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2021-636-E-Health-El Futuro-Outside Agency & MOE
Orange County Outside Agency ARPA Fund and Managed Care Fund Performance Agreement Revised 9/2021 OUTSIDE AGENCY FUNDS AND MANAGED CARE FUNDS PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2021, (“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 El Futuro, Inc., a not-for-profit corporation, located at 2020 Chapel Hill Road, Suite 23, Durham, North Carolina 27707 (“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 Provider agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2021 to June 30, 2022. 2. Scope of Services. a. Provider will provide services to the residents of Orange County, as outlined in the attached Outside Agency Funding Application and Managed Care (Maintenance of Effort) Funds Scope of Work which are attached as Exhibit “A” and “B” respectively, and herein incorporated by reference. The Scope of Services and the Program Budget may be different from the original Outside Agency Funding Application based on County appropriation. Revisions or amendments to the Agreement must be in writing, approved by the County, and attached to this Agreement. 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. Outside Agency Funding. i. Outside Agency Funding. The County agrees to appropriate funds for the provision of services as described in Exhibit C, Outside Agency Scope of Services and may be more particularly described in the Revised Program Budget in Exhibit C, the maximum sum of $35,000 in Outside Agency Funds. ii. The Provider shall be paid Outside Agency Funds in four equal installments in the amount of $8,750. 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. b. Managed Care Funding. i. Managed Care Funding. The County agrees to appropriate funds for the Services DocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 2 Orange County Outside Agency Fund and Managed Care Fund Performance Agreement Revised 10/2021 described in the “Program Services” section of Exhibit B, Scope of Work Statement and Revised Program Budget, and may be more particularly outlined in the “Expense Section” of Exhibit B, the maximum sum of $22,200 in Managed Care Funds. ii. The Provider shall be paid Managed Care Funds in twelve monthly installments in the amount of $1,850. The first payment is contingent upon receipt of the agency’s fully executed performance agreement; the remaining payments are contingent Provider satisfactorily supplying County with receipts for reimbursement with related supporting documentation. Documentation must be supplied to County’s satisfaction, County will not unreasonable withhold payment. c. All funds appropriated shall be used for purposes described in Exhibits B and C. 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 and Work Statement, at the discretion of the County the Provider may be required to repay the funds to the County. d. The County’s obligation to make the payments is contingent upon receipt of Progress Reports and/or request for reimbursement as provided in Section 4 below, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services and Work Statement. e. Once Provider has satisfied its obligations as provided in Sections 3 and/or 4 payment will be made 21 days after receipt of the Progress Report or Request for Reimbursement. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Outside Agency Funds Reporting. Provider will provide Orange County a Quarterly Progress Report for Outside Agency funds that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report due 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. Managed Funds Reporting. Provider will provide Orange County a Monthly Progress Report for Managed Care funds that includes a fiscal report and updates on performance measures as outlined in the Exhibit B, Work Statement. Progress Reports are due by the 15th of the next month following the month being reported. c. 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. Termination for Cause. 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: DocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 3 Orange County Outside Agency Fund and Managed Care Fund Performance Agreement Revised 10/2021 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 perform satisfactorily any part of the work identified in the Scope of Services, Scope of Work, 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. c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided 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. e. Waiver. Payment of any sums by the County under this Agreement or the failure of the County to require compliance by the Provider with any provisions of this Agreement or the waiver by the County of any breach of this Agreement shall not constitute a waiver of any claim for damages by the County for any breach of this Agreement or a waiver of any other required compliance with this Agreement. 6. Responsibilities of the County. Cooperation and Coordination. The County has designated (Quintana Stewart) to act as the County's representative with respect to the Project who shall have the authority to render decisions within guidelines established by the County Manager or the County Board of Commissioners and who shall be available during working hours as often as may be reasonably required to render decisions and to furnish information. 