Request for Proposals

Transcription

1 Request for Proposals Minnesota Accountable Health Model Emerging Professions Integration Grant Program Round Two July 28, 2014

2 Table of Contents Minnesota Accountable Health Model... 1 Overview... 3 State Innovation Model (SIM)... 3 Background... 6 Why Emerging Professions?... 6 Community Health Worker... 7 Community Paramedic... 8 Dental Therapist... 9 Goals and Outcomes Eligible Applicants Available Funding and Estimated Awards Grant Timeline Application Instructions Required Application Documents Proposal Review Process Contact Information Appendix A Proposal Cover Form Appendix B Budget Form Appendix C Minnesota Emerging Professions Integration Grant Program 2

3 Overview The Minnesota Department of Health (MDH) requests proposals for the Minnesota Emerging Professions Integration Grant Program with the goal of integrating emerging professions into the workforce, including models of accountable care. The grant program will have three funding cycles. This request for proposals (RFP) is for the Minnesota Emerging Professions Integration Grant Program - Round Two. Grant funds from round two are focused on three emerging professions: community health workers, community paramedics and dental therapists/advanced dental therapists. Funds may be used to support professional salary and fringe benefits during the grant period, in order to facilitate the integration of emerging professions into care delivery models. The emerging professional must be a new hire or an existing employee moving into a new role, and have the appropriate training and credentials in one of the three above mentioned emerging professions. Priority will be given to emerging professions practitioners who will work in, or closely partner/coordinate care with, behavioral health, long-term care, local public health, and/or social services settings, and organizations that are participating in, or preparing to participate in, an Accountable Care Organization or similar health care delivery model that provides accountable care (including, but not limited to, the Medicare Shared Savings Program, the Medicare Pioneer ACO Program, or the Medicaid Integrated Health Partnerships program). As health reform continues to change towards deeper coordination of services, better sharing of information, and more accountability for the care delivered, this grant opportunity intends to explore new relationships and team-based approaches using the work of emerging professions as a tool for employers seeking this change. Emerging professions can act as a bridge between clinical or programmatic goals and broader outcomes such as population-based health initiatives. MDH is especially interested in how integrating emerging professions into a team environment changes the work and capacity of others on the team and seeks to evaluate this. For example, by bringing on a community health worker, what changes occur in the output of others on the team, and is the quality of care affected? State Innovation Model (SIM) The Minnesota Emerging Professions Integration Grant Program is part of the Minnesota Accountable Health Model being implemented through the State Innovation Model (SIM) grant. The Minnesota Accountable Health Model (MAHM) is a State Innovation Model (SIM) testing grant awarded by the Center for Medicare & Medicaid Innovation ( Minnesota Emerging Professions Integration Grant Program 3

4 to the Minnesota Department of Human Services (DHS) and Minnesota Department of Health (MDH) in The purpose of the SIM-Minnesota project is to provide Minnesotans with better value in health care through integrated, accountable care using innovative payment and care delivery models that are responsive to local health needs. The funds will be used to help providers and communities work together to create healthier futures for Minnesotans, and drive health care reform in the state. The vision of the Minnesota Accountable Health Model is as follows: Every patient receives coordinated, patient-centered primary care. Providers are held accountable for the care provided to Medicaid enrollees and other populations, based on quality, patient experience and cost performance measures. Financial incentives are fully aligned across payers and the interests of patients, through payment arrangements that reward providers for keeping patients healthy and improving quality of care. Provider organizations effectively and sustainably partner with community organizations, engage consumers and take responsibility for a population s health through Accountable Communities for Health that integrate medical care, mental/chemical health, community health, public health, social services, schools and long-term supports and services. The Minnesota Accountable Health Model will test whether increasing the percentage of Medicaid enrollees and other populations in accountable care payment arrangements will improve the health of communities and lower costs of health care delivery. To accomplish this, the state will expand the Integrated Health Partnerships (IHP) demonstration, formerly called the Health Care Delivery Systems (HCDS) demonstration, administered by the Department of Human Services. ( electionmethod=latestreleased&ddocname=dhs16_161441) The expanded focus will be on the development of integrated service delivery models and use of coordinated care methods to integrate health care, behavioral health, long-term and postacute care, local public health and social services centered on patient needs. To achieve the vision of shared cost and coordinated care, the Minnesota Accountable Health Model includes key investments in five Drivers that are necessary for accountable care models to be successful ( Minnesota Emerging Professions Integration Grant Program 4

