HomeMy WebLinkAbout100818_ca07615 Sheridan Street
Port Townsend, WA 98368
www.JeffersonCountyPublicHealth.org
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Philip Morley, County Administrator
FROM: Vicki Kirkpatrick, Director
Anna McEnery, DD & 1/10TH of 1% County Coordinator
DATE:
Consent Agenda
August 17, 2018
SUBJECT: Agenda Item — Professional Services Agreement, Jumping Mouse;
August 1, 2018 —July 31, 2019; $34,145.00
STATEMENT OF ISSUE:
Jefferson County Public Health (JCPH), as the fund manager of the Mental Health and Substance Abuse
sales tax treatment funds, is requesting Board approval of a Professional Services Agreement with the
Jumping Mouse Children's Center. Recognizing the lack of access and resources in this rural location of
South Jefferson County, Jumping Mouse is committed to a one-year pilot project located in the Brinnon
School in order to provide mental health services for young children in the Brinnon School District (along
with support for their parents/caregivers), who have suffered trauma, including loss, abuse, neglect, and
exposure to violence, mental illness, and substance abuse; August 1, 2018 — July 31, 2019; $34,145.00.
ANALYSIS STRATEGIC GOALS PRO'S and CON'S:
This agreement is between JCPH and Jumping Mouse, for clinical and care management services for up to
4 slots for children (and their caregivers) who attend school at the Brinnon School District. This service may
include long-term therapy to children affected by and/or with risk factors for mental illness or substance
abuse at home and/or in the community. Jumping Mouse will utilize promising and/or evidence based
models of treatment, referrals for mental health medication, provide parental support and education to the
adults of the children served and monitoring as required.
FISCAL IMPACT/COST BENEFIT ANALYSIS:
This is sales tax revenue raised by the County in the 1/10 of 1% Fund and is allocated by the BOCC with
advice from the Mental Health and Substance Abuse Advisory Committee. The agreement states if the
sales tax revenue decreases the vendor will be contacted and the contract may be renegotiated.
Community Health
Developmental Disabilities
360-385-9400
360-385-9401 (f)
Always working for a safer and healthier community
Environmental Health
Water Quality
360-385-9444
(f) 360-379-4487
615 Sheridan Street
Port Townsend, WA 98368
www.JeffersonCountyPublicHealth.org
Public Hea
This Professional Services Agreement is recommended by the Mental Health and Substance Abuse Sales
Tax Advisory Committee.
RECOMMENDATION:
JCPH management requests approval of the Professional Services Agreement with Jumping Mouse; August
1, 2018 — July 31, 2019; $34,145.00.
REVIEWED BY:
Philip MorlWtonty Date
Community Health
Developmental Disabilities
360-385-9400
360-385-9401 (f)
Always working for a safer and healthier community
Environmental Health
Water Quality
360-385-9444
(f) 360-379-4487
CONTRACT AGREEMENT
For Professional Services
Between
Jefferson County
And
Jumping Mouse Children's Center
For Expanded Mental Health (MH) & Chemical Dependency (CD) Treatment 2018/2019
Section 1: PURPOSE:
THIS AGREEMENT for Professional Services is entered into between Jefferson County herein
referred to as the "County" and Jumping Mouse Children's Center, herein referred to as the
"Contractor" to provide mental health services to children and their caregivers in the Brinnon
School District impacted by mental health/substance abuse issues in Jefferson County,
Washington.
Section 2: TERMS:
This Agreement shall commence on August 1, 2018 and continue through July 31, 2019, unless
terminated as provided herein. Work performed consistent with this Agreement during its term,
but prior to the adoption of this Agreement, is hereby ratified.
Section 3: SCOPE OF AGREEMENT:
Jumping Mouse will increase mental health treatment options as outlined in EXHIBIT A, Scope
of Work, attached hereto and incorporated herein. As described in EXHIBIT A, Jumping
Mouse's services will provide long-term therapy to children affected by and/or with risk factors
for mental illness or substance abuse at the Brinnon School District.
The goal of this funding and sales tax increase is to improve the quality of life for Jefferson
County citizens by improving access to mental health and substance abuse treatment.