7. Insurance. DocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 4 Orange County Outside Agency Fund and Managed Care Fund Performance Agreement Revised 10/2021 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. v. Sexual Misconduct. Sexual Abuse/Molestation Insurance is required when Provider works directly one-on-one with children, elderly or other at-risk populations. 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 • Sexual Misconduct $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. For more information see the Orange County Risk Transfer Policy and Orange County Minimum Insurance Coverage Requirements, (each document is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php.) 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: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 5 Orange County Outside Agency Fund and Managed Care Fund Performance Agreement Revised 10/2021 8. General Provisions. 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 identified, on the list created by the State Treasurer pursuant to G.S. 147-86.58. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.81. b. 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, which is incorporated herein by reference and can be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php. The County may enforce this provision by an 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. c. Dispute Resolution. Any and all suits or actions to enforce, interpret or seek damages with respect to any provision of, or the performance or non-performance of, this Agreement shall be brought in the General Court of Justice of North Carolina sitting in Orange County, North Carolina. It is agreed by the parties that no other court shall have jurisdiction or venue with respect to such suits or actions. Binding arbitration may not be initiated by either Party, however, the Parties may agree to nonbinding mediation of any dispute prior to the bringing of such suit or action. d. 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 Orange County Living Wage Policy, which is incorporated herein by reference, can be viewed at: http://www.orangecountync.gov/departments/purchasing_division/contracts.php. The County’s living wage is $15.40 per hour. To the extent possible, Orange County recommends that Provider provide a living wage to its employees. e. 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. f. 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 DocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 6 Orange County Outside Agency Fund and Managed Care Fund Performance Agreement Revised 10/2021 time of execution of this Agreement or are adopted at any time following execution of this agreement. g. 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. h. 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. i. 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. j. 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. k. 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. l. Entire Agreement. This Agreement represents the entire and integrated agreement between the County and the Provider and supersedes all prior negotiations, representations or agreements, either written or oral. This Agreement may be amended only by written instrument signed by both parties. Modifications may be evidenced by facsimile signatures. m. Notices. Any notice required by this Agreement shall be in writing and delivered by certified or registered mail, return receipt requested to the following: Orange County Provider’s Name El Futuro, Inc. Attention: Kimberlee Quatrone Attention: Luke Smith P.O. Box 8181 Address: 2020 Chapel Hill Rd. Ste. 23 Hillsborough, NC 27278 Durham, NC 27707 Email:kquatrone@orangecountync.gov Email: lsmith@elfuturo-nc.org n. 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. DocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 7 Orange County Outside Agency Fund and Managed Care Fund Performance Agreement Revised 10/2021 [SIGNATURE PAGE TO FOLLOW] 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 _____________________________ _______________________ Luke Smith, Executive Director Date For and on behalf of Orange County Government _______________________________ ________________________ Bonnie Hammersley, County Manager Date DocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 10/28/2021 11/1/2021 8 Orange County Outside Agency Fund and Managed Care Fund Performance Agreement Revised 10/2021 ORANGE COUNTY—DEPARTMENT USE ONLY ______________________________________________________________________________ Party/Vendor Name: El Futuro, Inc. Party/Vendor Contact Person: Kerry Brock Contact Phone: 919-688-7101 x632 Party/Vendor Address: 2020 Chapel Hill Road, Suite 23 City Durham State: NC Zip: 27707 Department: Health Amount: $57,200 Purpose: Outside Agency & MOE Budget Code(s): 10414020-630000 Vendor # 57915 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date 7-1-21 Approved by Board Yes No Agenda Date: June 15, 2021 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: Waiting on updated template. 