HomeMy WebLinkAbout2022-059-E-Health-Club Nova Community-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 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 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 $25,000 in Outside Agency Funds.
ii. The Provider shall be paid Outside Agency Funds in four equal installments in the
amount of $6,250. 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: 11DA72B8-CC83-439E-A25C-F64DE607C614
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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 $163,000 in Managed
Care Funds.
ii. The Provider shall be paid Managed Care Funds in twelve monthly installments in
the amount of $13,583.33. 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:
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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.
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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.
8. General Provisions.
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Orange County Outside Agency Fund and Managed Care Fund Performance Agreement
Revised 10/2021
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 time of
execution of this Agreement or are adopted at any time following execution of this
agreement.
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Orange County Outside Agency Fund and Managed Care Fund Performance Agreement
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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 Club Nova Community, Inc.
Attention: Kimberlee Quatrone Attention: Karen Kincaid Dunn
P.O. Box 8181 Address: 103-D West Main Street
Hillsborough, NC 27278 Carrboro, NC 27510
Email:kquatrone@orangecountync.gov Email: karendunn@nc.rr.com
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.
[SIGNATURE PAGE TO FOLLOW]
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Orange County Outside Agency Fund and Managed Care Fund Performance Agreement
Revised 10/2021
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
DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614
2/7/2022
2/10/2022
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Orange County Outside Agency Fund and Managed Care Fund Performance Agreement
Revised 10/2021
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: $188,000 Purpose: Outside Agency & MOE Budget Code(s): 10495050-719048/10420020-710050
Vendor # 805426 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one)
New Renewal Amendment Effective Date 7-1-21 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 paperwork from vendor.
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: 11DA72B8-CC83-439E-A25C-F64DE607C614
2/7/2022
2/7/2022
2/10/2022
2/10/2022
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COVER PAGE
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: PO Box 1346, Carrboro, NC 27510
Applicant Organization’s Web Address: clubnova.org
Executive Director: Karen Kincaid Dunn
Telephone Number: 919-968-6682 E-Mail: karendunn@nc.r.com ;
kdunn@clubnova.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 Total
Critical Safety Net –
Livelihood Security
& Improved Health
Outcomes
$22,000 Personnel
& Operations
$22,000 Personnel
& Operations
$15,000 Personnel &
Operations
$59,000
Transportation $65,000 Personnel &
Operations
$65.000
Employment $22,000 Personnel &
Operations
$22,000
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614
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Psychiatric
Rehabilitation
Services – ACTT
Members
$18,000 Personnel &
Operations
$18,000
Totals $22,000 $22,000 $120,000 $164,000
TOCH – Impact
Award –
Comprehensive
Integrated Critical
Safety Net
$50,000 $50,000
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: 1/14/2021
Executive Director Date
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.
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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Signature: 1/14/2021
Board Chairperson Date
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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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?
Two Club Nova members serve on the Club Nova Community, Inc. Board of
Directors.
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
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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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: 1/14/2021
Executive Director Date
Signature: 1/14/2021
Board Chairperson Date
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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Program information P a g e 13 o f 55
AGENCY INFORMATION
Please provide the following information about your agency:
1. Date of Incorporation (Month/Year): August / 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 33 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 is a two-time recipient of
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? No
If no, please briefly explain.
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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Program information P a g e 14 o f 55
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) that
are currently furloughed. The rates of pay have been $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 Positions: 10 # of FTE –
Part-Time Paid Positions: 4 furloughed positions that will be brought back once it
is safe to reopen our physical facility.
PROGRAM INFORMATION
*Please submit for each program if applying for funding for more than one program.
5. Program Name: Club Nova Community, Inc.
Program Primary Contact and Title: Heather Talton
Telephone Number: 919-968-6682 E-Mail: htalton@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
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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Program information P a g e 15 o f 55
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
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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Program information P a g e 16 o f 55
7. Target Population: Please complete the table below with numbers (not
percentages) of individuals served and projected to be served.