Section 4. CONTRACT REPRESENTATIVES:
JCPH and Jumping Mouse Children's Center will each have a contract representative who will
have responsibility to administer the contract for that party. A party may change its
representative upon providing written notice to the other party. The parties' representatives are as
follows:
JCPH Contract Representative
Anna McEnery
Jefferson County Public Health
615 Sheridan St.
Port Townsend, WA 98368
(360) 385-9400
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JUMPING MOUSE- Brinnon SD Mental Health Pilot Project
2018-2019
Contractor's Contract Representative
Jenny Manza
Jumping Mouse Children's Center
1809 Sheridan St.
Port Townsend, WA 98368
(360) 379-5109
Section 5: COMPENSATION:
The Contractor will be reimbursed for all work performed under the terms of this contract as
outlined in EXHIBIT C — Fee Schedule. The total amount payable under this Contract by
County to Contractor shall not exceed $34,145.00 in the completion of this project without
express written amendment signed by both parties to this Agreement.
A. Contractor shall be paid for services as outlined in EXHIBIT A, Scope of Work.
B. Contractor shall submit monthly invoices to JCPH, 615 Sheridan St., Port Townsend, WA
98368, Attn: Anna McEnery, for payment of work completed the prior month.
C. Invoices must be submitted by the 15th of the month for the previous month's expenses.
Invoices submitted after the 7th of the month may not be paid until the following month.
The County will review such invoices, and upon approval thereof, payment will be made
to the Contractor in the amount approved. Failure to submit timely invoices or timely
reports pursuant to Section 11 of this Agreement may result in a denial of reimbursement.
Invoices not submitted within 60 days may be denied.
D. Contractor shall provide invoices and necessary backup documentation for all services
including timesheets and statements (specifying the services provided). Any indirect
charges require the submittal of an indirect cost methodology and rate using 2 C.F.R. Part
225 and 2 C.F.R. Part 230.
E. County reserves first right to use as match the chemical dependency mental health tax
funds and the services funded by them for purposes of qualifying for additional funding
and grants. County may allow Contractor to use the chemical dependency mental health
tax funds as match, at the County's sole discretion. Should the County decline to use
chemical dependency mental health tax funds as match for additional funding and/or
grants, then the County may authorize the Contractor to use such funds for match (see
ATTACHMENT A).
F. Where Contractor proposes to use chemical dependency mental health County tax funds
for match, Contractor shall be solely responsible for compliance with all state and federal
laws and regulations, including, but not limited to DSHS, CMS and DBHR funding rules,
applicable to the use of MH/SA sales tax monies as match. Contractor shall document
they have met this responsibility by submitting to the County Administrator, in writing,
their match formula, allocation plan and any other documentation required of them
pursuant to ATTACHMENT A, attached hereto and incorporated in this Agreement.
G. The County may withhold authorization to utilize the MH/SA sales tax monies as match.
Contractor's failure to provide adequate documentation does not relieve the Contractor of
their responsibility to comply with all state and federal laws and regulations related to
match.
H. The County will make final payment of any balance due the Contractor promptly upon
determining that: i) the Contractor has completed its obligations under this Agreement
and ii) the County can and does accept the work performed by the Contractor.
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JUMPING MOUSE- Brinnon SD Mental Health Pilot Project
2018-2019
I. Contractor records and accounts pertaining to this agreement are to be kept available for
inspection by representatives of the County and state for a period of six (6) years after
final payments. Copies shall be made available upon request.
J. An audit will be submitted to the County upon request.
a) Upon request, Contractor will submit the most recent financial audit within 30 days.
b) The audit or its equal, shall be completed by the WA State Auditor's Office or a
mutually agreed upon entity. Upon request the County shall have the option of
performing an onsite review of all records, statements, and documentation.
c) If the County finds indications of potential non-compliance during the monitoring
process, the County shall notify Contractor within ten (10) days. County and
Contractor shall meet to discuss areas of contention in an attempt to resolve issues.
d) Audit will provide statements consistent with the guidelines of Reporting for Other
Non -Profit Organizations AICPA SOP 78-10, and is performed in accordance with
generally accepted auditing standards and with Federal Standards for Audit of
Governmental Organizations, Programs, Activities and Functions, and meeting all
requirements of OMB Circular A-133, as applicable.
Section 6: INDEMNIFICATION:
The Contractor shall indemnify, defend and hold harmless the County, its officers, agents and
employees, from and against any and all claims, lawsuits, demands for money damages, losses or
liability, or any portion thereof, including attorney's fees and costs, arising from any injury to
person or persons (including the death or injury of the Contractor or damage to personal property)
if said injury or damage was caused by the negligent acts or omissions of the Contractor.
Section 7: INSURANCE:
The Contractor shall obtain and keep in force during the terms of this Agreement, or as otherwise
required:
A. Commercial Automobile Liability Insurance providing bodily injury and property
damage liability coverage for all owned and non -owned vehicles assigned to or used
in the performance of the work for a single limit of not less than $500,000 per
occurrence and an aggregate of not less than one million dollars ($1,000,000).
