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FinalKittitasCountyReviewForm/KlTTIT45flWTT1Grants&ContractAgreementToday'sDatePACamasRequest#:06/15/2022Fund/DepartmentAgendaDate:116-PublicHealthContract/GrantInformationContract/GrantAgency:HCAAmendmentforABCDKittitasCountyPeriodBeginDate:July1,2022PeriodEndDate:June30,2024TotalGrant/ContractAmount:$25,386.00Grant/ContractNumber:K2747Amendment4Contract/GrantSummary:•TheMaximumCompensationpayabletotheContractorfortheperformanceofallthingsnecessaryfororincidenttotheperformanceoftheworkassetforthinScheduleA-3:StatementofWorkhasincreasedby$25,376.00,foranewContractMaximumCompensationof$68,638.00,andincludesanyallowableexpenses.•ScheduleA-2:StatementofWorkisreplacedinitsentiretywithScheduleA-3:StatementofWork,attachedheretoandincorporatedherein.•ExhibitA-2:ABCDQuarterlyCommunityandProviderOutreachandCaseManagementReportisreplacedinitsentiretywithExhibitA-3:ABCDQuarterlyCommunityandProviderOutreachandcaseManagementReport,attachedheretoandincorporatedherein.•ExhibitB-2:ABCDQuarterlyOutreachandCoordinationofCareReportisreplacedinitsentiretywithExhibitB-3:ABCDQuarterlyOutreachandCoordinationofCareReport,attachedheretoandincorporatedherein.•ExhibitC-1:ABCDYearlyBudgetToolisreplacedinitsentiretywithExhibitC-2:ABCDYearlyBudgetTool,attachedheretoandincorporatedherein.RecommendationforBoardofHealthReviewonDepartmentHeadSignature:,DirectorDate:KittitasCountyProsecutor,Auditor,andBoardofHealthReviewandComment:APPROVEDASTOFORM:SignatureofProsecutor'sOfficeDateSignatureofAuditor'sOfficeDateVerificationtheContractingAgencyisnotSuspended/Disbarred:Agencyisnotsuspended/disbarredONotChecked(reason)Grant/ContractReviewPage1 FinancialInformationTotalAmount$25,386.00StateFunds$FederalFunds$PercentageCountyFundsMatchingFunds$CFDA#In-Kind$ExplainMquipmentbeingpurchased?Whoownsequipment?NewPersonnelbeinghired?ContactHRhiring--reportingrequirementsFutureimpactsorliabilitytoKittitasCounty:BudgetInformationBudgetAmendmentNeeded?YesattachbudgetformNowhynotNewDivisionCreated?116.612.24.1.333.93778(Fed)RevenueCode116.612.24.1.334.06901(State)ExpenseCode116.612.24.1PassThroughInformationAgencytoPassThroughAmounttoPassThroughExpenseCode:Sub-contractApprovedDate:ProsecutorReviewHastheProsecutorreviewedthisagreement?YesNoOCountyDepartmentsImpactedAuditor¯FacilitiesMaintenanceInformationServicesHumanResourceProsecutorTreasurerBOCCApprovalNeeded?Yes[X]NoStaffMemberPresenting:AudiMartinezAssignmentofTrackingInformationAuditor'sOfficeHumanResourceProsecutor'sOfficeWhoSignedthegrantapplicationReviewerDateGrant/ContractReviewPage2 DocuSignEnvelopeID:FF14B287-E90C-42B9-8AOF-A14FA00E82AFCONTRACTHCAContractNo.:K2747WashingtonStateAMENDMENTAmendmentNo.:04HealthCareuthorityABCDFDNTALSERVICESTHISAMENDMENTTOTHECONTRACTisbetweentheWashingtonStateHealthCareAuthorityandthepartywhosenameappearsbelow,andiseffectiveasofthedatesetforthbelow.CONTRACTORNAMEASSIGNEDSERVICEREGIONICOUNTYKittitasCountyPublicHealthNetworkKittitasCounty'CONTRACTORADDRESSWASHINGTONUNIFORMBUSINESSIDENTIFIER507NorthNanumSt,Suite#201(UBI)Ellensburg,WA98926WHEREAS,HCAandContractorpreviouslyenteredintoaContractfortoprovide'AccesstoBabyandChildDentistry'(ABCD)servicestodetectandpreventearlychildhooddentaldecaybyengagingdentistsinseeingAppleHealth/Medicaid-eligibleClients,agesbirthtosix(6),withanemphasisonchildrenofcolorandchildren0-2,agessi×(6)tothirteen(13)whoareclientsoftheDevelopmentalDisabilitiesAdministrationandothereligiblebutunderservedchildrenintheservicearea,andengaginglocalpublichealthdepartmentsinoutreachandcasemanagement,and;WHEREAS,HCAandContractorwishtoamendtheContractpursuanttoSection4.3torevisedefinitions,extendtheterm,increasefunds,updatetheScheduleA:StatementofWork,andupdateExhibits;NOWTHEREFORE,thepartiesagreetheContractisamendedasfollows:1.Section3,SpecialTermsandConditions,thefollowingdefinitionsarerevisedtoreadasfollows:a)"ABCD"meansAccesstoBabyandChildDentistry,aprogramdesignedtodetectandpreventearlychildhooddentaldecaybyengagingdentistsinseeingbirthtosix(6)yearoldMedicaideligiblechildrenandclientsoftheDevelopmentalDisabilitiesAdministration(DDA)birthtothirteen(13)yearsoldandengaginglocalpublichealthdepartmentsinoutreachandcasemanagement.e)"Client"meansMedicaideligibleClientsagesbirththroughsix(6)yearsofageandclientsoftheDevelopmentalDisabilitiesAdministration(DDA)birthtothirteen(13)yearsold.h)"Coordinator"meanstheindividualhiredtoorganizeeventsandactivitiesrelatedtotheABCDprogramandwhoalsoactsasaliaisonladvocatebetweenprovidersandfamiliesofABCDeligiblechildrenbirthuptosix(6)yearsoldandclientsoftheDevelopmentalDisabilitiesAdministration(DDA)birthtothirteen(13)yearsold.2.Section3.2Term,subsection3.2.1isdeletedandreplacedinitsentiretyasfollows:Page1of20HCAContractNo.:K2747-04 