Request for Proposals

Transcription

1 Request for Proposals Release date: June 18, 2018 Due date: July 18, 2018 Learning Community Grant Health Care Home, Public Health, Behavioral Health Partnership Learning Community Minnesota Department of Health Division of Health Policy

2 Table of Contents Overview... 3 Grant Timelines... 4 Available Funding and Estimated Awards... 4 The Grant Applicant... 5 Required Deliverables and Activities... 6 Grant Application and Program Summary... 8 Proposal Instructions Signed Grant Application Face Sheet (Form A) Applicant Experience and Capacity (Limit 3 pages, 35 Points) Learning Community Project Proposal (Limit 6 pages, 45 Points) Required Application Supporting Documents: Budget (20 Points)...11 Proposal Evaluation...14 Review Process...14 Grant Participation Requirements...15 Required Forms...15 Form A: Application Face Sheet...16 Form B: Learning Community Budget Template...18 Form C: Budget Justification Form...20 Form D: Due Diligence...22 Appendices...28 Appendix A: MDH Sample Grant Agreement...29 Appendix B: MDH EXAMPLE Invoice...40 Appendix C: Resources

3 Overview The Minnesota Department of Health (MDH) is seeking proposals to advance the work of Health Care Homes (HCH) through partnering with a local public health agency and a behavioral health organization in a Learning Community to address shared goals to improve the health and health outcomes of a community. The grants are intended to increase and strengthen partnerships between primary care, local public health or a Tribal health division, behavioral health, and other community based organizations through the use of data and information to support shared population health goals. Applications must be submitted by a MDH certified health care home on behalf of the partnership. The Learning Community, established by the Minnesota Department of Health, will be led and guided by MDH HCH program staff. For the purpose of this grant, a Learning Community is defined as learning teams that have common goals or interests, share best practice knowledge, focus on community health improvement, and are actively engaged in building a relationship between a certified health care home, local public health or a Tribal health division, and a behavioral health organization to develop an action plan to share data and information to support shared population health goals. This grant funding will support participation of a MDH certified Health Care Home, local public health or a Tribal health division, and a behavioral health organization in a Learning Community to develop a shared narrative; advance knowledge of primary care, public health, and behavioral health; and engage in a process to share de-identified data to better understand the health status of a shared population and support combined population health goals. The strategy of the Learning Community is to convene partners to identify shared priorities, using both population health from the local public health or Tribal health division and clinical data; and increase the capacity to share electronic health record (EHR) data or any other data to improve community health. The learning community is expected to identify how this work will address health disparities or inequities. Partners participating in this project must commit to continuing to move the work forward once funding has ended. While the focus of this grant is on primary care, public health and behavioral health partnership, it is encouraged that grant funding be used to support other community partners who may be engaged in the project. Applicants must be a MDH certified health care home (primary care clinic or practice) that has an existing working relationship with local public health or a Tribal health division, and a behavioral health organization or clinic. The partners will work with the State HCH staff in the Learning Community. Support available from the State may include: building mutual understanding of roles and partnership benefits, identifying best practices, supporting use of data for decision making, providing resources to advance the capacity of the partner organizations in data sharing, and coaching on data sharing implemention plan strategies and measure identification. 3

4 Grant Timelines MDH staff expects to follow the schedule below for the grant opportunity; however, the timelines are estimates and subject to change. RFP Activity Date/Time Request for Proposal Posted June 18, 2018 Direct Contact Questions about the Learning Community grant or the proposal process can be directed to: Janet Howard Minnesota Department of Health Health Care Homes / Health Policy Division janet.howard@state.mn.us. Other state staff are not allowed to respond to questions about this procurement, and any discussions may result in disqualifying applications. Proposals Due July 18, 2018 Estimated Notice of Awards July 31, 2018 Estimated Grant Start Date September 4, 2018 Available Funding and Estimated Awards Learning Community Grant Grant term is for (9) nine months from the start date, and is required to be completed by June 30, Total of up to $120,000 is available for four grants of up to $30,000 each. MDH reserves the right to not award grants. Funding Restrictions Funds may not be used to pay for direct patient care service fees, purchase of computers or other equipment, building alterations or renovations, construction, fund raising activities, political education or lobbying, or out of state travel. There is no requirement for matching funds. Indirect costs are not allowed in this proposal. Background The Minnesota Department of Health, Office of Health Information Technology, published Connecting Communities with Data: A practical guide for using electronic health record data to support community health-version This report highlights Minnesota s recognition that collaboration across clinical care and local public health can improve the health of all people in their communities through three 1 4

