Common use of For Information Only Clause in Contracts

For Information Only. Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at: xxxx://xxx.xxxxxxxx.xxx/wp-content/uploads/PHAB-Standards-and-Measures-Version-1.0.pdf Program Specific Requirements/Narrative Program Manual, Handbook, Policy References Guide for Public Health Case Management of Children with Elevated Blood Lead Levels xxxxx://xxx.xxx.xx.xxx/Portals/1/Documents/4000/334-414.pdf A Targeted Approach to Blood Lead Screening in Children, Washington State 2015 Expert Panel Recommendations xxxxx://xxx.xxx.xx.xxx/Portals/1/Documents/Pubs/334-383.pdf Special References (RCWs, WACs, etc) Laboratories are required to report to the Department of Health all Blood Lead test results (WAC 246-101-201). Elevated results (≥5 mcg/dL) must be reported within 2 days; non- elevated results ≤5 mcg/dL need to be reported within one month. Monitoring Visits (frequency, type) Telephone calls with contract manager at least once every quarter. Definitions BLL- Blood Lead Level EBLL- Elevated Blood Lead Level PEHSU- Pediatric Environmental Health Specialty Units Special Billing Requirements Reimbursement for pre-approved travel expenses including mileage, lodging and meals will be calculated at the current federal General Services Administration (GSA) rates at the time of travel. Current per diem rates by state can be found at: xxxxx://xxx.xxx.xxx/travel/plan-book/per-diem-rates/per-diem-rates-lookup Special Instructions Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable written report to include a plan of care. Payment to completely expend the “Total Consideration” for a specific funding period will not be processed until all deliverables are accepted and approved by DOH. Invoices must may be submitted monthly by the 30th of each month following the month in which the expenditures were incurred as needed within 60 days after home visit completion and must be based on actual allowable direct program costs. Billing for services on a monthly fraction of the “Total Consideration” will not be accepted or approved. If needed, additional funding may be added upon request and DOH approval while funds are available. Contact xxxx@xxx.xx.xxx for additional information. Note: blood lead case management reimbursement excludes indirect costs. DOH Program Contact Xxxxxxx Xxxxxx, Health Services Consultant Office of Environmental Public Health Sciences Washington State Department of Health Street Address: 000 Xxxxxx Xx XX, Xxxxxxxx, XX 00000 Telephone: 000-000-0000 / Fax: 000-000-0000 Email: xxxxxxx.xxxxxx@xxx.xx.xxx DOH Fiscal Contact Xxxxxxxx Xxxxx, Management Analyst 1 Assistant Secretary’s Office Telephone: 000-000-0000 Exhibit A Statement of Work Contract Term: 2018-2020 DOH Program Name or Title: HIV Client Services - Effective January 1, 2018 Local Health Jurisdiction Name: Kitsap Public Health District Contract Number: CLH18248 SOW Type: Revision Revision # (for this SOW) 3 Funding Source Federal Subrecipient State Other Federal Compliance (check if applicable) FFATA (Transparency Act) Research & Development Type of Payment Reimbursement Fixed Price Period of Performance: January 1, 2018 through June 30, 2019 Statement of Work Purpose: The purpose of this statement of work is a provision of a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum. Includes all types of case management encounters with or on behalf of client (face-to-face, phone contact, any other forms of communication). Activities may include: 1) initial assessment of need; 2) development of individualized care plan; 3) coordinated access to health and support services; 4) client monitoring to assess the care plan; 5) re-evaluation of the care plan; 6) ongoing assessment of client's needs; 7) treatment adherence counseling; 8) client specific advocacy or review of utilization of services; 9) benefits counseling; 10) provide clinic space for Harborview Medical Center physician to provide primary medical care to HIV-positive individuals: Registered Nurse to assist physician one day per week and an additional day every other week; and administrative support staff to assist with the project. Revision Purpose: The purpose of this revision is to add funding for Task PRO-3 (Peer Navagation) and correct the BARS revenue code for RW HIV PROVISO funding from 334.04.98 to 333.93.91 and add the CFDA #93.917. Chart of Accounts Program Name or Title CFDA # BARS Revenue Code Master Index Code Funding (LHJ Use Start Date Period Only) End Date Current Consideration Change Increase (+) Total Consideration FFY17 ADAP Rebate Local 17-19 N/A 334.04.98 12618570 01/01/18 06/30/18 266,278 0 266,278 FFY17 ADAP Rebate Local 17-19 N/A 334.04.98 12618570 07/01/18 06/30/19 307,556 0 307,556 FFY18 RW HIV PROVIDER CAPACITY-PROVISO 93.917 333.93.91 1261228B 04/01/18 03/31/19 30,695 0 30,695 FFY18 RW HIV PEER NAV PROJ-PROVISO 93.917 333.93.91 1261228A 04/01/18 03/31/19 34,541 22,871 57,412 STATE HIV CS / END AIDS WA N/A 334.04.91 12630100 03/01/18 06/30/18 3,123 0 3,123 STATE HIV CS / END AIDS WA N/A 334.04.91 12630100 07/01/18 12/31/18 6,246 0 6,246 STATE HIV PREVENTION PrEP N/A 334.04.91 12430100 01/01/18 06/30/18 4,586 0 4,586 STATE HIV PREVENTION PrEP N/A 334.04.91 12430100 07/01/18 06/30/19 9,172 0 9,172 TOTALS 662,197 22,871 685,068 Task Number