HomeMy WebLinkAboutHCA Amendment SignedKittitas County
Review Form
Grants & Contract Agreement
Contract/G ra nt I nformation
Recommendation for Board of Health Review on
verification the contracting Agency is not suspended/Disbarred:
Today's Date
06/Ls/2022 PA camas Request r, Wtrhh
Fund/Department
116-Public Health Agenda Date:
Contract /Grant Agency: HCA Amendment for ABCD Kittitas County
Period Begin Date: July I,2022 Period End Date: June3O,2024
Total G rant/Contract Amount: $ZS,g8O.OO
Grant/Contract Numb er: K2747 Amendment 4
Contract/G rant Sum mary
o The Maximum Compensation payable to the Contractor for the performance of all things necessary for or
incident to the performance of the work as set forth in Schedule A-3: Statement of Work has increased by
$25,376.00, for a new Contract Maximum Compensation of 568,638.00, and includes any allowable expenseso Schedule A-2: Statement of Work is replaced in its entirety with Schedule A-3: Statement of Work, attached
hereto and incorporated herein.
o Exhibit A-2: ABCD Quarterly Community and Provider outreach and Case Management Report is replaced in
its entirety with Exhibit A-3: ABCD Quarterly Community and Provider Outreach and Case Management
Report, attached hereto and incorporated herein.
r Exhibit B-2:ABCD QuarterlyOutreach and Coordination of Care Report is replaced in itsentiretywith Exhibit
B-3: ABCD Quarterly Outreach and Coordination of Care Report, attached hereto and incorporated herein.o Exhibit C-1: ABCD Yearly Budget Tool is replaced in its entirety with Exhibit C-2: ABCD yearly Budget Tool,
attached hereto and inco orated herein.
Department Head Signature LLDirector Date: t I ul
Kittitas county Prosecutor, Auditor, and Board of Health Review and comment:
Signature of P s Office Date
Signature of ditor's Office Dat
# i-uti +-4 d:-,''tl zL
APP TO FORM
! Agency is not suspended/disbarred ! Not Checked (reason)
Grant/Contract Review Page L
Financial lnformation
Bud lnformation
Pass Through lnformation
Agency to Pass Through
Amount to Pass Through Expense Code
Sub-Contract Approved Date:
Prosecutor Review
Total Amount S25,386.00 State Funds $Federal Funds 5
Percentage County Funds Matching Funds S CFDA#
ln-Kind $
ls Equipment being purchased?Who owns equipment?
New Personnel bei hired?Contact HR hirin - reportin uirements
Future impacts or liability to Kittitas County:
Budget Amendment Needed?
New Division Created?
Yes ! attach budget form No n why not
Revenue Code 116.612.24.1.333.937 78 ( Fed )
7L6.6L2.24. L.334.06901 (State)
Expense Code LI6.612.24.1.
Has the Prosecutor reviewed this agreement?Yes No
Cou De rtments lm
BOCC Approval Needed?
Assignment of Tracking lnformation
Auditor Facilities Maintenance
lnformation Services Human Resource
Prosecutor Treasurer
Yes I NoE
Staff Member Presenting: Audi Martinez
Auditor's Office
Human Resource
Prosecutor's Office t ')u 'tlr'
Who Signed the grant application (\J
Grant/Contract Review Page 2
Reviewer Date
DocuSign Envelope lD: FF 1 48287 -E90C-4289-BA0F-A1 4FAoOE82AF
WHEREAS, HCA and Contractor previously entered into a Contract for to provide 'Access to Baby and
Child Dentistry' (ABCD) services to detect and prevent early childhood dental decay by engaging
dentists in seeing Apple Health/Medicaid-eligible Clients, ages birth to six (6), with an emphaiis on
children of color and children 0-2, ages six (6) to thirteen (13) who are clients of the Developmental
Disabilities Administration and other eligible but underserved children in the service area, and engaging
local public health departments in outreach and case management, and;
WHEREAS, HCA and Contractor wish to amend the Contract pursuant to Section 4.3 to revise
definitions, extend the term, increase funds, update the Schedule A: Statement of Work, and update
Exhibits;
NowTHEREFORE, the parties agree the contract is amended as follows:
1. Section 3, Special Terms and Conditions, the following definitions are revised to read as follows:
a) "ABCD" means Access to Baby and Child Dentistry, a program designed to detect and
prevent early childhood dental decay by engaging dentists in seeing birth to six (6) year old
Medicaid eligible children and clients of the Developmental Disabilities Administration (DDA)
birth to thirteen (13)years old and engaging local public health departments in outreach and
case management.
e) "Client" means Medicaid eligible Clients ages birth through six (6) years of age and clients
of the Developmental Disabilities Administration (DDA) birth to thirteen (13) years old.
h) "Goordinator" means the individual hired to organize events and activities related to the
ABCD program and who also acts as a liaison/advocate between providers and families of
ABCD eligible children birth up to six (6) years old and clients of the Developmental
Disabilities Administration (DDA) birth to thirteen (13) years ord.
2. Section 3.2 Term, subsection 3.2.1 is deleted and replaced in its entirety as follows:
Washington State
Health Ca 0
CONTRACT
AMENDMENT
For
ABCD DENTAL
SERVICES
HCA Contract No.: K2747
Amendment No.: 04
THIS AMENDMENT
and the party whose
is between the Washington State Health Care Authority
and is effective as of the date set forth below.