5 Driver 1 is Health Information Technology/Health Information Exchange: Providers have the ability to exchange clinical data for treatment, care coordination and quality improvement. Driver 2 is Data Analytics: Providers have analytic tools to manage cost/risk and improve quality. Driver 3 is Practice Transformation: Expanded numbers of patients are served by teambased integrated/coordinated care. Driver 4 is Accountable Communities for Health (ACH): Provider organizations partner with communities and engage consumers, to identify health and cost goals, and take on accountability for population health. Driver 5 is Accountable Care Organization (ACO) Alignment: ACO performance measurement, competencies and payment methodologies are standardized, and focus on complex populations. The activities contained in this RFP, focusing on integrating emerging professions into the care delivery team, are linked to Driver 3. Through the Minnesota Accountable Health Model, Minnesota is working to achieve the vision of the Triple Aim: improved consumer experience of care, improved population health, and lower per capita health care costs. The Minnesota Accountable Health Model: Continuum of Accountability Matrix ( estreleased&rendition=primary&allowinterrupt=1&nosaveas=1&ddocname=dhs16_181836) is designed to illustrate the basic capabilities, relationships and functions that organizations or partnerships should have in place to achieve the long-term vision of the Minnesota Accountable Health Model. It will help the state to identify criteria and priorities for investment, and to lay out developmental milestones that indicate organizations or partnerships are making progress towards the vision. In addition, the Minnesota Accountable Health Model: Continuum of Accountability Matrix Assessment Tool ( is an interactive tool that allows organizations to determine their location on the matrix continuum. MDH and DHS will use this tool to better understand SIM-Minnesota participants and their status in achieving the goals of the Minnesota Accountable Health Model, what SIM supports are needed to achieve the goals, and how we may be able to provide additional tools or resources. This tool will be used to help us develop targets and goals for participating organizations, and to assess their progress. In the Assessment Tool, the terms organization and provider are meant to include a broad range of health and health care providers and support services providers that may or may not Minnesota Emerging Professions Integration Grant Program 5

6 formally be part of an existing ACO, but that are moving towards greater accountability for quality, cost of care and health of the populations they serve. Many types of organizations, including not only providers of medical care but also organizations that operate in the behavioral health, social services, local public health, long term care/post-acute care settings, community organizations, and other public/private sector partners that provide supportive services to individuals and families, can all have a role in convening, leading or participating in these models. For more information on the SIM grant, the Minnesota Accountable Health Model and other health reform activities visit the State Innovation Model Grant website ( Background The goal of the Minnesota Emerging Professions Integration Grant Program is to foster the integration of emerging professions into the workforce in roles that support the broad goals of the Minnesota Affordable Health Model (MAHM) related to providing coordinated care, across settings, for complex patients, populations and models of accountable care. The background information provides an overview of the emerging professions that are targeted in round two: community health workers, community paramedics and dental therapists/advanced dental therapists. Why Emerging Professions? Minnesota has an ongoing program to track and analyze the state s health care workforce, centered in the MDH s Office of Rural Health and Primary Care (ORHPC). As part of this ongoing work, MDH conducts regular workforce surveys covering a wide range of licensed professions, works with stakeholders around the state to identify, synthesize, and as appropriate respond to emerging workforce concerns, and serves as the lead content experts for discussions on current and future healthcare workforce needs and strategies to resolve potential shortages. Through these and other activities, Minnesota has previously identified a current and growing shortage of primary care and related providers that will, if not addressed, present challenges to accomplishing the state s health reform goals. MDH continues both its statewide workforce monitoring and its state investments in health professions education, loan forgiveness and other workforce development strategies. In addition, through this federal State Innovation Model (SIM) Program, MDH will advance the development of and monitor the impact of three emerging professions: the Community Health Worker (CHW); the Community Paramedic (CP); and Dental Therapy which includes the Minnesota Emerging Professions Integration Grant Program 6