DocuSignEnvelopeID:FF14B287-E90C-42B9-8AOF-A14FA00E82AF3.2.1TheinitialstartdateoftheContractisJuly1,2018,thetermhasbeenextendedforanadditionaltwo(2)yeartear,andsettocontinuethroughJune30,2024,unlessterminatedsoonerasprovidedherein.3.Section3.3Compensation,subsection3.3.1isrevisedtoreadasfollows:3.3.1TheMaximumCompensationpayabletotheContractorfortheperformanceofallthingsnecessaryfororincidenttotheperformanceoftheworkassetforthinScheduleA-3:Statementof1/Vorkhasincreasedby$25,376.00,foranewContractMaximumCompensationof$68,638.00,andincludesanyallowableexpenses.4.Section4,GeneralTermsandConditions,subsection4.23,LegalandRegulatoryComplianceisreplacedinitsentiretyasfollows:4.23LegalandRegulatoryCompliance4.23.1DuringthetermofthisContract,Contractormustcomplywithalllocal,state,andfederallicensing,accreditationandregistrationrequirements/standards,necessaryfortheperformanceofthisContractandallotherapplicablefederal,stateandlocallaws,rulesandregulations.4.23.2WhileontheHCApremises,ContractormustcomplywithHCAoperationsandprocessstandardsandpolicies(e.g.,ethics,Internet/emailusage,data,networkandbuildingsecurity,harassment,asapplicable).HCAwillmakeanelectroniccopyofallsuchpoliciesavailabletoContractor.4.23.3PursuanttoProclamation21-14-COVID-19VaccinationRequirement(datedAugust9,2021)asamendedbyProclamation21-14.1--COVID-19VaccinationRequirement(datedAugust20,2021)("Proclamation")allcontractorsandanyoftheiremployeesand/orsubcontractorswhoprovidecontractedserviceson-siteatHCAfacilitiesmustcertifythattheyarefullyvaccinatedagainsttheCOVID-19virus,unlessproperlyexceptedorexemptedfordisabilityorsincerelyheldreligiousbeliefsassetforthintheProclamation.Contractorswhocannotsocertifyareprohibitedfromcontractingwiththestate.4.23.4ContractorrepresentsandwarrantsthatshouldtheirresponsibilitiestotheHCAinvolveon-siteservicesasofOctober18,2021,Contractor'spersonnel(includingsubcontractors)providingsuchserviceswillbefullyvaccinatedagainsttheCOVID-19virusunlessproperlyexceptedorexemptedfordisabilityorsincerelyheldreligiousbeliefsassetforthintheProclamation.Contractorfurtherunderstandsthat,uponrequest,ContractorpersonnelmustprovidetoHCAproofofvaccination,inamannerestablishedbytheHCA.FailuretomeettheserequirementsmayresultintheimmediateterminationofthisContract.4.23.5FailuretocomplywithanyprovisionsofthissectionmayresultinContracttermination.5.ScheduleA-2:StatementofWorkisreplacedinitsentiretywithScheduleA-3:StatementofWork,attachedheretoandincorporatedherein.Page2of20HCAContractNo.:K2747-04 DocuSignEnvelopeID:FF14B287-E90C-42B9-8ADF-A14FA00E82AF6.ExhibitA-2:ABCDQuarterlyCommunityandProviderOutreachandCaseManagementReportisreplacedinitsentiretywithExhibitA-3:ABCDQuarterlyCommunityandProviderOutreachandCaseManagementReport,attachedheretoandincorporatedherein.7.ExhibitB-2:ABCDQuarterlyOutreachandCoordinationofCareReportisreplacedinitsentiretywithExhibitB-3:ABCDQuarterlyOutreachandCoordinationofCareReport,attachedheretoandincorporatedherein.8.ExhibitC-1:ABCDYearlyBudgetToolisreplacedinitsentiretywithExhibitC-2:ABCDYearlyBudgetTool,attachedheretoandincorporatedherein.9.ThisAmendmentwillbeeffectiveJuly1,2022("EffectiveDate").10.AllcapitalizedtermsnototherwisedefinedhereinhavethemeaningascribedtothemintheContract.11.AllothertermsandconditionsoftheContractremainunchangedandinfullforceandeffect.ThepartiessigningbelowwarrantthattheyhavereadandunderstandthisAmendmentandhaveauthoritytoexecutetheAmendment.ThisAmendmentwillbebindingonHCAonlyuponsignaturebybothparties.CONTRACTORSIGNATUREPRINTEDNAMEANDTITLEDATESIGNEDChelseyLoeffersPublicHealthDirectorHCASIGNATUREPRINTEDNAMEANDTITLEDATESIGNEDAuRachelleAmerineContractsAdministrator6/3/2022Page3of20HCAContractNo.:K2747-04 DocuSignEnvelopeID:FF14B287-E90C-42B9-8A0F-A14FA00E82AFScheduleA-3:StatementofWork(SOW)TheContractorshallprovidetheservicesandstaff,andotherwisedoallthingsnecessaryfororincidentaltotheperformanceofwork,assetforthbelow:A.InaccordancewithdeadlinesinExhibitA-3,ABCDQuarterlyCommunityandProviderOutreachandCaseManagementReport,developandimplementanABCDactionplaninaccordancewiththeABCDprogramprinciplesandsubmitcorrespondingbudget,usingExhibitC-2,ABCDYearlyBudgetTool.TheABCDprogramprinciplesareoutlinedbelow.1.ProvideoutreachandlinkageofAppleHealth/Medicaid-eligibleClients,agesbirthtosix(6),withanemphasisonchildrenofcolorandchildren0-2,agessix(6)tothirteen(13)whoareclientsoftheDevelopmentalDisabilitiesAdministrationandothereligiblebutunderservedchildrenintheserviceareaincollaborationwithotherorganizations,including,butnotlimitedto:a)Provideoutreachbyattending,visitingorworkingwiththebelow,butnotlimitedtothefollowing:i.Outreachandmarketingeventsandactivitiessuchashealthfairs,useofsocialmedia(i.e.,Facebook,Twitter,Instagram,ConstantContact,etc.)toperformtargetedoutreachactivitiesthateffectivelyconnectwithfamiliesofeligiblechildren;ii.SmileMobile(sponsoredbytheArcoraFoundation)locations(amobiledentalclinicprovidingdentalservicestochildren,pregnantwomen,andothers;iii.Women,Infants,andChildrenWICoffices(afederalassistanceprogramoftheFoodandNutritionServicesoftheUnitedStatesDepartmentofAgriculture;iv.HeadStartandEarlyHeadStartfacilities(afederalprogramthatpromotestheschoolreadinessofchildrenunderfivefromlow-incomefamilies);v.EarlyLearningRegionalCoalitions(thatareanot-for-profitallianceofemployersandcommunitysubsidizedbeforeandafterschoolchildcare);vi.DayCarefacilitiesthroughoutthestateofWashington;vii.Connectwithcommunityhealthworkerorregionalnetworktogainresources,communityconnectionsonoutreacheffortsforeligiblechildrenofcolorandchildrenages0-2;andviii.ConnectandcollaboratewithyourlocalChildrenwithSpecialHealthCareNeeds(CSHCN)program,localDevelopmentalDisabilitiesAdministration(DDA)officeand/orotherorganizationswhoworkwithchildrenwithdisabilitiestofindmethodsandresourcesonhowtoidentifyeligiblechildrenforoutreachwork.b)Providecarecoordination,including:i.Providefamilyorientation;includingbutnotlimitedto,sharinginformationaboutthevalueofaninfant,toddler,oryoungchildgoingtothedentist,whatactivitiestoexpectatthedentist'soffice,andtheimportanceoforalhealthcareathomeandtheimportanceofkeepinganappointment.ii.ConnectfamilieswithanABCDcedifieddentistwhoacceptsAppleHealth/Medicaid,andprovidinginformationincluding,butnotlimitedto,namesandreferralstodentists,sharinginformationaboutinterpretersandtransportationbenefits,andassistinPage4of20HCAContractNo.:K2747-04 DocuSignEnvelopeID:FF14B287-E90C-42B9-8A0F-A14FA00E82AFschedulingappointmentsforeligiblechildrenandfollowingupafteranappointment,ifappropriate;c)WorkwiththeDentistLinkteamtoalignDentistLinktoolwithlocalprogram'sreferralprocessestoensureABCDclientshaveavarietyofcomplementaryavenuesforreferralandlinkagetoABCDproviders.i.CoordinateABCDprogram'sdentistrecruitmentandsupporteffortswithDentistLink'sbyassuringbothprogramshavethesameupdatedinformation:ii.Contacteachpracticetoupdateparticipating-ABCDdentistroster:1.numberandfrequencyofclientsaccepted;2.appointmenttimes/days;3.translationavailabilitytimes/days;4.changebusinessstatusofpractice(notacceptingnewABCDclients,acceptingmoreclients,etc.);5.newproviders,PhaseI,Phasell;and6.other.iii.UpdateABCDproviderrostertoDentistLinkelectronically.iv.Identifyandaddressfamilybarrierstoaccessingoralhealthcare.d)Bi-annuallyconveneorparticipateinacounty-wideorregionaloralhealthcoalitionorABCDsteeringcommitteeorothergroupswhichfocusesonhealthcare,accessorearlylearninginordertobuildawarenessoftheABCDprogramandsolicitinputonprocessimprovementsi.InvitetoparticipateinthemeetingwiththeABCDstatemanagingdirector,theArcoraFoundation,andtheHealthCareAuthoritydentalprogramadministrator.e)ContinuouslycoordinatewiththelocalABCDDentalChampion(s)to:i.IdentifyandrecruitdentalproviderstoacceptandprovidecaretoAppleHealth/Medicaidclientsbirthtosix(6)yearsthroughtheABCDProgram;ii.MaintainalistofactiveABCDdentalandmedicalproviderswhoacceptAppleHealth/MedicaidClientsbirthtosix(6)years,agessix(6)tothirteen(13)whoareclientsoftheDevelopmentalDisabilitiesAdministrationandmonitorprovideravailabilitytoacceptnewClient'sbirthtosix(6)yearsintotheirpractice;iii.SuppodcurrentABCDprovidersbycommunicatingprogramchangesandpolicyupdatesthroughin-personmeetingsandwrittencommunication;iv.Planandimplement,incoordinationwiththeUWSchoolofDentistry,timelyABCDprovidertrainings(PhaseI,II,IIIandrefreshertraining)leadingtocertificationofprovidersandonboardingoftheirstaff;v.AssureproviderABCDcertificationprocessiscompleted;Page5of20HCAContractNo.:K2747-04 DocuSignEnvelopeID:FF14B287-E90C-42B9-8A0F-A14FA00E82AFvi.Provideorarrangefor,timelyAppleHealth/MedicaidbillingtrainingassistancetoABCDofficestaffandproviders,asneeded;vii.Atminimumannuallyupdatedentalsociety(orlocaldentists/studyclubsincountieswithoutasociety)ontheABCDProgramandsupporttheircontinuedparticipationintheprogramandencouragerecruitmentofnewAppleHealth/Medicaidproviders;andviii.SupporttheDentalChampion(s)participationinmeetingsandactivitiesnecessarytoeffectivelyconductAppleHealth/Medicaidprovideroutreach,recruitmentandtraining,includingfinancialsupportofattendance(travel,lodging,etc.)inDevelopmentDay.ix.ParticipateintheannualstatewideABCDChampionDevelopmentDaymeetingtoremaincurrentwithnewclinicalpracticesandopportunities.Meet,network,andshareknowledgewithotherchampionsregardingprogramroadblocksandsuccesses.1.ExtendinvitationtoABCDDentalChampiontoattendtheannualABCDChampionDevelopmentDaymeeting.2.ABCDChampiontravelreimbursement,ifany,toattendDevelopmentDay,isincludedinthetotalcompensation.f)IdentifyandrecruitprimarycaremedicalproviderstoparticipateinAppleHealth/MedicaidasABCDcertifiedproviders,securetheirtrainingthroughArcoraFoundationinpreventiveoralhealthcaretechniques(FamilyOralHealthEducation,fluoridevarnish,etc.)andbuildtheirroleinreferringAppleHealth/Medicaid-eligiblechildrentotheABCDProgram.g)Participateinallthree(3)statewideABCDCoordinatorsgroupmeetingstoremaincurrentwithABCDpolicies,practicesandopportunities.ProgramswhichdonotmeetthisannualcontractrequirementwillbesubjecttocontractreviewbyHCAandpotentially,tolossofthiscontract.h)IdentifyanABCDCoordinatorwithinthecontractingorganizationwhowilldevelopandmaintainadeskmanualthatoutlinestheexpectedABCDcontractualdeliverablesandhowthecontractormeetseachdeliverable.TheCoordinatorwillutilizethismanualtofulfillthecontractualrequirementsandtoorientnewleadstaffwithintheorganizationtotheABCDprogram.i)IftheContractor'sCoordinatorvacatestheposition,theContractormustnotifytheHealthCareAuthoritywithintwoweeksofthecoordinator'sdeparture,and;i.SharetheContractor'sdevelopedworkplanthatoutlineshowtheexpectedcontractdeliverableswillbemet;ii.IncludetheHCAandtheStateManagingPartner,ArocraFoundation,inthehiringprocesstofindanewcoordinator;iii.SharewithHCAthecontactinformationofthenewlyhiredorappointedCoordinator;iv.CoordinatewithHCAtoassureasmoothtransitionoftheexpectedcontractedworkdeliverables,includingparticipationinprogramorientationwithHCAandotherstatepartnersand;v.ABCDCoordinatornewhiremustreasonablymeettheexpectationsasidentifiedinExhibitDABCDCoordinatorPerformanceExpectationsandAbilities.Page6of20HCAContractNo.:K2747-04 DocuSignEnvelopeID:FF14B287-E90C-42B9-8A0F-A14FA00E82AFj)IftheContractordeterminesthatitcannolongerserveastheABCDContractor,reasonablenotice90daysmustbegiventoHCAinordertoassureuninterruptedservicetoclientsandworkwithprovidersand:i.WorkwithHCAandotherstatepartnerstoidentifypotentialnewABCD-leadagencies.2.Eachquarter,thecontractormustcompleteandsubmitthefollowingviaemail:a)CommunityandProviderOutreachandCoordinationCaresummarywhichshallinclude;i.ExhibitA-3,ABCDQuarterlyCommunityandProviderOutreachandCaseManagementReportforthespecificquarter;andii.ExhibitB-3,ABCDQuarterlyOutreachandCoordinationofCareReport.3.Eachyear,thecontractormustcompleteandsubmitviaemailtheExhibitC-2,ABCDYearlyBudgetTool,asapplicabletotherequirements,containedinExhibitA-3.4.ThecontractormustmeetwiththeStateManagingPartner,ArcoraFoundation,onayearlybasistoreviewlocalneeds,utilization,andreviewthedeskmanualthatoutlinestheABCDcontractualdeliverablesandhowthecontractorhasmetorplanstomeetthosedeliverables.5.EachquarterthecontractormustsubmitafullycompletedinvoicethatcorrelateswithdollarvaluesforcompleteddeliverablesoutlinedinExhibitA-3:a)ExhibittemplatesareavailableontheABCDwebsitehttp://abcd-dental.orqlfor-coordinators/:andb)Reportsandbillingmustbesubmittednolaterthanonemonthaftereachquarterenddate,unlessotherwisemutuallyagreedbybothparties.Page7of20HCAContractNo.:K2747-04 DocuSign Envelope ID:FF14B287-E90C-42B9-8A0F-A14FA00E82AF Exhibit A-3 ABCD Quarterly Communityand Provider Outreach and Case ManagementReport Year One July 1,2022 -June 30,2023•1st O.uarter Report Please complete and submit repoli electronically to: Janice Tadeo,ABCD Program Manager at lanice.tadeo®hca.wa.qov Cc:Pixie Needham,Dental Program Administrator at pixie.needham@hca.wa.gov and Heather Gallagher,ABCD State Managing Director,hqallaqher@arcorafoundation.org Organization: ABCD Contact Person: Phone and Email: 1st Quarter 7/1/2022 - Report Due:10/31/2022 9/30/2022 Brief description (for events,provide date heldlattendedl for Maximum staff assignments,provide name and title)-no more than 100 $$available for words (complete Exhibit A-3 and attach supporting document if Performance Category Yes/No this deliverable _groviding additional detail) Attend and participate in ABCD Coordinator/Program Meeting $1,000.00 Community and Provider Outreach _|$1,298.00 |Complete_Exhibit B-3 Coordinate Care $324.00 Complete Exhibit B-3 Complete budget tool and year two action i plan ____I $0 Complete Exhibit C-2 Provide outcome information such as minutes,copies of informationConveneHealthCoalition/ABCD Steering provided or list of items provided,examples of type of OrganizationscommitteeorparticipateinaCoalitionorattended,what were outcomes or next steps for ABCD.Steering Committee Focused on Health Care,Access or Early Learning with ABCD ... as a Quarterly Agenda Item.Send invitation and report back any concernslissues to HCA Dental $500.00 Program Administrator &ABCD Administrator Page 8 of 20 HCA Contract No.:K2747-04 DocuSign Envelope ID:FF14B287-E90C-42B9-8A0F-A14FA00E82AF Exhibit A-3 ABCD Quarterly Communityand Provider Outreach and Case ManagementReport Year One July 1,2022 -June 30,2023•2nd ÛUarter ÑOpOft Please complete and submit report electronically to: Janice Tadeo,ABCD Program Manager at lanice.tadeo hca.wa.gov Cc:Pixie Needham,Dental Program Administrator at pixie.needham@hca.wa.gov and Heather Gallagher,ABCD State Managing Director,hqallaqher@arcorafoundation.orq Organization: ABCD Contact Person: Phone and Email: 2nd Quarter 10/1/2022 - Report Due:01/31/2023 12/31/2022 Maximum Brief description (for events,provide date heldlattendedl for $$available staff assignments,provide name and title)-no more than 