5 examples of collaboration in Minnesota. The lessons learned through these collaborations is presented to encourage the use of data and information to improve the health of populations in Minnesota. This grant provides an opportunity for MDH certified health care homes to work with their local public health or Tribal health division and behavioral health partners to understand and address the physical, behavioral, social, and economic factors of health impacting the population being served through the use of shared data and use this to better inform strategies to address these factors. The learning community will give the partners the opportunity to build trust, look closely at how data is collected, and strengthen the ability to share information between agencies to provide a fuller picture of the health of populations served in the community. The Grant Applicant The applicant must be a MDH-certified health care home with an existing partnership/relationship with a local public health agency or Tribal health division, and a behavioral health organization. Applications must include the commitment from at least one partner from a local public health or a Tribal health division, and a behavioral health organization or clinic. Preference will be given to certified Behavioral Health Home services providers or those working towards certification. The MDH-certified health care home must be designated as the lead agency. Non-profit or other organizations may be included in the grant application, but are not eligible to apply and may not be the lead agency. Learning teams shall be the primary recipients of the learning and implementation work. Work may be focused on a specific clinic population, community or combined service area. Qualified applications will be from an established partnership that includes MDH-certified health care home as the lead, and include a local public health agency or a Tribal health division, and at least one behavioral health organization or clinic. The applications should address the following elements: Inventory data resources Engage community partners Assess capacity to use EHR data and other data source information Analyze, summarize, and distribute information Applicants must demonstrate leadership commitment and sufficient capacity to engage in the project. Each participating agency should self-select at least two (2) individuals representing their organization to actively participate in the learning community. Staff representatives from participating agencies should include at least one person knowledgeable on how the agency collects and uses data, and the impact on care for the population. There should also be an understanding of some of the challenges of sharing data across different sectors of care such as data privacy and security, HIPAA/Minnesota Health Records Act, and state or federal regulations involving each sector. A MDH-certified health care home must submit the application and include a commitment letter from their other partners. Funding decisions will be made based on the ability of the applicant to meet the criteria established in this RFP, and only applications from an MDH-certified health care home will be funded. The applicant and its partners must be located in the State of Minnesota, and meet the State s fiscal requirements and other grant participation requirements, including the ability to collect and submit evaluation data, manage staff, communications, and other grant operations. 5

6 Required Deliverables and Activities This grant opportunity is intended to support collaboration and partnership between a MDH-certified health care home, a local public health or Tribal health division, and a behavioral health organization or clinic in a Learning Community, and may include other community based organizations. The goal of the grant is for these partners to improve the health and health outcomes of a shared population through the better use of data and information. Applicants for this grant funding will be required to meet the following deliverables: 1. Work with the MDH HCH staff to identify learning needs, approaches, and applicable best practices. 2. Prepare an inventory of available data resources relevant to a shared population. 3. Create a shared vision for the partnership with mutual expectations to share information that is supported by leadership of the health care home, its local public health or Tribal health division, and behavioral health partners. 4. Assess capacity of partners to use EHR data, registries, local public health needs assessments, and other data sources. 5. Use PDSA (plan-do-study-act) or other QI approaches throughout the process for continuous quality improvement. 6. Develop a data dictionary with common language to promote understanding of terminology used across each of the partner agencies. 7. Analyze and summarize information on the shared population they are serving. 8. By June 30, 2019 develop an implementation plan with partners to address a health priority after the grant period is completed. The State will be responsible for convening all meetings and working with participants to develop a learning agenda. Partners will be required to participate in the following Learning Community activities: Participate in a kick-off meeting to be apprised of the nature of the project. Attend up to four in-person trainings conducted by state facilitator (include travel in budget for all staff traveling to the metro area for training). Attend monthly meetings in person or by phone with Learning Community team members, facilitated by MDH at a location convenient to learning community team. Participate in up to four webinars or on-line learning modules to strengthen information sharing and relationships with partner agency staff. Use population health data, clinical data, utilization data, and community and patient experiences to identify actionable goals and strategies to collaboratively partner in improving community health. Engage each of the partner agencies in sharing and using data to identify a priority area to address. 6

7 Grantee shall: Submit detailed invoices for payment on a quarterly basis, using the Invoice template supplied by MDH. Submit a written report, using the format provided by MDH, with each invoice that discusses progress in the analysis of data resources, the participation in the learning events, and the outcomes of applying the knowledge to improve data sharing between partner agencies. Respond to surveys as requested by State staff and participate in evaluation as requested. Capitalize on the expertise of learning team members by capturing participant stories and reflections for inclusion in final report and presentations. Document progress on the project and share resulting innovations that would be helpful to others engaged in health care home, public health, and behavioral health partnerships. For example, power points, handouts, templates, videos, forms, and toolkits. Upon Completion Prepare and present a session on the Learning Community project during a Health Care Home learning event. Submit a final project report using the format the State will provide. Ensure that all materials (e.g., electronic documents, webpages, or other electronic materials) are made fully accessible in accordance with the applicable law Minnesota State Accessibility Standard ( 7