Contractor shall provide proof of insurance to the County c/o Contracts Manager at
Jefferson County Public Health, 615 Sheridan St. Port Townsend, WA 98368 prior to
commencing employment.
B. General Liability (1) — with a minimum limit per occurrence of one million dollars
($1,000,000) and an aggregate of not less than two million dollars ($2,000,000) for
bodily injury, death and property damage unless otherwise specified in the contract
specifications. This insurance coverage shall contain no limitations on the scope of
the protection provided and indicate on the certificate of insurance the following
coverage:
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JUMPING MOUSE- Brinnon SD Mental Health Pilot Project
2018-2019
1. Broad Form Property Damage with no employee exclusion;
2. Personal Injury Liability, including extended bodily injury;
3. Broad Form Contractual/Commercial Liability including completed operations
(contractors only);
4. Premises — Operations Liability (M&C);
5. Independent Contractors and Subcontractors; and
6. Blanket Contractual Liability.
(1) Note: The County shall be named as an additional insured party under
this policy.
C. Professional Liability Insurance providing $2,000,000 per incident; $3,000,000
aggregate. Contractor shall name Jefferson County Public Health as additional
insured.
D. The Contractor shall participate in the Worker's Compensation and Employer's
Liability Insurance Program as may be required by the State of Washington.
E. It is agreed by the parties that insurers shall have no right of recovery or subrogation
against the County (including its employees and other agents and agencies) it being
the intention of the parties that the insurance policies listed above shall protect both
parties and be primary coverage for any and all losses covered by the above -listed
insurance policies. It is further agreed by the parties that any and all deductibles
made part of the above -listed insurance policies shall be assumed by, paid for and at
the risk of the Contractor.
F. Any coverage for third party liability claims provided to the County by a
"Risk Pool" created pursuant to Ch. 48.62 RCW shall be non-contributory with
respect to any policy of insurance the Contractor must provide to comply with this
Agreement.
G. If the proof of insurance or certificate indicating the County is an "additional
insured" to a policy obtained by the Contractor refers to an endorsement (by number
or name) but does not provide the full text of that endorsement, then it shall be the
obligation of the Contractor to obtain the full text of that endorsement and forward
that full text to the County.
H. The County may, upon the Contractor's failure to comply with all provisions of this
contract relating to insurance, withhold payment or compensation that would
otherwise be due to the Contractor.
Section 8: CONFIDENTIALITY:
Contractor, its employees, subcontractors and their employees will maintain the confidentiality
of all information provided by JCPH or acquired in performance of this Agreement as required
by HIPAA and other privacy laws. This Contract, once executed by the parties, is and remains a
Public Record subject to the provision of Ch. 42.56 RCW, the Public Records Act.
Section 9: ASSIGNMENTS AND SUBCONTRACTING:
The Contractor shall not sublet or assign any of the services covered by this agreement without
the express written consent of the County.
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JUMPING MOUSE- Brinnon SD Mental Health Pilot Project
2018-2019
Section 10: INDEPENDENCE:
The Contractor and the County agree that the Contractor is an independent Contractor with
respect to the services provided pursuant to this agreement. Nothing in this agreement shall be
considered to create the relationship of employer and employee between the parties hereto. The
Contractor shall not be entitled to any benefits accorded County employees by virtue of the
services provided under this agreement. The County shall not be responsible for withholding or
otherwise deducting federal income tax or social security or for contributing to the state
industrial insurance program, otherwise assuming the duties of an employer with respect to
employee.
Section 11: REPORTING:
The Contractor will provide a monthly invoice to the County for the previous month's work.
The invoice shall include the total hours worked by which staff. A quarterly report of services
and will be recorded on a form created or approved by the Public Health contracted
Epidemiologist.
Jumping Mouse shall submit:
• Monthly invoices with timesheets and receipts specifying the services provided. Each
invoice may include only hours directly related to EXHIBIT A, Scope of Work.
• Quarterly electronic reports to Philip Ramunno of Kitsap County Health District in a
form as specified by Jefferson County Public Health and/or Kitsap County Health
District, as outlined in EXHIBIT B, 2018/2019 Quarterly Evaluation Reporting
Template.
• Jumping Mouse will send a copy of each electronic report to the JCPH Contract
Representative.
Upon request, additional reports of activities and services provided, to the JCPH
Contract Representative.
The monthly invoice to Jefferson County Public Health in care of Anna McEnery, DD
Coordinator, 615 Sheridan, Port Townsend, and WA 98368. The County will review
such invoices, and upon approval thereof, payment will be made to the Contractor in the
amount approved. Failure to submit invoices within 60 days of the due date, may result
in a denial of reimbursement.
