HomeMy WebLinkAbout2021-372-Health-Club Nova Community-Outside agency funding
Club Nova
Orange County Outside Agency Performance Agreement
Revised 7/2018 Page 1 of 9
OUTSIDE AGENCY PERFORMANCE AGREEMENT
THIS AGREEMENT, made and entered into the first day of July 2020, (“Effective Date”) by and between
the County of Orange, a political subdivision of the State of North Carolina, Post Office Box 8181,
Hillsborough, North Carolina, 27278, ("County") and Club Nova Community, Inc., a not-for-profit
corporation, located at 103 D. West Main Street, Carrboro, North Carolina 27510 (“Provider”).
WITNESSETH:
WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby
enhance its availability to residents of the County, and said program addresses an important community
human services need, as identified by the Board of Commissioners.
NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set
forth, the County and «Agencys_Name» agree as follows:
1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1,
2020 to June 30, 2021.
2. Scope of Services.
a. Provider will provide services, as outlined in the attached Outside Agency Funding
Application and any amendments or revision thereto which is attached as Exhibit “A” and
incorporated by reference, to the residents of Orange County. The Scope of Services and
the Program Budget may be different from the original application based on County
appropriation; however, any revisions or amendments to this Agreement must be approved
in writing by the County and attached to this Agreement as Exhibit B.
b. The Provider shall be solely responsible for the means, methods, techniques, sequence,
safety program and procedures necessary to properly and fully complete the work set forth
in the Scope of Services.
3. Funding.
a. The County agrees to appropriate for the provision of services described in Exhibit A,
Scope of Services and more particularly described in the Revised Program Budget, the
maximum sum of $19,813.
b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not
used for the purposes stated shall be returned to the County. Any changes in the use of
funds must be authorized in writing by the County prior to any expenditure of the funds by
the Provider. If the funds are expended not in accordance with the Scope of Services, at the
discretion of the County the Provider may be required to repay the funds to the County.
c. The Provider shall be paid in four equal installments in the amount of $4,953.25. The first
payment is contingent upon receipt of the agency’s performance agreement; the remaining
payments are contingent upon receipt of the request for reimbursement and related
supporting documentation.
d. The County’s obligation to make the quarterly payments is contingent upon receipt of
Progress Reports, which show satisfactory progress toward completion of performance
measures and an accounting of expenditures as detailed in the attached Scope of Services.
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Orange County Outside Agency Performance Agreement Page 2 of 9
Rev. 1/21
e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21
days after receipt of the Progress Report and Request for Reimbursement or 21 days after
due date of Progress Report whichever is later.
f. The County is not obligated to provide any other support to Provider in this or in
succeeding fiscal years.
4. Agency Reporting.
a. Provider will provide Orange County a Progress Report that includes a fiscal report and
updates on performance measures as outlined in the Scope of Services. Progress Report
dates are: July 1 – December 31; January 1 – March 31 and April 1 - June 30. Reports are
due on January 10, April 10, and July 10 of the program fiscal year.
b. Provider agrees to allow the County to inspect its financial books and records, which
document costs of those services, upon reasonable notice during normal working hours.
5. Termination.
a. In the event of any of the circumstances set forth below (hereinafter referred to as
“default”), the County may immediately terminate this Agreement, in whole or in part, and
from time to time. Notice of termination must be in writing, state the reason or reasons for
the termination, and specify the effective date of the termination:
i. In the event that Provider shall cease to exist as an organization or shall enter
bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all
of its assets, or significantly reduce its services or accessibility to Orange County
residents during the term of this Agreement; or
ii. In the event that Provider shall fail to render a satisfactory accounting as provided
section 4 above, the County may terminate this Agreement and Provider shall
return all payments already made to it by the County for services which have not
been provided or for which no satisfactory accounting has been rendered; or
iii. In the event of any fraudulent representation by the Provider in an invoice or other
verification required to obtain payment under this Agreement or other dishonesty
on a material matter relating to the performance of services under this Agreement.
iv. Nonperformance, incomplete service or performance, or failure to satisfactorily
perform any part of the work identified in the Scope of Services or to comply with
any provision of this Agreement, as determined by the County in its sole discretion.
v. Failure to adhere to the terms of applicable county, state or federal laws,
regulations, or stated public policy.
b. In the event of default by the Provider, the county may elect to terminate this Agreement, in
whole or in part and/or require the Provider to repay the funds within ten (10) business days
from written notice of default. The County may (but shall not be required to) grant the
Provider an opportunity to cure the default without termination of this Agreement. This
clause shall not be interpreted to limit the County’s remedies in law or in equity.
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Orange County Outside Agency Performance Agreement Page 3 of 9
Rev. 1/21
c. Notwithstanding the foregoing, either party may terminate the agreement at any time
without penalty; provided that written notice of such termination is furnished to the other
party at least 30 days prior to termination. In the event of such termination, any payment
due shall be prorated to the date of termination and any unused funds shall be returned to
the County within 10 days of termination.
d. Any termination of this Agreement for default under this section that is later deemed to be
unjustified shall be deemed a termination for convenience.
6. Insurance.
a. General Requirements. The Provider shall purchase and maintain, during the period of
performance of this Agreement, insurance:
i. Worker’s Compensation. For protection from claims under workers' or workmen's
compensation acts;
ii. Comprehensive General Liability Insurance covering claims arising out of or
relating to bodily injury, including bodily injury, sickness, disease or death of any
of the Consultant's employees or any other person and to real and personal property
including loss of use resulting thereof;
iii. Comprehensive Automobile Liability Insurance, including hired and non-owned
vehicles, if any, covering personal injury or death, and property damage; and
iv. Professional Liability Insurance, covering personal injury, bodily injury and
property damage and claims arising out of or related to the performance under this
Agreement by the Consultant or his agents, consultants and employees.
b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows:
INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE
• Worker's Compensation Limits for Coverage A - Statutory State
NC & Coverage B - Employers Liability
$500,000 each accident, disease policy limit and
disease each employee
• Commercial General $1,000,000 Each Occurrence
Liability $2,000,000 Aggregate
• Automobile Liability $500,000 Combined Single Limit
• Professional Liability $1,000,000 Each Occurrence
$2,000,000 Aggregate
c. All insurance policies (with the exception of Worker's Compensation and Professional
Liability) required under this Agreement shall name the County as an additional insured
party and as a certificate holder. Evidence of such insurance and all correspondence shall
be sent to:
Orange County Risk Manager
Post Office Box 8181
Hillsborough, NC 27278
d. Nothing in this section is intended to affect or abrogate the County’s sovereign immunity
defenses.