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: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 10/28/2021 10/29/2021 11/1/2021 11/1/2021 Cover Page Page 2 of 11 COVER PAGE Applicant Contact Information Applicant Organization’s Legal Name: El Futuro, Inc. Applicant Organization’s Physical Address: 2020 Chapel Hill Road, Suite 23, Durham, NC 27707 Applicant Organization’s Mailing Address: 2020 Chapel Hill Road, Suite 23, Durham, NC 27707 Applicant Organization’s Web Address: www.elfuturo-nc.org Executive Director: Luke Smith, MD Telephone Number: 919-688-7101 E-Mail: lsmith@elfuturo-nc.org Tax ID Number: Funding Request Please list all Fiscal Year 2022 Human Services (HS) funding requested for all programs and the proposed use of funds (please list program name only) Program Carrboro - HS Chapel Hill - HS Orange County-HS Orange Co Health Dept Total Avanza: Mental Health Access and Engagement for Latino Immigrant Youth and Families $8,500 Personnel $12,500 Personnel $35,000 Personnel $22,200 Personnel $78,200 Personnel Totals $8,500 $12,500 $35,000 $22,200 $78,200 Briefly explain your proposed use of funds: 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. Signature: January 13, 2021 Executive Director Date Signature: January 13, 2021 Board Chairperson Date Provide direct mental health treatment services for Orange County Latino families through our Durham clinic and school-based services (via telehealth as long as COVID persists); provide prevention and education through workshops and seminars for Latino parents in partnership with schools and other agencies. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 Cover Page Page 3 of 11 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. YES NO a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? 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? c) Current beneficiaries of the program for which funds are being requested? 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 of these 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. I 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. Signature: January 13, 2021 Executive Director Date Signature: January 13, 2021 Board Chairperson Date EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 Program information Page 4 of 11 AGENCY INFORMATION Please provide the following information about your agency: 1. Date of Incorporation (Month/Year): 11/2004 2. Agency’s Purpose/Mission (no more than a few sentences): El Futuro nurtures stronger familias to live out their dreams. We do so by providing proven, bilingual mental health and substance abuse treatments in an immigrant-welcoming environment of healing and hope. 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). El Futuro has a 16-year history of successfully providing culturally-sensitive, accessible mental health treatment for low-income Latino families. We serve over 1,700 individuals per year with over 13,000 treatment sessions – a rate of service that has continued to grow even through a transition to 100% telehealth services as a result of COVID-19. We have a successful record of managing proposed budgets and timeline with a high proportion of recurring funding over time and consistently between 30-40 active funders. Consistently over 80% of our clients experience clinical and functional improvements or stabilization. 4. Living Wage: Does this agency pay permanent employees a minimum living wage? (Yes / No) Yes If yes, is this agency an Orange County Living Wage Certified Employer? No If no, please briefly explain. With our base of operations in Durham, El Futuro is a Certified Living Wage Employer in Durham County. We have not completed the certification process in Orange County. Schedule of Positions: # of FTE – Full-Time Paid Positions: 36_ # of FTE – Part-Time Paid Positions: 8_ PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 5. Program Name: Avanza: Mental Health Access & Engagement for Latino Immigrant Youth and Families Program Primary Contact and Title: Molly Hayes, M.Ed, LCMHCS Telephone Number: 919-688-7101 E-Mail: mhayes@elfuturo-nc.org EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 Program information Page 5 of 11 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) Demand for El Futuro’s services has grown significantly as a result of the disproportionate impacts of COVID-19 on Latino families. In addition to providing direct treatment (via telehealth until it is safe to be face-to-face), we will also continue to work closely with school and other partners to provide prevention and education workshops for Latino parents and caregivers. In this way, we will ensure access to services for one of our most vulnerable populations, meeting the Orange Co BOCC goal of promoting the well-being of all residents and the CH/Carrboro goal of improving health outcomes for even the most under-served. 7. Target Population: Please complete the table below with numbers (not percentages) of individuals served and projected to be served. Program Target Population Demographics Projected 2019-2020 Actual 2019-20 Projected 2020-21 Projected 2021-22 Gender Men 100 83 100 153 Women 120 115 120 187 Nonbinary/Genderqueer Self-Describe Not tracked** 70 49 120 Total 290 247 340 340 Race and Ethnicity Black or African-American 2 2 2 American Indian or Alaska Native 0 0 0 Asian 0 1 0 0 White 10 11 8 8 Native Hawaiian or other Pacific Islander 0 0 0 Two or more races 0 186 0 0 Some other race 0 0 0 Not tracked** 278 49 330 330 Total 290 247 340 340 Of the above, how many Hispanic/Latino 280 186 290 330 Of the above, how many non-Hispanic/Latino 10 12 10 10 Not tracked** 49 40 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 Program information Page 6 of 11 Total 290 247 340 340 Age 0-5 years 5 2 5 5 6-18 years 95 99 95 168 19-50 years 100 86 100 148 51+ years 20 11 20 19 Not tracked 70 49 120 Total 290 247 340 340 Geographic Location Town of Chapel Hill 80 58 80 80 Town of Carrboro 30 29 30 30 Orange County ( Outside of Chapel Hill/Carrboro) 110 111 110 230 Outside of Orange County 0 0 0 Not tracked** 70 49 120 Total 290 247 340 340 Income Low-income – Not tracked* Total 0 0 0 0 *Consistently more than 95% of our clients fall below 200% of poverty; however, we do not collect income data at levels other than that. **Previously we did not track the demographic characteristics of participants at psycho-education groups or prevention seminars / webinars. We will begin tracking that data in FY22. 