HomeMy WebLinkAbout1994 S Health - Amendment to the Consolidated Contract for 1994-95 to Extend EPSDT Project -T/4y
A VY V
AMENDMENT NUMBER
to
CONSOLIDATED CONTRACT
between
THE STATE
and
THE ORANGE COUNTY/DISTRICT
HEALTH DEPARTMENT
This Contract covering the period from
July 1, 1994 to June 30, 1995
(Month) (Day) (Year) (Month) (Day) (Year)
is hereby amended to add the following activities:
ACTIVITIES
EPSDT Outreach Project
Family Planning
All provisions and clauses set forth in the Contract are hereby
incorporated in this Amendment and constitute the terms and
conditions applicable for the above activities involving State
funding.
CONTRACTOR SIGNATURES NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT, HEALTH, AND
` NATURAL RESOURCES
Jonathan B. Howes, Secretary
Health Director Date
Director
Div. of General Services
ly
Finance Officer D e Department Head's Signature
or Authorized Agent
al an of County Date
Commissioners
.j
DEHNR 2946A (Revised 3/93)
General Services Division (Review 10/95)
OCAL HEALTH DEPARTMENT BUDGET
N C. Deportment of Environment,
Health, and Natural Resources Revision Number
Division of General Services
SFy ivision of Maternal and Child Health --
P. O.Number
July 1 / 1994 June 30 / 1995 9 5 5 3 5 9 0 -0 –fL�
Effective Date Termination Date Contract Number
Contractor: Orange County Health Department Activity: EPSDT Outreach Project
Project Director: Daniel Reimer 10,000
Total Budget: $
ITEM DESCRIPTION CLASSIFICATION ITEM AMOUNT
E STATE EXPENDITURES:
X Salaries & Fringe Benefits SA/FR 1000 10.000
Operating Expenses OP EXP 2000
P Purchase of Equipment EQUIP 5000
E General Contracted or
N Purchased Services GENERAL 6100
School Health
€:SCH::' L .
D Clinician CLN 6863
I
T Laboratory LAB 6862
Pharmacy Services RX SERV 6865
U
Transfer
TXIX
R Subtotal State Expend. $ 10,000
E LOCAL EXPENDITURES: LOCAL EXP 9000
S
r� TOTAL EXPENDITURES—equal to Total Receipts $ 10,000
LOCAL FUNDS:
R Appropriation APPROP 101
E TXIX TXIX 102
Other Receipts OTHR REC 103
C
E Subtotal Local Funds $
STATE/FEDERAL/SPECIAL FUNDS:
I
P
i S3�- s35 - 3`76 3
T •�3S'- 53S''�i-3'7 i `f
S
Subtotal State/Federal/Special $
TOTAL RECEIPTS— equal to Total Expenditures $ 10,000
cep, IJ .30 9tF
Local Authorized Official Signature Date Branch Hnd Division/Section Signature Date
finance Officer Signature a e Accoununt Fiscal Management Si at a Date
lnicial
DEHNR 2948(Revised 2/93)
:jeneral Services Division(Review 2/94)
N.C. Department of Environment.Health, and Natunl Resources Page 1 of 1
Division of General Services
CONTRACT ADDENDUM FY 94/95
Childrtn and Youth Secrion 9553590068
Office, Section, or Branch Contract Number
Orange County Health Department EPSDT Outreach Project
Contractor Activity
The local health department agrees to participate in an EPSDT Outreach
Project. The expected outcomes of the Project are:
I. To increase the utilization rates of EPSDT services on the part of
eligible children, with an emphasis on screening services.
2. To increase referral completion rates for children referred as a
result of screening services, with an emphasis on children with
special health care needs.
3. To increase the age-appropriate immunization rates of EPSDT-eligible
children, with an emphasis on infants and toddlers.
4. To increase the WIC participation rates of EPSDT-eligible children
less than 5 years of ace.
The local health department agrees to the following activities:
1. To develop a county-based EPSDT Outreach Plan aimed at attaining the
outcomes listed above. The Plan will outline the interagency
relationships and responsibilities of at least the following agencies
and programs:
a. Department of Social Services
b. Head Start Centers
C. Community Migrant, Rurnl Health Centers
d. Carolina Access
e. Immunization
f. Child Service Coordination
g. WIC
h. Preventive & primary care providers, e.g. , physicians & dentists
c. To hire staff with resources available through this Project to:
a. Maintain an EPSDT client tracking system to identify eligible
children who are not receiving screening services or are not
utilizing specialized services to which they have been referred.
b. Facilitate access to care for such children by offering families
assistance with appointment scheduling, transportation, etc.
c. Offer assistance to all EPSDT providers in assuring that families
schedule and keep appointments.
d. Disseminate information regarding EPSDT services and eligibility.