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Orange County Outside Agency Performance Agreement Page 4 of 9
Rev. 1/21
7. Relationship of the Parties. Provider is an independent contractor of the County. Provider
represents that they have or will secure, at his own expense, all personnel required in performing
the services under this Agreement. Such personnel shall not be employees or have any
contractual relationship with the County. All personnel engaged in work under this Agreement
shall be fully qualified and shall be authorized and permitted under federal, state and local law to
perform such services.
8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws,
ordinances, orders and regulations of the federal, state or local governments, as well as their
respective departments, commissions, boards, and officers, which are in effect at the time of
execution of this Agreement or are adopted at any time following execution of this agreement.
9. Subcontract. The County and Provider deem the services provided under this Agreement to be
personal in nature and Provider may not subcontract any rights or duties under this Agreement to
any other party without prior written consent from the County.
10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to
any other party without the prior written consent of the County.
11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all
loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury,
including death or property damage, to any person or persons caused in whole or in part by the
negligence or willful misconduct of the Provider, except to the extent same are caused by the
negligence or willful misconduct of the County. It is the intent of this section to require Provider
to indemnify the County to the extent permitted under North Carolina law. Nothing in this
section is intended to affect or abrogate the County’s sovereign immunity defenses.
12. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the
specified services and may be terminated at any time if such funds become unavailable.
13. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange
County the parties hereto for themselves, their agents, officials, employees and servants agree not
to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap,
religion, sexual orientation, familial status or veterans status with reference to any activities
carried out by the grantee, no matter how remote. The parties hereto further agree in all respects
to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and
the Orange County Non-discrimination Policy. This provision is enforced by action for specific
performance, injunctive relief, or other remedy as by law provided; this provision shall be
binding on the grantees, the successors and assigns of the parties hereto with reference to the
above subject manner.
14. Living Wage. Orange County is committed to providing its employees with a living wage and
encourages agencies if funds to pursue the same goal. The County’s living wage is $ 14.95 per
hour. To the extent possible, Orange County recommends that Provider provide a living wage to
its employees.
15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the
last known address shall constitute sufficient notice to the County and the Provider. All notices
required and/or made pursuant to this Agreement to be given to the County and the Provides shall
be in writing and mailed to the party addressed as follows:
County: Finance & Administrative Services Provider: Club Nova Community, Inc.
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Orange County Outside Agency Performance Agreement Page 5 of 9
Rev. 1/21
16. E
n
tire Agreement. This Agreement, including any referenced attachments, constitutes the entire
Agreement between the parties and shall supersede, replace or nullify any and all prior
Agreements of understandings; written or oral, relating to the matters set forth herein, and any
such prior Agreements or understandings shall have no force or affect whatsoever on this
Agreement. The County and Provider have read this Agreement and agree to be bound by all of
its terms, and further agree that this Agreement constitutes the complete and exclusive statement
of the Agreement between the County and Provider.
17. Severability. All clauses found herein shall act independently of each other. If a clause is found
to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It
is understood by the parties hereto that if any part, term or provision of this Agreement is by the
Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United
States, the validity of the remaining portions or provisions shall not be affected, and the rights
and obligations of the parties shall be construed and enforced as if the Agreement did not contain
the particular part, term or provision held to be invalid.
a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of
respective parties hereunder shall be governed by the laws of the State of North Carolina. By
executing this Agreement Provider affirms that Provider and any subcontractors of Provider are
and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General
Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and
has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer
pursuant to G.S. 147-86.58.
18. Signatures. This Agreement together with any amendments or modifications may be executed
electronically. All electronic signatures affixed hereto evidence the intent of the Parties to
comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66.
IN WITNESS WHEREOF, the Orange County and the Provider have signed this Agreement, effective on
the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures
below.
For and on behalf of the Provider
_____________________________ _______________________
Karen Kincaid Dunn, Executive Director Date
For and on behalf of Orange County Government
_______________________________ ________________________
Bonnie Hammersley, County Manager Date
Orange County
Post Office Box 8181
Hillsborough, NC 27278
103 D. West Main Street
Carrboro, NC 27510
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
6/30/2021
7/1/2021
Orange County Outside Agency Performance Agreement Page 6 of 9
Rev. 1/21
ORANGE COUNTY—DEPARTMENT USE ONLY
______________________________________________________________________________
Party/Vendor Name: Club Nova Community, Inc. Party/Vendor Contact Person: Karen Kincaid Dunn Contact
Phone: 919-968-6682 Party/Vendor Address: 103-D West Main Street City Carrboro State: NC Zip: 27510
Department: Health Amount: $19,813 Purpose: Outside Agency Funding Budget Code(s): 10495050-719048
Vendor # 805426 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one)
New Renewal Amendment Effective Date 7-1-20 Approved by Board Yes No Agenda Date:
This agreement is approved as to technical form and content and I as Department Director affirmatively state work on
this project has not been initiated prior to execution of the agreement:
Department Director’s Signature ________________________________________ Date: ________
Agreements for emergency services or repair are not subject to the above affirmation. If services related to this
agreement have already begun or been completed please briefly describe the nature of the emergency condition that
was addressed: Turnover in original department generating contract.
Information Technologies
(Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is
approved as to information technology content and specifications:
Office of the Chief Information Officer___________________________________ Date: ________
Risk Management
This agreement is approved for sufficiency of insurance standards, specifications, and requirements:
Office of the Risk Management Officer___________________________________ Date: _________
Financial Services
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act:
Office of the Chief Financial Officer ____________________________________ Date: _________
Legal Services
This agreement is approved as to legal form and sufficiency:
Office of the County Attorney __________________________________________Date: ________
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov
The following signature block is for hard copies only and is not required for Docusign contracts:
Office of the Clerk to the Board __________________________________________Date:_________
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
7/1/2021
7/1/2021
7/1/2021
Applicant Contact Information
Applicant Organization's Legal Name: Club Nova Community. Inc.
