwise

Medicare

Private Insurance

Sliding Fee Scale

Birth ­ 18 19-64 Over 65 Total

Chronic Disease Patients Diabetes Cardiovascular Depression Asthma Other

New Diagnosis

Number of active patients this year

State Form 52633 (R/2-07)

16

Form F - ISDH Priorities:
Priority Health Initiatives: Please write no more than one page for each Priority Health Initiative describing what the CHC is doing now to meet these objective and in the future. Data driven efforts for both health conditions and health systems initiatives
· · · ·

Effective, efficient, and timely data collection Data-driven policy-making Evidence-based and results-oriented programming Informatics: integrated and linked medical with public health records

INShape Indiana
· · ·

Agency-wide promotion of prevention and individual responsibility, especially in the areas of obesity prevention through good nutrition, exercise and tobacco use cessation. Engage all components of communities ­ collaborative partners. Integrate INShape Indiana opportunities in all programming and communications.

Integration of medical care with public health
· · · ·

Medicaid medical policy that values public health principles Appropriately targeted access to care for underserved Hoosiers Opportunities for Medicaid demonstration projects to showcase successful public healthbased interventions If not a Medicare/Medicaid provider, explain your application process or why not.

Preparedness
· · ·

Continual scanning for developing public health threats regardless of cause of the threat. Planning and training for poised and effective response to threats that cannot be prevented. Collaboration with the Local Public Health Coordinator and community agencies.

State Form 52633 (R/2-07)

17

Form F 1 - ISDH Priorities:
Please write one page or less describing what the CHC is doing now and in the future. Priority Health Initiative: Data driven efforts for both health conditions and health systems initiatives. Discuss how you are developing or expanding data-driven, policy making, collection and integrating informatics into your CHC operations.

State Form 52633 (R/2-07)

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Form F 2 - ISDH Priorities:
Please write one page describing what the CHC is doing to meet this initiative with the patient and staff now and in the future. Priority Health Initiative: INShape Indiana. Discuss collaborative efforts for good nutrition, obesity treatment, tobacco cessation and development of fitness programs.

State Form 52633 (R/2-07)

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Form F 3 - ISDH Priorities:
Please write one page or less describing what the CHC is doing to meet this initiative now and in the future. Priority Health Initiative: Integration of medical care with public health. Discuss medical model, community needs, patient diseases, Medicaid participation and barriers to success.

State Form 52633 (R/2-07)

20

Form F 4 - ISDH Priorities:
Please write one page describing what the CHC is doing to meet this initiative now and in the future. Priority Health Initiative: Preparedness. Discuss collaboration, planning, training and future development of response activities.

State Form 52633 (R/2-07)

21

Form G ­ Program Narrative (List subsequent pages Form G-2; G-3; etc.)

State Form 52633 (R/2-07)

22

Form H ­Expansions (Two page limit.)

State Form 52633 (R/2-07)

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Form I ­ SLIDING FEE SCHEDULE (Provide the applicant organization's sliding
fee schedule.)

State Form 52633 (R/2-07)

24

Appendix A ­Performance Measures
Provider Name:
CHC Performance Measure 1: Proportion of low birth-weight births.

SFY 2005
Annual Performance Objective: Reduce the percent of low birth-weight infants among all live births to:

SFY 2006

SFY 2007

SFY 2008

HP 2010

% %

% %

% %

% %

5

%

Annual Performance Indicator [N/D x 100]:
(Actual progress performance from which to improve.) Numerator (N): # of live births in Project with birth weight < 2500 grams

Denominator (D): # of live births in Project to women seen through 32 weeks who had at least 3 visits (For Semiannual and Annual Report use only) PERFORMANCE OBJECTIVE MET: YES NO DATA SOURCE: Work Plan Measurable How will activities be measured What documentation or demonstrated? is used to measure? Activities 1. 100% of all prenatal clients will Min. chart audit (10 charts) 1. Chart audit receive preterm labor education at 2024 weeks. 2. 100% of clients will be educated in Chart Audit for documented Weight gain grid and appropriate weight gain at first visit. weight gain grid at first visit and chart documentation. each visit thereafter 3. Semi annual review of all LBW LBW and Infant Death Screening Documentation of births and neonatal deaths tool will be used for review with LBW and neonatal summary of improvements to be deaths reviewed twice made. a year.