Program Target Population Demographics
Projecte
d
2019-
2020
Actual
2019-
20
Projected
2020-21
Projecte
d
2021-22
Gender
Men 80 87 80 90
Women 37 37 37 38
Nonbinary/Genderqueer 0 0 0 0
Self-Describe 0 0 0 0
Total 117 124 117 128
Race and Ethnicity
Black or African-American 22 23 22 24
American Indian or Alaska Native 0 0 0 0
Asian 2 1 2 1
White 87 94 87 95
Native Hawaiian or other Pacific Islander 0 0 0 0
Two or more races 1 1 1 1
Some other race 5 5 5 7
Total 117 124 117 128
Of the above, how many Hispanic/Latino 4 4 4 6
Of the above, how many non-Hispanic/Latino 113 120 113 122
Total 117 124 117 128
Age
0-5 years 0 0 0 0
6-18 years 0 0 0 0
19-50 years 53 62 53 66
51+ years 64 62 64 62
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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Program information P a g e 17 o f 55
Total 117 124 117 128
Geographic Location
Town of Chapel Hill 37 47 37 49
Town of Carrboro 42 49 42 50
Orange County ( Outside of Chapel Hill/Carrboro) 26 13 26 14
Outside of Orange County 12 15 12 15
Total 117 124 117 128
Income
Low-income (80% of the Area Median Income and
Below) Please see income table in the attachments 117 123
116 127
Total 117 124 117 128
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 914,916 997,300 1,050,000
Total # of Individuals 124 117 128
Cost Per Individual 7,378 8,524 8,204
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.
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Program information P a g e 18 o f 5 5
Program Name: *** FY 2019-2020: 105 includes number of members who physically
attended Club Nova; 124 includes the additional members we reached out to and
engaged during COVID 19
Strategic
Objective
(please choose
one from the
Results
Framework)
Children improve their educational outcomes
Residents Increase their livelihood security
Residents improve their health outcomes
Intermediate
Result
(please choose
one from the
Results
Framework)
Residents access the most appropriate social safety net services.
RESULTS Actual
2019-20
Projected
2020-21
Projected
2021-22
Performance
Indicators
% and # of program
participants who maintain or
improve their housing status
99%
104 out of
105
99%
123 out of
124
99% or 116
99% or 127
Performance
Indicators
% and # of program
participants who have
access to affordable meals
100%
105 out of
105
100%
100% or 117 100% or 128
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Program information P a g e 19 o f 55
124 out of
124
Performance
Indicators
% and # of participants who
do not become court
involved during the program
99%
104 out of
105
99%
123 out of
124
100% or 117 100% or 128
Strategic
Objective
(please choose
one from the
Results
Framework)
Children improve their educational outcomes
→Residents Increase their livelihood security
Residents improve their health outcomes
Intermediate
Result
(please choose
one from the
Results
Framework)
Residents increase job skills appropriate for the local economy
RESULTS Actual
2019-20
Projected
2020-21
Projected
2021-22
Performance
Indicators
% and # of participants who
engage in educational
programs
14% or 17 17% or 20 17% or 22
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Program information P a g e 20 o f 55
Performance
Indicators
% and # of program
participants who secure
employment
37%
39 out of
105
31%
39 out of
124
38% or 44 34% or 44
Performance
Indicators
% and # of participants who
engage in Clubhouse work
ordered day and other
Clubhouse opportunities
that build competencies for
pursuing education and
employment
100% or
124
100% or 117 100% or 128
Performance
Indicators
% and # of participants who
increase incomes (wages,
disability, public benefits, or
other income)
31% or 39 36% or 42 34% or 44
Performance
Indicators
% and # of participants who
maintain incomes (wages,
disability, public benefits, or
other income)
100%
105 out of
105
100%
124 out of
124
100% or 117 100% or 128
Strategic
Objective
(please choose
one from the
Results
Framework)
Children improve their educational outcomes
Residents Increase their livelihood security
→Residents improve their health outcomes
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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Program information P a g e 21 o f 55
Intermediate
Result
(please choose
one from the
Results
Framework)
Residents access basic health care services (primary, behavioral, dental)