Section 12: TERMINATION:
The County reserves the right to terminate this contract in whole or in part, with 30 days' notice,
in the event that expected or actual funding from any funding source is withdrawn, reduced, or
limited in any way after the effective date of this agreement. In the event of termination under
this clause, the County shall be liable for only payment for services rendered prior to the
effective date of termination.
A. This agreement may also be terminated as provided below:
1. With 30 days' notice by the Board of County Commissioners for any
reason, or
2. With 30 days' notice by the Board of County Commissioners for non-
performance of the specific job duties in EXHIBIT A, or
3. With 30 days' notice by the Contractor by voluntary resignation.
PAGE 5
JUMPING MOUSE- Brinnon SD Mental Health Pilot Project
2018-2019
Section 13: MODIFICATION:
This professional services agreement may be modified at any time by written agreement of either
parties and may be modified if tax revenue decreases.
Section 13: DISPUTE RESOLUTION:
Any dispute or disagreement concerning the terms and obligations of this Contract shall initially
be brought to the attention of the Public Health Director via a written document. The Public
Health Director shall make a determination with reasonable promptness (i.e., a decision within
ten business days shall be deemed to have been made with reasonable promptness). If the
aggrieved party is not happy with that decision, then the Jefferson County Administrator (or as
may hereafter be amended), will decide the appeal of the Director's decision.
Section 14: INTEGRATED AGREEMENT:
This Agreement together with attachments or addenda represents the entire and integrated
agreement between the County and the Contractor and supersedes all prior negotiations,
representations, or agreements written or oral between the parties. This agreement may be
amended only by written instrument signed by both County and Contractor.
Approved this day of 12018.
BOARD OF COUNTY COMMISSIONERS
JEFFERSON COUNTY, WASHINGTON
David Sullivan, Chair
Jefferson Board of County Commissioners
Jumping Mouse Children's Center
ATTEST:
Deputy Clerk of the Board
APPROVED AS TO FORM:
&2q c. /
Philip l-1 unsucker, Chief Civil Deputy rosecutor
PAGE 6
JUMPING MOUSE- Brinnon SD Mental Health Pilot Project
2018-2019
EXHIBIT A
Scope of Work
RESPONSIBILITIES:
The Jumping Mouse Children's Center Services agency as a contracted provider, agrees
to:
1. Clinical and care management services for up to 4 children weekly using the Jumping
Mouse model of play therapy at the Brinnon School District.
2. Prior to the beginning of the school year, this project will also include:
o discussions with teachers and staff in Brinnon before initiating services for
the families;
o establish a confidential and designated play room environment for the
children in therapy;
o establish a confidential space in which to meet with parents and other
adults; and attain buy -in from all parties who are bringing this partnership
into action.
3. Provide support and education to the parents/caregivers of the children covered in this
contract through monthly meetings and on-call support.
4. Provide classroom observation, ACEs (Adverse Childhood Experiences) education,
support, and consultation for the teachers and staff in the Brinnon School District.
5. Work with social services or other agencies as needed for dually served families with
mental health or chemical dependency issues.
6. Provide care coordination with other involved agencies, and referrals to supportive
services such as housing, transportation and vocational services and track client
involvement in recommended services.
7. Maintain a secure records system guaranteeing the confidentiality of PHI pursuant to
HIPPA.
8. Bill other revenues whenever they exist.
9. Provide individual therapy, using promising and/or evidence based models of treatment.
Applicant will identify the number of clients seen, how often each week and the number
of hours per week and per month for treatment enrollment.
10. Make referrals for mental health medication and monitoring, as needed.
11. Prepare progress reports, if needed (e.g., for care coordination purposes).
12. Provide staff including 2 master's level Licensed Mental Health Counselors, a Clinical
Supervisor and support staff to include billing and administration.
13. Ensure all employees or subcontractors of the Contractor undertaking the performance of
mental health/substance abuse services under this agreement are professionally licensed
or certified by the State.
PAGE 7
JUMPING MOUSE- Brinnon SD Mental Health Pilot Project
2018-2019
14. Complete background checks; to be redone for every employee every 3 years. The names
of licensed therapists will be given to the County.
15. Provide opportunities for regular clinical supervision and consultation for Jumping
Mouse therapists staff who are working at the Brinnon site. Provide supervision for all
therapists consisting of a minimum of one hour per week in individual consultation, one
hour per week in group consultation and three hours per month in a clinical staff meeting.