Adjustments in work plan

Problems

Staff Responsible

State Form 52633 (R/2-07)

25

Work Plan Measurable Activities

How will activities be measured or demonstrated?

What documentation is used to measure?

Adjustments in work plan

Problems

Staff Responsible

State Form 52633 (R/2-07)

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Provider Name:
CHC Performance Measure 2: Proportion of children who have completed age appropriate immunizations by age 3.

SFY 2005
Annual Performance Objective: Increase the percent of two-year-olds who have received the full schedule of age-appropriate immunizations to: %

SFY 2006
%

SFY 2007
%

SFY 2008
%

HP2010
80 %

Annual Performance Indicator [N/D x 100]:
(Actual progress performance from which to improve.) Numerator (N): # of two-year-olds in Project who received full schedule of immunizations by their 3rd birthday Denominator (D): # of children in Project who were seen more than 1 time during the fiscal year who were enrolled before 18 months of age, and were 24-35 months of age on the last day of fiscal year (For Semiannual and Annual Report use only) PERFORMANCE OBJECTIVE MET: YES

%

%

%

%

NO

DATA SOURCE: What documentation is used to measure? 1. Written clinic procedure. 2.Chart audit Adjustments in work plan

Work Plan Measurable Activities
1. > 90% of children who are on a delayed immunization schedule will be identified, provided with an immunization, or referred to provider for immunization.

How will activities be measured or demonstrated? 1. Documentation of clinic procedure for identifying, and providing services. 2. Chart documentation.

Problems

Staff Responsible

State Form 52633 (R/2-07)

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Provider Name: CHC Performance Measure 3: Proportion of clients who reduced or stopped smoking/tobacco use.

SFY 2005
Annual Performance Objective: Increase the percent of clients served by CHC who reduce or stop smoking/tobacco use to: %

SFY 2006
%

SFY 2007
%

SFY 2008
%

HP2010
NA

Annual Performance Indicator [N/D x 100]:
(Actual progress performance from which to improve or baseline.) Numerator (N): # of clients served by Project who smoked/used tobacco at the initial visit who reduced or stopped tobacco by last trimester or last visit. Denominator (D): # of clients served by Project who smoked/used tobacco at the initial visit for: 1. Prenatal Care - and were seen through 32 weeks of pregnancy, received at least 3 visits and delivered; or 2. Primary Care - for at least two visits during the year. 3. Dental Care- for every visit conducted.

%

%

%

%

(For Semiannual and Annual Report use only) PERFORMANCE OBJECTIVE MET: YES NO DATA SOURCE: Work Plan Measurable How will activities be measured What documentation or demonstrated? is used to measure? Activities 1. 100% of clients will be asked if 1.Chart audit 1.Chart documentation they use tobacco at the initial visit. (Charts should be flagged if clients are identified as smokers/users.) 2. ____% identified as smokers/users 1.Chart audit 1.Chart documentation will have tobacco use status documented at every visit. 3. ____% identified as smokers/users 1.Chart audit 1. Chart documentation who were helped onsite or referred to a cessation program, off premises.

Adjustments in work plan

Problems

Staff Responsible

State Form 52633 (R/2-07)

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Provider Name: CHC Performance Measure 4: Proportion of Adults receiving Hemoglobin A1c Measurement

SFY 2005
Annual Performance Objective: Increase percentage of adults with diabetes who had a Hemoglobin A1c measurement at least once in the past state fiscal year. %

SFY 2006
%

SFY 2007
%

SFY 2008
%

HP2010
%

Annual Performance Indicator [N/D x 100]:
(Actual progress performance from which to improve.) Numerator (N): # of diabetic patients with at least one visit to Project who had at least one hemoglobin A1c measurement taken during the past state fiscal year. Denominator (D): # of unduplicated diabetics seen by the Project at least once during the past state fiscal year. (For Semiannual and Annual Report use only) PERFORMANCE OBJECTIVE MET: YES NO How will activities be Work Plan Measurable measured or Activities demonstrated? Flag charts of all diabetic patients. Chart Audit Develop a protocol for obtaining hemoglobin A1c for each diabetic. Implement protocol.

%

%

%

%

DATA SOURCE: What documentation is used to measure? Chart Audit Adjustments in work plan

Problems

Staff Responsible

State Form 52633 (R/2-07)

29

Provider Name: CHC Performance Measure 5: Percentage of adults with Diabetes who received influenza immunization.