100forthiswords(complete Exhibit A-3 and attach supporting document ifPerformanceCategoryYes/No ,deliverable providing additional detail) Community and Provider Outreach _ I _ $1,298.00 Complete Exhibit B-3 Coordinate Care $324.00 Complete Exhibit B-3 Update DentistLink roster $100.00 Complete Exhibit B-3 Submit invoice showing expenses for dental champion to attendAttendandparticipateindevelopmentday$2,000.00 developmentday. Page 9 of 20 HCA Contract No.:K2747-04 DocuSign Envelope ID:FF14B287-E90C-42B9-8A0F-A14FA00E82AF Exhibit A-3 ABCD Quarterly Communityand Provider Outreach and Case ManagementReport Year One July 1,2022 -June 30,2023•3rd Quarter Report Please complete and submit report electronically to: Janice Tadeo,ABCD Program Manager at lanice.tadeo@hca.wa.gov Cc:Pixie Needham,Dental Program Administrator at pixie.needham@hca.wa.qov and Heather Gallagher,ABCD State Managing Director,hqallaqher@arcorafoundation.org Organization: ABCD Contact Person: Phone and Email: 3rd Quarter 1/1/2023 - Report Due:04/30/2023 3/31/2023 Maximum Brief description (for events,provide date heldlattendedl for $$available staff assignments,provide name and title)-no more than for this 100 words (complete Exhibit A-3 and attach supporting Performance Category Yes/No deliverable document if providing additional detail) Attend and participate in ABCD Coordinator/Program Meeting $1,000.00 Community and Provider Outreach $1,298.00 Complete Exhibit B-3 Coordinate Care __$324.00 Complete Exhibit B-3 Provide outcome information such as minutes,copies of Convene Health Coalition/ABCD Steering information provided or list of items provided,examples of type committee or participate in a Coalition or Steering of Organizations attended,what were outcomes or next steps Committee Focused on Health Care,Access or for ABCD. Early Learning with ABCD as a Quarterly Agenda Item.Send invitation and report back any concernslissues to HCA $500.00 Dental Program Administrator &AB_CD Administrator Page 10 of 20 HCA Contract No.:K2747-04 DocuSign Envelope ID:FF14B287-E90C-42B9-8A0F-A14FA00E82AF Exhibit A-3 ABCD Quarterly community and Provider Outreach and Case ManagementReport Year One July 1,2022 -June 30,2023•4th Quarter Report Please complete and submit report electronically to: Janice Tadeo,ABCD Program Manager at lanice.tadeo@hca.wa.qov Cc:Pixie Needham,Dental Program Administrator at pixie.needham hca.wa.gov and Heather Gallagher,ABCD State Managing Director,hqallagher@arcorafoundation.orq Organization: ABCD Contact Person: Phone and Email: 4th Quarter Report Due:07/09/2023 (report due on this 4/1/2023 - date to allow HCA to close out fiscal year)6/30/2023 Maximum Brief description (for events,provide date heldlattendedl for $$available staff assignments,provide name and title)-no more than for this 100 words (complete Exhibit A-3 and attach supporting Performance Category _Yes/No deliverable document if providing additional detail) Attend and participate in ABCD Coordinator/Program Meeting $1,000.00 Update ABCD provider roster to DentistLink $100.00 Complete Exhibit B-3 Community and Provider Outreach |$1,298.00 I Complete Exhibit B-3 Coordinate Care |$324.00 Complete Exhibit B-3 Page 11 of 20 HCA Contract No.:K2747-04 DocuSign Envelope ID:FF14B287-E90C-42B9-8A0F-A14FA00E82AF Exhibit A-3 ABCD Quarterly Community and Provider Outreach and Case ManagementReport Year Two July 1,2023 -June 30,2024•1st O.uarter Report Please complete and submit report electronically to: Janice Tadeo,ABCD Program Manager at lanice.tadeo@hca.wa.gov Cc:Pixie Needham,Dental Program Administrator at pixie.needham@hca.wa.gov and Heather Gallagher,ABCD State Managing Director,hqallaqher arcorafoundation.orq Organization: ABCD Contact Person: Phone and Email: 1st Quarter 7/1/2023 - Report Due:10/31/2023 9/30/2023 Brief description (for events,provide date heldlattendedl forMaximumstaffassignments,provide name and title)-no more than 100 $$available for words (complete Exhibit A-3 and attach supporting document ifPerformanceCategoryYes/No i this deliverable _p_roviding additional detail)Attend and participate in ABCD ,Coordinator/ProgramMeeting $1,000.00 i Community and Provider Outreach $1,298.00 Complete Exhibit B-3CoordinateCare _ $324.00 Complete Exhibit B-3 Complete budget tool and year two action plan $0 Complete Exhibit C-2 .Provide outcome information such as minutes,copies of informationConveneHealthCoalition/ABCD Steenng provided or list of items provided,examples of type of OrganizationscommitteeorparticipateinaCoalitionorattended,what were outcomes or next steps for ABCD.Steering Committee Focused on Health Care,Access or Early Learning with ABCD i as a Quarterly Agenda Item.Send invitation and report back any concernslissues to HCA Dental $500.00 Program Administrator &ABCD Administrator Page 12 of 20 HCA Contract No.:K2747-04 DocuSign Envelope