TO THE CONTRACT
name appears below,
CONTRACTOR NAME
Kittitas County Public Health Network
ASSIGNED SERVICE REGION/COUNTY
Kittitas County
CONTRACTOR ADDRESS
507 North Nanum St, Suite# 201
Ellensburg, WA 98926
WASHINGTON UNIFORM BUSINESS IDENTIFIER
(uBr)
HCA Contract No.: K2747-04
Page 1 of 20
DocuSign Envelope lD: FF 1 4B.287 -Eg0C-4289-8A0F-A14FAO0E824F
3.2.1 The initial start date of the Contract is July 1,2018, the term has been extended for an
additional two (2) year tear, and set to continue through June 30, 2024, unless terminated
sooner as provided herein.
3. Section 3.3 Compensation, subsection 3.3.1 is revised to read as follows:
3.3.1 The Maximum Compensation payable to the Contractor for the performance of all things
necessary for or incident to the per-formance of the work as set forth in Schedule A-3:
Statement of Work has increased by $25,376.00, for a new Contract Maximum
Compensation of $68,638.00, and includes any allowable expenses.
4. Section 4, General Terms and Conditions, subsection 4.23, Legal and Regulatory Compliance is
replaced in its entirety as follows:
4.23 Legal and Regulatory Compliance
4.23.1 During the term of this Contract, Contractor must comply with all local, state,
and federal licensing, accreditation and registration requirements/standards,
necessary for the performance of this Contract and all other applicable
federal, state and local laws, rules and regulations.
4.23-2 While on the HCA premises, Contractor must comply with HCA operations
and process standards and policies (e.g., ethics, lnternet / email usage,
data, network and building security, harassment, as appricabre). HCA will
make an electronic copy of all such policies available to contractor.
4.23.3 Pursuant to Proclamation2l-14 - COVID-19 Vaccination Requirement
(dated August 9,2021) as amended by Proclamation2l-14.1 -covtD-19Vaccination Requirement (dated August 20, 2021) ("proclamation") all
contractors and any of their employees and/or subcontractors who provide
contracted services on-site at HCA facilities must certify that they are fully
vaccinated against the coVlD-19 virus, unless properly excepted or
exempted for disability or sincerely held religious beliefs as set forth in the
Proclamation. contractors who cannot so certify are prohibited from
contracting with the state.
4-23.4 Contractor represents and warrants that should their responsibilities to the
HCA involve on-site services as of october 18, 2021, contractor's
personnel (including subcontractors) providing such services will be fully
vaccinated against the coVlD-19 virus unlesi properly excepted or
exempted for disability or sincerely held religious beliefs as set forth in the
Proclamation. Contractor further understands that, upon request, Contractor
personnel must provide to HCA proof of vaccination, in a manner
established by the HCA. Failure to meet these requirements may result in
the immediate termination of this Contract.
4.23.5 Failure to comply with any provisions of this section may result in Contract
termination.
5. Schedule A-2: Statement of Work is replaced in its entirety with Schedule A-3: Statement of
Work, attached hereto and incorporated herein.
HCA Contract No.: K2747-04
Page 2 of 20
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6. Exhibit A-2: ABCD Quarterly Community and Provider Outreach and Case Management Report
is replaced in its entirety with Exhibit A-3: ABCD Quarterly Community and Provider Outreach
and Case Management Report, attached hereto and incorporated herein.
7. Exhibit B-2: ABCD Quarterly Outreach and Coordination of Care Report is replaced in its entirety
with Exhibit B-3: ABCD Quarterly Outreach and Coordination of Care Report, attached hereto
and incorporated herein.
8. Exhibit C-1: ABCD Yearly Budget Tool is replaced in its entirety with Exhibit C-2: ABCD yearty
Budget Tool, attached hereto and incorporated herein.
9. This Amendment will be effective July 1 ,2022 ("Effective Date").
10.All capitalized terms not othenruise defined herein have the meaning ascribed to them in the
Contract.
1 1. All other terms and conditions of the Contract remain unchanged and in full force and effect.
The parties signing below warrant that they have read and understand this Amendment and have
authority to execute the Amendment. This Amendment will be binding on HCA only upon signature by
both parties.
PRINTED NAME AND TITLE
elsey Loeffers Public Health Director
DATE SIGNED
- (zt fzz
HCA SIGNATURE PRINTED NAME AND TITLE
DocuSigned by:tt*rJL
-+,,,-^;^*chelleAmerine ContractsAdministrator
DATE SIGNED
6t3t2022
HCA Contract No.: K2747-04
Page 3 of20
DocuSign Envelope ID: FF1 48287-E90C-4289-8A0F-A1 4FA00E82AF
Schedule A-3:
Statement of Work (SOW)
The Contractor shall provide the services and staff, and otherwise do all things necessary for or incidental
to the performance of work, as set forth below:
A. ln accordance with deadlines in Exhibit A-3, ABCD Quarterly Community and Provider Outreach and
Case Management Report, develop and implement an ABCD action plan in accordance with the
ABCD program principles and submit corresponding budget, using Exhibil C-2, ABCD Yearly Budget
Tool. fhe ABCD program principles are outlined below.