SFY 2005
Annual Performance Objective: Increase the number of adult diabetic patients who received an influenza immunization. % %

SFY 2006
% %

SFY 2007
% %

SFY 2008
% %

HP2010
%

Annual Performance Indicator [N/D x 100]:
(Actual progress performance from which to improve.) Numerator (N): # of adult diabetic patients with at least one visit during the state fiscal year who received an influenza immunization. Denominator (D): # of adult patients with at least one visit during the state fiscal year.

(For Semiannual and Annual Report use only) PERFORMANCE OBJECTIVE MET: YES NO DATA SOURCE: Work Plan Measurable How will activities be What documentation measured or demonstrated? is used to measure? Activities 100% of adult diabetic patients with at Chart Audit Chart Audit least one visit during influenza immunization period will receive influenza immunization during the state fiscal year. All diabetic patients will receive a reminder to come in for immunization before the influenza season.

Adjustments in work plan

Problems

Staff Responsible

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Provider Name: CHC Performance Measure 6: Proportion of Adults whose Blood Pressure is checked and Proportion of Adults whose Blood Pressures are < 130 mm Hg systolic or < 80 mm Hg diastolic.

SFY 2005
Annual Performance Objective: Increase the number of adults whose blood pressures are < 130mm Hg systolic or < 80 mm Hg diastolic. %

SFY 2006
%

SFY 2007
%

SFY 2008
%

HP2010
%

Annual Performance Indicator [N/D x 100]:
(Actual progress performance from which to improve.) Numerator (N): # of adult patients who visit the Project and have a blood pressure check. Denominator (D): # of adult patients who visit the Project. Numerator (N): # of adult patients who visit the Project at least twice, whose most recent blood pressure check was < 130 mm Hg/ < 80 mm Hg. Denominator (D): # of adult patients who visit the Project at least twice. Numerator (N): # of adult/teen patients served by the Dental Clinic who have a blood pressure check.. Denominator (D): # of adult/teen patients served by the Dental Clinic. Numerator (N) # of adult/teen dental patients whose blood pressures are > 120 Hg systolic or > 80 mm Hg diastolic, who are referred to their physicians. Denominator (D) # of adult/teen dental patients who had blood pressures taken. (For Semiannual and Annual Report use only)
State Form 52633 (R/2-07)

%

%

%

%

31

PERFORMANCE OBJECTIVE MET:

Work Plan Measurable Activities
All adults will receive a blood pressure check every visit, unless reason for skipping procedure is noted in chart. Charts of patients with blood pressures > 120 mm Hg/ 80 mm Hg are identified to be followed. Lifestyle modifications (weight control, physical activity, alcohol moderation, moderate sodium restrictions, and emphasis on consumption of fruits and vegetables and low-fat dairy products) will be initiated with all patients whose blood pressure measures > 120 mm Hg/80 mm Hg (as per AHA/ACC Secondary Prevention Guidelines). Follow AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update. Follow AHA/ACC Guidelines Secondary Prevention for Patients with Coronary and Other Vascular Disease: 2001 Update.

YES NO DATA SOURCE: How will activities be What documentation measured or demonstrated? is used to measure? Chart blood pressures. Chart Audit

Adjustments in work plan

Problems

Staff Responsible

Charts of patients with high blood pressures will be marked so staff can readily identify them. Lifestyle modification education will be charted when given.

Chart Audit.

Chart audit.

Record in chart the guidelines that are being followed.

Chart Audit

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Provider Name:
CHC Performance Measure 7a: Check BMI of all Adults and Identify the Proportion of Adult Patients who's BMIs are > 25.

SFY 2005
Annual Performance Objective: Determine the baseline or reduce the percent of adult patients whose BMIs are > 25 to: %

SFY 2006
%

SFY 2007
%

SFY 2008
%

HP 2010
15%

Annual Performance Indicator [N/D x 100]:
(Actual progress performance from which to improve.) Numerator (N): # of adult patients whose BMIs are > 25 Denominator (D): # of adult patients Numerator (N): # of adult patients whose BMIs are > 25 - <29 Denominator (D): # of adult patients Numerator (N): # of adult patients whose BMIs are > 29 Denominator (D): # of adult patients

%

%

%

%

(For Semiannual and Annual Report use only) PERFORMANCE OBJECTIVE MET: YES NO DATA SOURCE: Work Plan Measurable How will activities be What documentation is measured or demonstrated? used to measure? Activities 1. 100% of all charts of patients with Min. chart audit (10 charts) 1. Chart audit BMI of 25 or greater will be identified for follow-up. 2. 100% of clients with BMI of 25 ­ Chart Audit for documented 1. Chart audit 29.9, (classified as overweight), or patients with a BMI of 30 or greater (classified as obese) will be provided intervention or given appropriate community referrals.
State Form 52633 (R/2-07)

Adjustments in work plan

Problems

Staff Responsible

33

Work Plan Measurable Activities

How will activities be measured or demonstrated?