RESULTS Actual
2019-20
Projected
2020-21
Projected
2021-22
Performance
Indicators
% and # of program
participants who have
access to primary care
100%
105 out of
105
100%
124 out of
124
100% or 117 100% or 128
Performance
Indicators
% and # of program
participants who have
access to behavioral care
100%
105 out of
105
100%
124 out of
124
100% or 117 100% or 128
Performance
Indicators
% and # of program
participants who have
access to dental care
100%
105 out of
105
100%
124 out of
124
100% or 117 100% or 128
Performance
Indicators
% and # of program
participants who obtain
preventative screenings
62% or 77 44% or 52 60% or 77
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Program information P a g e 22 o f 55
Performance
Indicators
% and # of program
participants who have
access to needed substance
abuse treatment
100%
105 out of
105
100%
124 out of
124
100% or 117 100% or 128
Performance
Indicators
% and # of participants with
Care Plans with
individualized goals,
including a crisis plan with
preferred crisis response
100%
105 out of
105
100%
124 out of
124
100% or 117 100% or 128
Strategic
Objective
(please choose
one from the
Results
Framework)
Children improve their educational outcomes
Residents Increase their livelihood security
→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
% and # of people with
healthier functionality and
100% 100% or 117 100% or 128
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Program information P a g e 23 o f 55
lifestyle behaviors (improved
nutrition, conflict resolution
skills, stress reduction
practices, exercise at least
30min 3x a week, annual
check-ups, etc.)
105 out of
105
100%
124 out of
124
Performance
Indicators
% and # of program
participants with new,
sustained, improved, or
restored social skills
100%
105 out of
105
100%
124 out of
124
100% or 117 100% or 128
Performance
Indicators
% and # of program
participants with new,
sustained, improved, or
restored social connections
(social activities, outreach
calls and visits, community
involvement)
100%
105 out of
105
100%
124 out of
124
100% or 117 100% or 128
Performance
Indicators
% and # of program
participants who meet one
wellness goal
100%
105 out of
105
100%
124 out of
124
100% or 117 100% or 128
Performance
Indicators
% and # of hospitalization
rates among program
participants with substance
abuse and/or psychiatric
disorders
15%
16 out of
105
16%
20 out of
124
10% or 12 9% or 12
Performance
Indicators
% and # of participants who
engage in activities that
100% 100% or 117 100% or 128
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Program information P a g e 24 o f 55
promote self-worth and
confidence
105 out of
105
100%
124 out of
124
Performance
Indicators
% and # of participants who
have access to fresh food
100%
105 out of
105
100%
124 out of
124
100% or 117 100% or 128
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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Outside Agencies/Human Services
Program information P a g e 25 o f 55
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 equivale nce.
Please ensure your performance measures are outcome based and not outputs.
Program Goal # 1
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’s 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.
Performance Measure
(How will you accomplish
your goal?)
When the physical Clubhouse reopens, 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
_________________
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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Outside Agencies/Human Services
Program information P a g e 26 o f 55
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
mileage for all trips
• 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
transportation
Actual Results
(Outcome)
Ending FY19-20
100% or 124 of our members had access to
transportation to shopping, medical appointments,
social events, community activism, work-related tasks,
and Clubhouse promotional events throughout the
year. We closed our facility on March 14, 2020 due to
COVID-19 but continued to provide transportation to
and from appointments as needed. During the fiscal
year 2019-2020, we provided approximately 14,710
miles. The mileage includes 6.5 months of normal
operation and 5.5 months of remote access due to the
pandemic. During the pandemic, staff provided limited
rides to appointments only.