7 Dental Therapist (DT) and the Advanced Dental Therapist (ADT). MDH has been involved in the conception and development of these occupations, in large part because of their potential to contribute to the spread of team care models and the roll out of Health Care Homes and other emerging models of care delivery. Emerging professions have the potential to work for a wide range of organizations and in a wide range of settings. For example, a medical clinic may hire a community health worker to partner with local public health and extend a range of services to an underserved community. A hospital may hire a community paramedic and partner with long-term care organizations to provide services through transitions of care. A dental clinic may hire a dental therapist and work across sectors to expand services to behavioral health patients. These examples, and similar scenarios, display how emerging professions may be integrated into the workforce in ways that align with the overall goals of the SIM grant. Community Health Worker According to the American Public Health Association, a CHW is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy. ( According to Minnesota Statute 256B.0625, subdivision 49, ( the state s Medical Assistance (MA) program covers care coordination and patient education services provided by a CHW if the CHW has: 1. Received a certificate from the Minnesota State Colleges and Universities System approved community health worker curriculum; or 2. At least five years of supervised experience with an enrolled physician, registered nurse, advanced practice registered nurse, mental health professional as defined in section , subdivision 18, clauses (1) to (6), and section , subdivision 27, clauses (1) to (5), or dentist, or at least five years of supervised experience by a certified public health nurse operating under the direct authority of an enrolled unit of government. Community Health Workers must work under the supervision of a Medical Assistance-enrolled physician, registered nurse, advanced practice registered nurse, mental health professional as defined in section , subdivision 18, clauses (1) to (6), and section , subdivision Minnesota Emerging Professions Integration Grant Program 7

8 27, clauses (1) to (5), or dentist, or work under the supervision of a certified public health nurse operating under the direct authority of an enrolled unit of government. Care coordination and patient education services covered under this subdivision include, but are not limited to, services related to oral health and dental care. Minnesota s Medicaid program has covered CHW services since Covered services are defined as diagnosis-based health education as ordered by the CHW s supervising provider. As defined above, many provider types may supervise CHWs, including physicians, dentists, public health nurses and mental health professionals among others. The supervising provider is responsible for developing the patient health curriculum with the CHW, ordering the service, and billing Medicaid on the CHW s behalf. Community Paramedic A 2012 Legislative Report from the Minnesota Department of Human Services describes how the concept of the Community Paramedic (CP) grew from the traditional career ladder of Emergency Medical Technicians (EMTs). Most EMTs begin with a basic curriculum in emergency medicine and, over the course of a career, gain new skills and certifications through training. The typical ladder begins as a certified First Responder, then an Emergency Medical Technician Basic (EMT-B), then an Emergency Medical Technician Intermediate (EMT-I). Eventually, EMTs can obtain a certification to become an Emergency Technician Paramedic (EMT-P). The Community Paramedic certification offers career Paramedics a new level of training and a new way to contribute their skills. ( Paramedics-Legislative-Report.pdf) According to Minnesota Statute 256B.0625, subdivision 60 ( ws.0.1.0) Medical Assistance covers services provided by community paramedics who are certified under section 144E.28, subdivision 9, when the services are provided in accordance with this subdivision to an eligible recipient. Payment for services provided by a CP under this subdivision must be a part of a care plan ordered by a primary health care provider in consultation with the medial director of an ambulance service and must be billed by an eligible provider enrolled in medical assistance that employs or contracts with the community paramedic. The care plan must ensure that the services provided by a CP are coordinated with other community health providers and local public health agencies and that CP services do not duplicate services already provided to the patient, including home health and waiver services. Community Paramedic services are to include health assessment, chronic disease monitoring and education, medication compliance, immunizations and vaccinations, laboratory specimen collection, hospital discharge follow-up care, and minor medical procedures approved by the ambulance medical director. Services Minnesota Emerging Professions Integration Grant Program 8