ID:FF14B287-E90C-42B9-8A0F-A14FA00E82AF Exhibit A-3 ABCD Quarterly Communityand Provider Outreach and Case ManagementReport Year Two July 1,2023 -June 30,2024•2nd Quarter Report Please complete and submit report electronically to: Janice Tadeo,ABCD Program Manager at |anice.tadeo@hca.wa.qov Cc:Pixie Needham,Dental Program Administrator at pixie.needham@hca.wa.gov and Heather Gallagher,ABCD State Managing Director,hqallaqher@arcorafoundation.org Organization: ABCD Contact Person: Phone and Email: 2nd Quarter 10/1/2023 - Report Due:01/31/2024 12/31/2023 Maximum Brief description (for events,provide date heldlattended/for $$available staff assignments,provide name and title)-no more than 100 for this words (complete Exhibit A-3 and attach supporting document if Performance Category Yes/No deliverable providing additional detail Community and Provider Outreach $1,298.00 |Complete Exhibit B-3 Coordinate Care $324.00 Complete Exhibit B-3 Update DentistLink roster $100.00 Complete Exhibit B-3 Submit invoice showing expenses for dental champion to attend Attend and participate in developmentday $2,000.00 |developmentday. Page 13 of 20 HCA Contract No.:K2747-04 DocuSign Envelope ID:FF14B287-E90C-42B9-8A0F-A14FA00E82AF Exhibit A-3 ABCD Quarterly Communityand Provider Outreach and Case ManagementReport Year Two July 1,2023 -June 30,2024•3rd Quarter Report Please complete and submit report electronically to: Janice Tadeo,ABCD Program Manager at lanice.tadeo@hca.wa.qov Cc:Pixie Needham,Dental Program Administrator at pixie.needham@hca.wa.gov and Heather Gallagher,ABCD State Managing Director,haallagher@arcorafoundation.orq Organization: ABCD Contact Person: Phone and Email 3rd Quarter 1/1/2024 - Report Due:04/30/2024 3/31/2024 Maximum Brief description (for events,provide date heldlattended/for $$available staff assignments,provide name and title)-no more than for this 100 words (complete Exhibit A-3 and attach supporting Performance Category Yes/No deliverable document if providing additional detail) Attend and participate in ABCD Coordinator/Program Meeting $1,000.00 Community and Provider Outreach I $1,298.00 Complete Exhibit B-3 Coordinate Care i $324.00 Complete Exhibit B-3 Provide outcome information such as minutes,copies of Convene Health Coalition/ABCD Steering information provided or list of items provided,examples of type committee or participate in a Coalition or Steering of Organizations attended,what were outcomes or next steps Committee Focused on Health Care,Access or i for ABCD. Early Learning with ABCD as a Quarterly Agenda Item.Send invitation and report back any concernslissues to HCA $500.00 Dental Program Administrator &ABCD Administrator Page 14 of 20 HCA Contract No.:K2747-04 DocuSign Envelope ID:FF14B287-E90C-42B9-8A0F-A14FA00E82AF Exhibit A-3 ABCD Quarterly community and Provider Outreach and Case ManagementReport Year Two July 1,2023 -June 30,2024•4th O.uarter Report Please complete and submit report electronically to: Janice Tadeo,ABCD Program Manager at lanice.tadeo@hca.wa.qov Cc:Pixie Needham,Dental Program Administrator at pixie.needhamdhca.wa.qovand Heather Gallagher,ABCD State Managing Director,hqallagher@arcorafoundation.org Organization:I ABCD Contact Person: i |Phone and Email: 4th Quarter Report Due:07/09/2024 (report due on this 4/1/2024 - date to allow HCA to close out fiscal year)6/30/2024 Maximum Brief description (for events,provide date heldlattendedl for $$available staff assignments,provide name and title)-no more thanforthis100words(complete Exhibit A-3 and attach supportingPerformanceCategory __Yes/No deliverable document if providing additional detail)Attend and participate in ABCD Coordinator/Program Meeting _$1,000.00 Update ABCD providerroster to DentistLink $100.00 Complete Exhibit B-3 Community and Provider Outreach $1,298.00 Complete Exhibit B-3CoordinateCare$324.00 _Complete Exhibit B-3 Page 15 of 20 HCA Contract No.:K2747-04 DocuSign Envelope ID:FF14B287-E90C-42B9-8A0F-A14FA00E82AF Exhibit B-3 ABCD Quarterly Outreach and Coordination of Care Report COMMUNITY OUTREACH ABCD AGES 0-5 PROGRESS REPORT (Describe your outreach work,who you reached out to,how many families were reached,progress of workplan and measurable goals outlined in Action Plan.) ABCD EXPANSION PROGRESS REPORT (Describe collaboration with organization who work with children with disabilities,progress of workplan and measurable goals outlined in Action Plan) ABCD EQUITY AND CLIENTS AGES 0-2 PROGRESS REPORT (Describe collaboration with community health worker or regional network,progress of workplan and measurable goals outlined in Action Plan) | Page 16 of 20 HCA Contract No.:K2747-04 DocuSign Envelope ID:FF14B287-E90C-42B9-8A0F-A14FA00E82AF WORK WITH CHAMPIONIRECRUITPROVIDERS Provider Trainings Held How Many Place and Date I i PROGRESS REPORT (Describe outreach done to recruit both dental and