8 Grant Application and Program Summary Description Eligibility for Grant Funds Total Funds Available Grant Amount Duration of Funding Grant Purpose Application Requirements Order for Completed Application Submission Submitting the Proposal Application Deadline Summary Eligible applicants are MDH-Certified Health Care Homes in partnership with at least one local public health or Tribal health division, and one behavioral health organization partner. (Preference will be given to a partnership with a certified behavioral health home services provider or organization working towards certification.) The MDH-certified health care home is designated as the lead agency. Non-profit or other organizations may be included in the grant application, but are not eligible to apply alone and may not be the lead agency. Learning teams shall be the primary recipients of the learning and implementation work. $120,000 $30,000, up to four awards Nine months To participate in State sponsored learning activities, and implement work to advance the partnership of an existing MDH certified health care home, local public health or Tribal health division, and a behavioral health organization or clinic through participation in a Learning Community to improve the sharing of data and information that benefits the population being served. Narrative portions of the applications must be written in 12-point font, single spaced with one-inch margins. All pages must be numbered consecutively. Applicants must submit one (1) signed unbound original and three (3) unbound copies of the proposal as well as an electronic version of the proposal on an USB drive. Faxed or ed applications will not be accepted. Applications must meet application deadline requirements. Late applications will not be reviewed. Applications must be complete and signed where noted. Incomplete applications will not be considered for review. Each application must contain the following items in the order listed: Signed Application Face Sheet (Form A) Applicant Experience and Capacity (Limit 3 pages) Learning Community Project Proposal (Limit 6 pages) Learning Community Budget (Form B) Project Budget Justification (Form C) Due Diligence Review Form (Form D) (For Nongovernmental Organizations) submit only 1 copy of Due Diligence Review Form and any required documentation Applicants must submit one (1) signed unbound original and three (3) unbound copies of the proposal and an electronic version of the proposal on a USB drive. Faxed or ed applications will not be accepted. Late applications will not be considered for review. July 18, 2018 To meet the deadline, proposals must be either: 8

9 Description Applications Sent Contact Information Summary Hand delivered to the 2nd floor reception desk of the Golden Rule Building 85 East Seventh Place, Suite 220 on or before July 18, 2018 by 4:30 PM CDT; or Arrive by mail, Fed Ex, or courier service on or before July 18, 2018 by 4:30 PM CDT. Late applications, applications lost in transit by courier, or faxed/ ed applications will not be considered for review. Mailing Address: Janet Howard Minnesota Department of Health Health Care Homes / Health Policy Division PO Box Saint Paul, MN Courier Address: Janet Howard Minnesota Department of Health Health Care Homes / Health Policy Division Golden Rule Building 85 East Seventh Place, Suite 220 Saint Paul, MN Questions about the Learning Community grant and the proposal process can be directed to: Janet Howard Minnesota Department of Health Health Care Homes / Health Policy Division Janet.Howard@state.mn.us Grant Start Date Other state staff are not allowed to respond to questions or have discussions about this procurement, and discussions may result in disqualification of an application. September 2018, or the date all required signatures on the grant agreement are obtained, whichever is later. Proposal Instructions The following are the minimum required application components, listed in the order of documents to be submitted. Applicants should place emphasis on completeness and clarity of content. 1. Signed Grant Application Face Sheet (Form A) Include all applicable information required by the form. 2. Applicant Experience and Capacity (Limit 3 pages, 35 Points) In this section, applicant must: 9

10 a) Provide a brief description of the current partnership between the MDH certified health care home, local public health agency or a Tribal health division, and behavioral health organization (identify if it is a certified behavioral health home service provider) including the length of time the partnership has existed, the nature and scope of the relationship(s) and successes and challenges in developing and maintaining the relationship. b) Identify staff participating from each partner organization including their qualifications, skills and experience. Describe the roles and responsibilities for each staff member participating in the learning community. c) Identify the shared population the partnership serves, and whether it will be expanded to additional populations. d) Describe anticipated barriers and challenges in implementing this project and potential solutions. Review Criteria: a) Applicant described the relationship between the health care home, local public health or Tribal health division, and the behavioral health organization or clinic including length of time the partnership has existed, focus of partnership and its successes and challenges. Priority will be given to applications that include a behavioral health organization or clinic that is a certified Behavioral Health Home services provider or actively working toward toward BHH certification. b) Applicant has identified at least two staff from each partner, and they have the capacity to participate in the Learning Community as described by roles and responsibilities of the participating partners staff members, including qualifications, skills and experience relative to the Learning Community. c) Applicant identifies the shared population served by the health care home and the partner organizations and whether it will be expanded to new populations. d) Applicant described possible barriers and challenges for implementation and the potential solutions. 3. Learning Community Project Proposal (Limit 6 pages, 45 Points) Proposals must address, in sufficient detail, how the applicant would fulfill the expected outcomes and features described below: In this section, applicant must discuss: a) The motivation for building on the partner relationship between the health care home, local public health or a Tribal health division, and behavioral health partners. b) Goals, expectations, and expected impact of participation in the Learning Community on: o information sharing between partners and their ability to serve the shared population as a result o strengthening the relationship between the health care home, local public health, and behavioral health partners o engaging community partners in the future c) Current challenges and limitations faced by the health care home and partner agencies in being able to share data sets with partner agencies due to: o data privacy, HIPAA, MN Health Records Act, or other regulations from State or federal entities o technology o understanding availability of data and how it relates to population being served 10