1. Provide outreach and linkage of Apple Health/Medicaid-eligible Clients, ages birth to six (6), with
an emphasis on children of color and children 0-2, ages six (6) to thirleen (13) who are clients of
the Developmental Disabilities Administration and other eligible but underserved children in the
service area in collaboration with other organizations, including, but not limited to:
a) Provide outreach by attending, visiting or working with the below, but not limited to the following:
i. Outreach and marketing events and activities such as health fairs, use of social
media (i.e., Facebook, Twitter, lnstagram, Constant Contact, etc.)to perform
targeted outreach activities that effectively connect with families of eligible children;
ii. SmileMobile (sponsored by the Arcora Foundation) locations (a mobile dental clinic
providing dental services to children, pregnant women, and others;
iii. Women, lnfants, and Children WIC offices (a federal assistance program of the
Food and Nutrition Services of the United States Department of Agriculture;
iv. Head Start and Early Head Start facilities (a federal program that promotes the
school readiness of children under five from low-income families);
v. Early Learning Regional Coalitions (that are a not-for-profit alliance of employers
and community subsidized before and after school child care);
vi. Day Care facilities throughout the state of Washington;
vii. Connect with community health worker or regional network to gain resources,
community connections on outreach efforts for eligible children of color and
children ages 0-2; and
viii. Connect and collaborate with your local Children with Special Health Care Needs
(CSHCN) program, local Developmental Disabilities Administration (DDA) office
and/or other organizations who work with children with disabilities to find methods
and resources on how to identify eligible children for outreach work.
b) Provide care coordination, including:
i. Provide family orientation; including but not limited to, sharing information about the
value of an infant, toddler, or young child going to the dentist, what activities to expect at
the dentist's office, and the importance of oral health care at home and the importance of
keeping an appointment.
ii. Connect families with an ABCD certified dentist who accepts Apple Health/Medicaid, and
providing information including, but not limited to, names and referrals to dentists,
sharing information about interpreters and transportation benefits, and assist in
HCA Contract No.: K2747-04
Page 4 of 2O
Docusign Envelope lD: FF 1 48287 -E90C-4289-8A0F-A1 4FA00EB2AF
scheduling appointments for eligible children and following up after an appointment, if
appropriate;
c) Work with the Dentistlink team to align DentistLink toolwith local program's referral processes to
ensure ABCD clients have a variety of complementary avenues for referral and linkage to ABCD
providers.
i. Coordinate ABCD program's dentist recruitment and support efforts with Dentistlink's by
assuring both programs have the same updated information:
ii. Contact each practice to update participating-ABCD dentist roster:
1. number and frequency of clients accepted;
2. appointment times/days;
3. translation availability times/days;
4. change business status of practice (not accepting new ABCD clients, accepting
more clients, etc.);
5. new providers, Phase l, Phase ll; and
6. other.
iii. Update ABCD provider roster to DentistLink electronically.
iv. ldentify and address family barriers to accessing oral health care.
d) Bi-annually convene or participate in a county-wide or regional oral health coalition or ABCD
steering committee or other groups which focuses on health care, access or early learning in
order to build awareness of the ABCD program and solicit input on process improvements
i. lnvite to participate in the meeting with the ABCD state managing director, the Arcora
Foundation, and the Health Care Authority dental program administrator.
e) Continuously coordinate with the localABCD Dental Champion(s) to:
i. ldentify and recruit dental providers to accept and provide care to Apple Health/Medicaid
clients birth to six (6) years through the ABCD Program;
ii. Maintain a list of active ABCD dental and medical providers who accept Apple
Health/Medicaid Clients birth to six (6) years, ages six (6) to thirteen (13) who are clients
of the Developmental Disabilities Administration and monitor provider availability to
accept new Client's birth to six (6)years into their practice;
iii. Support current ABCD providers by communicating program changes and policy updates
through in-person meetings and written communication;
iv. Plan and implement, in coordination with the UW School of Dentistry, timely ABCD
providertrainings (Phase l, ll, lll and refreshertraining) leading to certification of
providers and onboarding of their staff;
v. Assure provider ABCD certification process is completed;
HCA Contract No.: K2747-O4
Page 5 of 20
DocuSign Envelope lD: FF 148287 -E90C-4289-8A0F-A14FA00E82AF
vi. Provide or arrange for, timely Apple Health/Medicaid billing training assistance to ABCD
office staff and providers, as needed;
vii. At minimum annually update dental society (or local dentists/study clubs in counties
without a society) on the ABCD Program and support their continued participation in the
program and encourage recruitment of new Apple Health/Medicaid providers; and
viii. Support the Dental Champion(s) participation in meetings and activities necessary to
effectively conduct Apple Health/Medicaid provider outreach, recruitment and training,
including financial support of attendance (travel, lodging, etc.) in Development Day.
ix. Participate in the annual statewide ABCD Champion Development Day meeting to
remain current with new clinical practices and opportunities. Meet, network, and share
knowledge with other champions regarding program roadblocks and successes.
1. Extend invitation to ABCD Dental Champion to attend the annual ABCD Champion
Development Day meeting.