•100% or 124 of members had access to our
transportation services and were able to get
transportation to the Clubhouse, where they had
access to our services (0% were be unable to
participate due to lack of transportation.)
•68% or 80 of Club Nova members utilized
transportation opportunities.
•$2,730 was spent on gas
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Outside Agencies/Human Services
Program information P a g e 27 o f 55
•100% or 4 drivers attended all needed trainings.
•Transportation services enabled engagement by
members in the larger community.
Projected Results
(Outcome)
Ending FY2021
Club Nova will provide approximately 20,000 miles of
unreimbursed transportation services to members.
Club Nova will remain shut down until the vaccination
process is completed and it is safe to gather in person
with no concern or worry about COVID-19.
•100% or 117 of members will have access to our
transportation services and will be able to get
transportation to the Clubhouse, where they can
access our services once we re-open. (0% will be
unable to participate due to lack of transportation.)
•51% or 60 of Club Nova members will utilize
transportation opportunities.
•Approximately $3,000 on gas expenditures.
•Transportation services will continue to enable
engagement by members in the larger community.
Projected Results
(Outcome)
Ending FY2022
Club Nova will provide approximately 50,000 miles of
unreimbursed transportation services to members.
•100% or 128 of members will have access to our
transportation services and will be able to get
transportation to the Clubhouse, where they can
access our services once we re-open. (0% will be
unable to participate due to lack of transportation.)
•80% or 102 of Club Nova members will utilize
transportation opportunities.
•Approximately $8,400 on gas expenditures.
•100% or 4 drivers will attend all necessary trainings.
•Transportation services will continue to enable
engagement by members in the larger community.
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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Outside Agencies/Human Services
Program information P a g e 28 o f 55
Program Goal # 2
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
safety support of these members.
Performance Measure
(How will you accomplish
your goal?)
16 current members who receive Assertive Community
Treatment Team (ACTT) non-billable services (typically
those members who experience the most disabling
effects of mental illness) will continue to receive full
access to the supports and opportunities provided by
Club Nova.
Actual Results
(Outcome)
Ending FY19-20
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% or 16 Club Nova members who received
ACTT services maintained their Club Nova
membership, and received supports and
services provided through Club Nova.
Due to COVID-19 pandemic and the closing of
the Clubhouse on March 14, 2020 the number of
ACTT members participating in the Zoom
activities offered by the clubhouse is 44% or 7
ACTT members.
Projected Results
(Outcome)
Ending FY2021
100% or 117 Club Nova members who receive ACTT
services will maintain their Club Nova membership and
receive supports and services provided through Club
Nova.
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Outside Agencies/Human Services
Program information P a g e 29 o f 55
After it is deemed safe for members and staff to return
to the clubhouse, the projection will remain the same
44% or 7 ACTT members participation in the
Clubhouse zoom activities
Projected Results
(Outcome)
Ending FY2022
100% or 128 Club Nova members who receive ACTT
services will maintain their Club Nova membership and
receive supports and services provided through Club
Nova.
After it is deemed safe for members and staff to return
to the clubhouse, the projection will increase to 88% or
14 ACTT members participation in the Clubhouse
zoom activities
Program Goal # 3
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.
Club Nova builds relationships with businesses
throughout the county, resulting in structured
Transitional Employment (TE) sites.
We provide on-jobsite training and support, absence
coverage, job skill development, transportation to and
from, and ongoing communication with the employers.
Club Nova provides one-on-one skill-building,
educational goal planning, resume writing, benefits
counseling and general goal planning.
We hold a weekly employment support meeting with
employment staff to go over goals, progress and skills.
Performance Measure
(How will you accomplish
your goal?)
39 Club Nova members will return to paid employment
in the community through our Transitional (TE) and
Supported Employment (SE) Programs.