16. Provide for clerical, billing, and general office support.
17. Provide agency oversight regarding record keeping, data collection, legal and ethical
issues and standards of care are up to date and meet State of Washington standards.
18. Collect and prepare data for internal and external evaluation purposes, provide a monthly
invoice to JCPH and a quarterly data report. Provide quarterly data on client utilization,
referrals, outcomes, and any other required reporting, on a standard template provided by
JCPH.
19. Provide data including:
• Number of intakes, individual sessions, psychiatric visits, and adult education visits
provided.
• Age, sex, drug of choice, psychiatric diagnosis of clients.
• Referrals to other agencies.
• Client satisfaction form indicating client's view of how program helped in their life.
Type of education provided to Brinnon School District Staff and participation
numbers
20. At a regularly scheduled meeting, provide a progress evaluation report to the Mental
Health Substance Abuse Sales Tax Advisory Committee once during the contract periods.
21. Provide quarterly statistics in an electronic form, an illustrative example of which is
shown in EXHIBIT B of this contract, as may be revised by Jefferson County Public
Health in consultation with Jumping Mouse, for statistical and program data collection.
• Jumping Mouse Children's Center will ensure that quarterly electronic reports are
sent to Philip Ramunno of Kitsap County Health District, 345 6th Street, Suite
300, Bremerton WA 98337 and/or fViii .Ratllunno cckitsa ublichealth.c>>
and that a copy of each electronic report is also sent to Anna McEnery of
Jefferson County Public Health at arncgnery@g9Jefferspn.wa.us.
• Due dates for reports are as follows: August -October is due by 11/30, November -
January is due by 2/28, February -April is due by 5/30 and May -July is due by
8/30.
• Quarterly reports will be reviewed by Public Health and Philip Ramunno for
accuracy. Any questions will be referred back to the Jumping Mouse.
PAGE 8
JUMPING MOUSE- Brinnon SD Mental Health Pilot Project
2018-2019
EXHIBIT B
Jefferson County 1/10th of 1% for Mental Health & Substance Abuse
2018/2019 Quarterly Evaluation Reporting Template
Jumping Mouse will provide quarterly statistics in an electronic form, an illustrative example of
which is shown below, that will be developed, and may be revised, by Jefferson County Public
Health in consultation with Jumping Mouse.
The parties acknowledge that funding for this contract is contingent on the continuation of sales tax
revenue in 2018/2019. If the sales tax revenue decreases by ten percent (10%) when applicable sales tax
revenues are compared between the most recently completed quarter year and the same quarter year
revenues for 2018, then this contract may be renegotiated. The parties acknowledge the funding
connected to this contract is revenue of last resort and therefore Contractor will bill all other sources of
revenue first.
Jefferson County 1/10th of 1% for Mental Health & Substance Abuse
2018 Evaluation Reporting Template
Reporting Agency : Jumping Mouse (Brinnong Report Quarter:
THIS SECTION IS FOR All
CLIENTS SERVED YEAR TO DATE
Total Individuals (unduplicated)
children
caregivers
teachers/staff
SECTIONTHIS •- All SERVICE
A -
INQUIRIESQUARTER
Service Inquiries
IService
Service Inquirysposon: Disposition:
Enrollments by Client Status:
6
New client
Wait list: some service
Existing client
Wait list: no sendce
Previous client
Closed prior: some service
Client refused
Agency denied out of service
areatwaitlist closed
Referred to other
Lost to follow-up
Crisis call/walk-in
SECTIONTHIS •- All CLIENTS
•-
SERVED DURING CURRENT QUARTER
Service Counts:
Service
Session Counts:
Total clients served:
Child
Total clients eligible for 1/10th 1%: a portion
ineligible due to paperwork status
Parent
Total caregivers of all clients served:
Teacher/Staff
PAGE 9
JUMPING MOUSE- Brinnon SD Mental Health Pilot Project
2018-2019
Clients by Zipcode of Residence
98325
98365
98376
98320
Unknown due to paperwork status
Other:
Housing Status at Intake
Rent/own apartment or house
Doubled up/Couch surfing
Unsheltered
Unknown
Total 0
Parent/Caregiver Employment Status
Not in the work force
Employed work full time
Employed work part time
Unknown
Total 0
