Page 1 of 9

ATTACHMENT A: Activity 351 Child Health – Title: DIRECT SERVICES

Program Deliverable # _____ of _____

Program Background

  1. Examples of data to be reviewed on a regular basis to support provision of non-Medicaid direct healthcare services:

Health disparities in your county:

Data available from NCCHILD County Reports:

  • Percent uninsured and percent below 200% poverty level in your county
  • Unemployment rate for your county
  • Percent of Medicaid children who are delinquent on periodicity schedule
  • The number of children under age 18
  • Percent of Latino and African American children less than 18

Access to care for children in your county:

  • Number of pediatric practices accepting Medicaid
  • Number of Federally Qualified Health Centers
  • Free clinics providing pediatric preventative and sick care

Agency direct services data:

NOTE: CY HIS data is provided as a handout (). Due to the batch county data transfer issues, we cannot provide reliable HIS data for FY15-16. The local agency is responsible for pulling HIS or vendor reports to review the following data points to assist in developing your deliverables. Agencies will also be required to provide documentation that they have met the negotiated deliverables in August 2017.

  • Total number of visits, total unduplicated children with the average number of visits per year per child—are you providing episodic or continuity care?
  • Top ten diagnostic codes—are you seeing a high number of obese children or children with asthma?
  • County and agency immunization required and recommended rates
  • Age range for visits—what ages are you seeing most frequently?
  • Percent Medicaid, percent commercial, percent sliding fee ( non-Medicaid) visits
  • Percent LEP clients or average visits per week requiring interpreter services (onsite and language line)
  • Total number of dental assessments and varnishing
  • Practice Management Resources:
  • Average cost per visit
  • Visit capacity and utilization
  1. Evidence-based/evidence-informed intervention/strategy and the scope of work to be accomplished:
  1. If your agency is providing or contracting for non-Medicaid direct services, indicate, by checking the appropriate boxes below, the direct services your agency will use Title V funds to support (check all that apply). Complete and submit the Child Health Non-Medicaid Direct Services Worksheet on page7 to determine the total deliverable amount.
  1.  The agency will provide child health clinical services meeting Bright Futures evidence-informed guidelines.

List services to be provided and the total dollar amount based on attached spreadsheet calculations.

Preventative care ONLY

Preventative AND sick care

Behavior health services

Medical nutrition therapy

Dental Services

Other clinical services: please specify______

Scope of Work

  1. Prior to May 30, 2018, the agency will provide non-Medicaid child health clinical services for children 0-20 years of age meeting or exceeding the dollar amountdefined above which meet all Health Check Billing Guide and CMS documentation and coding requirements and programmatic guidelines.

TOTAL:$______

  1.  The agency will provide reproductive health services to teens ages 11-19 which meet the current CMS documentation and coding requirements and Family Planning Program guidelines. Check if these services are to be counted as Child Health deliverables and NOT COUNTED as Family Planning Program deliverables.

Complete and submit the Reproductive Health Non-Medicaid Direct Services Worksheet on page 8 to determine the total deliverable amount.

Scope of Work

  1. Prior to May 30, 2017, the agency will provide the non-Medicaid reproductive health services for adolescents through age 20 years meeting or exceeding the dollar amount defined above which meet all CMS documentation and coding requirements and Family Planning programmatic guidelines.

TOTAL:$______

  1.  The agency subcontracts with local provider to deliver direct health care services,including the following which meet Medicaid quality standards and billing requirements per monitoring by the local health department.

List contracted services to be provided:

Pediatric preventative care ONLY

Pediatric preventative AND sick care

Dental care for children meeting eligibility requirements

Vision care for children meeting eligibility requirements

Specialty care (orthopedics or cardiology) for children meeting eligibility requirements

Other: please specify______

Scope of Work

  1. Prior to submittingthis agreement, a provider memorandum of agreement(MOA) will be developed with the contracting agencies and included with this agreement. The agreement will specify the following: services to be provided, DMA rate for services provided, and for services such as dental or vision, the projected cost per patient.The MOA will also include the method by which the contracting agency will provide service counts and internal audit data to the local health department that assures adherence to quality care.
  2. Prior to May 30, 2017, the agency will assure eligibility assessment, referral, and delivery of the contracted services outlined above in the dollar amount that meet Medicaid quality and billing requirements.