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Program information P a g e 30 o f 55
Ac tual Results
(Outcome)
Ending FY19-20
100% or 124 Club Nova members had access to our
TE and SE services. 39 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 against mental illness
• Increased member civic engagement
Five positions are on hold during the pandemic, four
transitional employment and one independent
employment.
Due to COVID-19, we have four transitional
employment placements on hold and one independent
employment position on hold.
Projected Results
(Outcome)
Ending FY2021
100% or 117 Club Nova members will have access to
our TE and SE services. An estimated 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 against mental illness
•Increased member civic engagement
Projected Results
(Outcome)
Ending FY2022
100% or 128 Club Nova members will have access to
our TE and SE services. An estimated 44 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 against mental illness
•Increased member civic engagement
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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Program information P a g e 31 o f 55
Program Goal # 4
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
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
•Transportation to access Club Nova (already included
in Orange County request)
•An Employment/Education Program: Addresses high
unemployment rates and interrupted educations
(Employment is covered in Orange County request)
•The 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
•Technology devices for members during the pandemic
including cellphones to be used for zoom meetings
offered by the clubhouse and tablets for members to
use to engage in Zoom activities offered by the
clubhouse during the pandemic
•Cell phone internet data for members to connect to the
work ordered day offered by the clubhouse and to
increase social interactions between members and
staff during the pandemic
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Program information P a g e 32 o f 55
•Telecommunications devices given to members so
that they may receive case support (including outreach
and crisis intervention) while the clubhouse is shut
down due to the pandemic
Performance Measure
(How will you accomplish
your goal?)
Club Nova will accomplish these goals by 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
Actual Results
(Outcome)
Ending FY19-20
Club Nova was open 6 days a week, 54-60 hours per
week through March 14, 2020 when the physical facility
was closed due to COVID-19. At that time, Club Nova
transitioned its services to be virtual and home-based.
Club Nova 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
99% or 123 of Club Nova members reported having
safe, secure, and affordable housing
1 person was incarcerated (0.8%)
90% or 112 Club Nova members did not experience re-
hospitalization due to psychiatric concerns
100% or 124 Club Nova members reported having
access to primary and behavioral care
Each person who needed crisis prevention and
intervention services received those supports from
Club Nova
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Program information P a g e 33 o f 55
All members needing assistance with securing and
maintaining benefits received that assistance
100% or 124 members had access to healthy and
affordable meals
Outreach was conducted through cards, calls, and or
visits to all members
100% of the 124 members who physically attended
Club Nova participated in the work-ordered day that
provides a sense of community, common purpose, and
opportunities to contribute building confidence, skills,
and self-worth.
99% or 123 Club Nova members will report having
safe, secure, and affordable housing, with 0.9 % (1)
person homeless.
Projected Results
(Outcome)
Ending FY2021
Club Nova will be open 6 days a week, 54-60 hours per
week while the physical facility is closed due to COVID-
19. Club Nova transitioned its services to be virtual.
Club Nova 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.
99% or 116 of Club Nova members reported having
safe, secure, and affordable housing
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.
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Program information P a g e 34 o f 55
90% or 105 Club Nova members will not experience re-
hospitalization due to psychiatric concerns
100% or 117 Club Nova members will have access to
primary and behavioral 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
100% or 117 members will have access to healthy and
affordable meals
Outreach will be conducted through cards, calls, and or
visits to all members
100% of the 117 members will participate in the work-
ordered day, which provides a sense of community,
common purpose, and opportunities to contribute to
building confidence, skills, and self-worth.
99% or 116 Club Nova members will report having
safe, secure, and affordable housing, with 0.9 % (1)
person homeless.
Projected Results
(Outcome)
Ending FY2022
Club Nova will be open 6 days a week, 54-60 hours per
week. Club Nova will continue offering virtual services
once the Clubhouse reopens. Club Nova 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.
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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Program information P a g e 35 o f 55
0% (0) will be incarcerated.