Applicant Organization's Physical Address: 103 D West Main Street, Carrboro, NC 27510
Applicant Organization's Mailing Address: 103 D West Main Street, Carrboro. NC 27510
Applicant Organization's Web Address: clubnova.org
Executive Director: Karen Kincaid Dunn
Telephone Number: 919-968-6682 E-Mail: karendunn@nc.rr.com; kdunn@clubnova.org
Tax ID Number:--
Funding Request
Please list all Fiscal Year 2021 Human Services (HS) funding requested for all programs and the proposed
use of funds {please list program name only)
Program Carrboro -HS Cha~el Hill -HS Orange County-HS
Critical Safety Net-$22,000 Personnel $22,000 Personnel $15,000 Personnel &
Livelihood Security & Operations & Operations Operations
& Improved Health
Outcomes
Transportation $65,000 Personnel &
Operations
Employment $22,000 Personnel &
Operations
Psychiatric $18,000 Personnel &
Rehabilitation Operations
Services -ACTT
Members
Totals $22,000 $22,000 $120,000
TOCH -Impact $50,000
Award-
Comprehensive
Integrated Critical
Safety Net
Briefly explain your proposed use of funds:
The Outside Agency funding will provide for staffing and other costs to operate Club
Nova, an accredited Clubhouse Model. The Clubhouse Model is one of the most
comprehensive, integrated, effective, community-based approaches in addressing
the health, safety, social, and economic risks of serious mental illness and provides
a critical safety net for individuals living with serious mental illness.
To the best of my knowledge and belief all information and data in this application is true and
current. The document has been duly authorized by the governing board of the applicant.
Total
$59,000
$65.000
$22,000
$18,000
$164,000
$50,000
Cover Page Page 6 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
::c; "-VO cj I 2-( I 0 O::Q 0
Date _;;;,.-l
DateJ·I( ' '' B(J J'j
/
Cover Page Page 7 of 33
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE
Are any of the Board Members or employees of the agency which will be carrying out this program or
members of their immediate families, or their business associates.
0 ~ a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill,
or Orange County?
0 ~ b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the
Town of Chapel Hill, or Orange County?
~ 0 c) Current beneficiaries of the program for which funds are being requested? Two Club Nova
members serve on the Club Nova Community, Inc. Board of Directors.
0 ~ d) Paid providers of goods or services to the program or having other financial interest in the
program?
If you have answered YES to any question, please provide a full explanation below.
NON-DISCRIMINATION
Provider agrees as part of consideration of the granting of funds by funding agencies to the parties
hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any
manner ofthese basis of race, color, gender, national origin, age, handicap, religion, sexual orientation,
gender identity/expression, familial status or veterans status with reference to any activities carried out
by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to
the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County
Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive
relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors
and assigns of the parties hereto with reference to the above subject manner.
To the best of my knowledge and belief all of the above information is true and current.
acknowledge and understand that the existence of a potential conflict of interest does not necessarily
make the program ineligible for funding, but the existence of an undisclosed conflict may result in the
termination of any grant awarded.
1 L{ 1 Judo
I
)
Signature: -~(,Lf-1Jll=oo'L'>-~"""a,~1'i-'?:::Z ___ _
Cover Page Page 8 of 33
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Please provide the following information about your agency:
1. Date of Incorporation (Month/Year): August I 2014
2. Agency's Purpose/Mission (no more than a few sentences):
Club Nova provides opportunities for individuals living with serious mental illness
(predominately schizophrenia, bipolar disorder, and major depression) to lead meaningful
lives of their choice in the community. Club Nova is an intentional, caring community
comprised of members and staff who work together as colleagues to directly address the
risks of serious mental illness and improve the health, education, housing, economic
stability, and quality of life of each member. Club Nova focuses on members' strengths
and potential rather than their illness.
3. Please provide a brief description of your organization's past achievements in carrying out similar
projects and evidence of successful record of meeting proposed budgets and timetables (no more than
100 words).
Club Nova has 32 years of experience providing the full range of Clubhouse Model
supports and opportunities. We are accredited through a rigorous process assuring
fidelity to the Model. This Model operates on proven standards and is replicated in 300
communities worldwide. The Model is included in the SAMHSA registry for Evidence-
Based Practices and received the Conrad N. Hilton Foundation award for humanitarian
work alleviating human suffering. Club Nova recently received the GSK Impact Award for
outstanding achievement in improving community health.
We have a long-established record meeting budgets and timetables amidst perpetual
changes in the NC mental health system.
4. Living Wage: Does this agency pay permanent employees a minimum living wage? {Yes/ No) No
If yes, is this agency an Orange County Living Wage Certified Employer? __
If no, please briefly explain.
Club Nova strives to pay our employees the living wage rate. All our full-time employees
are paid above the living wage. Additionally, Club Nova provides excellent health
insurance coverage for full-time employees with Club Nova paying 70% of the premium
and employees paying 30%.
We have four transportation positions that are .25 FTE ( -10 hours per week). The rates
of pay are $12.00 and $13.63. These rates of pay fall short of the living wage. With the
low Medicaid reimbursement rates and exclusions of services, it is a challenge to keep
all positions paid the living wage.
Schedule of Positions: #of FTE-Full-Time Paid Positons: 10 #of FTE-Part-Time Paid Positions: 2
#of FTE-Full-Time Vacant Positons: 2 #of FTE-Part-Time Vacant Positions: 2
ProgrClrn information Page 9 of 35
I
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
PRQGR~MIN.FPRtsliAT!Of.f ·· ..
*RJ~~·?.·sd!Amitfqr .each.· prqgrqm·if~pplyf!JgJJA!iiliti/iifJ'f&r !Jlp}~.fhqn·. c.?ne.ptqgr~!Jl,
5. Program Name: Club Nova Community, Inc.
Program Primary Contact and Title: Tammy Duncan
Telephone Number: 919-968-6682 E-Mail: admin@clubnova.org
6. Please briefly describe the proposed program, including an explanation of how it aligns with the Town of
Chapel Hill and Carrboro's Results Framework, and Orange County BOCC Goals and Priorities, and the target
population to benefit from the program. {100 words or less)
The Clubhouse Model-one of the most comprehensive, integrated, effective, community-
based approaches in addressing the health, safety, social, and economic risks of serious
mental illness-provides:
• Assistance accessing and navigating quality healthcare
• Supports to secure/maintain safe, affordable, dignified housing
• Crisis prevention and intervention
• Assistance securing and maintaining benefits
• Nutritious, affordable meals
• Outreach to combat isolation and loneliness
• Transportation to access Club Nova
• Employment/Education Program: Addresses high unemployment rates and
interrupted educations
• Work-Ordered Day: Provides a sense of community, common purpose, and
opportunities to contribute, building confidence, skills, and self-worth.
• Social Program: Addresses isolation and social connectedness
Program inforrnation Page 10 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
I
7. Target Population: Please complete the table below with numbers (not percentages) of individuals served
and projected to be served.