Parent/caregiver requesting
employment support
Referral to DVR
Length of Participation at Close of Quarter
0-4 weeks (less than 1 month)
9-12 weeks (2 months)
13-16 weeks (3 months)
17-20 weeks (4 months)
21-24 weeks (5 months)
25-28 weeks (6 months)
6 months - 1 year
1 year or more
Homeless at any
time during the
quarter
Other categories JM does not collect:
Shelter Live in car/tent/ry
Transitional (inciudi�1✓11'tOtel
Child -served by Parent/
Insurance Status'Child-billable intern Caregiver
Private insurance
Medicaid
Medicare
Uninsured
Other
Unknown
Total 10 10 10 1
Clients by Age and Gender:
Diagnosis
Age Range Male Female
Total
0to6
0
7to9
0
10 to 12* may be >12 @ close
0
Total 1 0 0
0
Client Mental Health no mental health known unknown paperwork
Status: status
Diagnosis
Primary
Second Third Total
ADHD
0
Adjustment Disorder
0
Generalized Anxiety
0
Attachment Disorder
0
Major Depression
0
PTSD
0
or T code:
0
0 0 0
abuse/neglect
0
sexual abuse
0
family or relational problem
0
foster child problem
0
bereavement
0
academic problem
0
phase of life problem
0
PAGE 10
JUMPING MOUSE- Brinnon SD Mental Health Pilot Project
2018-2019
Q 11 0
Mood Disorder
Separation Anxiety
Learning Disability
Other Depressive w/Anxiety
Adverse Childhood Experiences -historical known
Parent/Household Mental Illness
Poroni/i-Inimphniri Ainnhniism nr nnin Addictinn
0
0
0
0
Q
0
Drug/Alcohol Exposure in Utero
Family Experience
Loss: Divorce or Separation
historical
Loss: Death
single parent
Loss: Abandonment
foster care
Loss: Foster Care of Adoption
adoptive care
Loss: Other
kinship care
e: tmotionai
e: Physical
e: Sexual
pct: Physical
mt: Emotional
is=
Homelessness
due to paperwork status (different
than reporting # due to 0 count
reporters)
Any (unduplicated)
Any (unduplicated)
Experience Count
CountlReporting
Yes
%of Reporting %of Total
Non -Reporting
#DIV/01
0 Experiences
0
#DIV/01 #DIV/01
1 Experiences
0
#DIV/011 #DIV/01
2 Experiences
0
#DIV/01 #DIV/01
3 Experiences
0
#DIV/01 #DIV/0!
4 Experiences
0
#DIV/01 #DIV/01
5 Experiences
0
#DIV/01 #DIV/011
6 or more Experiences
0
#DIV/01 #DIV/01
Client Discharge Outcome:
Successful completion Other (please specify # and type)
Disappeared/Left services Not yet reported
Dropped out/Quit
Hospitalized
Deceased What did client die from?
Moved out of County
PAGE 11
JUMPING MOUSE- Brinnon SD Mental Health Pilot Project
2018-2019
ANNUAL OUTCOMES
SMART Objective Tvoe of Measure Source Numerator Denominator % auto ca f
# a vera ge
80% of teachers /staff will
tea cher/staff
#teacher/staff
score atleast4orabove on
sessions scoring
session scores
#VALUEI
the ACEs education section of
equal to or
ourevaluation tool
annual outcome
ACEs Education
exceed! ng 4
90%of children served will
_Se
#children
#children
successfully participate in
successfully
participants
#VALUEI
there py
annual outcome
]MCC Program
partici atin
# pa rent
80% of parents served will
participants
#parents
#VALUEI
successfully develop intended
successfully
participants
skills/behaviors of program
annual outcome
JMCC Program
developing
# pa rent
#parent
participants
participants
80% of pa rent pa rti cl pa nts
reporting program
completing
#VALUEl
report program has helped
has helped
parenting skills
them improve parenting skills
satisfaction
imp rove pa rent
4 or 5
outcome
survey
skills
question
#participants
#participants
reporting program
80%of participants report
has helped reach
completing
#VALUE!
program has helped them
goals forfamac
ily
family and self
reach goals for family and self
satisfaction
and self
goals question
4 or 5
outcome
survey
#teachers and
staff reporting
#teachers and
80% of teachers and staff
program has
staff with
#VALUEI
report program has helped
helped child and
consultations
child and family reach goals
satisfaction
family reach
4 or S
outcome
survey
goals
PAGE 12
JUMPING MOUSE- Brinnon SD Mental Health Pilot Project
2018-2019
EXHIBIT C
Fee Schedule
Therapy and Care Management by two licensed therapists -up to $19,300 per contract
Clinical Supervisor -up to $4,468 per contract
Supplies/Materials-up to $3,000 per contract
Travel -up to $4,500 per contract
Other -up to $500 per contract
Administration -up to $2,377 per contract
Not to exceed $34,145 in completion of services for the duration of this contract without
express written amendment.