11 d) Insights into health equity factors in the community and how health equity will be considered in the use of data and information. e) Strategies for how the partners could implement and sustain the work after the grant is completed. Review Criteria: a) Applicant describes the motivation for building a stronger partnership between the health care home, local public health or Tribal health division, and behavioral health and the population being served. b) Applicant identifies the goals and expectations of participation in the learning community and the impact on information sharing between partners and their ability to serve the shared population, strengthening the partnership and engaging community partners in the future. c) Applicant describes challenges and limitations faced by the health care home and partner agencies in being able to share data sets due to data privacy, HIPPA. regulations from State or federal entities, technology, and understanding of data and the population being served d) Applicant describes how health equity will be supported by data and community input. e) Applicant demonstrates a commitment to sustaining collaboration after the grant is over. 4. Required Application Supporting Documents: (Pass/Fail) a) Support letter from organizational leadership identifying at least two staff to participate in the Learning Community from each partner agency. b) Signed agreement from all partners indicating participation of attendance and commitment to attend Learning Community activities. i. Up to four in-person trainings conducted by state facilitator (include travel in budget for all staff traveling to the metro area for training). ii. Monthly meetings with Learning Community team members facilitated by MDH HCH Staff. (location convenient to learning community team members) iii. Participate in up to four monthly webinars and on-line learning courses Review Criteria: a) Support letter is included from all partners identifying staff to participate. b) Signed agreement of attendance in learning community activities. 5. Budget (20 Points) Budget Forms: Budget Template Form B. Budget Justification Narrative see template Form C. Due Diligence Review Form D. Due Diligence Review Form (For Nongovernmental Organizations submit 1 copy of Due Diligence Review Form and required documentation) This form must be completed by the lead applicant s administrative staff, for example, finance manager, accountant or executive director. It is a standard form MDH uses to determine the accounting system and financial capability of all grant applicants (submit only 1 copy of Due Diligence Review Form and any required documents) 11

12 Eligible Expenses: Grant funds may be used to cover costs of personnel, consultants, supplies, grant related travel, and other allowable costs. Ineligible Expenses: Funds may not be used to pay for direct patient care service fees, purchase of computers or other equipment, building alterations or renovations, construction, fund raising activities, political education or lobbying, or out of state travel. Indirect Costs: Indirect costs are not allowed in this proposal. In-Kind: Matching Funds Requirement: There are no requirements for matching funds. Budget Form The budget form must be completed for a nine month grant period. Section One is a summary of the eligible expenses by line item. Provide information on how each line item in the budget was calculated. A. Salaries and Wages: For all positions (of lead agency) proposed to be funded from this grant, provide the position title, the hourly rate, and the number of hours allocated to this project. In the budget narrative, provide a brief position description for each of the positions listed. B. Fringe: List the rate of fringe benefits calculated for the total salaries and wages for positions in 1A. C. Consultant Costs: Provide the name of contractors or organizations, the services to be provided, hourly rate, and projected costs. This includes costs for staff participation from partner agencies in the learning community. In the budget narrative, include brief background information about contractors/partners, including how their previous experience relates to the project. If a contractor has not been selected, include a description of the availability of contractors for the services and/or products required and the method for choosing a contractor in the budget narrative. D. Equipment: Equipment, including medical equipment, is not allowed in this grant. E. Supplies: Expected costs for general operating expenses, such as office supplies, postage, photocopying, printing and software. For software the type of software must be specified in the budget including the cost per person, the number of people using the software and total costs. Software costs must be specific to the Learning Communities project work and described in the budget justification narrative. F. Travel: 12