2. ABCD Champion travel reimbursement, if any, to attend Development Day, is
included in the total compensation.
f) ldentify and recruit primary care medical providers to participate in Apple Health/Medicaid as
ABCD certified providers, secure their training through Arcora Foundation in preventive oral
health care techniques (Family Oral Health Education, fluoride varnish, etc.) and build their role
in referring Apple Health/Medicaid-eligible children to the ABCD Program.
g) Participate in all three (3) statewide ABCD Coordinators group meetings to remain current with
ABCD policies, practices and opportunities. Programs which do not meet this annual contract
requirement will be subject to contract review by HCA and potentially, to loss of this contract.
h) ldentify an ABCD Coordinator within the contracting organization who will develop and maintain
a desk manual that outlines the expected ABCD contractual deliverables and how the contractor
meets each deliverable. The Coordinator will utilize this manual to fulfill the contractual
requirements and to orient new lead staff within the organization to the ABCD program.
i) lf the Contractor's Coordinator vacates the position, the Contractor must notify the Health
Care Authority within two weeks of the coordinator's departure, and;
Share the Contractor's developed work plan that outlines how the expected contract
deliverables will be met;
ii. lnclude the HCA and the State Managing Partner, Arocra Foundation, in the hiring
process to find a new coordinator;
iii. Share with HCA the contact information of the newly hired or appointed Coordinator;
iv. Coordinate with HCA to assure a smooth transition of the expected contracted work
deliverables, including participation in program orientation with HCA and other state
partners and;
v. ABCD Coordinator new hire must reasonably meet the expectations as identified in
Exhibit D ABCD Coordinator Performance Expectations and Abilities.
HCA Contract No.: K2747-04
Page 6 of 20
Docusign Envelope lD: FF 1 4F.287 -E90C-42B9-8A0F-A1 4FAo0EB2AF
j) lf the Contractor determines that it can no longer serve as the ABCD Contractor, reasonable
notice 90 days must be given to HCA in order to assure uninterrupted service to clients and work
with providers and:
i. Work with HCA and other state partners to identifu potential new ABCD-lead agencies.
2. Each quarter, the contractor must complete and submit the following via email:
a) Community and Provider Outreach and Coordination Care summary which shall
include;
i. Exhibit A-3, ABCD Quarterly Community and provider Outreach and Case Management
Report forthe specific quarter; and
ii. Exhibit B-3, ABCD Quarterly Outreach and Coordination of Care Report.
3. Each year, the contractor must complete and submit via email the Exhibit C-2, ABCD Yearly
Budget Tool, as applicable to the requirements, contained in Exhibit A-3.
4. The contractor must meet with the State Managing Partner, Arcora Foundation, on a yearly basis
to review local needs, utilization, and review the desk manual that outlines the ABCD contractual
deliverables and how the contractor has met or plans to meet those deliverables.
5. Each quarter the contractor must submit a fully completed invoice that conelates with dollar
values for completed deliverables outlined in Exhibit A-3:
a) Exhibit templates are available on the ABCD website http://abcd-dental.orq/for-coordinators/:
and
b) Reports and billing must be submitted no later than one month after each quarter end date,
unless othenrvise mutually agreed by both parties.
HCA Contract No.: K2747-O4
PageT of20
DocuSign Envelope lD: FF 1 48.287 -E90C-4289-8A0F-Al 4FA00E82AFExhibit A-3Please complete and submit report electronically to:Janice Tadeo, ABCD Program Manager at ianice.tadeo@hca.wa.qovCc: Pixie Needham, Dental Program Administrator at pixie.needham@hca.wa.qov andHeath er Gallagher, ABCD State Manag i n g Di rector, hqallaq her@a rcorafo u ndation.orqABCD Quarterly Community and Provider Outreach and Case Management ReportYear One July 1 ,2022 - June 30,2023 o 1st Ouarter ReportBrief description (for events, provide date held/attended/ forstaff assignments, provide name and title) - no more than 100words (complete Exhibit A-3 and attach supporting document ifdinadditional detailComplete Exhibit B-3Complete Exhibit B-3Exhibit C-2Provide outcome information such as minutes, copies of informationprovided or list of items provided, examples of type of Organizationsattended, what were outcomes or next steps for ABCD.Send invitation and report back any concerns/issues to HCA DentalPram Administrator & ABCD AdministratorMaximum$$ available forthis deliverable$1,000.00$1.298.00$324.00$o$500.001st Quarter7t1t2022 -9t30t2022Yes/NoOrganization:ABCD Contact PersonPhone and EmailReport Due:1013112022Performance CateqorvAttend and participate in ABCDCoordinator/Proqram MeetinqCommunity and Provider OutreachCoordinate CareComplete budget tool and year two actionplanConvene Health Coalition/ABCD Steeringcommittee or participate in a Coalition orSteering Committee Focused on HealthCare, Access or Early Learning with ABCDas a Quarterly Agenda ltem.HCA Contract No.: K2747-04Page 8 of 20