91% or 116 Club Nova members will not experience re-
hospitalization due to psychiatric concerns
100% or 128 Club Nova members will have access to
primary and behavioral 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
100% or 128 members will have access to healthy and
affordable meals
Outreach will be conducted through cards, calls, and or
visits to all members
100% of the 128 members will participate in the work-
ordered day, which provides a sense of community,
common purpose, and opportunities to contribute to
building confidence, skills, and self-worth.
99% or 127 Club Nova members will report having
safe, secure, and affordable housing, with 0.9 % (1)
person homeless.
Program Goal # 5 Club Nova will address food insecurity and diet related
disease by providing at least 12,000 healthy, affordable
meals, engaging at least 80% or 102 clubhouse
members in meals, and providing education and
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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Program information P a g e 36 o f 55
training related to cooking, nutrition, obtaining and
growing food.
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 when the Clubhouse is open. Since
closing the physical facility in March of 2020 due to
COVID-19, we have prepared and delivered 7 meals to
members weekly.
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 wellness to ensure they have the supports
needed.
Performance Measure
(How will you accomplish
your goal?)
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 will prepare and serve
13 meals per week when the physical facility reopens,
and continue preparing and delivering 7 meals per
week until then.
Members are given opportunities to engage in every
step of the process, including menu planning, grocery
shopping, cooking and cleaning. Club Nova uses its
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Program information P a g e 37 o f 55
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 wellness 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’ wellness
goals through progress notes.
Actual Results
(Outcome)
Ending FY19-20
Club Nova partnered with Farmer Foodshare to secure
437.5lbs of fresh produce by mid-March when Farmer
Foodshare suspended their operations.
100% of the 105 Club Nova members who physically
attended Club Nova had access to an average of 13
healthy, well-balanced meals each week (5 breakfasts,
6 lunches and 2 dinners); When the physical facility
closed in March, Club Nova began offering 7 meals
prepared and delivered weekly to members who
requested meals. Prior to the pandemic Club Nova
served roughly 7,000 meals. From March 16, 2020 until
June 30, 2020 Club Nova prepared and delivered
1,666 meals to members.
While the physical facility was open, Club Nova
members engaged in every step of the process,
including menu planning, grocery shopping, cooking
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614
Outside Agencies/Human Services
Program information P a g e 38 o f 55
and cleaning. While the facility was closed, members
were able to participate in menu planning.
This service 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
Projected Results
(Outcome)
Ending FY2021
Club Nova will partner with Farmer Foodshare once
they deem it is safe to resume operations.
100% or 117 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 once the Clubhouse’s
physical facility reopens. Until that time, Club Nova will
continue providing 7 prepared meals per week to
members who have requested this service. From July
1, 2020 until January 8, 2020 Club Nova prepared and
delivered 2,170 meals to members.
At least 85% or 99 Club Nova members will participate
in meals when it is safe for the physical Clubhouse to
reopen. Until then, approximately 56% or 66 members
will request to have weekly meals delivered.
When the Clubhouse reopens, Members will have
opportunities to engage in every step of the process,
including menu planning, grocery shopping, cooking
and cleaning. While the facility remains closed,
members are able to participate in menu planning.
This service will lead to:
• Decrease in food insecurity for members
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614
Outside Agencies/Human Services
Program information P a g e 39 o f 55
• 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.
Projected Results
(Outcome)
Ending FY2022
Club Nova will partner with Farmer Foodshare once
they deem it is safe to resume operations.
100% or 128 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 a
total of 12,000 healthy, nutritious meals served.
At least 85% or 109 Club Nova members will
participate in meals once it is safe for our Clubhouse to
reopen. Until then, 100% of Club Nova members have
the option to receive 7 meals prepared and delivered
weekly, we approximate that 54% or 70 members will
take request to have weekly meals delivered.
When the Clubhouse reopens, Members will have
opportunities to engage in every step of the process,
including menu planning, grocery shopping, cooking
and cleaning. While the facility remains closed,
members are able to participate in menu planning.