13 Include the cost for any proposed in-state travel as it relates to the completion of the project. This can include costs associated with staff from partner organizations that are participating in the learning community project. Provide the estimated number of miles planned for project activities and the rate of reimbursement per mile to be paid from project funds (not to exceed the current rate established by the Minnesota Management and Budget's Commissioner s Plan - Include expected travel costs for hotels and meals. Out of state travel is not an eligible expense. G. Other: If it is necessary to include expenditures in the Other category, include a detailed description of the proposed expenditures as they relate to the project. Add additional Other lines to the budget form as needed. Support Expenses: Telephone equipment and services, internet connection costs, teleconferences, videoconferences, meeting space rental, and equipment rental. Expense Reimbursement: Travel and child care expenses can be covered for consumers or other community members without a form of reimbursement to attend a scheduled meeting. You must be specific on your budget form and budget narrative for travel and childcare expenses for consumers or community members without another form of reimbursement. Review Criteria: The Budget section of the application will be reviewed and scored according to the following criteria. a. 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? b. Is the information contained in the Budget Justification Sheet consistent with what is proposed in the Project Narrative and Proposal? c. Are the projected costs reasonable and sufficient to accomplish the proposed activity? 13

14 Proposal Evaluation Grant proposals will be scored on a 100-point scale as listed in the following table: Items Points Percentage Applicant Experience and Capacity 35 points 35% Learning Community Project Description 45 points 45% Budget and Budget Justification 20 points 20% TOTAL 100 points 100% Review Process The State will evaluate proposals based on the review criteria as set forth in this RFP. Reviewers will score proposals individually using a provided score sheet. Proposals and reviewer scores will be discussed by review teams. Reviewers are able to modify scores based on discussions at the review meetings. Funding decisions will consider capacity of the organizations to complete the project goals. Grant proposals will be reviewed and evaluated by a panel familiar with the program. The panel will include staff from the Minnesota Department of Health, Health Care Home Section and the MN Department of Human Services, Behavioral Health Home Services Team, Community and Care Integration Reform Division. The panel will recommend selections to the Commissioner of Health. In addition to panel recommendations, the commissioner may also take into account other relevant factors in making a final award, including geographic location and a cross section of target populations. Only complete applications received on time according to the due date listed on or before July 18, 2018 at 4:30 pm CDT will be reviewed. Reviewers will use the criteria as outlined in the RFP and will make recommendations for funding. We anticipate that grant award decisions will be made by July 31, Applicants will be notified by letter whether or not their grant proposal was funded. MDH reserves the right to negotiate changes to budgets and work plans submitted with the proposal. MDH reserves the right to waive minor irregularities or request additional information to further clarify or validate information submitted in a proposal, provided the proposal, as submitted, substantially complies with the requirements of this RFP. There is, however, no guarantee MDH will look for information or clarification outside of the submitted written proposal. Therefore, it is important that all applicants ensure that all sections of their proposal have been completed to avoid the possibility of failing an evaluation phase or having their score reduced for lack of information. A Grant agreement will be entered into with the applicant that is awarded grant funds. The anticipated effective date of the agreement is September 2018, or the date upon which all signatures are obtained. No work on grant activities can begin until a fully executed grant agreement is in place. 14

15 Grant Participation Requirements Submit a final work plan and budget if requested. Submit three grant agreements with original signature to MDH for final signature. Grantee cannot start work or be reimbursed until a grant agreement is fully executed. Complete required activities as outlined in grant agreement. Participate in site visits or conference calls to report on progress, barriers or lessons learned. Provide additional details that may be requested to comply with state and federal reporting requirements. Provide ongoing progress reports submitted with each invoice. Final 10 percent of the total grant award will be withheld until grant duties are completed. Required Forms Below is a list of forms required for submission with the Learning Community Grant proposal. Forms are included in the RFP for reference only. Form A: Form B: Form C: Form D: Application Face Sheet with Instructions Learning Community Budget Template Budget Justification Narrative Due Diligence Review Form (submit only 1 copy of Due Diligence Review Form and any required documentation) 15

16 Form A: Application Face Sheet Learning Community 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 applicant agency (if different from number 4 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: ( ) 9. 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 Grant Agreement Title Date 16

17 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. 4. Director of the applicant agency Person responsible for direction at the applicant agency. 5. Fiscal Management Officer of applicant agency The chief fiscal officer for the applicant agency who would have primary responsibility for the grant agreement, grant funds expenditures, and reporting. 6. Operating Agency Complete only if other than the applicant agency listed in 1 above. 7. Contact Person for Applicant Agency The person who may be contacted concerning questions about implementation of this proposed program. Complete only if different from the individual listed in 5 above. 8. Contact person for Further Information Person who may be contacted for detailed information concerning the application or the proposed program. 9. Signature of Authorized Agent of Applicant Agency Provide an original signature of the director of the applicant agency, their title, and the date of signature. 17