9 provided by a CP to an eligible recipient who is also receiving care coordination services must be in consultation with the providers of the recipient s care coordination services. Community Paramedic services have been covered by Minnesota s Medicaid program since 2012, and Minnesota is the first state to cover this newly developed profession. Community Paramedics work under the direct supervision of the Medical Director of an ambulance service, who is responsible for coordinating CP services with the patient s primary care provider. Dental Therapist Dental Therapists (DT) and Advanced Dental Therapists (ADT) in Minnesota practice as part of a dental team to provide educational, clinical and therapeutic services. Minnesota law defines specific educational, examination and practice requirements for licensed dental therapists and advanced dental therapists. One distinctive provision is that, according to Minnesota Statute 150A.105, Subdivision 2 and 3, ( a DT or ADT is limited to primarily practicing in settings that serve low-income, uninsured, and underserved patients or in a dental health professional shortage area. A DT or ADT must enter into a written collaborative management agreement with a Minnesota-licensed dentist. A collaborating dentist is limited to entering into a collaborative agreement with no more than five DTs or ADTs at any one time. Collaboration agreement specifications for dental therapists ( %20CMA%20Approved%20Sept%2024% pdf) and advanced dental therapists ( CMA% approved.pdf) are available from the Minnesota Board of Dentistry. A collaborating dentist must be licensed and practicing in Minnesota. The collaborating dentist shall accept responsibility for all services authorized and performed by the DT or ADT pursuant to the management agreement. Any licensed dentist who permits a DT or ADT to perform a dental service other than those authorized under this section or by the board, or any DT or ADT who performs an unauthorized service, violates sections 150A.01 to 150A.12. Collaborative management agreements must be signed and maintained by the collaborating dentist and the DT or ADT. Agreements must be reviewed, updated and submitted to the board on an annual basis. Minnesota Statute 150A.105, subdivision provides further detail on the scope of practice, dispensing authority, and use of dental assistants for DTs or ADTs. Dental Therapists and Advanced Dental Therapists can significantly expand access to underserved populations by expanding the reach of a supervising dentist through a collaborative management agreement (in the case of DTs) or through independent practice (for ADTs). These midlevel professionals have the potential not only to increase access generally, Minnesota Emerging Professions Integration Grant Program 9

10 but also to reduce emergency visits for dental pain and infection. Minnesota Statute 150A.106, subdivisions 2 4 ( provides further detail on the scope of practice, practice limitation and medications for advanced dental therapists. Goals and Outcomes The goal of the Minnesota Emerging Professions Integration Grant Program is to foster the integration of emerging professions into the workforce in roles that support the broad goals of the Minnesota Affordable Health Model (MAHM) related to providing coordinated care, across settings, for complex patients, populations and models of accountable care. Grant funds from round two are focused on three emerging professions: community health workers, community paramedics and dental therapists/advanced dental therapists. Funds may be used to support professional salary and fringe benefits during the grant period, in order to facilitate the integration of emerging professions into care delivery models, including accountable care organizations. The Minnesota Emerging Professions Integration Grant Program has three main objectives to reach the goal of integrating emerging professions into the workforce. First, MDH will provide funds to support an employer who wants to include an emerging professional as a part of their team. The grant-supported position will be a new position, or an existing position moving into a new role, and will remain beyond the grant period. MDH recognizes that the grant award is not sufficient to cover all salary and fringe costs for such a position, and applicants will need to fund the difference through reimbursement for services or other sources. If the emerging professional terminates his/her position during the grant period, funds may then be re-directed to another candidate, with notification of and approval by the State. Applicants may or may not have identified the grant-supported professional to hire at the time of application. If the professional has been identified, the applicant may name him/her in the application. If the professional has not been identified, MDH recommends that the applicant begin the recruiting process as soon as possible. In that case, the applicant may include up to 30 days of recruitment time in the project work plan. Second, MDH will provide resources and technical assistance to grantees to help them integrate the emerging professional. MDH has an Emerging Professions Coordinator who will serve as the grant manager and can provide support to grantees. This may include assistance in recruitment of an emerging professions practitioner, facilitation of occasional meetings to monitor progress, Minnesota Emerging Professions Integration Grant Program 10