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.
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614
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: Club Nova
Program Name: Behavioral Health
Funding Award: $163,000
I. Budget. Outline how the agency will spend Orange County’s funding award. Please attach
additional sheets as necessary to provide detailed budget outline.
Expense Description Amount
Program Personnel Salary and Benefits and Other Operational Expenses $163,000
Funding will provide for staffing and other operational costs necessary to operate Club Nova as an accredited
Clubhouse Model and evidence-based practice.
II. Program Services
Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2022*
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 calls and visits to combat isolation and loneliness and prevent crises
• Transportation to access Club Nova, 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
Executive Director January 26, 2022
DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614
2/7/2022
Outside Agency Performance Funds and Managed Care Funds Performance Agreement
Certified by: Title: Date:
(Provider’s Signature)
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
Members report having safe, secure, and affordable housing with Club Nova providing
necessary supports to achieve this outcome
127/128
99%
Members are not incarcerated 128/128
100%
Members do not experience re-hospitalization for psychiatric reasons
116/128
91%
Performance Measures Anticipated
Results
Members report having access to primary care
Members who receive primary care
128/128
100%
64/128
50%
Each member who needs crisis prevention and intervention service receive those
supports from Club Nova
128/128
100%
Each member needing assistance with securing and maintaining benefits will receive
that assistance
128/128
100%
Club Nova provides outreach to all members to ensure their health, safety, and well-
being. Outreach includes cards, calls, and / or visits
128/128
100%
Members have sustained or increased social connections
128/128
100%
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
57/128
48%
Members pursue educational endeavors with Club Nova providing supports necessary 22/128
17%
Members participate in Social (Evening/Weekend/Holiday) Programming that increases
social connectedness, fosters a sense of community, and isolation
57/128
48%
Once safe to do so, members participate in employment through Transitional,
Supported, and Independent Employment Depends on Safety
44/128
34%
Each member who receives ACTT services will maintain their Club Nova membership and
receive supports and services provided through Club Nova
17/128
14%
Members have assistance from Club Nova to arrange for or provide transportation for
health care and other necessary activities
128/128
100%
Members have medicine, and other necessary provisions during pandemic
128/128
100%
Members continue to have access to necessary healthcare
128/128
100%
115/128
Executive Director January 26, 2022
DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614
2/7/2022
Outside Agency Performance Funds and Managed Care Funds Performance Agreement
Certified by: Title: Date:
(Provider’s Signature)
Members receive necessary healthcare 90%
Members obtain preventative health screenings
51/128
40%
Members have access to dental care
128/128
100%
Members meet one wellness goal
128/128
100%
Club Nova conducts home visits when necessary and when unable to reach member or
emergency contact
128/128
100%
Members have access to nutritious and affordable meals with Club Nova typically
offering 11 meals per week
128/128
100%
Members have the access to technology
128/128
100%
Members have access to our virtual Clubhouse programming with working groups,
engagement, social connections, and social activities
128/128
100%
Members receive necessary support to avert and mitigate crises, including housing crises
128/128
100%
Members have care plans with individualized goals, including a crisis plan with preferred
crisis response.
128/128
100%
Members receive necessary educational information about health precautions as well as
needed protective supplies
128/128
100%
*Please attach additional pages as necessary.
Sustaining Club Nova Operations During the Pandemic
The COVID 19 pandemic continues to have a significant impact on Club Nova and its members. Club Nova will
continue to provide services that make a difference, sometimes the difference between life and death, for our
members. We will adjust and adapt operations as needed to ensure the health, safety, and well-being of our
members. In turn, we are contributing to the health, safety, and well-being of the larger community.
Not only are our members living with serious mental illness, but most of our members are also 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. What we are
experiencing with COVID-19 has only increased the urgency of the work we are doing.
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.