DocuSign Envelope lD: F F 1 48.287 -E90C-4289-840F-A1 4FA00E82AFExhibit A-3Please complete and submit report electronically to:Janice Tadeo, ABCD Program Manager at ianice.tadeo@hca.wa.govCc: Pixie Needham, Dental Program Administrator at pixie.needham@hca.wa.gov andHeath er Gallagher, ABCD State Managi n g Director, hgallao her@arcorafoundation.orqABCD Quarterly Gommunity and Provider Outreach and Case Management ReportYear One July 1 ,2022 - June 30,2O2S o 2nd Ouarter ReportBrief description (for events, provide date held/attended/ forstaff assignments, provide name and title) - no more than 100words (complete Exhibit A-3 and attach supporting document ifdiadditionaldetaComExhibit B-3ComExhibit B-3Exhibit B-3Submit invoice showing expenses for dental champion to attenddevelopment day.Maximum$$ availablefor thisdeliverable$1,298.00$324.00$100.00$2,000.002nd Quarter10t1t2022 -12t31t2022Yes/NoOrqanizationABCD Contact PersonPhone and EmailReport Due:0113112023Performance CateqorvCommunity and Provider OutreachCoordinate CareUpdate Dentistlink rosterAttend and participate in development dayHCA Contract No.: K2747-04Page 9 of 20
DocuSign Envelope lD: FF 1 48287 -E90C-42B9-840F-A1 4FA00E82AFExhibit A-3Please complete and submit report electronically to:Janice Tadeo, ABCD Program Manager at ianice.tadeo@hca.wa.qovCc: Pixie Needham, Dental Program Administrator at pixie.needham@hca.wa.qov andHeath er Gallag her, ABCD State Managi n g Di rector, hgallaq her@arcorafoundation. orqABCD Quarterly Community and Provider Outreach and Case Management ReportYear One July 1 ,2022 - June 30,2023. 3rd Ouarter ReportBrief description (for events, provide date held/attended/ forstaff assignments, provide name and title) - no more than100 words (complete Exhibit A-3 and attach supportingdocument ifadditional detaiComplete Exhibit B-3Comlete Exhibit B-3Provide outcome information such as minutes, copies ofinformation provided or list of items provided, examples of typeof Organizations attended, what were outcomes or next stepsfor ABCD.Send invitation and report back any concerns/issues to HCADental Program Administrator & ABCD AdministratorMaximum$$ availablefor thisdeliverable$1.000.00$1.298.00$324.00$500.003rd Quarter1t1t2023 -3t31t2023Yes/NoOrganizationABCD Contact PersonPhone and Email:Report Due:.0413012023Performance CateqorvAttend and participate in ABCDCoord inator/Prog ram Meetin gCommunity and Provider OutreachCoordinate CareConvene Health Coalition/ABCD Steeringcommittee or participate in a Coalition or SteeringCommittee Focused on Health Care, Access orEarly Learning with ABCD as a Quarterly AgendaItem.HCA Contract No.: K2747-04Page 10 of 20
DocuSign Envelope lD: FF I 48287 -E90C-42B9-840F-A1 4FA00E82AFExhibit A-3Please complete and submit report electronically to:Janice Tadeo, ABCD Program Manager at ianice.tadeo@hca.wa.qovCc: Pixie Needham, Dental Program Administrator at pixie.needham@hca.wa.gov andHeather Gallag her, ABCD State Managi n g Director, hgallaq her@arcorafoundation. orqABCD Ouarterly Community and Provider Outreach and Gase Management ReportYear One July 1 ,2022 - June 30,2023 o 4th Ouarter ReportBrief description (for events, provide date held/attended/ forstaff assignments, provide name and title) - no more than100 words (complete Exhibit A-3 and attach supportingdocument if providinq additional detail)Complete Exhibit B-3Complete Exhibit B-3Complete Exhibit B-3Maximum$$ availablefor thisdeliverable$1,000.00$100.00$1.298.00$324.004th Quarter4t1t2023 -6t30t2023Yes/NoanizationABCD Contact Person:Phone and Email:Report Due: 07/09/2023 (report due on thisdate to allow HCA to close out fiscal year)Performance CateqorvAttend and participate in ABCDCoordinator/Proq ram MeetinqUpdate ABCD provider roster to DentistlinkCommunity and Provider OutreachCoordinate CareHCA Contract No.: K2747-04Page 11 of20
DocuSign Envelope lD: FF 1 48287 -Eg0C-4289-8A0F-A1 4FA00E82AFExhibit A-3Please complete and submit report electronically to:Janice Tadeo, ABCD Program Manager at ianice.tadeo@hca.wa.govCc: Pixie Needham, Dental Program Administrator at pixie.needham@hca.wa.qov andHeath er Gallagher, ABCD State Managin g Di rector, hgallag her@arcorafoundation.orgABCD Quarterly Community and Provider Outreach and Case Management ReportYear Two July 1, 2023 - June 30,2024 o 1st Ouarter ReportBriefdescription (for events, provide date held/attended/ forstaff assignments, provide name and title) - no more than 100words (complete Exhibit A-3 and attach supporting document ifadditional detaiComExhibit B-3ComExhibit B-3ComExhibit C-2Provide outcome information such as minutes, copies of informationprovided or list of items provided, examples of type of Organizationsattended, what were outcomes or next steps for ABCD.Send invitation and report back any concerns/issues to HCA DentalProqram Administrator & ABCD AdministratorMaximum$$ available forthis deliverable$1.000.00$1.298.00$324.00$o$500.001st Quarter71112023 -9130t2023Yes/NoOrqanizationABCD Contact PersonPhone and EmailReport Due:.1013112023Performance CateqorvAttend and participate in ABCDCoordinator/Proqram MeetinqCommunitv and Provider OutreachCoordinate CareComplete budget tool and year two actionplanConvene Health Coalition/ABCD Steeringcommittee or participate in a Coalition orSteering Committee Focused on HealthCare, Access or Early Learning with ABCDas a Quarterly Agenda ltem.HCA Contract No.: K2747-04Page 12 of 2O