What documentation is used to measure?

Adjustments in work plan

Problems

Staff Responsible

Provider Name:
CHC Performance Measure 7b: Check BMI of all Children and Identify the Proportion of Overweight or Obese Child Patients.

SFY 2005
Annual Performance Objective: Determine the baseline or reduce the percent of overweight/obese child patients to: %

SFY 2006
%

SFY 2007
%

SFY 2008
%

HP 2010
5%

Annual Performance Indicator [N/D x 100]:

% % (Actual progress performance from which to improve.) Numerator (N): # of child patients whose BMI is calculated. Denominator (D): # of child patients Numerator (N): # of child patients whose BMI is > than 85%ile. Denominator (D): # of child patients (For Semiannual and Annual Report use only) PERFORMANCE OBJECTIVE MET: YES NO DATA SOURCE: Work Plan Measurable How will activities be What documentation is measured or demonstrated? used to measure? Activities 1. 100% of child patients will be Growth Chart will be a part of 1. Chart audit. weighed and measured and a BMI the chart and plotted at each calculated and plotted. visit. 2. 100% of all charts of child patients Min. chart audit (10 charts) 1. Chart audit
State Form 52633 (R/2-07)

%

%

Adjustments in work plan

Problems

Staff Responsible

34

Work Plan Measurable Activities
with BMI determined by the CDC child protocols as overweight or obese will be identified for follow-up. 3. 100% of clients with BMI determined by the CDC child protocols as overweight or obese will be provided intervention or given appropriate community referrals.

How will activities be measured or demonstrated?

What documentation is used to measure?

Adjustments in work plan

Problems

Staff Responsible

Chart Audit for documented patients

1. Chart audit

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Provider Name: CHC Performance Measure 8: Performance Measures of Your Choice (optional)

SFY 2005
Annual Performance Objective: % %

SFY 2006
% %

SFY 2007
% %

SFY 2008
% %

HP2010
NA

Annual Performance Indicator [N/D x 100]:
(Actual progress performance from which to improve or baseline.) Annual Outcome Objective Annual Outcome Indicator (N/D-U) x 100) Numerator (N): Denominator (D) Unknown (U)

(For Semiannual and Annual Report use only) PERFORMANCE OBJECTIVE MET: YES NO DATA SOURCE: Work Plan Measurable How will activities be measured What documentation or demonstrated? is used to measure? Activities

Adjustments in work plan

Problems

Staff Responsible

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Appendix B ­ CHC REQUIREMENTS CHECKLIST
(Check the appropriate box) General Requirements
Yes Yes No No Established need as determined by the number of uninsured/underinsured patients who require comprehensive, prevention-oriented primary health care at a health care home. Access to primary health care in health professional shortage areas (HPSA), health professional shortage area populations (HPSA-POP), medically underserved areas (MUA), medically underserved populations (MUP) or other special populations. Special populations may include migrant and seasonal farm workers, the homeless, HIV-AIDS patients, ethnic minorities, the elderly, pregnant women, and others with special health needs and/or geographic, cultural and economic barriers to care. Sites are expected to make an effort to extend services and promote appropriate utilization of prevention services regardless of patients' age, gender or ability to pay. No one should be refused services. Sites shall have an adjusted fee schedule policy that is available, printed and posted so those who need to take advantage of it may do so. Chart and documentation of service delivery for each patient shall be maintained. OSHA basic requirements for a workplace will be met. Sites shall be willing to participate in health professionals training programs. Administrative documents to include mission statement, by-laws, Affirmative Action policy, list of contracts and leases, hours of operation, and proof of liability insurance will be on file.