Task/Activity/Description *May Support PHAB Standards/Measures Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount See contract tasks and deliverables below. Task: HCS-4 Case Management – Persons Living With HIV (PLWH) Budget Service Definition: Provision of a range of client-centered activities focused on improving health outcomes in A Salaries B Benefits C Service Contracts E Supplies/Goods G Travel J Equipment N Sub-Contracts O Other IDC % $198,414 $92,268 - $2,576 - - $122,142 support of the HIV care continuum. Includes all types of case management encounters with or on behalf of client (face-to-face, phone contact, any other forms of communication). Activities may include: 1) initial assessment of need; 2) development of individualized care plan; 3) coordinated access to health and support services; 4) client monitoring to assess the care plan; 5) re-evaluation of the care plan; 6) ongoing assessment of client's needs; 7) treatment adherence counseling; 8) client specific advocacy or review of utilization of services; 9) benefits counseling. Subtotal $415,400 Strategies: • Provide case management services for PLWH living in Kitsap, Xxxxx, Clallam, and Jefferson Counties in compliance with WA State HIV CM Standards. • Utilize Acuity Guidelines to ensure delivery of appropriate level of services and related resources. • Prioritize medical engagement/retention, viral suppression and stable housing as recognized indicators of positive health outcomes and quality of life. • Utilize Client Centered Approach. • Practice Cultural Humility in all aspects of care and service delivery. • Intentionally track and address Health Disparities for Populations of Interest within your community(ies) as related to Case Management services and outcomes. • Meaningfully incorporate consumer feedback into ongoing program design, implementation and evaluation. $415,400 – Rebates $207,700 for 01/01/18-06/30/18 and $207,700 for 07/01/18-12/31/18 Targeted population: Persons living with HIV Deliverables/Measures: Number of PLWH to be served: Kitsap 175 Xxxxx 30 Clallam 40 Jefferson 17 Total 262 Reporting: • Agency must create a CAREWare file for each PLWH receiving Case Management services within forty-eight (48) business hours from the time of Client Intake. • Agency must update Demographics, Annual Review, Services, Case Notes, Encounter Tab and all requisite Custom Tabs in CAREWare, as appropriate, within five (5) business days from Client Intake, identified change in Client Status, delivery of a support service or benefit, or interaction with or on behalf of Client. Requirements around documentation within CAREWare can be found in your HCS Manual. • Agency must Track and report within CAREWare any and all Performance Measures related to this Service Category as directed by DOH Quality Team. These include, but may not be limited to, medical engagement, medical retention, viral load, housing status, and household poverty level.

For Information Only. Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at: xxxx://xxx.xxxxxxxx.xxx/wp-content/uploads/PHAB-Standards-and-Measures-Version-1.0.pdf Program Specific Requirements/Narrative Program Manual, Handbook, Policy References Guide for Public Health Case Management of Children with Elevated Blood Lead Levels xxxxx://xxx.xxx.xx.xxx/Portals/1/Documents/4000/334-414.pdf A Targeted Approach to Blood Lead Screening in Children, Washington State 2015 Expert Panel Recommendations xxxxx://xxx.xxx.xx.xxx/Portals/1/Documents/Pubs/334-383.pdf Special References (RCWs, WACs, etc) Laboratories are required to report to the Department of Health all Blood Lead test results (WAC 246-101-201). Elevated results (≥5 greater than or equal to 5 mcg/dL) must be reported within 2 two (2) days; non- non-elevated results ≤5 mcg/dL need to be reported within one (1) month. Monitoring Visits (frequency, type) Telephone calls and/or in person meetings with contract manager at least once every quarteron as as-needed basis. Definitions BLL- BLL – Blood Lead Level EBLL- EBLL – Elevated Blood Lead Level PEHSU- PEHSU – Pediatric Environmental Health Specialty Units Special Billing Requirements Reimbursement The average total amount expended for pre-approved travel expenses including mileagelaboratory, lodging interpreter, and meals will translation services is suggested to be calculated at the current federal General Services Administration (GSAapproximately $185 per home visit, per child. It is recognized that more complex cases may require a higher level of services, while simpler cases may require fewer services. Total reimbursements may not exceed total funding consideration. Please note WDRS event number(s) rates at the time on invoice to allow DOH review of travel. Current per diem rates by state can be found at: xxxxx://xxx.xxx.xxx/travel/plan-book/per-diem-rates/per-diem-rates-lookup Special Instructions Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable written report to include a plan of carevia WDRS. Payment to completely expend the “Total Consideration” for a specific funding period will not be processed until all deliverables are accepted and approved by DOH. Invoices must may be submitted monthly by the 30th of each month following the month in which the expenditures were incurred as needed within 60 days