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. Actual 2019-20 Projected 2020-21** Projected 2021-22* Total Cost of Program $238,393 $264,959 $347,593 Total # of Individuals 247 340 340 Cost Per Individual $965.15 $779.29 $1,022.33 *Increasing costs projected for FY22 relate to a number of trends: a) Market-rate salary increases approved by the board two years ago but put on hold due to COVID - FY22 will be the first year in which salaries are at their full rates for the whole year; b) additional personnel dedicated to client outreach and engagement in Orange Co due to continued need for telehealth delivery and therefore more engagement activities needed - increases overall cost of service. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 Program information Page 7 of 11 ** Decreased cost / unit service relates to holds on new hires and raises in FY21 due to COVID uncertainties; additional clients plan to be served through workshops and other outreach, meaning more efficient delivery with the # of people planned to be served increasing at a higher rate than the costs. In FY22, the costs will catch up. 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: Avanza: Mental Health Access & Engagement for Latino Immigrant Youth and Families – CHAPEL HILL Strategic Objective (please choose one from the Results Framework) Children improve their educational outcomes Residents Increase their livelihood security X Residents improve their health outcomes Intermediate Result (please choose one from the Results Framework) Residents demonstrate new healthy lifestyle behaviors RESULTS Actual 2019-20 Projected 2020-21 Projected 2021-22 Performance Indicators 80% (64) of program participants will meet one wellness goal 80% (41) 80% (64) 80% (64) 80% (64) of program participants will report new, improved, or restored social connections 85% (43) 80% (64) 80% (64) 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: Avanza: Mental Health Access & Engagement for Latino Immigrant Youth and Families – CARRBORO EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 Program information Page 8 of 11 Strategic Objective (please choose one from the Results Framework) Children improve their educational outcomes Residents Increase their livelihood security X Residents improve their health outcomes Intermediate Result (please choose one from the Results Framework) Residents demonstrate new healthy lifestyle behaviors RESULTS Actual 2019-20 Projected 2020-21 Projected 2021-22 Performance Indicators 80% (24) of program participants will meet one wellness goal 80% (23) 80% (24) 80% (24) 80% (24) of program participants will report new, improved, or restored social connections 85% (25) 80% (24) 80% (24) EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 Outside Agencies/Human Services Program information Page 9 of 11 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. Program Goal # 1 Improve mental health outcomes for Latino residents of Orange County Performance Measure (How will you accomplish your goal?) Latino residents will experience improvement or stabilization of mental health symptoms and/or increased health literacy as a result of treatment provided by El Futuro Actual Results (Outcome) Ending FY19-20 147 Orange Co Latino residents (80% of those served) experienced improvement or stabilization of mental health symptoms Projected Results (Outcome) Ending FY2021 272 Orange Co Latino residents (80% of those served) will experience improvement or stabilization of mental health symptoms and/or improved health literacy Projected Results (Outcome) Ending FY2022 272 Orange Co Latino residents (80% of those served) will experience improvement or stabilization of mental health symptoms and/or improved health literacy Program Goal # 2 Improve the well-being of Latino residents of Orange County Performance Measure (How will you accomplish your goal?) Latino residents will indicate improvement or stabilization in their functional abilities (in typical roles at home, work, or school) due to their participation in therapy or learning activities EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 Outside Agencies/Human Services Program information Page 10 of 11 Actual Results (Outcome) Ending FY19-20 156 Orange Co Latino residents experienced improvement or stabilization in functional abilities Projected Results (Outcome) Ending FY2021 272 Orange Co Latino residents will experience improvement or stabilization in functional abilities Projected Results (Outcome) Ending FY2022 272 Orange Co Latino residents will experience improvement or stabilization in functional abilities Program Goal # 3 Ensure a community network of basic human