Program Target Population Demographics
Gender
Race and Ethnicity
Age
Geographic Location
Men
Women
Nonbinary/Genderqueer
Self-Describe
Total
Black or African-American
American Indian or Alaska Native
Asian
White
Native Hawaiian or other Pacific Islander
Two or more races
Some other race
Total
Of the above, how many Hispanic/Latina
Of the above, how many non-Hispanic/Latina
Total
0-5 years
6-18 years
19-50 years
51+ years
Total
Town of Chapel Hill
Town of Carrboro
Orange County (Outside of Chapel Hill/Carrboro)
Outside of Orange County
Total
Income
low-income (80% of the Area Median Income and Below) Please see
income table in the attachments
Total
Low-income (30% of the Area Median Income and Below)
Program information
Projected
2018-19
76
41
0
0
117
19
1
2
91
0
4
117
4
113
117
0
0
61
56
117
57
41
14
5
117
116
ih16 11'
112
Actual
2018-19
80
37
0
0
117
22
0
2
87
0
1
5
117
4
113
117
0
0
53
64
117
37
42
26
12
117
117
1117 11"
112
Projected Projected
2019-20 2020-21
80 80
37 37
0 0
0 0
117 117
22 22
0 0
2 2
87 87
0 0
1 1
5 5
117 117
4 4
113 113
117 117
0 0
0 0
53 53
64 64
117 117
37 37
42 42
26 26
12 12
117 117
117 117
1117 117 1117 117 1
112 112
Page 11 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
8. Cost Per Individual
This cost per individual must reflect the total program budget divided by the total number of program
individuals in this application .
. 2?d<r··.··•··········•· c_····· ..
Total Cost of Program 929,582 982,200 997,300
Total# of Individuals 117 117 117
Cost Per Individual 7,945 8,395 8,524
Program information Page 12 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
9. Performance Indicators
For Chapel Hill and Carrboro applicants:
Please complete the following chart with information about the Strategic Objective, Intermediate Result, and
the Agency Performance Indicator for each program for which you are applying for funding. Please see the
Results Framework in the Attachments section as a reference.
Program Name:
Strategic 0 Children improve their educational outcomes
Objective
(please choose one from 0 -?Residents Increase their livelihood security
the Results Framework)
0 Residents improve their health outcomes
.
--'-. ··. . · -. . ... . · .. \_ -.~ · . .. · ...
Intermediate Residents access the most appropriate social safety net services
Result
(please choose one from
the Results Fmmework)
.... RJ;SVLT.S • ·. ·•· .
I Actual Projecte'd l'roje~d .
.. . · .. ..
• ZOllH.9 .·• 2019;20 'lll20•2:1,
Performance % and# of program 97% or 114 98%or115 99% or 116
Indicators participants who maintain or
(Please choose at least improve their housing status
one perfonnance
indicatm· to repm1 ou
from the Results
Fmmewm·k, and add
additiotlal performance
indicators that you
would like to reporl to
the Towns. Please
inse11 additiona/J·ows as
needed, listing one per
row).
Performance % and # of program 100% or 100% or 117 100% or 117
Indicators participants who receive 117
affordable meals
Performance % and # of participants who 100% or 100%or117 100% or 117
Indicators do not become court 117
involved during the program
Program informdtion Page 13 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Strategic 0 Children improve their educational outcomes
Objective
(please choose one from 0 -?Residents Increase their livelihood security
tile Results Framework)
0 Residents improve their health outcomes
. ·• ....... · . · .... · . •·.·. ····· . ··.·· . . · · .. ·.. . ······ .. · .. .. · . .·.·. .... . . •·.
Intermediate Residents increase job skills appropriate for the local economy
Result
(please choose one from
the Results Framework)
..... . RES\J.~TS ·· .. Mtual .·· Pl'!lj¢cted . Pt!lll!cted
.· . .· I 2{1~11·19 .. .•.. 2.01f;l,20 202()-2.:1
Performance % and # of participants who 17% or 20 19% or 22 21%or24
Indicators engage in educational
(Please choose at least programs
one performance
indicator to report on
from the Results
Fmmewm·k, and add
additional perfonnance
indicators that you
woultllike to report to
the Towns. Please
insert additional rows as
needed, listing one per
row).
Performance % and # of program 32% or 38 36% or42 39% or46
Indicators participants who secure
emolovment
Performance % and# of participants who 100% or 100% or 117 100% or 117
Indicators engage in Clubhouse work
ordered day and other
117
Clubhouse opportunities
that build competencies for
pursuing education and
emolovment
Performance % and # of participants who 32% or 38 36% or42 39% or46
Indicators increase incomes (wages,
disability, public benefits, or
other income)
Performance % and # of participants who 100% or 100%or117 100% or 117
Indicators maintain incomes (wages,
disability, public benefits, or
117
other income)
Program information Page 11! of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Strategic D Children improve their educational outcomes
Objective
(please choose one from D Residents Increase their livelihood security
the Results Framework)
D -?Residents improve their health outcomes
''', ,, ,,,c-y, '',,
','', '' --',,' ' ,, ' ',, '< ','' ,' ,: '
Intermediate Residents access basic health care services (primary, behavioral, dental)
Result
(please choose one from
the Results Fmmework)
',, ' RESUI;:TS , ' ' ' ' ' Actu;~l Proje¢te<f ' , , , , , , Pr!ljected
'
'' ,'', '< ,,, ,'
', ZO'l8'19 '', Z01ll-20 , ,, ,', ~o~o,zt , ,
Performance % and # of program 100% or 100% or 117 100% or 117
Indicators participants who have 117
(Please choose at least access to primary care
one pe1[ormance
indicator to report on
from the Results
Framework, and add
additional pe1[ormance
indicators that you
would like to report to
the Towns. Please
insert additional rows as
needed, listing one per
row).
Performance % and # of program 100% or 100%or117 100% or 117
Indicators participants who have
access to mental health
117
care
Performance % and # of program 100% or 100% or 117 100% or 117
Indicators participants who have
access to dental care
117
Performance % and # of program 44% or 52 44% or 52 44% or 52
Indicators participants who obtain
preventative screeninas
Performance % and # of program 100% or 100%or117 100% or 117
Indicators participants who have 117
access to needed substance
abuse treatment
Performance % and # of participants with 100% or 100% or 117 100% or 117
Indicators Care Plans with 117
individualized goals,
including a crisis plan with
preferred crisis response
Program information Page 15 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Strategic 0 Children improve their educational outcomes
Objective
(please choose one from 0 Residents Increase their livelihood security
the Results Fmnunvork)
0 ~Residents improve their health outcomes
'• · ... •'
. ..·.· · .. • ... ·.· .
•' · .. '· .
.. ·' ...
.···• -c
~ ......... ..