after home visit completion and must be based on actual allowable direct program costs. Billing for services on a monthly fraction of the “Total Consideration” will not be accepted or approved. If needed, additional funding may be added requested and upon request and DOH approval while may be added if funds are available. Contact xxxx@xxx.xx.xxx for additional information. Note: blood lead case management Blood Lead Case Management reimbursement excludes indirect costs. DOH Program Contact Xxxxxxx XxxxxxDOH Fiscal Contact Xxx Xxxxxxxx, Health Services Consultant Consultant/Case Management Coordinator Xxxxxxxx Xxxxx, Management Analyst 1 Office of Environmental Public Health Sciences Assistant Secretary’s Office Washington State Department of Health Telephone: 000-000-0000 Street Address: 000 Xxxxxx Xx XX, Xxxxxxxx, Xxxxxxxx XX 00000 Telephone: 000-000-0000 / Fax: Fax 000-000-0000 Email: xxxxxxx.xxxxxx@xxx.xx.xxx DOH Fiscal Contact Xxxxxxxx Xxxxx, Management Analyst 1 Assistant Secretary’s Office Telephone: 000-000-0000 xxx.xxxxxxxx@xxx.xx.xxx Exhibit A Statement of Work Contract Term: 2018-2020 DOH Program Name or Title: HIV Client Services Office of Drinking Water Group A Program - Effective January 1, 2018 Local Health Jurisdiction Name: Kitsap Public Health District Contract Number: CLH18248 SOW Type: Revision Revision # (for this SOW) 3 5 Period of Performance: January 1, 2018 through December 31, 2020 Local Health Jurisdiction Name: Cowlitz County Health & Human Services Department Funding Source Federal Subrecipient Contractor State Other Federal Compliance (check if applicable) FFATA (Transparency Act) Research & Development Type of Payment Reimbursement Fixed Price Period of PerformanceContract Number: January 1, 2018 through June 30, 2019 CLH18242 Statement of Work Purpose: The purpose of this statement of work is a provision of a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum. Includes all types of case management encounters with or on behalf of client (face-to-face, phone contact, any other forms of communication). Activities may include: 1) initial assessment of need; 2) development of individualized care plan; 3) coordinated access to health and support services; 4) client monitoring to assess the care plan; 5) re-evaluation of the care plan; 6) ongoing assessment of client's needs; 7) treatment adherence counseling; 8) client specific advocacy or review of utilization of services; 9) benefits counseling; 10) provide clinic space for Harborview Medical Center physician to provide primary medical care funding to HIVthe LHJ for conducting sanitary surveys and providing technical assistance to small community and non-positive individuals: Registered Nurse to assist physician one day per week and an additional day every other week; and administrative support staff to assist with the projectcommunity Group A water systems. Revision Purpose: The purpose of this revision is to add extend funding periods from 12/31/19 to 12/31/20 for Yr22 SRF SS and TA, increase Total Consideration to incorporate 2020 SS and TA, revise Special Billing Requirements and Special Instructions, and remove language in the Task/Activity/Description and the Deliverables/Outcomes sections for Task PRO-3 (Peer Navagation) and correct the BARS revenue code for RW HIV PROVISO funding from 334.04.98 to 333.93.91 and add the CFDA #93.9171. Chart of Accounts Program Name or Title CFDA # BARS Revenue Code Master Index Code Funding (LHJ Use Start Date Period Only) End Date Current Consideration Change Increase (+) Total Consideration FFY17 ADAP Rebate Yr 21 SRF - Local 17-19 Asst (15%) (FS) SS N/A 334.04.98 12618570 346.26.64 24139221 01/01/18 06/30/18 266,278 06/30/19 3,750 0 266,278 FFY17 ADAP Rebate 3,750 Yr 21 SRF - Local 17-19 Asst (15%) (FS) TA N/A 334.04.98 12618570 07/01/18 346.26.66 24139221 01/01/18 06/30/19 307,556 884 0 307,556 FFY18 RW HIV PROVIDER CAPACITY884 Yr 22 SRF - Local Asst (15%) (FO-PROVISO 93.917 333.93.91 1261228B 04/01/18 03/31/19 30,695 0 30,695 FFY18 RW HIV PEER NAV PROJ-PROVISO 93.917 333.93.91 1261228A 04/01/18 03/31/19 34,541 22,871 57,412 STATE HIV CS / END AIDS WA SW) SS N/A 334.04.91 12630100 03/01/18 06/30/18 3,123 0 3,123 STATE HIV CS / END AIDS WA 346.26.64 24239222 01/01/19 12/31/20 4,250 3,750 7,500 Yr 22 SRF - Local Asst (15%) (FO-SW) TA N/A 334.04.91 12630100 07/01/18 12/31/18 6,246 0 6,246 STATE HIV PREVENTION PrEP N/A 334.04.91 12430100 01/01/18 06/30/18 4,586 0 4,586 STATE HIV PREVENTION PrEP N/A 334.04.91 12430100 07/01/18 06/30/19 9,172 0 9,172 346.26.66 24239222 01/01/19 12/31/20 1,750 2,000 3,750 TOTALS 662,197 22,871 685,068 10,634 5,250 15,884 Task Number Task/Activity/Description *May Support PHAB Standards/Measures Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount 1 Trained LHJ staff will conduct sanitary surveys of small community and non-community Group A water systems identified by the DOH Office of Drinking Water (ODW) Regional Office. See contract tasks and deliverables belowSpecial Instructions for task activity. Task: HCS-4 Case Management – Persons Living With HIV (PLWH) Budget Service Definition: Provision of a range of client-centered activities focused on improving health outcomes in A Salaries B Benefits C Service Contracts E Supplies/Goods G Travel J Equipment N Sub-Contracts O