services and infrastructure that maintains, protects, and promotes the well-being of all county residents Performance Measure (How will you accomplish your goal?) Partnering agencies through whom El Futuro distributes mental health information (recorded webinars, seminars, other) will indicate the information helped their clients Actual Results (Outcome) Ending FY19-20 0 – This is a new, proposed program activity in response to COVID-19 and its ongoing impacts. Projected Results (Outcome) Ending FY2021 0 – This is a new, proposed program activity in response to COVID-19 and its ongoing impacts. Projected Results (Outcome) Ending FY2022 At least 4 partnering agencies through whom El Futuro distributes mental health information (recorded webinars, seminars, other) will indicate the information helped their clients EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 Outside Agency Performance Funds and Managed Care Funds Performance Agreement Certified by: _______________________ Title: __________________________ Date: ____________ (Provider’s Signature) EXHIBIT “B” Managed Care (Maintenance of Effort) Funds Scope of Work Statement and Program Budget – FY 2021-2022 Agency Name: El Futuro, Inc. Program Name:Avanza: Mental Health Access & Engagement for Latino Immigrant Families Funding Award: $22,200 I. Budget. Outline how the agency will spend Orange County’s funding award. Please attach additional sheets as necessary to provide detailed budget outline. II. Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2022. * • Provide direct mental heatlh treatment services (individual and group) for Orange Co Latino residents via in-clinic services, school-based treatment, and/or telehealth delivery • Provide mental health prevention and education workshops for Latino parents and caregivers • Collect data and provide program leadership in order to consistently evaluate and adapt based on changing client needs and COVID realities • • III. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only. 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 Latino residents of Orange Co will experience improvement or stabilization of mental health symptoms and/or increased health literacy as a result of treatment provided by El Futuro 272 Latino residents will indicate improvement or stabilization in their functional abilities (in typical roles at home, work, or school) due to their participation in therapy or learning activities 272 Partnering agencies through whom El Futuro distributes mental health information (recorded webinars, seminars, other) will indicate the information helped their clients 4 Expense Description Amount Personnel $22,200 DocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 10/28/2021Executive Director Outside Agency Performance Funds and Managed Care Funds Performance Agreement Certified by: _______________________ Title: __________________________ Date: ____________ (Provider’s Signature) EXHIBIT “C” FY 2021-2022 Outside Agency Funds Revised Scope of Services and Program Budget – Agency Name: El Futuro, Inc. Program Name:Avanza: Mental Health Access & Engagement for Latino Immigrant Families Funding Award: $35,000 I. Budget. Outline how the agency will spend Orange County’s funding award. Please attach additional sheets as necessary to provide detailed budget outline. II. Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2022.* • Provide direct mental heatlh treatment services (individual and group) for Orange Co Latino residents via in-clinic services, school-based treatment, and/or telehealth delivery • Provide mental health prevention and education workshops for Latino parents and caregivers • Collect data and provide program leadership in order to consistently evaluate and adapt based on changing client needs and COVID realities • • III. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only. 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 Latino residents of Orange Co will experience improvement or stabilization of mental health symptoms and/or increased health literacy as a result of treatment provided by El Futuro 272 Latino residents will indicate improvement or stabilization in their functional abilities (in typical roles at home, work, or school) due to their participation in therapy or learning activities 272 Partnering agencies through whom El Futuro distributes mental health information (recorded webinars, seminars, other) will indicate the information helped their clients 4 Expense Description Amount Personnel $35,000 DocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 10/28/2021Executive Director 13 Orange County Outside Agency Fund and Managed Care Fund Performance Agreement Revised 10/2021 ATTACHMENT “A” Orange County Certifications – FY 2021-22 Orange County Outside Agency Fund and Managed Care Fund 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) DocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 Executive Director 10/28/2021 DocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD ELFUT-1 OP ID: AT 10/27/2021 Insurance People of NC P.O. Box 3006 Durham, NC 27715 919-383-0442 919-382-3378 Employers Preferred Ins. EL Futuro, Inc. 2020 Chapel Hill Rd. Ste 23 Durham, NC 27707 XA EIG485992200 11/12/2021 11/12/2022 1,000,000 1,000,000 1,000,000 ORANGCO Orange County 300 West Tryon Street Hillsborough, NC 27278 919-383-0442 DocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165