Executive Director January 26, 2022
DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614
2/7/2022
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: Club Nova
Program Name: Behavioral Health
Funding Award: $25,000
I. Budget. Outline how the agency will spend Orange County’s funding award. Please attach
additional sheets as necessary to provide detailed budget outline.
Expense Description Amount
Program Personnel Salary and Benefits and Other Operational Expenses $25,000
Funding will provide for staffing and other operational costs necessary to operate Club Nova as an accredited
Clubhouse Model and evidence-based practice.
II. Program Services
Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2022*
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 calls and visits to combat isolation and loneliness and prevent crises
• Transportation to access Club Nova, 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
Executive Director January 26, 2022
DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614
2/7/2022
Outside Agency Performance Funds and Managed Care Funds Performance Agreement
Certified by: Title: Date:
(Provider’s Signature)
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
Members report having safe, secure, and affordable housing with Club Nova providing
necessary supports to achieve this outcome
127/128
99%
Members are not incarcerated 128/128
100%
Members do not experience re-hospitalization for psychiatric reasons
116/128
91%
Performance Measures Anticipated
Results
Members report having access to primary care
Members who receive primary care
128/128
100%
64/128
50%
Each member who needs crisis prevention and intervention service receive those
supports from Club Nova
128/128
100%
Each member needing assistance with securing and maintaining benefits will receive
that assistance
128/128
100%
Club Nova provides outreach to all members to ensure their health, safety, and well-
being. Outreach includes cards, calls, and / or visits
128/128
100%
Members have sustained or increased social connections
128/128
100%
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
57/128
48%
Members pursue educational endeavors with Club Nova providing supports necessary 22/128
17%
Members participate in Social (Evening/Weekend/Holiday) Programming that increases
social connectedness, fosters a sense of community, and isolation
57/128
48%
Once safe to do so, members participate in employment through Transitional,
Supported, and Independent Employment Depends on Safety
44/128
34%
Each member who receives ACTT services will maintain their Club Nova membership and
receive supports and services provided through Club Nova
17/128
14%
Members have assistance from Club Nova to arrange for or provide transportation for
health care and other necessary activities
128/128
100%
Members have medicine, and other necessary provisions during pandemic
128/128
100%
Members continue to have access to necessary healthcare
128/128
100%
115/128
Executive Director January 26, 2022
DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614
2/7/2022
Outside Agency Performance Funds and Managed Care Funds Performance Agreement
Certified by: Title: Date:
(Provider’s Signature)
Members receive necessary healthcare 90%
Members obtain preventative health screenings
51/128
40%
Members have access to dental care
128/128
100%
Members meet one wellness goal
128/128
100%
Club Nova conducts home visits when necessary and when unable to reach member or
emergency contact
128/128
100%
Members have access to nutritious and affordable meals with Club Nova typically
offering 11 meals per week
128/128
100%
Members have the access to technology
128/128
100%
Members have access to our virtual Clubhouse programming with working groups,
engagement, social connections, and social activities
128/128
100%
Members receive necessary support to avert and mitigate crises, including housing crises
128/128
100%
Members have care plans with individualized goals, including a crisis plan with preferred
crisis response.
128/128
100%
Members receive necessary educational information about health precautions as well as
needed protective supplies
128/128
100%
*Please attach additional pages as necessary.
Sustaining Club Nova Operations During the Pandemic
The COVID 19 pandemic continues to have a significant impact on Club Nova and its members. Club Nova will
continue to provide services that make a difference, sometimes the difference between life and death, for our
members. We will adjust and adapt operations as needed to ensure the health, safety, and well-being of our
members. In turn, we are contributing to the health, safety, and well-being of the larger community.
Not only are our members living with serious mental illness, but most of our members are also 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. What we are
experiencing with COVID-19 has only increased the urgency of the work we are doing.
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.
Executive Director January 26, 2022
DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614
2/7/2022
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: 11DA72B8-CC83-439E-A25C-F64DE607C614
Executive Director 2/7/2022
DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614
DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614