Intermediate Residents demonstrate new healthy lifestyle behaviors
Result
(please choose one from
the Results Framework)
I . Rt;SJ:!LTS .... ~tual .... . ·· ... · l't!IJ~cte~ • •. •· . llrQj1!Ctep
. ..... ·.· ··•· ... ·.· ..... · .. ·, .. · .. · .. 20;1,8-:L~ · ··~Ol!J-2.0 2020,21
Performance % and # of people with 100% or 100% or 117 100%or117
Indicators healthier functionality and 117
(Please choose at least lifestyle behaviors (improved
one performance nutrition, conflict resolution
indicator to repm1 on skills, stress reduction
from the Results practices, exercise at least Framework, and add
additional performance 30min 3x a week, annual
indicators that you check-ups, etc.) would like to report to
the Towns. Please
inse11 atldltional rows as
needed, listing one per
I'OJV),
Performance % and # of program 100% or 100%or117 100%or117
Indicators participants with new, 117
sustained, improved, or
restored social skills
Performance % and # of program 100% or 100% or 117 100% or 117
Indicators participants with new,
sustained, improved, or
117
restored social connections
(social activities, outreach
calls and visits, community
involvement)
Performance % and # of program 100% or 100%or117 100%or117
Indicators participants with new, 117
sustained, improved, or
restored life skills or skills
maintained at the highest
level possible
Performance % and #of program 100% or 100% or 117 100% or 117
Indicators participants who meet one 117
wellness !=)Oal
Program information Page l6 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Performance % and # of hospitalization 10%or12 10% or 12 10% or 12
Indicators rates among program
participants with substance
abuse and/or psychiatric
disorders
Performance % and # of participants who 100% or 100%or117 100% or 117
Indicators engage in activities that 117
promote self-worth and
confidence
Performance % and # of participants who 100% or 100%or117 100% or 117
Indicators consume fresh food 117
Program information Page 17 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
~ORTI! CAROLINA
Outside Agencies/Human Services
Please use the drop down menu below to select which function area best aligns with your agency
and program(s) in which you are requesting funding. Please select only one from the drop down
menu below.
Behavior Health
If you selected other, please tell us what function area best aligns with your organization:
Please indicate three program goals/performance measures below.
A few notes:
• If you use percentages, please put the actual number equivalence.
• Please ensure your performance measures are outcome based and not outputs.
PrQgram. Goal# 1
P¢l"fo.-mance:W.easnl"e
(l{ow Wlll)'Oil accomplls/l,y91lrgoal?)
Program information
The goal is to ensure that all members have full access
to Club Nova's comprehensive, integrated supports and
opportunities by providing our Transportation Program
that removes the transportation barrier to Clubhouse
participation and recovery.
Club Nova transportation serves members who live in
areas not accessible to public transportation or are
unable to utilize the bus system for various reasons
(including symptoms related to diagnoses like paranoia)
and need viable transportation to Club Nova.
Club Nova will maintain a full transportation program
that employs and trains 100% (4 .25 FTEs) of
transportation staff, maintains its vehicles, and provides
our membership with approximately 44,329 miles of
transportation to and from Club Nova (plus socials and
occasional medical appointments) throughout Orange
County six days a week and on all major holidays.
Club Nova will:
Ensure Club Nova transportation staff receives
necessary training and certification. Staff maintains
vehicles.
• Maintain logs in each vehicle to track ridership and
milea e for all tri s
Page 18 of 3S
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Ac{Jlal Results
(Otd.COJJ;le}
EIJ!Iing FYJB-19
Projected Results
(Outcome)
Emling FY]OlO
Projec.ted Results
(Outcome)
Ending FY2021
Program information
NOR!ll CAROLINA
Outside Agencies/Human Services
• Maintain vehicle logs, tracking overall mileage and
gas expenditures
• Document certification of all trainings received by
drivers (in CPR, AED, 1st Aid, Blood Borne Pathogens,
etc.)
• Maintain log of social and community events attended
by Club Nova members through Club Nova
trans ortation
Club Nova provided 44,329 miles of unreimbursed
transportation services to members.
• 100% or 117 of members had access to our
transportation services and therefore had access to the
rest of our services. (0% were unable to participate due
to lack of transportation.)
• 79% or 93 of Club Nova members utilized
transportation opportunities.
• 100% of drivers attended all needed trainings.
Transportation continued to facilitate enhanced
en a ement b members in the lar er communi! .
Club Nova will provide 46,000 miles of unreimbursed
transportation services to members.
• 1 00% or 117 of members will have access to our
transportation services and therefore have access to
the rest of our services. (0% will not experience lack
of transportation as a barrier to participation.)
• 80% or 94 of Club Nova members will utilize
transportation opportunities.
•1 00% of drivers will attend all needed trainings.
Transportation will continue to facilitate enhanced
en a ement b members in the lar er communi! .
Club Nova will provide approximately 50,000 miles of
unreimbursed transportation services to members.
• 1 00% or 117 of members will have access to our
transportation services and therefore have access to
the rest of our services. (0% will be unable to
participate due to lack of transportation.)
• 80% or 94 of Club Nova members will utilize
transportation opportunities.
• 100% of drivers will attend all needed trainings.
• Transportation will continue to facilitate enhanced
engagement by members in the larger community.
Page 19 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Performance M~as11r~
{If ow will yo!f ~~co,nplisll yoOr go Ill?)
Actual Resnlts
(Outco.me)
EntlillgFY18"19
Proj~cted Results
(Outcome)
E11t1/nlf FY2Q2D.
Prt!jeeted Results
(Outcome)·
Ell(/illg FY20;21
Program information
~ORHI CAROliNA
Outside Agencies/Human Services
The goal is for Club Nova to offer the full spectrum of
services to ACTT members (typically those members
that experience the most disabling effects of mental
illness) regardless of our ability to receive payment for
these services, due to ACTT/PSR exclusion, which
amounts to roughly $120,000 annually. The ability to
participate in Club Nova maximizes recovery.
Club Nova actively collaborates with the ACTT
providers to coordinate care and ensure the health and
safet su ort of these members.
14 current members who receive Assertive Community
Treatment Team (ACTT) non-billable services (typically
those members that experience the most disabling
effects of mental illness) will continue to receive full
access to the supports and opportunities provided by
Club Nova.
Club Nova:
• Monitored our provision of services to ACTT
members through calculating monthly participation and
attendance hours.
• Wrote monthly service notes on each member
receiving ACTT services.
100% of Club Nova members who receive ACTT
services maintained their Club Nova membership, and
received supports and services provided through Club
Nova.
100% of Club Nova members who receive ACTT
services will maintain their Club Nova membership and
receive supports and services provided through Club
Nova.
100% of Club Nova members who receive ACTT
services will maintain their Club Nova membership, and
receive supports and services provided through Club
Nova.
