NEW MEXICO Trauma System Fund FY 10 Statewide Trauma System Development Application 1
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NEW MEXICO TRAUMA SYSTEM FUND for STATEWIDE TRAUMA SYSTEM DEVELOPMENT Request for Applications for State fiscal year 2010 01 July 2009 30 June 2010 Overview This Request for Applications document describes the required process for eligible projects to receive funding and only for the stated funding period, State fiscal year 2010. Funding will be issued through a separate agreement between each approved organization and the New Mexico Department of Health and will be subject to the state procurement code and sub-grant agreement process. The Trauma System Fund Authority Act (TSFAA) HB 266 was passed in the 2006 by the New Mexico Legislature in response to a 2005 Governor s Trauma Task Force study on the crisis in trauma care in New Mexico. The crisis and mitigation recommendations were described in the Task Force committee s report New Mexico TRAUMA CARE CRISIS 2006. * The TSFA established a Trauma System Fund Authority with clear direction and purpose to: sustain existing trauma centers; support the development of new trauma centers; and, develop a statewide trauma system. The TSFA also created a Trauma System Fund (TSF) to be distributed by the Authority for prescribed purposes The Authority discussed general guidelines for statewide trauma system development funding use; however, the Trauma Advisory and System Stakeholders Committee (TASSC) has been charged to develop the application process, review all applications and make prioritized recommendations to the Authority for funding approval and allocation. This document provides the application process and describes the procedures for submission and funding approval. Funding Focus and Guidelines As stated in the Governor s Task Force Report: (A) trauma system matches the needs of the traumatically injured person to the facility with the resources to treat the patient and achieve the best possible outcome. A trauma system is defined as: an organized, pre-planned approach to caring for the severely injured patient, facilitating optimal outcomes (i.e., life vs. death, health vs. disability). It includes a continuum of care: injury prevention, emergency medical services, community hospital emergency departments, hospital-based trauma centers, hospital inpatient care, rehabilitation and outpatient follow-up treatment. Applicants for funding must address how proposed projects will provide support to trauma system development in New Mexico and are in alignment with New Mexico trauma system strategic planning. Accountability This Application document describes the required process for eligible projects to receive funding and only for the stated funding period, fiscal year 2010. Funding will be issued through a separate agreement between each approved organization and the New Mexico Department of Health and will be subject to the state procurement code and sub-grant agreement process. Funding for future projects may be withheld and a request for the return of funds may occur if the agreement deliverables are not met. For projects resulting in certification, proof of successful certification must be submitted per deliverables as specified in the contract. It will be the responsibility of the funding recipient to submit a record of all costs and activities related to the administration of the project. Funds for projects must be expended or encumbered prior to June 1, 2010. Projects not completed by June 1, 2010 must have a request in writing submitted to the NM Trauma Systems Manager detailing reason for non-completion, expected completion date, and request for extension by June 1, 2010. Funding recipients must participate in a Trauma Advisory and System Stakeholder Committee (TASSC) sponsored subcommittee for the purpose of trauma system development and strategic planning during the funding period. Reports are to be submitted to the state trauma systems manager as detailed in final contract document. The trauma systems manager shall provide performance reports related to funded projects to the Authority to ensure accountability and to maintain an informed membership. 3
Eligible Costs Funding will be provided for approved costs associated with the project and detailed in the approved application and described in the resulting agreement. Examples of costs that are NOT applicable for funding include items such as FTE positions, fringe benefits, indirect costs, supplies, and day-to-day operating expenses (fuel, rent insurance payments, etc.). Land purchases and any construction do not qualify. In-kind commitment of personnel time and other costs toward project goals is expected. Priorities for trauma funding will include: (In no particular order) equipment and training, improvement of injury data collection, support for traumatic injury prevention programs, and rehabilitation programs, with specifics as identified in the cover letter. In cases where a project is not completed or the full allocation of funding is not used, the Authority may redistribute funds at its discretion. The Authority reserves the right to fund a project at any level it deems appropriate based on the merits of the application and available funding. Incurring