Other IDC % $198,414 $92,268 - $2,576 - - $122,142 support of the HIV care continuumProvide Final* Sanitary Survey Reports to ODW Regional Office. Includes all types of case management encounters with or on behalf of client (face-to-face, phone contact, any other forms of communication). Activities may Complete Sanitary Survey Reports shall include: 1) initial assessment . Cover letter identifying significant deficiencies, significant findings, observations, recommendations, and referrals for further ODW follow-up. Final Sanitary Survey Reports must be received by the ODW Regional Office within 30 calendar days of need; 2) development of individualized care plan; 3) coordinated access to health and support services; 4) client monitoring to assess conducting the care plan; 5) re-evaluation sanitary survey. Upon ODW acceptance of the care plan; 6) ongoing assessment of client's needs; 7) treatment adherence counseling; 8) client specific advocacy or review of utilization of services; 9) benefits counseling. Subtotal Final Sanitary Survey Report, the LHJ shall be paid $415,400 Strategies: • Provide case management services for PLWH living in Kitsap, Xxxxx, Clallam, and Jefferson Counties in compliance with WA State HIV CM Standards. • Utilize Acuity Guidelines to ensure delivery of appropriate level of services and related resources. • Prioritize medical engagement/retention, viral suppression and stable housing as recognized indicators of positive health outcomes and quality of life. • Utilize Client Centered Approach. • Practice Cultural Humility in all aspects of care and service delivery. • Intentionally track and address Health Disparities for Populations of Interest within your community(ies) as related to Case Management services and outcomes. • Meaningfully incorporate consumer feedback into ongoing program design, implementation and evaluation. $415,400 – Rebates $207,700 for 01/01/18-06/30/18 and $207,700 for 07/01/18-12/31/18 Targeted population: Persons living with HIV Deliverables/Measures: Number of PLWH to be served: Kitsap 175 Xxxxx 30 Clallam 40 Jefferson 17 Total 262 Reporting: • Agency must create a CAREWare file 250 for each PLWH receiving Case Management services within forty-eight (48) business hours from the time of Client Intake. • Agency must update Demographics, Annual Review, Services, Case Notes, Encounter Tab and all requisite Custom Tabs in CAREWare, as appropriate, within five (5) business days from Client Intake, identified change in Client Status, delivery sanitary survey of a support service non-community system with three or benefitfewer connections. Upon ODW acceptance of the Final Sanitary Survey Report, the LHJ shall be paid $500 for each sanitary survey of a non-community system with four or interaction with or on behalf of Client. Requirements around documentation within CAREWare can be found in your HCS Manual. • Agency must Track more connections and report within CAREWare any and all Performance Measures related to this Service Category as directed by DOH Quality Team. These include, but may not be limited to, medical engagement, medical retention, viral load, housing status, and household poverty leveleach community system.

For Information Only. Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at: xxxx://xxx.xxxxxxxx.xxx/wp-content/uploads/PHAB-Standards-and-Measures-Version-1.0.pdf Program Specific Requirements/Narrative Program Manual, Handbook, Policy References Guide for Public Health Case Management of Children with Elevated Blood Lead Levels xxxxx://xxx.xxx.xx.xxx/Portals/1/Documents/4000/334-414.pdf A Targeted Approach to Blood Lead Screening in Children, Washington State 2015 Expert Panel Recommendations xxxxx://xxx.xxx.xx.xxx/Portals/1/Documents/Pubs/334-383.pdf Special References (RCWs, WACs, etc) Laboratories are required to report to the Department of Health all Blood Lead test results (WAC 246-101-201). Elevated results (≥5 mcg/dL) must be reported within 2 days; non- elevated results ≤5 mcg/dL need to be reported within one month. Monitoring Visits (frequency, type) Telephone calls with contract manager at least once every quarter. Definitions BLL- Blood Lead Level EBLL- Elevated Blood Lead Level PEHSU- Pediatric Environmental Health Specialty Units Special Billing Requirements Reimbursement for pre-approved travel expenses including mileage, lodging and meals will be calculated at the current federal General Services Administration (GSA) rates at the time of travel. Current per diem rates by state can be found at: xxxxx://xxx.xxx.xxx/travel/plan-book/per-diem-rates/per-diem-rates-lookup Special Instructions Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable written report to include a plan of care. Payment to completely expend the “Total Consideration” for a specific funding period will not be processed until all deliverables are accepted and approved by DOH. Invoices must may be submitted monthly by the 30th of each month following the month in which the expenditures were incurred as needed within 60 days after home visit completion and must be based on actual allowable direct program costs. Billing for services on a monthly fraction of the “Total Consideration” will not be accepted or approved. If needed, additional funding may be added upon request and DOH