medical providers to participate in the ABCD program and work done to maintain relationship with participating providers.) COORDINATE CARE PROGRESS REPORT (How are you providing coordination of care to clients?Family orientation,assisting with needed services such as transportation and interpreter services,teaching the importation of making and keeping appointments?What barriers are you running into and what kinds of successes are you seeing?) Update provider roster on DentistLink.How Many Page 17 of 20 HCA Contract No.:K2747-04 DocuSign Envelope ID:FF14B287-E90C-42B9-8A0F-A14FA00E82AF I I Page 18 of 20 HCA Contract No.:K2747-04 DocuSign Envelope ID:FF14B287-E90C-42B9-8A0F-A14FA00E82AF Exhibit C-2 ABCD Yearly Budget Tool 2022-2024 Yearly Expenses (estimated) Year One Year Two EXPENSES July 1,2022 July 1,2023 to To June30,2023 June30,2024 Staffing/Salary &Benefits-add a column to identify %and hours per week for each year Program Coordinator (x hrs/week =.X FTE) Outreach Staff (x hrs/week =.X FTE) Program Manager (x hrs/week =.X FTE) Support Staff (clerical,IT,finance,communications/per staff,other x hrs/week =.X FTE) Administration (x hrs/week (.X FTE) Salary &Benefits Subtotal Operating Expenses Advertising/Marketing (print,broadcast ads;cable TV time,movie ads,weekly newspaper, billboards,social media) Office Equipment (Copier,Fax) Meeting Expenses (steering committee room,food,etc.) Postage Printing (Outside Vendors) Professional Services Office Supplies Operating Supplies Telephone ABCD Certification Training/dentists and staff (room,audiovisuals,food,thank you to participating families,promotion,etc.) Travel (Per Diem,Transportation,Mileage/airfare,accommodations as required)for 3x annual ABCD Coordinators meeting -2 Seattle,1 Central WA;and for 1x annual Dental Cont. Page 19 of 20 HCA Contract No.:K2747-04 DocuSign Envelope ID:FF14B287-E90C-42B9-8A0F-A14FA00E82AF Champion(s)travel/expenses to Development Day,Seattle (Coordinator participation in this meeting optional but recommended) Computer Support/Tech Services Rent/Insurance/Janitorial/Maintenance Utilities Operating Expenses Subtotal Indirect Costs TOTAL EXPENSES FUNDING SOURCES Year One Year Two Other Funding (United Way,Grants,Community Development Block Grant,etc.) Agency Funds and/or In-Kind Current Health Care Authority Contract TOTAL FUNDING Page 20 of 20 HCA Contract No.:K2747-04 DocuSignEnvelopeID:FF14B287-E90C-42B9-8AOF-A14FA00E82AFHCAContractNo.:K4677WashingtonStateDATASHAREAmendmentNo.:01HealthCareuthorityAAMGDMMNNTTHISAMENDMENTTOTHEDATASHAREAGREEMENTisbetweentheWashingtonStateHealthCareAuthorityandthepartywhosenameappearsbelow,andiseffectiveasofthedatesetforthbelow.RECEIVINGPARTYNAME¯RECEIVINGPARTYdoingbusinessas(DBA)KittitasCountyPublicHealthNetworkRECEIVINGPARTYADDRESSASSIGNEDSERVICEREGIONICOUNTY507NodhNanumSt.,Suite201KittitasCountyEllensburg,WA98926AMENDMENTSTARTDATEAMENDMENTENDDATECONTRACTENDDATEJuly1,2022June30,2024June30,2024WHEREAS,HCAandReceivingPartypreviouslyenteredintoaDataShareAgreement(DSA)toprovideAccesstoBabyandChildDentistry(ABCD)servicestodetectandpreventearlychildhooddentaldecayforengagingdentistsinseeingbirthtosixyearoldanddisabledsixtotwelveyearoldMedicaideligiblechildrenandengaginglocalpublichealthdepartmentsinoutreachandcasemanagement,and;WHEREAS,HCAandReceivingPartywishtoamendtheDSApursuanttoSection14toextendterm,reviseeligiblechildrenpopulation,adddefinition;NOWTHEREFORE,thepartiesagreetheDSAisamendedasfollows:1.TheDataShareAgreementtermisextendedfromJune30,2022toJune30,2024.2.Section1,Backgroundisamendedtoreadasfollows:1.BackgroundTheReceivingPartyhaspreviouslyenteredintoaContractwithHCA,K2747,in2018.ThepurposeoftheContractistoprovideAccesstoBabyandChildDentistry(ABCD)servicestodetectandpreventearlychildhooddentaldecayforengagingdentistsinseeingbirthtosix(6)yearoldanddisabledsix(6)totwelve(12)yearoldMedicaideligiblechildrenandengaginglocalpublichealthdepartmentsinoutreachandcasemanagement.3.Section2,PurposeoftheDSAisamendedtoreadasfollows:2.PurposeoftheDSAThepurposeofthisDataShareAgreement(DSA)istoidentify,describeandprotecttheMedicaiddatabeingprovidedbyHCAfromProviderOnetotheReceivingParty.ThepurposeforsharingtheDataisfortheReceivingPartytoidentifyeligibleABCDclientsinordertomatchthemtoadentist,thenprovideclientoutreachtofamilieswithchildrenundertheageofsix(6)anddisabledchildrenundertheageofthirteen(13).OutreachwillbedonebymakingphonecallstofamiliestoassistwithconnectingthechildtoanABCDcertifieddentist,andinformationregardingtheABCDprogramwillbesentviamail.TheDatawillhelpidentifyandaddressfamilybarrierstoaccessingoralhealthcare.4.Section3,JustificationandAuthorityforDataSharingisamendedtoreadasfollows:HCAContractNo.K4677-01Page1of3 