Costs and Unfunded Applications The Authority reserves the right to reject any or all applications and is not liable for any costs incurred by the applicant. Any costs incurred in the preparation the application shall be borne by the applicant. Application Procedure Deadline for submitting complete applications, including supporting documents, is due close of business April 1, 2009. Submit the completed application to: New Mexico Trauma Systems Manager EMS Bureau, NM DOH 1301 Siler Road, Building F Santa Fe, NM 87507 ATTN: Statewide Trauma System Development Funding Application Submitting an application does not ensure funding from the Trauma System Fund. If projects are funded, any costs incurred prior to the contract beginning date will not be reimbursed. Application Content Applications must be typed or computer generated in letter-sized paper with content described below and not to exceed five pages in length. The applicant may submit up to five additional pages of supporting documentation. Application packet must include: A. A description of the applying organization and service area related to project; B. A complete and specific descriptive statement of the problem the project is to address relating to funding purpose- develop a statewide trauma system and alignment with New Mexico DOH Strategic plan FY08 documents; Develop supportive relationships (system building) with and among New Mexico and adjacent state hospitals that care for New Mexicans with severe injuries. Support existing trauma centers and encourage community hospitals to become designated trauma centers. Promote the state trauma registry program, to include increased participation and receipt of data from additional New Mexico hospitals and adjacent state hospitals caring for New Mexicans with severe injuries. Revise regional and state trauma plans. Provide trauma clinical care and system development education to stakeholders along the trauma care continuum: injury prevention, pre-hospital (emergency medical services), acute care, and rehabilitation. C. A description of how the outcome(s) or impact of the project will be measured and reported; and, D. Estimated Cost of Project: Include a detailed budget narrative detailing specific expenditures); and in-kind contributions E. Letters of collaboration/support 4
. Application Review, Evaluation Process and Criteria All applications will be categorized as local/regional or statewide projects. All completed applications will be reviewed, evaluated, and prioritized with the following evaluation process. The Trauma System Fund Authority will have final approval on project funding. State Wide Projects will be reviewed, evaluated, and prioritized: 1. By ALL regional offices, and the Department of Health EMS Bureau 2. Then TASSC Executive committee, with recommendations from the regional offices, and the Department of Health EMS Bureau 3. Then TASSC General committee, with recommendations from TASSC Executive committee 4. Then to TSFA for review, final approval and allocation of funds, before July 31 Local/Regional Projects will be reviewed, evaluated, and prioritized: 1. By affiliated EMS Regional office, and the Department of Health EMS Bureau 2. Then TASSC Executive committee, with recommendations from the affiliated regional offices and the Department of Health EMS Bureau 3. Then TASSC General committee, with recommendations from TASSC Executive committee 4. Then to TSFA for review, final approval and allocation of funds Evaluation criteria includes, but are not limited to: Project relationship to funding focus and guidelines as outlined in this document, and cover letter, project goal(s)/objectives/activities and related timelines, service area, type of organization, total costs of project, inkind contributions by applicant, and the ability to complete project in the established time period. Past performance will be considered 5
Statewide Trauma System Development Application Begins on next page Please return type written pages below to the DOH Attention: Trauma Systems Manager 1301 Siler Road, Building F Santa Fe, NM 87505 6
Due Date: April 1, 2009 NEW MEXICO TRAUMA SYSTEM FUND for STATEWIDE TRAUMA SYSTEM DEVELOPMENT Request for Applications for State fiscal year 2010 01 July 2009 30 June 2010 APPLICATION AMOUNT REQUESTED Instructions: Every question must be answered. If a section does not apply to your organization, put N/A in the blank. Please enclose three copies of the completed application using the checklist below, to the following address, not later than 01 April 2009. NO FAXED OR IN-COMPLETE APPLICATIONS WILL BE ACCEPTED. New Mexico Trauma Systems Manager EMS Bureau, NM DOH 1301 Siler Road, Building F Santa Fe, New Mexico 87507 505-476-8200 Please follow all instructions, answer all questions, and complete all forms. If you have any questions, or need assistance in the application process, please contact the Trauma Systems Manager at the DOH/EMSBureau, or your regional trauma coordinator. Affiliation: Address: (Applying Agency / Service / Organization) (Street / Mailing Address) (City) (State) (Zip) (+4) Applicant/Contact: (Contact Person for this Application) (Title) (Telephone #) (Fax Phone #) (E-mail Address) Check (X) appropriate Regional EMS Office applicant is affiliated with: Region I Region II Region III Fiscal Agent: Address: (County / Municipality / Hospital / Other) (Street / Mailing Address) (City) (State) (Zip) (+4) Contact Person: (Name) (Title) (Telephone #) (Fax Phone #) (E-mail Address) 7