11 and assistance with components of the evaluation process during and at the completion of the grant period. Third, MDH will collect information from grantees to evaluate the level of success in emerging profession integration. Grantees will participate in an evaluation that will include reporting at the mid- and end-point of the grant period. Along with meeting the self-defined goals and objectives required as a part of the application, grantees should expect to provide qualitative feedback and quantitative data through a variety of evaluation activities, and to share tools or resources they have developed as part of their funded project. Evaluation activities may include key informant interviews, patient/client satisfaction surveys and data sharing. Grantees should include evaluation participation in their work plan, particularly near the end of the project. MDH expects that grantees will: Hire an emerging professions practitioner full-time, for the duration of the grant o Any costs in excess of the grant dollars available will be incurred by the grantee Participate in activities required for monitoring grant progress Fulfill reasonable requests for information and data related to evaluation of the grant Share resources developed and lessons learned during the grant period Grantees are also strongly encouraged to participate in other SIM activities, such as statewide learning collaboratives or topic-specific learning communities, as appropriate for their funded project and their organizational needs. In combination, the goals, objectives and outcomes of the Minnesota Emerging Professions Integration Grant Program will build a base of knowledge around emerging professions. MDH will continuously update and share information with internal and external partners about the progress of the program. Lessons learned from this grant program will also contribute to the development of several toolkits, which will be broadly shared as they are completed. Minnesota Emerging Professions Integration Grant Program 11

12 Eligible Applicants Eligible applicants for this RFP include any type of organization that has the capacity to employ a community health worker, community paramedic, dental therapist or advanced dental therapist. These emerging professions have the potential to work for a wide range of organizations in a wide range of settings. Potential examples of eligible applicants may include hospitals, clinics, ambulatory services, health care homes, emergency medical services, health care providers, nonprofits, educational settings, mental health centers, dental offices, senior centers, faith-based programs, nursing homes, local public health programs, group homes, inpatient mental health facilities, and human services programs, including substance use disorder treatment programs. Priority will be given to emerging professions practitioners who will work in, or closely partner/coordinate care with, behavioral health, long-term care, local public health, and/or social services settings, and organizations that are participating in, or preparing to participate in, an Accountable Care Organization (ACO) or similar health care delivery model that provides accountable care (including, but not limited to, the Medicare Shared Savings Program, the Medicare Pioneer ACO Program, or the Medicaid Integrated Health Partnerships program). Eligible applicants may receive funding for only one round of the Minnesota Emerging Professions Integration Grant Program. Applicants must include information about any other grant funding associated with the work of an emerging professions practitioner to be funded by this grant. Minnesota Emerging Professions Integration Grant Program 12