TOTAL:$______

  1. Additional strategies to support direct services for non-Medicaid clients:

Indicate by checking the appropriate boxes below, the strategies your agency will implement in FY17.

  1. Interpreter Services: the agency will assure Title VI requirements are met and evidence-based healthliteracy strategies are implemented using the client’s preferred language or communication method.By implementing the Title VI requirements and evidence-based health literacy strategies,the agency will assure understanding and enhanced ability to implement health information by parents or teens for which clinical services are provided through consistent access to a voice or sign language interpreter or language line.Assurance of client understanding and enhanced ability to implement health information will be demonstrated by client feedback from customer satisfaction surveys collected twice a year by the agency.

Scope of Work

  1. Prior to August1, 2016, the agency will develop and implement a customer satisfaction survey to assess applied evidence- based health literacy strategies, and develop an action plan to resolve any identified barriers, especially for LEP and sight orhearing impaired clients.
  2. Prior to May 30, 2017, the agency will report on the implementation of the action plan, including staff education, and client feedback to demonstrate improvement (percent increase in the measures) in the areas identified on the initial FY survey.

Total amount for interpreter services from attached budget sheet:$______

  1.  Enhanced Role Nurse Training: the agency will increase access (appointment times and days/week) for prevention visits by (add baseline and projected increase percentage; minimum of 10-25%) training an enhanced role nurse to provide preventative visits in consultation with agency medical staff.

Scope of Work

  1. Prior to August 1, 2016, the agency will work with the regional child health nurse consultant to develop a plan to assure adequate consultation resources and participant designated time are available to support successful completion of the Child Health Training Program.
  2. Prior January 1, 2017, the agency participant will successfully complete the required training and meet rostering requirements as demonstrated by the DPH rostering letter.
  3. Prior to March 1, 2017, DPH external audit of the ERRN’s clinical documentation will demonstrate compliance with Health Check Billing Guide, NC Board of Nursing scope of practice, and programmatic requirements.

Total amount for ERRN training from attached budget sheet:$______

  1.  Enhanced Role Nurse Continuing Education: the agency will maintain access for preventative services by supporting ongoing clinical education of the enhanced role nurse(s) to meet rostering requirements of 10 continuing education hours per year. Continuing education hours must meet DPH rostering requirements; if the education is not provided by DPH, please validate approval prior to the course.

Scope of Work

  1. Prior to June 30, 2016, the agency will have in place policies and procedures to support ERRN practice and systems to assess and report clinical practice and approved continuing education hours to support re-rostering in June 2018.
  2. Prior to May 30, 2017, the agency will provide, on request, documentation of ten hours of DPH approved continuing education to meet the 2018 ERRN rostering cycle requirements.

Total amount for ERRN continuing education from attached budget sheet:$______

  1.  Clinical Services Workforce Development: the agency will procure continuing education to support pediatric clinical service objectives outlined below for providers and staff. Workforce development must focus on clinical issues for your population; examples include an increase in recommended immunization rates, improvements in asthma management; and/or reduction or prevention of childhood obesity. Workforce development needs should be informed by local data demonstrating a need to improve clinical outcomes; examples include: asthma hospital discharge rate, immunization rates for recommended immunizations, or 2-4 year old obesity rates.

Scope of Work

Objectives must be written in SMART format and a description of how the educational content will be applied.

Example: Prior to October 1, 2016, the agency, in conjunction with the Immunization Branch consultant, will develop a plan to implement CDC strategies to increase recommended adolescent immunization rates by (add percent increase) percent as demonstrated by the NCIR report. The implementation plan will include appropriate staff training (Immunization Conference and CDC training), health literacy strategies and clinical process revisions to support engagement of parents and teens.

Completethe Direct Services Workforce Development Worksheeton page 9 and Budget Worksheets.

TOTAL amount for Workforce Development Objectives:$______

  1. Clinical Equipment:
  2.  ADA: Assure Americans with Disability Act (ADA) accessibility requirements will be met based on internal and external accessibility assessments.