DocuSign Envelope lD: FF'l 48287 -E90C-4289-8A0F-A1 4FA00E82AFExhibit A-3Please complete and submit report electronically to:Janice Tadeo, ABCD Program Manager at ianice.tadeo@hca.wa.govCc: Pixie Needham, Dental Program Administrator at pixie.needham@hca.wa.qov andHeath er Gallagher, ABCD State Managi n g Di rector, hgallaq her@arcorafoundation.orqABCD Quarterly Gommunity and Provider Outreach and Case Management ReportYear Two July 1, 2023 - June 30,2024 o 2nd Ouarter ReportBrief description (for events, provide date held/attended/ forstaff assignments, provide name and title) - no more than 100words (complete Exhibit A-3 and attach supporting document ifdiadditional detailComplete Exhibit B-3Exhibit B-3Exhibit B-3Submit invoice showing expenses for dental champion to attenddevelopment dav.Maximum$$ availablefor thisdeliverable$1,298.00$324.00$100.00$2,000.002nd Quarter10t1t2023 -12131t2023Yes/Nonization:ABCD Contact PersonPhone and EmailReport Due:.0113112024Performance GateqorvCommunity and Provider OutreachCoordinate CareUpdate Dentistlink rosterAttend and participate in development davHCA Contract No.: K2747-04Page 13 of 20
DocuSign Envelope lD: F F 1 48287 -E90C-42B9-8A0F-A1 4FA00E82AFExhibit A-3Please complete and submit report electronically to:Janice Tadeo, ABCD Program Manager at ianice.tadeo@hca.wa.govCc: Pixie Needham, Dental Program Administrator at pixie.needham@hca.wa.qov andHeath er Gallagher, ABCD State Managi n g Di rector, hgallaq her@arcorafo undation. orqABCD Quarterly Community and Provider Outreach and Case Management ReportYear Two July 1, 2023 - June 30,2024.3rd Quarter ReportBrief description (for events, provide date held/attended/ forstaff assignments, provide name and title) - no more than100 words (complete Exhibit A-3 and attach supportingdocument if providing additional detail)Complete Exhibit B-3Complete Exhibit B-3Provide outcome information such as minutes, copies ofinformation provided or list of items provided, examples of typeof Organizations attended, what were outcomes or next stepsfor ABCD.Send invitation and report back any concerns/issues to HCADental Program Administrator & ABCD AdministratorMaximum$$ availablefor thisdeliverable$1,000.00$1.298.00$324.00$500.003rd Quarter1t1t2024 -3t31t2024Yes/NoOrqanizationABCD Contact Person:Phone and Email:Report Due:.0413012024Performance GategoryAttend and participate in ABCDCoordinator/Proqram MeetinqCommunity and Provider OutreachCoordinate CareConvene Health Coalition/ABCD Steeringcommittee or participate in a Coalition or SteeringCommittee Focused on Health Care, Access orEarly Learning with ABCD as a Quarterly AgendaItem.HCA Contract No.: K2747-04Page 14 of 20
DocuSign Envelope lD: FF 1 48287 -E90C-4289-840F-A1 4FA00E82AFExhibit A-3Please complete and submit report electronically to:Janice Tadeo, ABCD Program Manager at ianice.tadeo@hca.wa.qovCc: Pixie Needham, Dental Program Administrator at pixie.needham@hca.wa.gov andHeath er Gallagher, ABCD State Managi n g Director, hqallaq her@arcorafoundation. orgABCD Quarterly Community and Provider Outreach and Case Management ReportYear Two July 1, 2023 - June 30,2024.4th Ouarter ReportBrief description (for events, provide date held/attended/ forstaff assignments, provide name and title) - no more than100 words (complete Exhibit A-3 and attach supportingdocument if providing additional detail)Colete Exhibit B-3Complete Exhibit B-3Complete Exhibit B-3Maximum$$ availablefor thisdeliverable$1.000.00$100.00$1,298.00$324.004th Quarter4t1t2024 -6t30t2024Yes/NoOrqanizationABCD Contact Person:Phone and Email:Report Due:.0710912024 (report due on thisdate to allow HCA to close out fiscal vear)Performance CateqorVAttend and participate in ABCDCoord inator/Program MeetingUpdate ABCD orovider roster to DentistlinkCommunity and Provider OutreachCoordinate CareHCA Contract No.: K2747-04Page 15 of 20
DocuSign Envelope lD: FF 1 48287 -E90C-42B9-8A0F-A1 4FA00E82AFExhibit B-3ABCD Ouarterly Outreach and Coordination of Care ReportCOMMUNITY OUTREACHABCD AGES O-5ABCD EXPANSIONPROGRESS REPORT(Describe collaboration with organization who work with children with disabilities, progress of workplan and measurable goalsoutlined in Action Plan)ABCD EOUITY AND CLIENTS AGES O-2PROGRESS REPORT(Describe collaboration with community health worker or regional network, progress of workplan and measurable goals outlined inAction Plan)(Describe your outreach work, who you reached out to, how many families were reached, progress of workplan and measurable goalsPROGRESS REPORToutlined in Action Plan.)HCA Contract No.: K2747-04Page 16 of 20