13 Available Funding and Estimated Awards MDH will release three Requests for Proposals under the Minnesota Emerging Professions Integration Grant Program. Release dates and award amounts are subject to change based on available funding. 1. Minnesota Emerging Professions Integration Grant Program Round One RFP Release Date: Monday, April 21, 2014 Estimated Grant Period: July, 2014 June 30, 2015 Total Funding Available: $180,000 Estimated Number of Grant Awards: Two (2) grants for each emerging profession, for a total of up to six (6) grants. Maximum Award Amount: Each grant is up to $30, Minnesota Emerging Professions Integration Grant Program Round Two RFP Release Date: Anticipated July 2014 Grant Period: November, 2014 October, 2015 Total Funding Available: $120,000 Estimated Grant Awards: Up to four (4) grants available; each grant is up to $30, Minnesota Emerging Professions Integration Grant Program Round Three RFP Release Date: Anticipated July 2015 Grant Period: October 1, 2015 September 30, 2016 Total Funding Available: $50,000 Estimated Grant Awards: Up to two (2) grants available; each grant is up to $25,000. Grant Timeline Below is the timeline for the Minnesota Emerging Professions Integration Grant Program Round Two. RFP posted: July 28, 2014 RFP informational call: August 6, 2014 from 3:00 p.m. 4:00 p.m. (Call-in Number: , Passcode: ) Proposals due to MDH: September 19, 2014 by 4:00 p.m. CST Estimated notice of awards: October, 2014 Estimated Grant start date: November 3, 2014 Grant end date: One year from execution of the grant agreement Minnesota Emerging Professions Integration Grant Program 13

14 Application Instructions This RFP and all of the required application documents are available on the MDH website ( You can also receive the documents by ing Kay Herzfeld at with Application Documents as the subject line. Applicants should only submit the documents listed in the Required Application Documents section. Extraneous materials will be discarded and not passed on to reviewers. Applicants must submit one unbound signed original and three unbound, copies of the application. Application forms must be completed using word processing and spreadsheet software. Narrative documents must be double-spaced with one-inch margins, and no longer than the designated page limit. The font size on forms and narratives must be 12-point font. All pages must be numbered sequentially. If possible, please send an electronic copy of the application, in addition to your paper submission, to Proposals must be received by 4:00 p.m., Friday, September 19, 2014, at the following address: Minnesota Department of Health Office of Rural Health and Primary Care ATTN: Kay Herzfeld Courier Address: Mailing Address: 85 East 7 th Place P.O. Box Saint Paul, Minnesota Saint Paul, Minnesota Out of fairness to the other applicants, late proposals will not be considered. Minnesota Emerging Professions Integration Grant Program 14

15 Required Application Documents Proposals for the Minnesota Emerging Professions Integration Grant Program must include the components outlined below. Proposals must not exceed 12 pages of double-spaced 12- point font. The 12-page limit includes only items 2-4 below. 1. Proposal Cover Form (see Appendix A) 2. Project Summary (1-2 pages). Brief summary of the emerging professions integration project including the hiring organization, areas/populations to be served, key partner organizations, demonstrated financial need and goals. 3. Emerging Professions Integration Description (6-8 pages) a. Brief description of the organization seeking to hire an emerging professional: Community Health Worker, Community Paramedic, Dental Therapist or Advanced Dental Therapist. b. Identify the grant-supported professional, if known. Identify the professional s credentials, and whether the professional is a new hire or an existing employee moving into a new role. If the emerging professional has yet to be identified, include plans for recruitment. c. Identify the supervisor who will be responsible for overseeing the work of the emerging professions employee. d. Describe the role of the grant-supported professional (goals/outcomes/objectives) with respect to community health needs and health care services. e. Describe how the emerging professions employee will be used to coordinate care across other sectors for example, behavioral health, long-term care, local public health, and/or social services. Include, if relevant, a description of partner organizations with which the organization or employee will be working. f. Describe any existing or planned participation by the applicant organization in an Accountable Care Organization (ACO) model or any similar shared-risk arrangement. g. Describe plans to orient the emerging professions employee and include how their work will be integrated into the workflow of the organization. Include plans for position sustainability beyond the grant period. Describe how the work of the emerging professions employee will impact the work of others in the organization. h. Describe the specific goals that the organization will achieve through grant funding, and how progress towards these goals will be measured. Examples could include number or type of patients served, types of services (including care coordination) provided, partnerships established, revenue, patient satisfaction, patient outcomes, or other indicators. i. Describe how the grant funding will be used to achieve the goals of accountable care and the triple aim of improving quality and patient experience and reducing costs. Minnesota Emerging Professions Integration Grant Program 15