approval while funds are available. Contact xxxx@xxx.xx.xxx for additional information. Note: blood lead case management reimbursement excludes indirect costs. DOH Program Contact Xxxxxxx Xxxxxx, Health Services Consultant Office of Environmental Public Health Sciences Washington State Department of Health Street Address: 000 Xxxxxx Xx XX, Xxxxxxxx, XX 00000 Telephone: 000-000-0000 / Fax: 000-000-0000 Email: xxxxxxx.xxxxxx@xxx.xx.xxx DOH Fiscal Contact Xxxxxxxx Xxxxx, Management Analyst 1 Assistant Secretary’s Office Telephone: 000-000-0000 Exhibit A Statement of Work Contract Term: 2018-2020 DOH Program Name or Title: HIV Client Services FPHS Communicable Disease & Support Capabilities - Effective January 1, 2018 Local Health Jurisdiction Name: Kitsap Public Health District Contract Number: CLH18248 SOW Type: Revision Original Revision # (for this SOW) 3 Funding Source Federal Subrecipient <Select One> State Other Federal Compliance (check if applicable) FFATA (Transparency Act) Research & Development Type of Payment Reimbursement Fixed Price One-Time Distribution Period of Performance: January 1, 2018 through June 30August 15, 2019 Statement of Work Purpose: The purpose of this statement of work is a provision to specify how Foundational Public Health Services (FPHS) state funds will be used. Note: The total lump sum payment for SFY18 (07/01/17-06/30/18) was distributed to LHJs in their 2015-2017 Consolidated Contracts that ended 12/31/17. This statement of a range work is to include tasks and deliverables for the remainder of clientSFY18 (01/01/18-centered activities focused on improving health outcomes 06/30/18) and SFY19 (07/01/18-06/30/19) in support of the HIV care continuum. Includes all types of case management encounters with or on behalf of client (face2018-to-face, phone contact, any other forms of communication). Activities may include: 1) initial assessment of need; 2) development of individualized care plan; 3) coordinated access to health and support services; 4) client monitoring to assess the care plan; 5) re-evaluation of the care plan; 6) ongoing assessment of client's needs; 7) treatment adherence counseling; 8) client specific advocacy or review of utilization of services; 9) benefits counseling; 10) provide clinic space for Harborview Medical Center physician to provide primary medical care to HIV-positive individuals: Registered Nurse to assist physician one day per week and an additional day every other week; and administrative support staff to assist with the project2020 Consolidated Contracts. Revision Purpose: The purpose of this revision is to add funding for Task PRO-3 (Peer Navagation) and correct the BARS revenue code for RW HIV PROVISO funding from 334.04.98 to 333.93.91 and add the CFDA #93.917. N/A Chart of Accounts Program Name or Title CFDA # BARS Revenue Code Master Index Code Funding (LHJ Use Start Date Period Only) End Date Current Consideration Change Increase (+) Total Consideration FFY17 ADAP Rebate Local 17FPHS FUNDING FOR LHJS DIR (Funding for SFY18 was distributed to LHJs in 2015-19 2017 Consolidated Contracts. The funding amount shown as Current Consideration in this Statement of Work is for Informational Purposes Only.) N/A 334.04.98 12618570 336.04.25 91106102 01/01/18 06/30/18 266,278 147,345 0 266,278 FFY17 ADAP Rebate Local 17-19 147,345 FPHS FUNDING FOR LHJS DIR N/A 334.04.98 12618570 336.04.25 91106102 07/01/18 06/30/19 307,556 0 307,556 FFY18 RW HIV PROVIDER CAPACITY-PROVISO 93.917 333.93.91 1261228B 04/01/18 03/31/19 30,695 0 30,695 FFY18 RW HIV PEER NAV PROJ-PROVISO 93.917 333.93.91 1261228A 04/01/18 03/31/19 34,541 22,871 57,412 STATE HIV CS / END AIDS WA N/A 334.04.91 12630100 03/01/18 06/30/18 3,123 0 3,123 STATE HIV CS / END AIDS WA N/A 334.04.91 12630100 07/01/18 12/31/18 6,246 0 6,246 STATE HIV PREVENTION PrEP N/A 334.04.91 12430100 01/01/18 06/30/18 4,586 0 4,586 STATE HIV PREVENTION PrEP N/A 334.04.91 12430100 07/01/18 06/30/19 9,172 0 9,172 147,345 147,345 TOTALS 662,197 22,871 685,068 147,345 147,345 294,690 Task Number Task/Activity/Description *May Support PHAB Standards/Impact Measures Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount See contract tasks and deliverables below. Task: HCS-4 Case Management – Persons Living With HIV (PLWH) Budget Service Definition: Provision of a range of client-centered activities focused on improving health outcomes in A Salaries B Benefits C Service Contracts E Supplies/Goods G Travel J Equipment N Sub-Contracts O Other IDC % $198,414 $92,268 - $2,576 - - $122,142 support 1 These funds are for delivering ANY or all of the HIV care continuumFPHS communicable disease service and can also be used for the FPHS capabilities that support FPHS communicable disease services as defined in the most current version of FPHS Definitions – Version 1.3 (November 2017) Control of Communicable Disease and Other Notifiable Conditions Percent of toddlers and school age children that have completed the standard series of recommended vaccinations. Includes all types Percent of new positive Hepatitis C lab reports that are received electronically which have a completed case management encounters with or on behalf of client report. SFY18 (face07/01/17-to06/30/18) Report: Actual Activities and Estimated Expenditures SFY19 (07/01/18-face06/30/19) Work