Reviewed by
DEHNR 3300(Revised 2/90)
General Services Division(Review 1195) Initials Datc
LOCAL HEALTH DEPARTMENT BUDGET
Department of Environment, /
-iealth, and Natural Resources Revision Numb r——
ision of General Services �/ G�
Division of Maternal and Child Health L ��-�—
Y' P. O. Number
07 / 94 06 / 95 9 5 5 1 5 __L-D- 0 6 8
Effective Date Termination Date Contract Number
,ntractor: Orange Co; Health Dept- Activity: Family Planning
eject Director: Daniel B. Reimer Total Budget:$ 557,055
ITEM DESCRIPTION CLASSIFICATION ITEM AMOUNT
STATE EXPENDITURES:
Salaries & Fringe Benefits SA/FR 1000 116,562
Operating Expenses OP EXP 2000
? Purchase of Equipment EQUIP 5000
General Contracted or -
Purchased Services GENERAL 6100 5,700
School Health €<°�SCH';HL ,... :.::..:..::.... ;;:>.;.>:>.. . ... :.: .... .. .r: . ...:.::.:.::...:.. ::.............
Clinician CLN 6863
I
Laboratory
Pharmacy Services
Transfer TXIX
Subtotal State Expend. $ 122,262
LOCAL EXPENDITURES: LOCAL EXP 9000 *3¢, 793
TOTAL EXPENDITURES—equal to Total Receipts $ 557,055
LOCAL FUNDS:
R Appropriation APPROP 101 3977212
F TXIX TXIX 102 26,201
Other Receipts OTHR REC 103 11,380
Subtotal Local Funds $ 434,793
E STATE/FEDERAL/SPECIAL FUNDS:
I
P HMHC Funds] 22,162
T Non-HMHC Funds] DEHNR 1515-6100-5151- X-�u-X 100,1'00 "
S
Subtotal State/Federal/Special $ 122,262
TOTAL RECE S —equal to Total Expenditures $557 05. -
Local A orized Official Signature Date Branch Hod Division/Section S' Lure y Date
InieW
Finance Officer Signature Date Arco- m Fiscal Management Signature Date
w�
:F-7R 2948(Revised 2/93)
neral Services Division(Review 2/94)
N.0 Department of Environment. Health and Natural Resources Pagel of 5
Division of General Services FY 1994-95
CONTRACT ADDENDUM
Women's Preventive Health Branch 95 51510 068
Office, Section, or Branch Contract Number
Orange Family Planning
Contractor Activity
1. --3- � 38 5Total new patients will be served.
a. -4-1-$ It S New patients aged 19 or less will be served. ]y
b. —2&F- 170 New patients aged 20 or above will be served.
2. x-1-9— 9\5 Total continuation patients will be served. o,
i
a. —2-6$- 265 Continuation patients aged 19 or less will be served.
b. 650 Continuation patients aged 20 or above will be served.
3. +245- 1300 Total patients will be served (item 1 + item 2).
a. -34-6" 380 Patients will be served, aged 19 or less (item La. + 2.a.).
b. 9a--Fi ITO Patients will be served, aged 20 or above (item Lb. + 2.b.).
4. Need Met
a. Percent of need will be met, patients aged 19 or less.
Note: For this calculation, the denominator to be used is the Alan
Guttmacher Institute (A GI) need estimate for IS to 19 year
olds.
b. 12 Percent of need will be met, patients aged 20 or above.
Note: For this calculation, the denominator to be used is the AGI
need estimate for 20 to 44 year olds at or below 150% of
federal poverty level.
5. 80 Percent of total caseload which will be from target population
6. The local health agency has written policies in place for family planning services:
(a) Description of local family planning services, including local
protocols, standing orders and components of Initial, Complete,
Limited and Extended Revisits.
Reviewed by
DEHNR 3300 (Revised 2/'94)
General Services Division (Review 1/95) Initials Date
N.0 Department of Environment,Health and Natural Resources Page2_of 5
Division of General Services FY 1994-95
CONTRACT ADDENDUM
Women's Preventive Health Brancb 95 51510 068
Office, Section, or -Branch Contract Number
Orange Family Planning
Contractor Activity
(b) Tracking mechanism for follow-up of abnormal tests and referrals.
(c) Follow-up of family planning patients with positive pregnancy tests to
assure patient has access to health care provider. (NOTE: An
intermediate sensitivity urine pregnancy test which can reliably detect
pregnancy within 14 days of conception should be used.)
(d) Follow-up of missed appointments.
(e) Follow-up and protocol for clients wanting permanent
contraception.