Type of Agency / Service / Organization: (check all that apply) Volunteer Service First Responders Fire Department EMS Service For-Profit Organization Rehabilitation Proposed Trauma System Development Project: (check all that apply) Trauma Related Professional Education Trauma Research Data Management Upgrading Service Rehabilitation Hospital Educational Organization Community-Based Injury Prevention Non-Profit Organization Other: Please list Community Education Trauma Care Equipment Injury Prevention Trauma Quality Improvement Other: Please list A. Service Area Description: Provide a detailed description of the local/regional or state trauma system development area which will be served with this project. B. Detailed Analysis A complete and specific descriptive statement of the problem the project is to address relating to funding purpose- develop a statewide trauma system and alignment with New Mexico DOH Strategic plan FY0 8
C. Project Impact: A description of how the project will address the problem identified in Section B, and how this will be measured and reported. D. Estimated Cost of Project: Include a detailed budget narrative detailing specific expenditures and In- Kind contributions. (Additional sheets maybe attached here) Project Components Anticipated Cost Cash/In Kind Contributions Actual Request from Trauma System Fund Authority (less cash/in kind) Total Cost of Project: Source(s): Attach additional sheet describing in-kind contributions. E. Letters of Collaboration/Support: Letters of Collaboration or support are required, and must be submitted with your application. Letters of support not included with the application will NOT be considered. Letters from relevant trauma care continuum must address HOW project will strengthen trauma system partnerships within the regional trauma or statewide and relevance to system development. (please attach to application) 9
F. Was the applicant funded by Trauma System Fund Authority in previous years? If yes, describe project, status and outcome: (Please attach sheet) YES NO G. Is this project being partially funded by other sources: YES Please give detailed description of the alternate funding sources for this project. NO 10
ASSURANCES The following are required assurances associated with your Statewide Trauma System Development Funding project for Fiscal Year 08-09: We agree that funds received through this distribution will be used only for the purposes and under the condition expressed in the application or its approved amendment(s); We agree that we will provide the support and involvement either cash and/or in kind contributions as described in this application; We agree that we understand and agree to comply with all applicable requirements of the New Mexico Department of Health; and We agree that the information contained in this application is true and correct to the best of my knowledge. We agree to participate in trauma planning committees as referenced on Page 10 A. 7. Project Coordinator (please print) Name: Title: Address: City, State, Zip: Telephone: Cellular: Fax: Email: Signature : Date : Alternate Contact Person (please print) Name: Title: Address: City, State, Zip: Telephone: Cellular: Fax: Email: Signature : Date : Person Authorized to sign agreement: (please print) Name: Title: Address: City, State, Zip: Telephone: Cellular: Fax: Email: Signature: Date: Medical Director (if needed for Project): (please print) Name: Title: Address: City, State, Zip: Telephone: Cellular: Fax: Email: Signature: Date: 11
NEW MEXICO TRAUMA SYSTEM FUND for STATEWIDE TRAUMA SYSTEM DEVELOPMENT Request for Applications for State fiscal year 2010 01 July 2009 30 June 2010 CHECKLIST Type of Application: (Check one) New Continuation The following checklist is provided to assure that pertinent information has been addressed and included in the application as well as proper signatures and assurances. Components and Factors for Review Maximum Points A. Service Area Description 20 B. Detailed Analysis and Need 25 C. Project Impact 30 D. Cost of Project and Description 15 E. Letters of Collaboration and Support 10 Total Score 100 Check list below will be utilized by DOH staff to verify completeness of application. A no in any of the boxes will deem this application incomplete and will NOT be considered for funding. 1. Amount requested listed on page 5 of application? 2. Proper applying agency/service/organization contact information? 3. Appropriate Regional EMS Office indicated? 4. Proper fiscal agent information provided? 5. Type of Agency / Service / Organization selected? 6. Has the service area for the entire project been sufficiently described? 7. Has the problem/need (detailed analysis) for the entire project been sufficiently described? 8. Has the project impact for the entire project been sufficiently described? 9. Has the budget for the entire proposed project period with sufficient detail been provided? 10. Has sufficient letters of collaboration/support been submitted? 11. Proper signatures and date on appropriate assurances? YES NO 12