Plan: Planned Activities and Projected Spending By 08/15/18 By 08/15/18 SFY19 (07/01/18-06/30/19) funds are available beginning July 1, phone contact, any other forms of communication). Activities may include: 1) initial assessment of need; 2) development of individualized care plan; 3) coordinated access to health 2018 and support services; 4) client monitoring to assess the care plan; 5) re-evaluation full year allocation will be dispersed upon receipt of the SFY18 Report and SFY19 Work Plan. Task Number Task/Activity/Description Impact Measures Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount 1-1. Provide timely, statewide, locally relevant and accurate information statewide and to communities on prevention and control of communicable disease and other notifiable conditions. 1-2. Identify statewide and local community assets for the control of communicable diseases and other notifiable conditions, develop and implement a prioritized control plan addressing communicable diseases and other notifiable conditions, seek resources and advocate for high priority prevention and control policies and initiatives regarding communicable diseases and other notifiable conditions. 1-3. Promote immunization through evidence based strategies and collaboration with schools, health care plan; 6providers and other community partners to increase immunization rates. 1-4. Ensure disease surveillance, investigation and control for communicable disease and notifiable conditions in accordance with local, state and federal mandates and guidelines. See activities in the definitions. Percent of new positive Hepatitis C case reports with completed investigations. Percent of Gonorrhea cases investigated. Percent of Gonorrhea cases investigated that are receiving dual treatment (treatment for both Gonorrhea and Chlamydia at the same time) ongoing assessment Percent of client's needs; 7) treatment adherence counseling; 8) client specific advocacy or review of utilization of services; 9) benefits counselingnewly diagnosed syphilis cases that receive partner services interview. Subtotal $415,400 Strategies: • Provide case management services for PLWH living in Kitsap, Xxxxx, Clallam, and Jefferson Counties in compliance with WA State HIV CM Standards. • Utilize Acuity Guidelines to ensure delivery of appropriate level of services and related resources. • Prioritize medical engagement/retention, viral suppression and stable housing as recognized indicators of positive health outcomes and quality of life. • Utilize Client Centered Approach. • Practice Cultural Humility in all aspects of care and service delivery. • Intentionally track and address Health Disparities for Populations of Interest within your community(ies) as related to Case Management services and outcomes. • Meaningfully incorporate consumer feedback into ongoing program design, implementation and evaluation. $415,400 – Rebates $207,700 for 01/01/18-06/30/18 and $207,700 for SFY19 (07/01/18-12/31/18 Targeted population06/30/19) Report: Persons living with HIV DeliverablesActual Activities and Estimated Expenditures (Note: Use DOH online tool for reports and work plans. See Special Instructions below.) By 08/15/19 Program Specific Requirements/Measures: Number of PLWH Narrative Special References (RCWs, WACs, etc) • Immunizations – xxxx://xxx.xxx.xx.xxx/YouandYourFamily/Immunization • Notifiable Conditions - xxxx://xxx.xxx.xx.xxx/ForPublicHealthandHealthcareProviders/NotifiableConditions • Sexually Transmitted Diseases (STD) – xxxx://xxx.xxx.xx.xxx/YouandYourFamily/IllnessandDisease/SexuallyTransmittedDisease • Human Immunodeficiency Virus (HIV) – xxxx://xxx.xxx.xx.xxx/YouandYourFamily/IllnessandDisease/HIVAIDS • Tuberculosis (TB) – xxxx://xxx.xxx.xx.xxx/YouandYourFamily/IllnessandDisease/Tuberculosis • Hepatitis C (HCV) - xxxxx://xxx.xxx.xx.xxx/ForPublicHealthandHealthcareProviders/NotifiableConditions/HepatitisC Definitions • FPHS Definitions, Version 1.3, November 2017 Special Instructions There are two different BARS Revenue Codes for “state flexible funds” to be served: Kitsap 175 Xxxxx 30 Clallam 40 Jefferson 17 Total 262 Reporting: • Agency must create a CAREWare file for each PLWH receiving Case Management services within forty-eight (48) business hours tracked separately and reported separately on your annual BARS report. These two BARS Revenue Codes and definitions from the time of Client Intake. • Agency must update Demographics, Annual Review, Services, Case Notes, Encounter Tab and all requisite Custom Tabs in CAREWare, as appropriate, within five State Auditor’s Office (5SAO’s) business days from Client Intake, identified change in Client Status, delivery of are listed below along with a support service or benefit, or interaction with or on behalf of Client. Requirements around documentation within CAREWare can be found in your HCS link to the BARS Manual. • Agency must Track and report within CAREWare any and all Performance Measures related 336.04.25 is the new BARS Revenue Code to use for the Foundational Public Health Services (FPHS) funds included in this Service Category as directed by DOH Quality Team. These include, but may not be limited to, medical engagement, medical retention, viral load, housing status, and household poverty levelstatement of work.