Yes

No

Yes Yes Yes Yes Yes

No No No No No

Staffing Requirements
Yes No While projects may utilize several part-time staff, there should be at least one full-time physician or nurse practitioner with prescriptive authority available on-site at least 20 hours per week to provide consistency and care continuity. Sites must demonstrate that all providers are licensed to practice in Indiana. Board certification or eligibility is preferred for physicians. Nurse practitioners and physician assistants must be nationally certified. Credentials must be current and in the individuals' personnel files. Sites should have, at a minimum, one physician or Nurse Practitioner on-site at least 20 hours per week that has hospital admitting privileges to the nearest local hospital.

Yes

No

Yes

No

State Form 52633 (R/2-07)

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Appendix B ­ 2 ­ CHC REQUIREMENTS CHECKLIST
Yes No All patients should have 24-hour access to providers affiliated with their health care home. Twenty-four hour coverage may be arranged through shared call among the health center's employed providers or through shared call among a broader group of providers through formal arrangement. Phone answering services that refer patients automatically to the nearest emergency room are not acceptable. Accommodation of patients who are unable to access a site's providers during regular business hours, sites should provide flexible hours to meet the need of the community without sacrificing popular week-day service hours. Efficiency standards shall be maintained for staff with direct patient involvement including: CPR certification based on current American Heart Association standards; demonstration of basic medical & nursing skills competency for licensure and certification; special certifications for ALS, EKG, and lab skills; and job descriptions for all staff. Sites shall maintain on file an organizational chart of health professional staff, administrative staff, subcontractors, volunteers, etc. who provide services and administer other aspects of the center's operations. Sites shall maintain on file a list of staff positions indicating full-time equivalencies of those positions that provide and administer primary care services. Educational and retraining opportunities should be in place to promote continuous quality improvement. State criminal background checks as appropriate at time of hire, personnel policies and procedures, and liability policies shall be in place.

Yes

No

Yes

No

Yes

No

Yes Yes Yes

No No No

Practice Guidelines
Yes Yes No No Sites shall make use of local best practices for protocol development Sites shall participate in the local health system including referral systems for local specialists, local primary care providers and hospitals; mental health providers; dental health providers; emergency services provisions; and coordination and referral with public health programs (e.g. WIC, EPSDT, family planning, HIV, immunization and communicable disease). Sites shall have in place written practice guidelines or a process in place for evaluation of service delivery and outsource service arrangements. Sites shall have in place written practice guidelines for mid-level practitioners.

Yes

No

Yes

No

State Form 52633 (R/2-07)

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Appendix B ­ 3 ­ CHC REQUIREMENTS CHECKLIST
Facility Requirements
Yes Yes Yes Yes No No No No The facility and layout shall accommodate projected patient volumes and facilitate efficient patient flow to the best of its ability. The entrance to the facility shall indicate it is smoke-free through use of the universal symbol for non-smoking, as well as posting signboards throughout the facility. The facility shall be handicap accessible, including parking spaces, entrances, restrooms, etc., that are marked appropriately. Adequate space will be met according to Department of Health and Human Services/Bureau of Primary Health Care for examination rooms, lab space, record retention, waiting area, etc. OSHA requirements will be met for biohazard materials. Facility hours of operation will be posted so they are visible from outside the building, as well as the after-hours phone number.

Yes

No

Equipment/Supplies
Yes Yes No No Inventories, warranties, service and maintenance agreements shall be kept on file. Sites shall submit an annual inventory of equipment purchased with State CHC funds costing over $500.00, and shall maintain records of all prior written approvals obtained for such equipment. Title to all property acquired with State funds by the grantee under the contract remains with the ISDH. These records will be subject to audit and/or inspections, as provided by law.

Yes

No

Community Participation/Collaboration
Yes No All sites should participate in collaborative efforts with residents, other public and private health care services, community groups, and agencies in their delivery of primary health care services. Collaborative efforts should be designed to avoid duplication and improve integration of local health services. All sites should actively solicit financial assistance from the communities that the CHC operates within. Memorandum of Agreement (MOA) /Memorandum of Understanding (MOU) of collaboration with other health care providers, health and human service agencies, government agencies are kept on file.