DocuSignEnvelopeID:FF14B287-E90C-42B9-8A0F-A14FA00E82AF3.JustificationandAuthorityforDataSharingTheDatatobesharedunderthisDSAarenecessarytohelpMedicaidclients,childrenundertheageofsix(6)anddisablechildrenundertheageofthirteen(13),inaccessingoralhealthcare.42C.F.R.438.208allowsforsharingofPHIforcoordinationandcontinuityofcare.RCW70.02.050allowsfordisclosurewithoutpatientauthorizationonaneed-to-knowbasisfortheprovisionofhealthcaretoapatient,forhealthcareeducation,ortoprovideplanningfortheprovisionofhealthcaretoapatient.5.Section4,Definitions,anewdefinition"Disabled"isaddedasfollows:"Disabled"meansclientswhoareenrolledintheDevelopmentalDisabilitiesAdministration(DDA).TheadministrationwithintheDepartmentofSocialandHealthServicesresponsibleforadministeringandoverseeingservicesandprogramsforclientswithdevelopmentaldisabilities.FormerlyknownastheDivisionofDevelopmentalDisabilities.6.Schedule1:DescriptionofSharedDataisreplacedinitsentiretyandattachedherein.7.ThisAmendmentwillbeeffectiveJuly1,2022("EffectiveDate").8.AllcapitalizedtermsnototherwisedefinedhereinhavethemeaningascribedtothemintheDSA.9.AllothertermsandconditionsoftheDSAremainunchangedandinfullforceandeffect.ThepartiessigningbelowwarrantthattheyhavereadandunderstandthisAmendmentandhaveauthoritytoexecutetheAmendment.ThisAmendmentwillbebindingonHCAonlyuponsignaturebybothparties.RECEIVINGPARTYSIGNATUREPRINTEDNAMEANDTITLEDATESIGNEDChelseyLoeffersPublicHealthDirectorREPRINTEDNAMEANDTITLEDATESIGNEDRachelleAmerineContractsAdministrator6/3/2022HCAContractNo.K4677-01Page2of3 DocuSignEnvelopeID:FF14B287-E90C-42B9-8A0F-A14FA00E82AFSchedule1:DescriptionofSharedDataPerK2747ContractwithHCA,theContractoristoidentifyeligibleABCDclientsandmatchthemtoadentalhome,providefamilyorientation,assistwithschedulingdentalappointments,identifyandaddressfamilybarrierstoaccessingoralhealthcare.TheDatawillbeprovidedsemiannuallyforthetimeframeofJuly2020throughJune2022,inanexcelformattransferredviaSecureFileTransfer(SFT).HCAwillprovideaccesstotheReceivingParty.TheHCADentalProgramManagerwilluploadtheexcelcontainingthespecifiedDatatotheirregion/countytotheABCDCoordinator'sassignedfolderinSFT.TheDatawillonlyincludeeligibleABCDclientsthathavenothadadentalclaiminthepast12months.1.DataElements:a.ClientID;b.Fullname;c.Age;d.DOB;e.Mailingaddress;f.Phonenumber;g.Headofhouseholdname;andh.Preferredlanguage.HCAContractNo.K4677-01Page3of3 DocuSignCertificateOfCompletionEnvelopeId:FF14B287E90C42B98A0FA14FA00E82AFStatus:SentSubject:DocuSignNOTIFICATION:ContractK2747-04&K4677-0IwithKittitasCountyPublicHealthSourceEnvelope:DocumentPages:37Signatures:2EnvelopeOriginator:CertificatePages:5Initials:0JanetStevensAutoNav:Enabled6268thAveSEEnvelopeldStamping:EnabledOlympia,WA98501TimeZone:(UTC-08:00)PacificTime(US&Canada)janet.stevens@hca.wa.govIPAddress:198.239.16.65RecordTrackingStatus:OriginalHolder:JanetStevensLocation:DocuSign6/2/20229:29:29AMjanet.stevens@hca.wa.govSignerEventsSignatureTimestampRachelleAmerine""Sent:6/2/20229:45:03AMrachelle.amerine@hca.wa.govViewed:6/3/20225:09:32AMContractsAdministrator71E1E£800774E7...Signed:6/3/20225:11:30AMCloudPWROBOWashingtonStateHealthCareSignatureAdoption:Pre-selectedStyleAuthority-SubAccount.Signedbylinksenttorachelle.amerine@hca.wa.govSecurityLevel:Email,AccountAuthentication(None)UsingIPAddress:198.239.13.95ElectronicRecordandSignatureDisclosure:NotOfferedviaDocuSignChelseyLoeffersSent:6/3/20225:11:33AMchelsey.loeffers@co.kittitas.wa.usViewed:6/13/20229:14:26AMPublicHealthDirectorSecurityLevel:Email,AccountAuthentication(None)ElectronicRecordandSignatureDisclosure:Accepted:6/13/20229:14:26AMID:311cb8e0-b362-4bbe-894e-84cde134a276InPersonSignerEventsSignatureTimestampEditorDeliveryEventsStatusTimestampAgentDeliveryEventsStatusTimestampIntermediaryDeliveryEventsStatusTimestampCertifiedDeliveryEventsStatusTimestampCarbonCopyEventsStatusTimestampLyudaKozlovaSent:6/2/20229:45:02AMlyudmila.kozlova@hac.wa.govCOPIED|SecurityLevel:Email,AccountAuthentication(None)ElectronicRecordandSignatureDisclosure:NotOfferedviaDocuSign CarbonCopyEventsStatusTimestampJaniceTadeoSent:6/2/20229:45:03AMjanice.tadeo@hca.wa.govCOPIEDSecurityLevel:Email,AccountAuthentication(None)ElectronicRecordandSignatureDisclosure:NotOfferedviaDocuSignCandiBlackfordSent:6/3/20225:11:33AMcandi.blackford@co.kittitaswa.usCOPIEDSecurityLevel:Email,AccountAuthentication(None)ElectronicRecordandSignatureDisclosure:NotOfferedviaDocuSignNeaAlfaroSent:6/3/20225:11:34AMnea.alfaro@co.kittitas.wa.usCOPIEDSecurityLevel:Email,AccountAuthentication(None)ElectronicRecordandSignatureDisclosure:NotOfferedviaDocuSignHCAFinancialServicesFINANCIALSVC@HCA.WA.GOVSecurityLevel:Email,AccountAuthentication(None)ElectronicRecordandSignatureDisclosure:NotOfferedviaDocuSignWitnessEventsSignatureTimestampNotaryEventsSignatureTimestampEnvelopeSummaryEventsStatusTimestampsEnvelopeSentHashed/Encrypted6/2/20229:45:03AMCertifiedDeliveredSecurityChecked6/13/20229:14:26AMPaymentEventsStatusTimestampsElectronicRecordandSignatureDisclosure 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