16 4. Target Population (1-2 pages) a. Identify the target patient population and communities the emerging professions employee will serve. Include details on how the emerging professions employee will serve the needs of the population. If applicable, describe how this project meets the needs of the community in rural and/or underserved areas. Priority will be given to projects that focus on patients/clients who are transitioning between care settings or from a care setting to home, who have multiple chronic conditions (including behavioral health as well as physiological conditions), or who are receiving medical and social services supports, or who are in need of primary prevention services. b. Describe how this project may improve health outcomes of the community to be served. Include a description of the emerging professional s potential to impact health disparities in the community or population being served. Describe how this project aligns with local public health needs assessment, hospital community health needs assessments, county gaps analysis survey for long-term care, and/or other state or local health planning efforts specific to the community being served. 5. Work Plan Describe the work plan to achieve all of the goals/objectives proposed in the project description section. Include a timeline for the work plan. Include plans to participate in evaluation activities. 6. Budget Salary and fringe benefit costs are eligible grant expenses for integrating the emerging professional. Attach a line-item budget as a separate document (see Appendix B for Budget Form). If applicable, include matching funds and revenue projections of Medicaid or other third-party billing for the emerging professional. Budget Narrative Provide information on how each of the line items shown in the budget were calculated. For example, include hourly wage and salary dollars and fringe benefit calculations. 7. Include a completed copy of Assessment Tool Results from the Minnesota Accountable Health Model: Continuum of Accountability Matrix Assessment Tool ( Note: This Minnesota Accountable Health Model: Continuum of Accountability Matrix location and/or specific assessment results will not be part of the criteria for grant award or funding decisions. It is a requirement of all grantees that receive SIM funding, and for purposes of this grant is being used primarily as a self-assessment tool 8. Applicant must complete the Financial Capability Form (please see Appendix C). 9. Applicant must submit an internal financial statement, an IRS Form 990, or the most recent certified financial audit. Minnesota Emerging Professions Integration Grant Program 16

17 Proposal Review Process Grant proposals will be reviewed and evaluated by a panel familiar with the Minnesota Accountable Health Model and the goals of integrating emerging professionals. The panel may include staff from the Minnesota Department of Health, Minnesota Department of Human Services, Advisory Task Force members and the community at large. The panel will recommend selections to the Commissioners of Health and Human Services. In addition to panel recommendations, the commissioners may also take into account other relevant factors in making final awards. The grant proposals will be scored on a 100-point scale as listed below. Criteria Project Description Target Population Work Plan Budget Maximum Points 30 points 30 points 30 points 10 points Total 100 points Contact Information Questions about the Minnesota Emerging Professions Integration Grant Program and the proposal process should be directed in writing to: Kay Herzfeld Office of Rural Health and Primary Care Minnesota Department of Health kay.herzfeld@state.mn.us Other personnel are NOT authorized to discuss this request for proposal with Responders, with the exception of the RFP informational call, before the proposal submission deadline. Contact regarding this RFP with any personnel not listed above could result in disqualification. Minnesota Emerging Professions Integration Grant Program 17

18 Appendix A Proposal Cover Form 1. Please select the Emerging Profession that will be supported with this grant: Community Health Worker Community Paramedic Dental Therapist/Advanced Dental Therapist 2. Lead Applicant Organization- organization that will serve as the fiscal agent for project. Grant agreement will be executed with this organization Legal Name Federal Tax ID # State Tax ID # 3. Total amount of state grant funds applied for: $ Total dollar value of match (cash or in-kind): $ 4. Contact Person for Further Information on Proposal: Name Title Organization: Address: Phone I certify that the information contained herein is true and accurate to the best of my knowledge, and I have been authorized to submit this proposal on behalf of the applicant organizations listed above. Signature of Authorized Official Title of Authorized Official Date Minnesota Emerging Professions Integration Grant Program 18