The goal is for Club Nova members to increase their
livelihood security through returning to paid
employment in the community through our Transitional
(TE) and Supported Employment (SE) Programs.
Page 20 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
]>erforD).~lleeMe~~ure
(HpW will~oll/lCCfiniplislt ym~r go~l?)
Aetu~lResults
(<McliJ»e)
En(ling FYJB-19
Projected Results
(Outcome)
E11ding FY2020
P:roj~~te~Resu)ts
((}ut,~!\m~) ·
Efl(lil!Ji F'Y202Z
Program information
;>.;OR II I CAROLINA
Outside Agencies/Human Services
Club Nova builds relationships with businesses
throughout the county, resulting in structured
Transitional Employment (TE) sites.
We provide on-site training and support, absence
coverage, job skill development, transportation to and
from, and ongoing communication with the employers.
Club Nova also assists with skill-building and
educational opportunities, resume writing, benefit
counseling and goal planning.
We hold a weekly employment support meeting with
emplo ment staff to o over oals, ro ress and skills.
38 Club Nova members will return to paid employment
in the community through our Transitional (TE) and
Su orted Em lo men! SE Pro rams.
1 00% of Club Nova members had access to our TE
and SE services, as well as, educational and/or job
skills opportunities. 38 members returned to paid
employment through these supports. These services
led to the following outcomes:
• Increased financial stability & independence
• Increased self-esteem
• Reduced community stigma
• Increased member civic en a ement
100% of Club Nova members will have access to our TE
and SE services, as well as, educational and/or job skills
opportunities. 42 members will return to paid
employment through these supports. These services
will lead to the following outcomes:
• Increased financial stability & independence
• Increased self-esteem
• Reduced community stigma
• Increased member civic en a ement
100% of Club Nova members will have access to our TE
and SE services, as well as, educational and/or job skills
opportunities. An estimated 46 members will return to
paid employment through these supports. These
services will lead to the following outcomes:
• Increased financial stability & independence
• Increased self-esteem
• Reduced community stigma
• Increased member civic en a ement
Page 21 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Program Goal #4
PerforiliiuiceMeasul'e
(H~w Mllyou qf:~emftti~k"fiJIJr goa(?)
Program information
:-.:ORB I CAR<)UNA
Outside Agencies/Human Services
Club Nova members will maximize their recovery by
participating in Club Nova's comprehensive, integrated,
effective, community based programming that
addresses the health, safety, social, and economic risks
of serious mental illness. We accomplish this goal
through providing the following:
• Assistance accessing and navigating quality
health care
• Supports to secure/maintain safe, affordable,
dignified housing
• Crisis prevention and intervention
• Assistance securing and maintaining benefits
• Nutritious, affordable meals
• Outreach calls and visits to combat isolation and
loneliness
• Transportation to access Club Nova (already
included in Orange County request)
• EmploymenUEducation Program: Addresses high
unemployment rates and. interrupted educations
(Employment is covered in Orange County
request)
• Work-Ordered Day: Provides a sense of
community, common purpose, and opportunities
to contribute, building confidence, skills, and self-
worth.
• Social Program: Addresses isolation and social
connectedness
Club Nova will accomplish these goals through
providing a well-trained staff that, along with our
members, works to carry out the multiple programs that
are integrated as whole person care utilizing the
Clubhouse Model.
Club Nova will be open 6 days a week, 54-60 hours per
week, and have the necessary assistance to pay the
cost of utility bills, staff compensation and benefits
(including payroll taxes and insurance), and necessary
programming supplies and training.
Page 22 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
.A~t~alJlesults
(Outt:om~)
Ending FY18-19
Program information
K01{!1 I CAROliNA
Outside Agencies/Human Services
Club Nova was open 6 days a week, 54-60 hours per
week, and had the necessary assistance to pay the cost
of utility bills, staff compensation and benefits (including
payroll taxes and insurance), and necessary
programming supplies and training.
The following are results for the previous year:
97% or 114 of Club Nova members reported having
safe, secure, and affordable housing, with 0.9% (1)
person homeless.
0 % (0) members were incarcerated.
90% or 110 of Club Nova members did not experience
re-hospitalization due to psychiatric concerns.
100% or 117 of Club Nova members reported having
access to health care with 50% or 59 members receiving
primary care .
Each person who needed crisis prevention and
intervention services received those supports from Club
Nova.
All members needing assistance with securing and
maintaining benefits received that assistance.
85 % (1 00) participated in nutritious and affordable
meals (See Next Goal)
Outreach was conducted through card, calls, and or
visits to all members-100% (117).
100 % (117) participated in the work-ordered day that
provides a sense of community, common purpose, and
opportunities to contribute building confidence, skills,
and self-worth.
17 % (20) participated in educational endeavors.
85% (100) participated in our Social
(Evening/Weekend/Holiday) Programming
Page 23 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Proje,cted Resnltll
(Oll_tcqme)
Jl;mli11g FY2020
l'r!l:lc!!ted~~Mt!!•···.
(Ol!.t~roe,)
.!It~dim: FXJ021
Program information
~OR!! I CAROU~A
Outside Agencies/Human Services
97% or 114 of Club Nova members will report having
safe, secure, and affordable housing, with 0.9% (1)
person homeless.
0% (0) will be incarcerated.
90% or 110 of Club Nova members will not experience
re-hospitalization due to psychiatric concerns.
100% or 117 of Club Nova members will report having
access to healthcare with 50% or 59 members receiving
primary care.
Each person who needs crisis prevention and
intervention services will receive those supports from
Club Nova.
All members needing assistance with securing and
maintaining benefits will receive that assistance.
85 % (1 00) will participate in nutritious and affordable
meals (See Next Goal)
Outreach will be conducted through cards, calls, and or
visits to all members-100% (117).
100 % (117) will participate in the work-ordered day that
provides a sense of community, common purpose, and
opportunities to contribute building confidence, skills,
and self-worth.
17 % (20) will participate in educational endeavors.
85% ( 1 00) will participate in our Social
(Evening/Weekend/Holiday) Programming
97% or 114 of Club Nova members will report having
safe, secure, and affordable housing, with 0.9% (1)
person homeless .
0% (0) will be incarcerated.
Page 24 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Program Goal #5
Program information
NORfll CAROliNA
Outside Agencies/Human Services
90% or 110 of Club Nova members will not experience
re-hospitalization due to psychiatric concerns.
100% or 117 of Club Nova members will report having
access to health care with 50% or 59 members receiving
primary care.
Each person who needs crisis prevention and
intervention services will receive those supports from
Club Nova.
All members needing assistance with securing and
maintaining benefits will receive that assistance.