18 Form B: Learning Community Budget Template Applicant: Total Contract Period: 9 months between September 2018 and June 2019 Budget Form Instructions for Applicants: 1. Complete a budget for the applications for the Learning Community. 2. Include costs for the grant recipient (fiscal agent) and Salaries & Wages, Fringe, Supplies, Travel, and Other categories in the appropriate budget line. 3. Include contractor costs (contracts with vendors and partners) in C. 4. Enter information in cells highlighted in blue as applicable for your project. Section One A. SALARIES & WAGES: For each position, provide the following information: position title, hourly rate, and number of hours allocated to the project. In Form C Budget Justification Narrative, provide a brief position description for each position listed. Title Hourly Rate Hours Total $ $ $ $ $ $ Total Salaries and Wages: 0 $ B. FRINGE: Provide information on the rate of fringe benefits calculated for the total salaries and wages for positions in A. Title Total Enter the fringe benefit rate as a % of the total salaries and wages in decimal format. Total Fringe: $ C. CONSULTANT COSTS: Provide the following information for consultants/contractors: name of contractor or organization, hourly rate, number of hours, services to be provided. In Form C provide a brief background about the contractor including how previous experience relates to the project. If the contractor has not been selected, include a description of the availability of contractors for the services or product, a description of the availability of contractors for the services or product, and the method that will be used for choosing a contractor. Hourly rate and number of hours Name: Organization: Services: Hourly Rate Hours Total $ 18

19 Hourly Rate Hours Total Total Consultant Costs: $ D. EQUIPMENT: Equipment costs are not allowed. Item Unit Cost/Unit Total Cost Total Equipment Costs: $ E. SUPPLIES: List each item requested, the number needed, and cost per unit. Include expected costs for general operating expenses such as office supplies, postage, photocopying, and printing. Item Unit Cost/Unit Total Cost $ $ $ $ Total Supply Costs: $ F. TRAVEL: Provide estimated travel costs below for in-state travel. Include travel costs for hotels, meals, and attending learning community meetings. Include the estimated number of miles planned for project activities and the rate of reimbursement per mile. Out of state travel is not an eligible expense. Travel costs are not to exceed rates established in the Commissioner's Plan ( Item Total Cost Total Travel Costs: $ G. OTHER: If applicable, list items not included in previous budget categories below. Include a detailed description of the proposed expenditures in Form C Budget Justification Narrative. Consult budget instructions in Section 11G for examples of allowable costs in this category. Item Total Total Other Costs: $ Item Total Cost GRAND PROJECT TOTAL $ 19

20 Form C: Budget Justification Form MDH Grant Program Name: Applicant Agency: Contact Person: Phone Number: Address: Budget Period: 9 month period between September 2018 and June 2019 Revision # (MDH use only): 1. Salary and Fringe: 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. Justification: REQUESTED DOLLARS: Total Salary and Fringe $ 2. Contractual Services: List the services your organization expects 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 expected to be paid. This can include staff from partner agencies. Supplies and travel of contractor should be included, if applicable. Itemize equipment rented or leased for the project Justification: REQUESTED DOLLARS: Total Contractual Services $ 3. Travel: Explain your expected instate travel costs, including mileage, parking, hotel and meals. At a minimum, your organization must include the cost for staff members to attend MDH-sponsored inperson trainings or meetings. If program staff will travel, itemize the costs, frequency and the nature of the travel. Justification: REQUESTED DOLLARS: Total Travel $ 20

21 4. Supplies and Expenses: Explain the expected costs for items and services your organization will purchase to run your program. Include telephone expenses that are part of this proposal; cell phones and new telephone equipment to be purchased, if applicable. Estimate postage if part of the project. List 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, equipment under $5,000 and items such as rent for program space, participant transportation, participant training and other direct costs as needed. Justification: REQUESTED DOLLARS: Total Supplies and Expenses $ 5. Other: 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 per year per person. Justification: REQUESTED DOLLARS: Total Other $ 6. TOTAL (sum of lines 1-5) $ Item Amount Salaries/Fringe $ Contractual Services $ Travel $ Supplies and Expenses $ Other $ Total $ 21

22 Form D: Due Diligence Due Diligence Review Form The Minnesota Department of Health (MDH) conducts pre-award assessments of all grant recipients prior to award of funds in accordance with federal, state and agency policies. The Due Diligence Review is an important part of this assessment. These reviews allow MDH to better understand the capacity of applicants and identify opportunities for technical assistance to those that receive grant funds. Organization Information Organization Name: Organization Address: If the organization has an Employer Identification Number (EIN), please provide EIN here: If the organization has done business under any other name(s) in the past five years, please list here: If the organization has received grant(s) from MDH within the past five years, please list here: Section 1: To be completed by all organization types Section 1: Organization Structure Points 1. How many years has your organization been in existence? Less than 5 years (5 points) 5 or more years (0 points) 2. How many paid employees does your organization have (part-time and full-time)? 1 (5 points) 2-4 (2 points) 5 or more (0 points) 3. Does your organization have a paid bookkeeper? No (3 points) Yes, an internal staff member (0 points) Yes, a contracted third party (0 points) SECTION 1 POINT TOTAL 22