Yes Yes

No No

State Form 52633 (R/2-07)

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Appendix B ­ 4 ­ CHC REQUIREMENTS CHECKLIST
Components of Comprehensive Primary Care
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No A list of services provided on-site and through arrangements shall be on file at the site. (Sites are not expected to be able to provide the full range of primary health care services.) No No No No No No No No No No No No No No No No No Primary health care services by physicians and/or mid-level practitioners including treatment for acute disease and management of chronic disease Preventive health services Case management and outreach Basic diagnostic laboratory services Pharmacy services needed to complete treatment Referrals to supplemental service providers Health education and counseling Diagnostic X-ray services Cultural competence employing an understanding of emotional and social factors in assessment and intervention for each individual client Preventive dental Optometric/Eye care Emergency services Services often essential to maintain or regain health Restorative dental services Services required ensuring access Transportation for patients who would otherwise lack access to care Translation services or bilingual staff

State Form 52633 (R/2-07)

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Appendix B ­ 5 ­ CHC REQUIREMENTS CHECKLIST
Governance
Yes No There will be a local governing board of 9-25 members which are representative of the community and which will include at a minimum one third consumers of the health care site (51 percent, if the site is a FQHC). A governing board has responsibility for reviewing and approving decisions regarding budgets, scope of services, hours of operation, payment policies and procedures, and staffing. A list of current board members and user status shall be on file. The local governing board will meet at a minimum 4 times per year. This will be documented and kept on file for review. The highest ranking paid employee of the organization will be responsible for supplying the governing board with current financials on each CHC operating budgets at each board meeting. This will be documented and kept on file for review. Sites shall maintain on file the site's ongoing quality improvement program, including provider performance, protocols, and chart audits. As appropriate, it should describe how the quality improvement program relates to Health plan Employer Data and Information Set or other managed care quality improvement programs. Sites shall maintain on file a complete set of administrative and clinical policies and procedures. A review process for policies and procedures shall be kept on file. Sites shall conduct chart audits on a regular basis as part of their quality improvement plan. The procedure for data collection and the results of chart audits shall be kept on file. Each facility shall have a written quality improvement process. The quality improvement process needs to make a critical examination of the clinical practice habits of the physician/mid-level practitioner staff. The review needs to consider professional knowledge, accuracy of diagnostic skills, appropriate therapies, appropriate consultations, competent decision-making and malpractice judgments­settled or pending. Sites shall maintain on file copies of patient satisfaction surveys, as well as documentation of how often these surveys are conducted and how the information is utilized. Sites shall have a written disaster preparedness plan. Sites shall have a written plan for coordination, referral and appropriate utilization of local hospital emergency room services.

Yes Yes

No No

Quality Improvement Systems
Yes No

Yes Yes Yes

No No No

Yes

No

Yes Yes

No No

State Form 52633 (R/2-07)

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Appendix B ­ 6 ­ CHC REQUIREMENTS CHECKLIST
Ancillary Arrangement
Yes No For those primary health care services not provided on-site, MOAs/MOUs or contracts shall be on file documenting that referral arrangements are in place which ensure continuity of care.

Financial Management
Yes No Sites shall have billing and collection procedures in place to maximize revenues as appropriate through patient fees on an adjusted fee schedule, through billing to third party insurers such as Medicaid, Medicare, and private insurance. Sites shall be Medicaid and Medicare providers, or at a minimum have filed their application to be a Medicaid/Medicare provider. Sites will bill Medicaid and Medicare. Sites shall be willing to participate in Medicaid Managed Care as primary medical providers. Sites are required to have an adjusted fee schedule for patients. Sites shall have a business plan in place for maximizing self-sufficiency. The business plan shall demonstrate community support, including direct financial support and in-kind materials and services from other sources such as the local hospital, the city or township, and other local and public sources.

Yes Yes Yes Yes

No No No No

MIS System
Yes No Sites shall have a financial management system in place for billing, accounting, budget, management, and other systems to maximize patient-generated revenues. Sites shall demonstrate fiscal integrity by having accounting and internal control systems appropriate to the size and complexity of the organization. Sites shall have a system which accurately collects and organizes data for reporting and which supports management decision-making, ideally integrating demographic, clinical, utilization, and financial information to reflect the operations and status of the organization as a whole.

Yes

No

State Form 52633 (R/2-07)

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Appendix B ­ 7 ­ CHC REQUIREMENTS PLAN (For each "No" response, please identify
by page number and explain in no more than three sentences.)

State Form 52633 (R/2-07)

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ADDITIONAL COMMENTS FOR REVIEWERS

State Form 52633 (R/2-07)

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