Scope of Practice

  1. Prior to September 1, 2016, the agency will schedule an external accessibility assessment through the Office on Disability and Health (ODH) and develop a plan to address priority accessibility issues directly impacting children and family services.
  2. Prior to May 30, 2017, the agency will expend funds required to address priority accessibility issues as outlined in the co-developed plan (ODH will assist).
  1.  Implementation of evidence- based hearing screening requirements

a.Prior to September 1, 2016, the agency will have an assessment and written recommendations by the regional audiology consultant regarding staff educational and equipment needs.

b.Prior to May 30, 2017, the agency will expend the funds allocated to improve hearing screening equipment and meet staff educational recommendations from the regional audiology consultant.

  1.  Other clinical equipment needs: describe specific equipment and evidence to support implementation and develop two SMART objectives to define the scope of work below.

Equipment need and evidence to support
Two SMART objectives to define the scope of work
Two Measures for the defined objectives

TOTAL amount for Clinical Equipment from attached budget sheet:$______

  1. Performance Measures

Note: The agency will be required to report the performance measure data mid-year (January 2017)and at the end of the fiscal year (August 2017). Agencies must have processes in place to capture and report data on request.If the end of the year data falls short of agreed upon deliverables the subsequent year AA may be re-negotiated.

  1.  Direct Services Child Health Measures
  1. FY 16-17 HIS or vendor data demonstrates that the number and dollar amount of the negotiated visits were provided (see B above). The agency will be required to report clinical data in an electronic survey to demonstrate meeting the negotiated deliverables.
  2. Internal and external audits will demonstrate compliance with HCBG, CMS Billing Guide, licensure requirements, and programmatic requirements. Internal audit findings must be provided on request by the Branch.
  1.  Direct Services Reproductive Health Measures
  1. FY 16-17 HIS or vendor data demonstrates that the number and dollar amount of the negotiated visits/contraceptive methods were provided (see B above). The agency will be required to report clinical data in an electronic survey to demonstrate meeting the negotiated deliverables and that the deliverables were counted only in the Child Health Program.
  2. Internal and external audits will demonstrate compliance with CMS documentation and coding guidance and Family Planning programmatic requirements. Women’s Health Branch external audit will be reviewed by Branch staff; internal audit findings must be provided on request by the Branch.
  1.  Contracted Direct Child Health Measures
  1. Agency reported FY16-17 contract vendor data demonstrates the number and dollar amount of the negotiated visits/contraceptive methods were provided (see B above). The agency will be required to report clinical data in an electronic survey to demonstrate meeting the negotiated deliverables.
  2. Agency will provide the Memorandum of Agreement (MOA) with the contracted provider as part of the agreement addenda submission. The MOA will include the processes and timeframes for vendor submission of the numbers and types of clinical services provided at the Medicaid rate and the vendor requirements for internal auditsto assure compliance with best practice clinical recommendations and the format for submitting the audit results.
  1.  Interpreter Services
  1. Internal and external audits will demonstrate that policies and procedures and training are in place to support evidence-based health literacy strategies for all clients.Internal audit findings must be provided on request by the Branch.
  2. 90% of LEP clients arerating “very satisfied” (scale: not satisfied, neutral, satisfied, very satisfied) on their ability to access care (appointment availability); and
  3. 90% of LEP clients are rating “very good” (scale: not at all; somewhat; good; very good) on their ability to understand information provided by the healthcare provider.
  1.  Enhanced Role Nurse Training
  1. ERRN candidates will provide documentation (PHNPDU Rostering letter) to support rostering by January 2017.
  2. Agency productivity reports will demonstrate an increase in appointment access by (add projected percent increase) % January 2017-May 2017.
  1.  Clinical Work Force Development

Specific Measures for clinical outcomes are recorded on the Workforce Development Worksheet on page 9.

  1.  ADA Clinical Equipment
  1. The Office on Disabilities Health (ODH) assessment report will be completed and made available to DPH and the local Board of Health by (add date).
  2. A plan to resolve identified ADA barriers will be completed prior to the end of the fiscal year, with an expectation that the majority of findings are resolved in a three year timeframe. The agency will provide a copy of the plan on request.
  1.  Audiology Equipment
  1. Regional Audiology Consultant report outlining assessment and recommendations will be completed and available prior to purchases
  2. Evidence to support completed training (rosters) and expenditure reports will be available.
  1.  Other Equipment

Defined in Grid E. 3. above

  1. Performance Monitoring

This agreement addendum will be monitored according to the following plan:

  1. Deliverables shall be monitored by site visits and required reports (electronic survey) at mid-year (December2016) and end of year (June2017). The local health department agrees to participate in periodic site visits as needed (with a minimum of one per year) as determined by the Program Contact. If the local health department is deemed out of compliance, program staff shall provide technical assistance, and funds may be withheld until the local health department is in compliance with deliverables. If technical assistance does not prove beneficial, the agreement addenda may be terminated.
  1. Total budget for DIRECT SERVICES: $______

SUBMIT the Budget Worksheet for each activity.