23 Section 2: To be completed by all organization types Section 2: Systems and Oversight Points 4. Does your organization have internal controls in place that require approval before funds can be expended? No (6 points) Yes (0 points) 5. Does your organization have written policies and procedures for the following processes? Accounting Purchasing Payroll No (3 points) Yes, for one or two of the processes listed, but not all (2 points) Yes, for all of the processes listed (0 points) 6. Is your organization s accounting system new within the past twelve months? No (0 points) Yes (1 point) 7. Can your organization s accounting system identify and track grant program-related income and expense separate from all other income and expense? No (3 points) Yes (0 points) 8. Does your organization track the time of employees who receive funding from multiple sources? No (1 point) Yes (0 points) SECTION 2 POINT TOTAL 23

24 Section 3: To be completed by all organization types Section 3: Financial Health Points 9. If required, has your organization had an audit conducted by an independent Certified Public Accountant (CPA) within the past twelve months? Not Applicable (N/A) (0 points) if N/A, skip to question 10 No (5 points) if no, skip to question 10 Yes (0 points) if yes, answer question 9A 9A. Are there any unresolved findings or exceptions? No (0 points) Yes (1 point) if yes, attach a copy of the management letter and a written explanation to include the finding(s) and why they are unresolved. 10. Have there been any instances of misuse or fraud in the past three years? No (0 points) Yes (5 points) if yes, attach a written explanation of the issue(s), how they were resolved and what safeguards are now in place. 11. Are there any current or pending lawsuits against the organization? No (0 points) If no, skip to question 12 Yes (3 points) If yes, answer question 11A 11A. Could there be an impact on the organization s financial status or stability? No (0 points) if no, attach a written explanation of the lawsuit(s), and why they would not impact the organization s financial status or stability. Yes (3 points) if yes, attach a written explanation of the lawsuit(s), and how they might impact the organization s financial status or stability. 12. From how many different funding sources does total revenue come from? 1-2 (4 points) 3-5 (2 points) 6+ (0 points) SECTION 3 POINT TOTAL 24

25 Section 4: To be completed by nonprofit organizations with potential to receive award over $25,000 (excluding formula grants) Office of Grants Management Policy requires state agencies to assess a recent financial statement from nonprofit organizations before awarding a grant of over $25,000 (excluding formula grants). Section 4: Nonprofit Financial Review Points 13. Does your nonprofit have tax-exempt status from the IRS? No - If no, go to question 14 Yes If yes, answer question 13A 13A. What is your nonprofit s IRS designation? 501(c)3 Other, please list: 14. What was your nonprofit s total revenue (income, including grant funds) in the most recent twelve-month accounting period? Unscored Unscored Unscored Enter total revenue here: 15. What financial documentation will you be attaching to this form? If your answer to question 14 is less than $50,000, then attach your most recent Boardapproved financial statement If your answer to question 14 is $50,000 - $750,000, then attach your most recent IRS form 990 If your answer to question 14 is more than $750,000, then attach your most recent certified financial audit Signature Unscored I certify that the information provided is true, complete and current to the best of my knowledge. SIGNATURE: NAME & TITLE: PHONE NUMBER: ADDRESS: 25

26 MDH Staff Use Only Section 4A: Nonprofit Financial Review Summary Complete Section 4A for nonprofit organizations with the potential to receive an award over $25,000 (with the exception of formula grants). Skip Section 4A and move to Section 5 for all other grantee types. 1. Were there significant operating and/or unrestricted net asset deficits? Yes if yes, answer questions 3 and 4 No if no, skip questions 3 and 4 and answer questions 5 and 6 2. Were there any other concerns about the nonprofit organization s financial stability? Yes if yes, answer questions 3 and 4 No if no, skip questions 3 and 4 and answer questions 5 and 6 3. Please describe the deficit(s) and/or other concerns about the nonprofit organization s financial stability: 4. Please describe how the grant applicant organization addressed deficit(s) and/or other concerns about the nonprofit organization s financial stability: 5. Granting Decision: 6. Rationale for grant decision: Section 5: Total Points Section 1 + Section 2 + Section 3 = Total Points + + = Section 6: Program Information MDH Grant Program Applicant Project Name MDH Grant Program Name Division/Section Date Nonprofit Review Completed Review conducted by Information 26

27 Minnesota Department of Health PO Box St. Paul, MN Revised 2/2018. To obtain this information in a different format, call: Printed on recycled paper. 27