85% (100) will participate in nutritious and affordable
meals (See Next Goal)
Outreach will be conducted through cards, calls, and or
visits to all members -100% (117).
100 % ( 117) will participate in the work-ordered day that
provides a sense of community, common purpose, and
opportunities to contribute building confidence, skills,
and self-worth.
17 % (20) will participate in educational endeavors.
85% (100) will participate in our Social
(Evening!Weekend/Holiday)Programming
Club Nova will address food insecurity and diet related
disease by providing at least 12,000 healthy, affordable
meals, engaging at least 80% or 93 clubhouse
members in meals, and providing education and training
related to cooking, nutrition, obtaining and growing food.
Club Nova partners with local food organizations to
secure approximately 750 pounds of fresh, local
roduce and meat Members and staff cook
Page 25 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Performance Measure
(How willyou acpomp/islryour goal?)
ActU,afE;e$l!Jt$
(Outcome
Program inforrnation
NORtH t:ARUUNA
Outside Agencies/Human Services
from scratch and address individual dietary needs in our
meals.
Club Nova members and staff prepare and serve 13
meals per week.
Members are given opportunities to engage in every
step of the process, including menu planning, grocery
shopping, cooking and cleaning. Club Nova uses its
garden as an educational and wellness activity and
engages community experts for workshops and
trainings related to well ness.
Staff work closely with members who have individual
goals specifically related to healthy eating and
increased well ness to ensure they have the supports
needed.
Club Nova partners with local food organizations to
secure approximately 750 pounds of fresh, local
produce and meat monthly. Members and staff cook
from scratch and address individual dietary needs in our
meals.
Club Nova members and staff prepare and serve 13
meals per week.
Members are given opportunities to engage in every
step of the process, including menu planning, grocery
shopping, cooking and cleaning. Club Nova uses its
garden as an educational and wellness activity and
engages community experts for workshops and
trainings related to wellness.
Staff work closely with members who have individual
goals specifically related to healthy eating and
increased well ness to ensure they have the supports
needed.
Club Nova will:
• Maintain records of the number of meals served daily.
• Maintain daily records of individuals eating at the
Clubhouse.
• Survey its membership yearly to evaluate the achieved
health and food security benefits of our healthy,
affordable meal program and nutrition education.
• Staff will closely monitor specific individuals' well ness
oals throu h pro ress notes.
100% or 117 of Club Nova members had access to an
avera e of 13 health , well-balanced meals each week
Page 26 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
l'I"oj~c;~~dRe£ults
(O~,J.tc;QP:te)
Emli~!JF¥2Q1.0.
·l'rojecte4.:Re$.Ults
(Outcome)
EIJdingFY4021
Program information
l':ORIII CAROliNA
Outside Agencies/Human Services
(5 breakfasts, 6 lunches and 2 dinners), with 12,015
meals served for the year.
85% or 100 of Club Nova members participated in
meals.
This service led to:
• Decreased food insecurity for members
• Increased knowledge of culinary skills, nutrition, and
gardening
• Increased knowledge in the health benefits related to
a healthy diet
• Decreased likelihood of nutrition-related diseases
100% or 117 of Club Nova members will have access to
an average of 13 healthy, well-balanced meals each
week (5 breakfasts, 6 lunches and 2 dinners), with an
estimated 12,100 meals served for the year.
An estimated 85% 100 of Club Nova members will
participate in meals.
This service will lead to:
• Decrease in food insecurity for members
• Increase in knowledge of culinary skills, nutrition, and
gardening
• Increase in knowledge in the health benefits related to
a healthy diet
• Decrease in likelihood of nutrition-related diseases
1 00% of Club Nova members will have access to an
average of 13 healthy, well-balanced meals each week
(5 breakfasts, 6 lunches and 2 dinners), with 12,200
meals served for the year.
At least 85% or 100 of Club Nova members will
participate in meals.
This service will lead to:
• Decrease in food insecurity for members
• Increase in knowledge of culinary skills, nutrition, and
gardening
• Increase in knowledge in the health benefits related to
a healthy diet
• Increase the opportunities for member to reduce the
likelihood of nutrition-based diseases.
Page 27 of 35
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
AGENCY REVENUE
Private Donations
Agency Budget
Operating Budget for Entire Agency
Agency Generated Revenue (fees)
Local Government Grants:
Human Services -Town of Carrboro
Other-Town of Carrboro
Human Services-Town of Chapel Hill j-f----,==:+~----:==;--f--;;:---==;;-t-----:;-;;;;71
Other -Town of Chapel Hill
Human Services-Orange County /-f--:;-:;--:;-;=:+~---,;-;-=;--1-.,---,.==;;-t----~
Other-Orange County
Other-Town of Hillsborough 1-f----:+~-----+------+----~
Other Government Grants
Triangle United Way (Changing Focus)
State Government
Federal Government (CDBG/HOME/etc.)
Private Foundation Grants
Other Revenue-Thrift Shop, Meals, Other
""CAPITAL CAMPAIGN REVENUE NOT LISTED''"
Compensation M Salary/wages/taxes/benefits
Rent & Utilities
Supplies & Equipment
Travel & Training
Other Expenses:
""CAPITAL CAMPAIGN EXPENSES NOT LISTED""
Total Agency Expenses
SURPLUS/(DEFICIT) FOR PERIOD:
FY 2018-19 Agency Budget
I$ (1,24sll $ 4,6131 $ 20,700
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
EXHIBIT “B”
Scope of Services – FY 2020-21
Outside Agency Performance Agreement
Agency Name:
Program Name:
Funding Award:
Club Nova
Club Nova
$95,000 MOE Funding and $19,813 from Orange County Direct
TOTAL = $114,813
Outline how the agency will spend Orange County’s funding award.
Expense Description Amount
*Staffing Expense: Salaries, health benefits, payroll taxes, 401-K
*Other Program Expenses: Required insurance, audits, and accreditations,
communications, other program supplies including food and protective necessities
$114,813
*May include expenses not covered by any other revenue stream
Critical Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2021.
The Outside Agency funding will provide for staffing and other costs to operate Club Nova, an
accredited Clubhouse Model. Club Nova members, including members who also receive ACTT
services, will maximize their recovery by participating in Club Nova’s comprehensive, integrated,
effective, community-based approach. Club Nova addresses the health, safety, social, and economic
risks of serious mental illness and provides a critical safety net for individuals living with serious
mental illness. We accomplish this goal through providing the following:
• Assistance accessing and navigating quality healthcare
• Supports to secure/maintain safe, affordable, dignified housing
• Crisis prevention and intervention
• Assistance securing and maintaining benefits
• Nutritious, affordable meals
• Outreach calls and visits to combat isolation and loneliness and prevent crises
• Transportation to access necessary services, food, and medication
• Employment/Education Program: Addresses high unemployment rates and interrupted educations
• Work-Ordered Day: Provides a sense of community, common purpose, and opportunities to
contribute, building confidence, skills, and self-worth.