PAGE 13
JUMPING MOUSE- Brinnon SD Mental Health Pilot Project
2018-2019
ATTACHMENT A
JEFFERSON COUNTY MH/CD TREATMENT TAX FUNDING -
MATCH POLICY
On October 14, 2013 Jefferson County Board of County Commissioners (BOCC) adopted the
following language in the allocation of the Mental Health Chemical Dependency treatment
dollars.
Agencies may not use Jefferson County mental health county/ chemical dependency
treatment tax funds for match, without prior authorization of their match formula and
allocation use, approved by the Jefferson County Administrator and fiscal team. The
match may not be used without written permission.
Definitions:
Match: is a requirement for the grantee to provide contributions of a specified amount or
percentage to match funds provided by another grantor. Matching can be in the form of
cash or in-kind contributions.
Auditors Objective: To determine whether the match amount or percentage of
contributions from JC is an allowable source of funding and that the vendor has an
accurate accounting system to track the match.
Regulations: The specific requirements for matching funds are unique to each federal or
state program. The A-102 Common Rule provides criteria for acceptable costs and
contributions in regard to match.
Jefferson County Policy:
In 2005, the Washington State Legislature created an option for counties to raise the local sales
tax by 0.1 percent, (the 1/10th of 1% sales tax initiative) to augment state funding for mental
health and chemical dependency treatment. Jefferson County collects and distributes the Mental
Health/Chemical Dependency (MH/CD) tax. Services purchased by the County are allocated
through a formal Request for Proposal (RFP) process, review and contracting; staffed by
Jefferson County Public Health, overseen by Jefferson County Mental Health Substance Abuse
Fund Advisory Committee and adopted by the Board of County Commissioners, (BOCC). The
BOCC does not assume any fiscal responsibility/liability for any of the vendors they contract for
services with. Services leveraged by a vendor using MH/CD tax as match have no oversight or
agency relationship to Jefferson County; funding cannot be used without prior authorization of
the vendor's match formula and allocation by the Jefferson County Administrator and fiscal
team.
PAGE 14
JUMPING MOUSE- Brinnon SD Mental Health Pilot Project
2018-2019
Following state, federal and local guidelines for match is the responsibility of the vendor.
Jefferson County will follow all administrative policies in authorizing that use. If a vendor is
disallowed the use of funds for match according to the State of Washington or the federal
government, Jefferson County funds will not be available as matching funds.
• For example, if a vendor provides Title XIX Medicaid services (the Policy
19.50.02 or 42CFR 430.30) they will not be allowed the use of match without
actually billing Medicaid for the services at the same time. If no Medicaid billing
exists, the match cannot be applied.
The County shall verify that the local entity's financial reporting system tracks
matching funds at a level to support the use of funds; that meets the level of
documentation required by federal or state statutes.
The verification and application process for Match use within the County will include the
following steps:
1. DSHS requires contractors to complete and submit a "Local Match Certification"
form (DSHS 06-155) or a form that has equivalent data elements prior to any
agreement for DSHS services. The County must review a copy of this application
and form prior to granting match authorization of MH/CD funds for Match and at
each monthly billing.
2. Submit the current administrative policy within WA State regulating your services
and the use of local match.
3. Submit to the County your last financial audit showing your use of match,
County funds and tracking systems.
4. Submit to the County the terms of the agreement to ascertain the MH/CD
allocation is an allowable source of match.
5. The County Administrator will authorize or deny the use of match in writing
within 30 days of the application.
PAGE 15
JUMPING MOUSE- Brinnon SD Mental Health Pilot Project
2018-2019
JEFFERSON COUNTY PUBLIC HEALTH
(LIic H
Department: Division: Section of Procedure Manual:
Jefferson County Public Health Community Health / Nursing Nursing
Title:
Depression Screening Guidelines
Subject:
Course of action for Staff to screen and evaluate clients for depression
Originated (date): Replaces (date): Effective (date): Renewal due (date): Page: 1 of: 2
01/02 01/02 03/13 03/15
Originated by: Yuko Umeda Approved by: Name Jean Baldwin
Depression Screening Guidelines
• Clients will be offered education, screening, and referrals for depression as indicated by program
guidelines and clinician's judgment. A standardized screening tool, PH -Q9, will be used.
• JCPH staff will administer the screen, discuss results, and if positive, develop with the client a plan for
self care and provide referral to mental health and medical care. Staff will assure adequate time to
complete the entire process during the clinic or home visit.