For Information Only. Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at: xxxx://xxx.xxxxxxxx.xxx/wp-content/uploads/PHAB-Standards-and-Measures-Version-1.0.pdf Program Specific Requirements/Narrative Program Manual, Handbook, Policy References Guide for Public Health Case Management of Children with Elevated Blood Lead Levels xxxxx://xxx.xxx.xx.xxx/Portals/1/Documents/4000/334-414.pdf A Targeted Approach to Blood Lead Screening in Children, Washington State 2015 Expert Panel Recommendations xxxxx://xxx.xxx.xx.xxx/Portals/1/Documents/Pubs/334-383.pdf Special References (RCWs, WACs, etc) Laboratories are required to report to the Department of Health all Blood Lead test results (WAC 246-101-201). Elevated results (≥5 greater than or equal to 5 mcg/dL) must be reported within 2 two (2) days; non- non-elevated results ≤5 mcg/dL need to be reported within one (1) month. Monitoring Visits (frequency, type) Telephone calls and/or in person meetings with contract manager at least once every quarteron as as-needed basis. Definitions BLL- BLL – Blood Lead Level EBLL- EBLL – Elevated Blood Lead Level PEHSU- PEHSU – Pediatric Environmental Health Specialty Units Special Billing Requirements Reimbursement The average total amount expended for pre-approved travel expenses including mileagelaboratory, lodging interpreter, and meals will translation services is suggested to be calculated at the current federal General Services Administration (GSAapproximately $185 per home visit, per child. It is recognized that more complex cases may require a higher level of services, while simpler cases may require fewer services. Total reimbursements may not exceed total funding consideration. Please note WDRS event number(s) rates at the time on invoice to allow DOH review of travel. Current per diem rates by state can be found at: xxxxx://xxx.xxx.xxx/travel/plan-book/per-diem-rates/per-diem-rates-lookup Special Instructions Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable written report to include a plan of carevia WDRS. Payment to completely expend the “Total Consideration” for a specific funding period will not be processed until all deliverables are accepted and approved by DOH. Invoices must may be submitted monthly by the 30th of each month following the month in which the expenditures were incurred as needed within 60 days after home visit completion and must be based on actual allowable direct program costs. Billing for services on a monthly fraction of the “Total Consideration” will not be accepted or approved. If needed, additional funding may be added requested and upon request and DOH approval while may be added if funds are available. Contact xxxx@xxx.xx.xxx for additional information. Note: blood lead case management Blood Lead Case Management reimbursement excludes indirect costs. DOH Program Contact Xxxxxxx XxxxxxDOH Fiscal Contact Xxx Xxxxxxxx, Health Services Consultant Consultant/Case Management Coordinator Xxxxxxxx Xxxxx, Management Analyst 1 Office of Environmental Public Health Sciences Assistant Secretary’s Office Washington State Department of Health Telephone: 000-000-0000 Street Address: 000 Xxxxxx Xx XX, Xxxxxxxx, Xxxxxxxx XX 00000 Telephone: 000-000-0000 / Fax: Fax 000-000-0000 Email: xxxxxxx.xxxxxx@xxx.xx.xxx DOH Fiscal Contact Xxxxxxxx Xxxxx, Management Analyst 1 Assistant Secretary’s Office Telephone: 000-000-0000 xxx.xxxxxxxx@xxx.xx.xxx Exhibit A Statement of Work Contract Term: 2018-2020 DOH Program Name or Title: HIV Client Services Office of Drinking Water Group A Program - Effective January 1, 2018 Local Health Jurisdiction Name: Kitsap Public Health District Contract Number: CLH18248 SOW Type: Revision Revision # (for this SOW) 3 6 Period of Performance: January 1, 2018 through December 31, 2020 Local Health Jurisdiction Name: Kitsap Public Health District Funding Source Federal Subrecipient Contractor State Other Federal Compliance (check if applicable) FFATA (Transparency Act) Research & Development Type of Payment Reimbursement Fixed Price Period of PerformanceContract Number: January 1, 2018 through June 30, 2019 CLH18248 Statement of Work Purpose: The purpose of this statement of work is a provision of a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum. Includes all types of case management encounters with or on behalf of client (face-to-face, phone contact, any other forms of communication). Activities may include: 1) initial assessment of need; 2) development of individualized care plan; 3) coordinated access to health and support services; 4) client monitoring to assess the care plan; 5) re-evaluation of the care plan; 6) ongoing assessment of client's needs; 7) treatment adherence counseling; 8) client specific advocacy or review of utilization of services; 9) benefits counseling; 10) provide clinic space for Harborview Medical Center physician to provide primary medical care funding to HIVthe LHJ for conducting sanitary surveys and providing technical assistance to small community and non-positive individuals: Registered Nurse to assist physician one day per week and an additional day every other week; and administrative support staff to assist with the projectcommunity Group A water systems. Revision Purpose: The purpose of this revision is to increase Contract Consideration to add funding for Task PRO-3 (Peer Navagation) 1 survey and correct the BARS revenue code for RW HIV