(f) Offering HIV-STD prevention method (condoms and spermicide) to
clients who have high-risk behaviors (use high-risk behaviors for
HIV as defined by HIV/STD Prevention Program).
(g) Identification of high risk contraceptors.
(h) Counseling family planning postpartum clients to delay pregnancy
for at least 12 months after delivery.
7. Persons enrolled in the local agency's family planning program will be
provided the following services as documented in their medical records:
(a) All patients will receive an initial or updated history which consists
of: medical; social; family; surgical; menstrual; douching;
contraception; drugs/medication; obstetrical and immunization (Td,
Rubella) on initial or complete visits.
(b) All patients will receive an annual physical examination on initial or
complete visits which consists of: weight; height (if growth not
complete); blood pressure; breasts; heart; lungs; abdomen;
extremities; complete pelvic examination and rectal examination, if
indicated.
Reviewed by
�L C
DEHNR 3300 (Revised 2/94)
General Services Division (Review 1/95) Initials Date
N.C. Department of Environment, Health and Natural Resources PageLof 5
Division of General Services FY 1994-95
CONTRACT ADDENDUM
Women's Preventive Health Branch 95 51510 068
Office, Section, or Branch Contract Number
Orange .Family Planning '
Contractor Activity
(c) Limited revisits include reason for visit, method specific history,
weight, blood pressure and education and counseling if indicated.
8. The following tests will be obtained on all initial or complete visits and
documented in the medical record:
(a) Hematocrit or hemoglobin
(b) Urinalysis for sugar and protein
(c) Pap smear
(d) Gonorrhea culture
(e) Syphilis Serology (required on initial visits, required on
complete visits in the presence of a positive gonorrhea culture
or on other visits as indicated by the clinician). Note: HIV
testing is recommended in the presence of a positive syphilis
serology.
9. Immunity Assessment for Rubella & Tetanus-diphtheria will be
documented in the patient's record on all initial and complete visits:
(a) Rubella assessment`includes documentation of Rubella vaccine or
laboratory test indicating immunity. Once immune, no future
assessments are needed. If no documentation of vaccine or
immunity, Rubella vaccine is given to non-pregnant clients (see
Medical Guidelines).
(b) Tetanus-diphtheria assessment includes documentation of Tetanus-
diphtheria vaccine.
Assessment on complete visits is not required if TD vaccine was given and
documented within the last ten years. If no documentation, Td vaccine
should be given (See Medical Guidelines).
Reviewed by
DEHNR 3300 (Revised 2/'94) A<-5 _ � ?--cj
General Services Division(Review 1/95) Initials Date
N.C. Department of Environment, Health and Natural Resources Paged of S
Division of General Services FY 1994-95
CONTRACT ADDENDUM
Women's Preventive Health Branch 95 51510 068
Office, Section, or Branch Contract Number
Orange Family Planning
Contractor Activity
10. Education and Counseling:
(a) Client received information on all contraceptive methods and their
risks and benefits (including natural family planning and abstinence
for teens). See Medical Guidelines.
(b) Client received additional information specific to the contraceptive
method(s) to be used.
(c) Education in HIV infection and AIDS including counseling on risk
assessment, HIV prevention and how to get tested (on site or
referral) was provided.
(d) Breast self examination was taught or education reviewed.
(e) Minors under 18 years of age were counseled about the importance
of discussing birth control needs with parent(s) and minor signs
form.
(f) Required education offered outside the family planning clinic is
documented and updated as appropriate according to the needs of the
individual family planning patient.
(g) Information about emergency and after-hour services was provided.
11. Method specific consent form was reviewed with client, dated, signed by
client, and copy given to client.
(a) A new consent form is signed with any change in method.
(b) Any individual risk to contraceptive method was identified on the
method specific consent form.
Reviewed by
DEHNR 3300 (Revised 2194) �,-
GeneraI Services Division (Review 1195) Initials Date
N.C. Department of Environment, Health and Natural Resources Pages of 5
Division of General Services FY 1994-95
CONTRACT ADDENDUM
Women's Preventive Health Branch 95 51510 068
Office, Section, or Branch Contract Number
Orange Family Planning
Contractor Activity
12. Screening, Diagnosis, Treatment and Follow-up Services
There is evidence in the record that:
(a) Significant problems are identified and documented.
(b) Problems, conditions and abnormal findings are appropriately
followed.
(c) There is evidence that significant abnormal clinical and laboratory
findings were discussed with client.
13. The lowest level provider of care on all Initial and Complete Visits for oral
contraceptive, IUD, Norplant and Depo Provera users was a physician or
physician extender (nurse practitioner, CNM or physician assistant).
Reviewed by
DEHNR 3300 (Revised 2/94) --S S:e? c
General Services Division (Review 1/95) Initials Date