• For a positive screen, the client will be referred to their Primary Care Provider (PCP) and Mental Health
services. The client can choose to take a copy of the screen or sign a Release of Information (ROI) form
so the screen can be faxed to the PCP. If the client chooses to have the form faxed, staff will fax the
screen, the ROI, and a letter to providers.
• The screening tool will be signed, dated by staff, and filed in History & Physical in chart. Screening
results and plan will be documented in nursing notes in chart.
• If client has positive answers to questions about suicidality, staff will evaluate client using JCPH Suicide
Risk Assessment tool (see next page). If situation is emergent, notify lead staff and conduct plan of care
as directed in risk assessment. After transfer of client to appropriate care providers occurs, 1) debrief
situation with lead staff, and 2) document assessment, plan and outcome in EMR.
Depression Screening Guidelines 20130301_Depression_Screen_Guide LF Page 1 of 2
JEFFERSON COUNTY PUBLIC HEALTH
P lie HFGaV
Department: Division: Section of Procedure Manual:
Jefferson County Public Health Community Health/Nursing Nursing
Title:
Adverse Childhood Experiences (ACE) Screening in Family Health Services Programs
Subject:
Course of action for staff to screen, evaluate and discuss ACE with clients
Originated (date): Replaces (date): Effective (date): Renewal due (date): Page: 1 of: 1
07/2014 07/2014 107/2016
Originated by: Yuko Umeda Approved by: Jean Baldwin
Adverse Childhood Experiences (ACE) Screening Guidelines in Family Health Team
Programs
• All Family Health Services providers will receive education on Adverse Childhood
Experiences (ACE), the ACE questionnaire, and how to administer and discuss
questionnaires with individuals before clinical use. Family Health Services providers
will participate in reviews of ACE and use of ACE questionnaire annually.
• All providers conducting ACE questionnaires will receive training on mandatory
reporting and review mandatory reporting requirements annually.
• The standard short version of the ACE questionnaire (see attached tool) or the
Resilience Trumps ACEs cards produced by the Children's Resilience Initiative
will be used.
• All individuals >= age 18, entering Family Health Team programs, including
Maternity Support Services (MSS), Infant Case Management (ICM), Nurse
Family Partnership (NFP), and Early Intervention Program (EIP), will be offered
ACE screening, with provider discretion, as part of the program enrollment and
assessment process. Answering the questionnaire is voluntary and can be
administered at any time during program participation.
• Provider discretion will be used in conducting ACE discussion with clients under
age 18.
• The ACE score total will be documented in the electronic medical system (EMR).
Individual ACE questionnaire items will not be documented in EMR and copies of
the questionnaire will not be filed in JCPH records nor given to clients. All paper
copies will be shredded.
For staff directory listings, press 555 and follow the instructions to get a specific voicemail
box.
For Environmental Health and Water Quality, including information about the Food
Workers' class, press 2. Or you may hang up and call (360) 385-9444.
Visit our website at: www;Teffersoilcountypublichealth.ora.
Thank you for calling.
Adverse Childhood Experiences (ACE) Screening 20140701ACE5creening Page 1 of 1
JEFFERSON COUNTY PUBLIC HEALTH
Pu lic
_J111ZI A
Department: Division: Section of Procedure Manual:
Jefferson County Public Health Community Health / Nursing Nursing
Title:
Nurse -Family Partnership Referral and Admission
Subject:
Criteria for Client Eligibility for Admission to NFP
Originated (date): Replaces (date): Effective (date): Renewal due (date): Page: 1 of: 1
11/14 07/14 07/16
Originated by: Yuko Umeda Approved by: Name Jean Baldwin
U j
Jefferson County Public Health Protocol for
Nurse -Family Partnership (NFP) Referral and Admission
The criteria listed below will be applied to determine client eligibility for admission to the Jefferson County
Public Health Nurse -Family Partnership (NFP) program and to prioritize client outreach. Pregnant women
referred from JCPH programs, community agencies and general community will be screened by the NFP nurse
for eligibility.
• AGE: priority given to the youngest, 24 years of age and younger. Clients older than 24 and presenting
with risk factors may be considered depending on caseload capacity.
• GESTATION: 28 weeks or less with priority given to those with the earliest gestation
• INCOME: 200% or less of the current Federal Poverty Guidelines
• RISK FACTORS: priority given to those with known risk factors including but not limited to:
o current or history of mental health problem for themselves or within family
o current or history substance use problem for themselves or within family
o ACE score higher than 3
• INTEREST: priority given to those with risk factors and who express an interest in enrolling and completing
the NFP program.
Nurse -Family Partnership Referral and Admission 20140701_NFPRefAdm Page 1 of 1