DocuSign Envelope lD: FF 1 48287 -E90C-4289-8A0F-A1 4FA00E82AFCOORDINATE CAREWORK WITH CHAMPION/RECRUIT PROVIDERSPlace and DatePROGRESS REPORT(Describe outreach done to recruit both dental and medical providers to participate in the ABCD program and work done to maintainrelationship with participating providers.)How ManyProvider Trainings HeldPROGRESS REPORT(How are you providing coordination of care to clients? Family orientation, assisting with needed services such as transportation andinterpreter services, teaching the importation of making and keeping appointments? What barriers are you running into and whatkinds of successes are you seeing?)How ManyUpdate provider roster on DentistLink.HCA Contract No.: K2747-04Page 17 of20
DocuSign Envelope lD: FF 1 48287 -E90C-4289-8A0F-A1 4FA00E82AFHCA Contract No.: K2747-O4Page 18 of20
DocuSign Envelope lD: FF 1 48287 -E90C-4289-8A0F-A1 4FA00E82AFExhibit C-2ABCD Yearly Budget Tool2022-2024 Yearly Expenses (esti mated)Year TwoJuly 1,2023ToJune 3A,2O24Year OneJuly 1,2022toJune 30,2023EXPENSESStaffing/Salary & Benefits- add a column to identify o/o and hours per week for eachyea rProgram Coordinator (x hrs/week = .X FTE)Outreach Staff (x hrs/week = .X FTE)Pm Manager (x hrs/week =.X FTE)Support Staff (clerical, lT, finance, communications/per staff, other x hrs/week = .X FTE)Administration (x hrs/ week (.X FTE)Salary & Benefits SubtotalOperating ExpensesAdvertising/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.)PostaePrinting (Outside Vendors)Professional ServicesOffice SuppliesonSuliesTelephoneABCD Certification Training/dentists and staff (room, audiovisuals, food, thank you toparticipating families, promotion, etc.)Travel (Per Diem, Transportation, Mileagelairfare, accommodations as required) for 3x annualABCD Coordinators meeting - 2 Seattle, 1 Central WA; and for 1x annual DentalCont.HCA Contract No.: K2747-O4Page 19 of 20
DocuSign Envelope lD: FF'l 48287 -E90C-42B9-840F-A1 4FAo0E82AFChampion(s) travel/expenses to Development Day, Seattle (Coordinator participation in thismeeting optional but recommended)Year TwoYear OneComputer SupporVTech ServicesRenVlnsu ra nce/Ja nitoria l/Ma intenanceUtilitiesOperating Expenses Subtotallndirect CostsTOTAL EXPENSESFUNDING SOURCESother Funding (United way, Grants, community Development Block Grant, etc.)Agency Funds and/or ln-KindCurrent Health Care Authority ContractTOTAL FUNDINGHCA Contract No.: K2747-O4Page 20 of 20
DocuSign Envelope lD: FF 1 48287 -E90C-4289-840F-A1 4FAO0E824F
Washington State 1 -f,1
Health Care fiilthority
DATA SHARE
AGREEMENT
AMENDMENT
HCA Contract No.: K4677
Amendment No.: 01
THIS A M E N DM E NT TO T H E DA T A SHA RE A G REE M E NT IS between the Washi ngto n State Hea Ith Care Autho rity
and t he pa rty wh ose name a ppears below an d is effective AS of t he date S et fo rth below
RECEIVING PARTY NAME
Kittitas County Public Health Network
RECEIVING PARTY doing business as (DBA)
RECEIVING PARTY ADDRESS
507 North Nanum St., Suite 201
Ellensburg, WA 98926
ASSIGNED SERVICE REGION/COUNTY
Kittitas County
AMENDMENT START DATE
July 1, 2022
AMENDMENT END DATE
June 30,2024
GONTRACT END DATE
June 30,2024
WHEREAS, HCA and Receiving Party previously entered into a Data Share Agreement (DSA) to provide Access
to Baby and Child Dentistry (ABCD) services to detect and prevent early childhood dental decay for engaging
dentists in seeing birth to six year old and disabled six to twelve year old Medicaid eligible childien anOlngaging
local public health departments in outreach and case management, and;
WHEREAS, HCA and Receiving Party wish to amend the DSA pursuant to Section 14 to extend term, revise
eligible children population, add definition;
NOW THEREFORE, the parties agree the DSA is amended as follows:
1. The Data Share Agreement term is extended from June 30,2022 to June 30,2024.
2. Section 1, Background is amended to read as follows:
1. Background
The Receiving Party has previously entered into a Contract with HCA, K2747, in 2018. The purpose
of the Contract is to provide Access to Baby and Child Dentistry (ABCD) services to detect and
prevent early childhood dental decay for engaging dentists in seeing birth to six (6) year old and
disabled six (6) to twelve (12) year old Medicaid eligible children and engaging locai public health
departments in outreach and case management.
3. Section 2, Purpose of the DSA is amended to read as follows:
2. Purpose of the DSA
The purpose of this Data Share Agreement (DSA) is to identify, describe and protect the Medicaid
data being provided by HCA from ProviderOne to the Receiving Party. The purpose for sharing the
Data is for the Receiving Party to identify eligible ABCD clients in order to match them to a dentist,
then provide client outreach to families with children under the age of six (6) and disabled children
under the age of thirteen (13). Outreach will be done by making phone calls to families to assist with
connecting the child to an ABCD certified dentist, and information regarding the ABCD program will
be sent via mail. The Data will help identify and address family barriers to accessing oral health care.