  1. Contact information of the staff member with primary responsibility for DIRECT SERVICES:

This is the person responsible for assuring the activity/intervention is implemented with program fidelity to meet the outcome objectives, and assuring ongoing monitoring and reporting.

______

NameTitlePhone NumberEmail Address

CHILD HEALTH NON-MEDICAID DIRECT HEALTHCARE SERVICES WORKSHEET

COMPLETE IF PROVIDING THESE SERVICES

CPT CODE / Description / Number / Rate / Cost
90801 / Psychiatric Diagnostic Interview / Exam / x / $128.29
90802 / Interactive Psychiatric Diagnostic Interview Exam / x / $136.76
90804 / Individual Psychotherapy (20-30 min face-to-face) / x / $56.28
90806 / Individual Psychotherapy (45-50 min face-to-face) / x / $78.98
90808 / Individual Psychotherapy (75-80 min face-to-face) / x / $116.21
90810 / Individual Psychotherapy Interactive (20-30 min face-to-face) / x / $59.79
90812 / Individual Psychotherapy Interactive (45-50 min face-to-face) / x / $85.91
90814 / Individual Psychotherapy Interactive (75-80 min face-to-face) / x / $124.66
90846 / Family Psychotherapy (patient not present) / x / $73.71
90847 / Family Psychotherapy (patient present) / x / $91.53
90853 / Group Psychotherapy / x / $26.09
97802 / Medical Nutrition Therapy – initial assessment and intervention* / x / $24.51
97803 / Medical Nutrition Therapy – re-assessment and intervention* / x / $21.44
TOTAL DOLLAR AMOUNT ABOVE SERVICES
99201 / Office Visit / Health Check Treatment Visit / x / $62.10
99202 / Office Visit / Health Check Treatment Visit / x / $93.15
99203 / Office Visit / Health Check Treatment Visit / x / $132.48
99204 / Office Visit / Health Check Treatment Visit / x / $194.58
99205 / Office Visit / Health Check Treatment Visit / x / $244.26
99211 / Office Visit / Health Check Treatment Visit / x / $34.16
99212 / Office Visit / Health Check Treatment Visit / x / $56.93
99213 / Office Visit / Health Check Treatment Visit / x / $78.66
99214 / Office Visit / Health Check Treatment Visit / x / $122.13
99215 / Office Visit / Health Check Treatment Visit / x / $182.16
99381 / Health Check Periodic / Interperiodic Screening Visit / x / $90.00
99382 / Health Check Periodic / Interperiodic Screening Visit / x / $90.00
99383 / Health Check Periodic / Interperiodic Screening Visit / x / S154.00
99384 / Health Check Periodic / Interperiodic Screening Visit / x / $90.00
99385 / Health Check Periodic / Interperiodic Screening Visit / x / $90.00
99391 / Health Check Periodic / Interperiodic Screening Visit / x / $90.00
99392 / Health Check Periodic / Interperiodic Screening Visit / x / $90.00
99393 / Health Check Periodic / Interperiodic Screening Visit / x / $90.00
99394 / Health Check Periodic / Interperiodic Screening Visit / x / $90.00
99395 / Health Check Periodic / Interperiodic Screening Visit / x / $90.00
99502 / Home Visit for Newborn Care & Assessment / x / $60.00
D1206 / Topical Fluoride Varnish application / x / $15.72
D0145 / Oral Evaluation for a Patient under 3years of Age and Counseling / x / $35.62
TOTAL CLINICAL SERVICES
15% OF TOTAL CLINICAL SERVICES (Labs, immunization administration, and procedures)*
TOTAL AMOUNT ALL NON- MEDICAID SERVICES ABOVE

NON-MEDICAID DIRECT REPRODUCTIVE HEALTH SERVICES