28 Appendices Appendix A: Appendix B: Appendix C: MDH Sample Grant Agreement MDH Sample Invoice Resources 28

29 Appendix A: MDH Sample Grant Agreement Grant Agreement Number [insert grant number] Between the Minnesota Department of Health and [insert grantee name] Minnesota Department of Health Grant Award Cover Sheet NOTE: THIS GRANT AWARD COVER SHEET, FORMERLY A STAND-ALONE DOCUMENT, IS NOW INCLUDED AS THE FIRST TWO PAGES IN EACH GRANT AGREEMENT AND AMENDMENT TEMPLATE. SEE BELOW FOR INFORMATION ON WHEN IT IS REQUIRED AND WHEN IT IS OPTIONAL. INSTRUCTIONS: FILL IN ALL BLANKS AND DELETE ALL INSTRUCTIONS. INSTRUCTIONS ARE IN RED TEXT. WHEN THIS COVER SHEET IS REQUIRED: IF THE GRANTEE IS RECEIVING FEDERAL FUNDS, SEND THIS ENTIRE FORM TO THE GRANTEE WITH THE FULLY EXECUTED COPY OF THEIR GRANT AGREEMENT. IF THE GRANTEE IS A COMMUNITY HEALTH BOARD (CHB), REGARDLESS IF THEY ARE RECEIVING STATE OR FEDERAL FUNDS, SEND THIS COVER SHEET WITH THEIR FULLY EXECUTED COPY OF THEIR GRANT PROJECT AGREEMENT, AWARD LETTER, OR AMENDMENT WHEN THIS COVER SHEET IS OPTIONAL: GRANT MANAGERS ARE ENCOURAGED TO ALWAYS SEND THE GRANT AWARD COVER SHEET WITH GRANT AGREEMENTS, AWARD LETTERS, OR AMENDMENTS, BUT IF THE GRANTEE IS NOT A CHB, AND THE GRANTEE IS NOT RECEIVING FEDERAL FUNDS, THIS FORM IS OPTIONAL AND ITS PAGES CAN BE DELETED FROM THE TEMPLATE. You have received a grant award from the Minnesota Department of Health (MDH). Information about the grant award, including funding details, are included below. Contact your MDH Grant Manager if you have questions about this cover sheet. DATE: Date grant manager sends cover sheet to grantee ATTACHMENT: Grant Agreement CONTACT FOR MDH: Grant manager name, grant manager phone number, grant manager Grantee SWIFT Information Grant Agreement Information Funding Information Name of MDH Grantee: You can find this information on the first page of the grant agreement Grant Agreement/Project Agreement Number: You can find this information in the grant agreement header Total Grant Funds (all funding sources): $ This is the total dollar amount of state AND federal funds being awarded to the grantee under the grant agreement. 29

30 Grantee SWIFT Information Grant Agreement Information Funding Information Grantee SWIFT Vendor Number: You can find this on the encumbrance worksheet SWIFT Vendor Location Code: You can find this on the encumbrance worksheet Period of Performance Start Date: This is the effective date in the grant agreement. Effective date is the date listed on the grant agreement OR the date all signatures are collected and the agreement is fully executed, whichever is later. Period of Performance End Date: This is the expiration date in the grant agreement. Total State Grant Funds: $ This is the total dollar amount of state funds being awarded to the grantee under the grant agreement. Total Federal Grant Funds: $ This is the total dollar amount of federal funds being awarded to the grantee under the grant agreement. Instructions for completing this form are bracketed. Fill in every blank and delete all instructions, including these instructions, before sending this document to Financial Management for review. Include an encumbrance worksheet to enable Financial Management to encumber the funds for this agreement. Minnesota Department of Health Grant Agreement This grant agreement is between the State of Minnesota, acting through its Commissioner of the Department of Health ("State") and Insert name of Grantee ("Grantee"). Grantee's address is Insert complete address. Recitals 1. Under Minnesota Statutes and Insert the program s specific statutory authority to enter into the grant, the State is empowered to enter into this grant agreement. 2. The State is in need of Add 1-2 sentences describing the overall purpose of the grant. 3. The Grantee represents that it is duly qualified and will perform all the duties described in this agreement to the satisfaction of the State. Pursuant to Minnesota Statutes section 16B.98, subdivision 1, the Grantee agrees to minimize administrative costs as a condition of this grant. 1. Term of Agreement Grant Agreement 1.1 Effective date Spell out the full date, e.g., January 1, 2012, or the date the State obtains all required signatures under Minnesota Statutes section 16C.05, subdivision 2, whichever is later. The Grantee must not begin work until this contract is fully executed and the State's Authorized Representative has notified the Grantee that work may commence. 1.2 Expiration date Spell out the full date, e.g., December 31, 2012, or until all obligations have been fulfilled to the satisfaction of the State, whichever occurs first. 30