• Social Program: Addresses isolation and social connectedness
DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2
Performance
Measures
Anticipated
Results
Members report having safe, secure, and affordable housing 114 of 117
Members are not incarcerated 116 of 117
Members do not experience re-hospitalization for psychiatric reasons 105 of 117
Members report having access to health care
Members receiving primary care
117 of 117
59 of 117
Each member who needs crisis prevention and intervention service receive those
supports from Club Nova 100 %
Each member needing assistance with securing and maintaining benefits will
receive that assistance 100 %
Members receive nutritious and affordable meals
100 of 117 or
85 %
Members receive outreach conducted through cards, calls, and / or visits 117 of 117
Members participate in work-ordered day that provides a sense of community,
common purpose, and opportunities to contribute that lead to building
confidence, skills, and self-worth
75 of 117
Members pursue educational endeavors 20 of 117
Members participate in Social (Evening/Weekend/Holiday) Programming 100 of 117
Once safe to do so, members participate in employment through Transitional,
Supported, and Independent Employment
Depends on
Safety
Each member who receives ACTT services will maintain their Club Nova
membership and receive supports and services provided through Club Nova 100 %
Members have assistance from Club Nova to arrange for or provide transportation
for health care and other necessary activities 100 %
Critical Program Services
Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes
below, by June 30, 2021.
Information on Club Nova Operations During the Pandemic
The COVID 19 pandemic has dramatically affected how Club Nova provides services.
Club Nova provides services that are truly the difference between life and death for our members.
What we are experiencing with COVID-19 has increased the urgency of the work we are doing.
Not only are our members living with serious mental illness, the majority of our members are in the
high risk category for COVID-19 due to co-occurring serious health conditions including a high
prevalence of diabetes, as well as respiratory and heart conditions, and compromised immune
systems. The life expectancy for individuals living with serious mental illness is 25 years shorter than
the general population.
With the majority of our members at risk, our physical facility has been closed since March 15.
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Prior to closing the facility to members, we proactively updated emergency contacts, ensured
members had medication and food, provided education on precautions, and identified access to
technology.
Despite funding uncertainty, Club Nova immediately pivoted and adapted operations without
hesitation to include intensive, daily outreach checking on health and well-being of members, as well
as medication and food supplies; home wellness visits, two of which were literally life-saving; crisis
intervention; solving housing crises, preparation and delivery of at least 2200 meals to members thus
far; establishing a virtual platform structure with over 40 hours of structured workgroups of
members and staff including:
• Reach Out
• Note Tracking
• Billing
• Business Continuation
• Resource Development
• Administration
• Newsletter
• Wellness
• Social and Wellness Planning
• Club Nova Racial Injustice Statement
• Survey
• Clubhouse Culture
• Technology
• U.S. Census Completion
• Voting
It is unclear how long the majority of our members will need to practice physical distancing since
they are in the high risk category. Physical isolation quickly results in social Isolation. Social isolation
can be lethal for our members. Some of our members live in 24 hour residential facilities. They are
experiencing the most extreme isolation, mostly confined to their rooms. Again, the work that we
are doing is even more critical in the midst of this pandemic.
The changes in how services are delivered and reimbursed have a dramatic economic impact on Club
Nova. Prior to the pandemic, Club Nova was routinely reimbursed ~$35,000 per month in state and
Medicaid revenues for services provided. Starting in mid-March, these revenues are averaging less
than half per month of what they were prior to the pandemic.
During recent months, we have seen a trend of members experiencing having more housing issues
and crises.
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With the majority of our members at high risk, it is unclear when Club Nova will be able to open our
physical facility to members.
We are working to secure funding to remain operational until such time that it is safe for our
members to return to the physical facility.
All funding we receive at this time will help us continue our critical life-saving services and help us
remain operational during this time and at the same time benefit the larger community immensely.
Anticipated Outcomes
The Anticipated Results column must include quantifiable results in the form of number of
persons/units served within Orange County, only (all Towns and municipalities).
If you use percentages, you must also provide the total number of participants within that
measure’s description or for an earlier performance measure.
Performance
Measures
Anticipated
Results
Club Nova provides outreach to all members to ensure their health, safety, and
well-being. 100 %
Members have medicine, and other necessary provisions during pandemic 100 %
Members continue to have access to and receive necessary healthcare `100 %
Club Nova conducts home visits when necessary and when unable to reach
member or emergency contact and when circumstances 100 %
Members who need meals receive meals prepared and delivered by Club Nova 100 %
Members have the access to technology
Members have access to our virtual Clubhouse with at least 40 hours of
programming with working groups, engagement, social connections, and social
activities
Members receive necessary support to avert and mitigate crises, including housing
crises 100 %
Members receive necessary educational information about health precautions as
well as needed protective supplies 100 %
Certified by:
(Provider’s Electronic
Signature)
Title: Date:
**You will sign this document electronically with your performance agreement.
Executive Director September 1, 2020Karen Kincaid Dunn
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6/30/2021
Orange County Outside Agency Performance Agreement Page 9 of 9
Rev. 1/21
ATTACHMENT “A”
Orange County Certifications – FY 2020-21
Outside Agency Performance Agreement
Chief Contact, Administrators, Chief Executive Officer and Chief Financial Officer
I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief
financial officer for my agency with this Agreement and that I will keep it current to the County of Orange.
The list should be in writing with the name, title, residential address; phone and email address and if
possible, fax number.
Officers and Board of Directors
I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and
that we will continue to update the list as changes occur. The list should be in writing, with the name,
physical address, mailing address and if possible, phone, fax and email address.
Budget Submission
I certify that I have provided a budget for the period to be covered by funding Orange County, and that any
substantive changes made to this budget have been in advance authorized in writing by Orange County.
Annual Financial Review
I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget
adopted by the agency for the fiscal years encompassing this Agreement. If not, please explain on a
separate sheet of paper.
Alignment with Organization’s Mission
I certify that the programs and services for which this funding is requested align with the mission of the
organization.
Intended Purpose
I certify that the funds provided to the agency under the terms of this Agreement will be used for a public
purpose and shall only be used for the purposes intended and any money not used for those purposes will be
promptly returned to Orange County.
Certified by: _______________________ Title: __________________________ Date: ___________
(Provider’s Signature)
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Executive Director 6/30/2021
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