4. Section 3, Justification and Authority for Data Sharing is amended to read as follows:
HCA Contract No. K4677-0'1 Page 1 of 3
DocuSign Envelope lD: FF1 4B287-E90C-4289-8A0F-A1 4FAO0E82AF
3. Justification and Authority for Data Sharing
The Data to be shared under this DSA are necessary to help Medicaid clients, children under the age
of six (6) and disable children underthe age of thirteen (13), in accessing oral health care.
42 C.F.R. 438.208 allows for sharing of PHI for coordination and continuity of care.
RCW 70.02.050 allows for disclosure without patient authorization on a need-to-know basis for the
provision of health care to a patient, for health care education, or to provide planning for the provision
of health care to a patient.
5. section 4, Definitions, a new definition "Disabled" is added as follows:
"Disabled" means clients who are enrolled in the Developmental Disabilities Administration (DDA). The
administration within the Department of Social and Health Services responsible for administeiing and
overseeing services and programs for clients with developmental disabilities. Formerly known ai tfre
Division of Developmental Disabilities.
6. Schedule 1: Description of Shared Data is replaced in its entirety and attached herein.
7. This Amendment will be effective July 1 , 2022 ("Effective Date").
B. All capitalized terms not otherwise defined herein have the meaning ascribed to them in the DSA.
9. All other terms and conditions of the DSA remain unchanged and in full force and effect.
The parties signing below warrant that they have read and understand this Amendment and have authority to
execute the Amendment. This Amendment will be binding on HCA only upon signature by both parties.
RECEIVING ;NATURE PRINTED NAME AND TITLE
Chelsey Loeffers public Health Director
DATE SIGNED,luln
2*t fL -A-n^^nn*
PRINTED NAME AND TITLE
RachelleAmerine contractsAdministrator
DATE SIGNED
6t3t2022
HCA Contract No. K4677-0'l Page 2 of 3
DocuSign Envelope lD: FF148287-E90C-4289-8AOF-A14FAO0EB2AF
Schedule 1: Description of Shared Data
Per K2747 Contract with HCA, the Contractor is to identify eligible ABCD clients and match them to a dental home
provide family orientation, assist with scheduling dental appointments, identify and address family barriers to
accessing oral health care. The Data will be provided semiannually for the timeframe of July 2020 through June
2022, in an excel format transferred via Secure File Transfer (SFT). HCA will provide access to the Receiving party.
The HCA Dental Program Manager will upload the excel containing the specified Data to their region/county to the
ABCD Coordinator's assigned folder in SFT. The Data will only include eligible ABCD clients that have not had a
dental claim in the past 12 months.
1,. Data Elements:
a. Client lD;
b. Full name;
c. Age;
d. DOB;
e. Mailing address;
f. Phone number;
g. Head of household name; and
h. Preferred language.
HCA Contract No. K4677-01 Page 3 of 3
D*ocuSign
Certificate Of Gompletion
Envelope ld : FF1 48287E90C42898A0FA1 4FAO0E82AF
Subject: Docusign NOTIFICATION: Contract K2747-04 &K4677-01 with Kittitas County Public Health
Source Envelope:
Document Pages: 37 Signatures:2
Certificate Pages: 5 lnitials: 0
AutoNav: Enabled
Envelopeld Stamping: Enabled
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Record Tracking
Status: Original
61212022 9:29:29 AM
Signer Events
Rachelle Amerine
rachelle.amerine@hca.wa.gov
Contracts Administrator
CloudPWR OBO Washington State Health Care
Authority-Sub Account
Security Level: Email, Account Authenticalion
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Chelsey Loeffers
chelsey.loeffers@co.kittitas.wa.us
Public Health Director
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted: 611312022 9:14:26 AM
lD: 31 1 cb8e0-b362-4bbe-894e-84cde134a27 6
ln Person Signer Events
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Lyuda Kozlova
lyudmila.kozlova@hac.wa.gov
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Holder: Janet Stevens
janet.stevens@hca.wa. gov
Signature
ffi.,,::*
Status: Sent
Envelope Originator:
Janet Stevens
626 8th Ave SE
Olympia, WA 98501
janet.stevens@hca.wa.gov
lP Address: 1 98.239.16.65
Location: DocuSign
Timestamp
Sent: 61212022 9:45 :03 AM
Viewed: 61312022 5:09:32 AM
Signed: 6/3/2022 5:11:30 AM
Sent: 6/3/2022 5:11:33 AM
Viewed: 611312022 9:14:26 AM
Timestamp
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Senl: 6 1212022 9:45 :02 AM
Signature Adoption: Pre-selected Style
Signed by link sent to rachelle.amerine@hca.wa.gov
Using lP Address: 1 98.239.13.95
Signature
Status
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COPIED
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Janice Tadeo
ja nice.tadeo@hca.wa.gov
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
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Candi Blackford
candi. blackford@co. kittitas.wa. us
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure
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Nea Alfaro
nea.alfaro@co. kittitas.wa.us
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure
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Status
COPIED
COPIED
COPIED
Timestamp
Senl: 6 1212022 9:45:03 AM
Senf: 61312022 5:1 1 :33 AM
Senl: 61312022 5:1 I :34 AM
Timestamp
Timestamp
Timestamps
61212022 9:45:03 AM
611312022 9:14:26 AM
Timestamps
HCA Financial Services
F r NANCTALSVC@HCA.WA.GOV
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Electronic Record and Signature Disclosure
Electronic Record and Signature Disclosure created on: Sl22l201g 6:4g:33 AM
Parties agreed to: Chelsey Loeffers
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