PROVISO funding from 334.04.98 to 333.93.91 revise Special Billing Requirements and add the CFDA #93.917Special Instructions. Chart of Accounts Program Name or Title CFDA # BARS Revenue Code Master Index Code Funding Period (LHJ Use Only) Start Date Period Only) End Date Current Consideration Change Increase (+) Total Consideration FFY17 ADAP Rebate Local 17-19 Yr 20 SRF - Prog Mgmt (10%) (FS) TA N/A 334.04.98 12618570 346.26.66 24137220 01/01/18 06/30/18 266,278 12/31/18 1,268 0 266,278 FFY17 ADAP Rebate 1,268 Yr 21 SRF - Local 17-19 Asst (15%) (FS) SS N/A 334.04.98 12618570 07/01/18 346.26.64 24139221 01/01/18 06/30/19 307,556 14,250 0 307,556 FFY18 RW HIV PROVIDER CAPACITY-PROVISO 93.917 333.93.91 1261228B 04/01/18 03/31/19 30,695 0 30,695 FFY18 RW HIV PEER NAV PROJ-PROVISO 93.917 333.93.91 1261228A 04/01/18 03/31/19 34,541 22,871 57,412 STATE HIV CS / END AIDS WA 14,250 Yr 21 SRF - Local Asst (15%) (FS) TA N/A 334.04.91 12630100 03/01/18 06/30/18 3,123 346.26.66 24139221 01/01/18 06/30/19 1,900 0 3,123 STATE HIV CS / END AIDS WA 1,900 Yr 22 SRF - Local Asst (15%) (FO-SW) SS N/A 334.04.91 12630100 07/01/18 12/31/18 6,246 0 6,246 STATE HIV PREVENTION PrEP 346.26.64 24239222 01/01/19 12/31/20 21,250 500 21,750 Yr 22 SRF - Local Asst (15%) (FO-SW) TA N/A 334.04.91 12430100 01/01/18 06/30/18 4,586 346.26.66 24239222 01/01/19 12/31/20 4,249 0 4,586 STATE HIV PREVENTION PrEP N/A 334.04.91 12430100 07/01/18 06/30/19 9,172 0 9,172 4,249 TOTALS 662,197 22,871 685,068 42,917 500 43,417 Task Number Task/Activity/Description *May Support PHAB Standards/Measures Deliverables/Outcomes Due Date/Time Frame Payment Information and/or Amount 1 Trained LHJ staff will conduct sanitary surveys of small community and non-community Group A water systems identified by the DOH Office of Drinking Water (ODW) Regional Office. See contract tasks and deliverables belowSpecial Instructions for task activity. Task: HCS-4 Case Management – Persons Living With HIV (PLWH) Budget Service Definition: Provision of a range of client-centered activities focused on improving health outcomes in A Salaries B Benefits C Service Contracts E Supplies/Goods G Travel J Equipment N Sub-Contracts O Other IDC % $198,414 $92,268 - $2,576 - - $122,142 support of the HIV care continuumProvide Final* Sanitary Survey Reports to ODW Regional Office. Includes all types of case management encounters with or on behalf of client (face-to-face, phone contact, any other forms of communication). Activities may Complete Sanitary Survey Reports shall include: 1) initial assessment . Cover letter identifying significant deficiencies, significant findings, observations, recommendations, and referrals for further ODW follow-up. Final Sanitary Survey Reports must be received by the ODW Regional Office within 30 calendar days of need; 2) development of individualized care plan; 3) coordinated access to health and support services; 4) client monitoring to assess conducting the care plan; 5) re-evaluation sanitary survey. Upon ODW acceptance of the care plan; 6) ongoing assessment of client's needs; 7) treatment adherence counseling; 8) client specific advocacy or review of utilization of services; 9) benefits counseling. Subtotal Final Sanitary Survey Report, the LHJ shall be paid $415,400 Strategies: • Provide case management services for PLWH living in Kitsap, Xxxxx, Clallam, and Jefferson Counties in compliance with WA State HIV CM Standards. • Utilize Acuity Guidelines to ensure delivery of appropriate level of services and related resources. • Prioritize medical engagement/retention, viral suppression and stable housing as recognized indicators of positive health outcomes and quality of life. • Utilize Client Centered Approach. • Practice Cultural Humility in all aspects of care and service delivery. • Intentionally track and address Health Disparities for Populations of Interest within your community(ies) as related to Case Management services and outcomes. • Meaningfully incorporate consumer feedback into ongoing program design, implementation and evaluation. $415,400 – Rebates $207,700 for 01/01/18-06/30/18 and $207,700 for 07/01/18-12/31/18 Targeted population: Persons living with HIV Deliverables/Measures: Number of PLWH to be served: Kitsap 175 Xxxxx 30 Clallam 40 Jefferson 17 Total 262 Reporting: • Agency must create a CAREWare file 250 for each PLWH receiving Case Management services within forty-eight (48) business hours from the time of Client Intake. • Agency must update Demographics, Annual Review, Services, Case Notes, Encounter Tab and all requisite Custom Tabs in CAREWare, as appropriate, within five (5) business days from Client Intake, identified change in Client Status, delivery sanitary survey of a support service non-community system with three or benefitfewer connections. Upon ODW acceptance of the Final Sanitary Survey Report, the LHJ shall be paid $500 for each sanitary survey of a non-community system with four or interaction with or on behalf of Client. Requirements around documentation within CAREWare can be found in your HCS Manual. • Agency must Track more connections and report within CAREWare any and all Performance Measures related to this Service Category as directed by DOH Quality Team. These include, but may not be limited to, medical engagement, medical retention, viral load, housing status, and household poverty leveleach community system.