19 Appendix B Budget Form Salary Categories Grant Funding Requested Funding from Other Sources Total Fringe TOTAL Note: The budget must be accompanied by a budget justification narrative that explains each line item. Include other funding sources and calculations, including revenue projections from third-party billing. Minnesota Emerging Professions Integration Grant Program 19

20 Appendix C The Accounting System and Financial Capability Questionnaire is on the next page. This form is also available on the MDH Office of Rural Health and Primary Care website ( Minnesota Emerging Professions Integration Grant Program 20

21 ACCOUNTING SYSTEM AND FINANCIAL CAPABILITY QUESTIONNAIRE This is the standard form to be used in order to determine the financial capacity of grant applicants. The creation and implementation of this form is in response to the best practices stated in the Office of Legislative Auditor s report State Grants to Nonprofit Organizations, January This form should be used for applicant agencies that: are requesting, or will receive, more than $50,000; are new to state granting; are recently incorporated (five years or less); had previous unfavorable financial performance with federal and/or state funds; had significant audit findings; or for any applicant whose financial capacity is unknown or questionable. No applicants will be excluded from receiving funding based solely on the answers to these questions. SECTION A: APPLICANT INFORMATION 1. Organization Name and Address 2.Employer Identification Number 3.Number of Employees Full Time: Part Time: 4. When did the applicant receive its 501(c)3 status? (MM/DD/YYYY)? 5. Is the applicant affiliated with or managed by any other organizations (Ex. regional or national offices)? YES NO If Yes, provide details: 6a. Total revenue in most recent accounting period (12 months). 5b. Does the applicant receive management or financial assistance from any other organizations? YES NO If Yes, provide details: 6b. How many different funding sources does the total revenue come from? 7. Does the applicant have written policies and procedures for the following business processes? a. Accounting Yes No Not Sure If yes please attach a copy of the table of contents b. Purchasing Yes No Not Sure If yes please attach a copy of the table of contents c. Payroll Yes No Not Sure If yes please attach a copy of the table of contents SECTION B: ACCOUNTING SYSTEM 1.Has a Federal or State Agency issued an official opinion regarding the adequacy of the applicants accounting system for the collection, identification and allocation of costs for grants Yes No Note: If a financial review occurred within the past three years, omit Questions 2 6 of this Section and 1-3 of Section C. a. If yes, provide the name and address of the reviewing agency: b. Attach a copy of the latest review and any subsequent documents. 2. Which of the following best describes the accounting system? Manual Automated Combination 3. Does the accounting system identify the deposits and expenditures of program funds for each and every grant separately? Yes No Not Sure 4. If the applicant has multiple programs within a grant, does the accounting system record Yes No Not Sure the expenditures for each and every program separately by budget line items? Not Applicable 5. Are time studies conducted for an employee(s) who receives funding from multiple Yes No Not Sure sources? No Multiple Sources 6. Does the accounting system have a way to identify over spending of grant funds? Yes No Not Sure SECTION C: FUND CONTROL 1. Is a separate bank account maintained for grant funds? Yes No Not Sure 2. If grant funds are mixed with other funds, can the grants expenses be easily identified? Yes No Not Sure 3. Are the officials of the organization bonded? Yes No Not Sure SECTION D: FINANCIAL STATEMENTS 1. Did an independent certified public accountant (CPA) ever examine the organization s financial statements? Yes No Not Sure SECTION E: CERTIFICATION I certify that the above information is complete and correct to the best of my knowledge. 1. Signature 2. Date / / 3. Title 21