Agenda 05/27/2008 Item #16D 4
Agenda Item No. 1604
May 27, 2008
Page 1 of 31
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EXECUTIVE SUMMARY
Recommendation to approve application and Memorandum of Understanding for a
Health Information Technology Special Congressional Initiative from the U.S.
Department of Health and Human Services in the amount of $323,911 and, if
awarded, to serve as the Fiscal Agent and to authorize staff to negotiate an
agreement with the Physician Led Access Network (PLAN) to implement the
program.
OBJECTIVE: To approve application for a Health Information Technology Special
Congressional Initiative earmark from the United States Department of Health and
Human Services to develop and implement a shared informational database between the
portals of entry for the poor into the health care system.
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CONSIDERATIONS: In the fall of 2007, staff of the Housing and Human Services
Department met with representatives of The Ferguson Group to discuss and present a
project questionnaire on a proposed project for health care access for the uninsured in
partnership with a local not for profit provider, the Physician Led Access Network
(PLAN). A total of 33 county projects were originally submitted for consideration to The
Ferguson Group representatives who professionally evaluated the funding potential of
each project and based on opportunities available, with the PLAN project being one of
nine (9) projects recommended for Collier County's Fiscal Year 2008 Federal Legislative
Agenda. The Board of County Commissioners approved this project as one of their
legislative priorities on February 13, 2007.
TIris appropriation was approved as part of the Consolidated Appropriations Act, 2008
(PL 110-161), signed into law on December 26,2007. Upon notification of the approval
of the federal earmark for the Health Care for the Uninsured Initiative, Housing and
Human Services was directed to wait for instructions forthcoming to apply for the grant.
These instructions were received on April 29, 2008 and the grant application is due in
Grants.gov on May 29, 2008.
The purpose of this Collier County Government Access for the Uninsured project is to
establish a shared information database to provide for a more effective and efficient
method of health care service for our uninsured population. By establishing this shared
information network between the portals of entry for the poor into the system, patients
needs will be met by the appropriate medical service in a more timely and cost-efficient
manner. This information network will be created and established throughout multiple
locations in Collier County, including two area hospitals and three health care clinics.
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When the grant is awarded, Collier County will enter into an agreement with PLAN.
This agreement, along with the actual grant agreement for the federal dollars will be
presented to the Board of County Commissioners for approval. PLAN is the community-
based referral network that coordinates volunteer medical care for eligible low-income,
uninsured adults in need of health services in Collier County. Led by our physicians, it is
Agenda Item No. 1604
May 27, 2008
Page 2 of 31
a community partnership that brings together our physicians, community clinics,
hospitals, diagnostic and laboratory facilities, and other healthcare providers through an
integrated delivery system of volunteer care. PLAN is an initiative launched by the
Collier County Medical Society. This past year, PLAN coordinators facilitated over 900
patient encounters; these patients received over one million seven hundred thousand
dollars in donated care.
Collier County Housing and Human Services will serve as the Fiscal Entity for this
grant. There is no match required and no general fund dollars will be expended.
FISCAL IMPACT: Serving as the fiscal entity for the administration of this project will
require a minimal amount of staff involvement. Administrative expenses and travel
associated with the grant will be included in the application resulting in no further fiscal
impact.
GROWTH MANAGEMENT IMPACT: There is no growth management impact due
to this request.
LEGAL CONSIDERATIONS: The Memorandum of Understanding is legally
sufficient and ready for Board consideration and approval. HF AC
RECOMMENDATION: That the Board of County Commissioners approve submittal
of an application for a Health Information Technology Special Congressional Initiative
grant and authorize the Chairman to sign the Memorandum of Understanding and when
awarded, authorize staff to negotiate an agreement with the Physician Led Access
Network.
Prepared by: Marcy Krumbine, Director, Housing and Human Services
Agenda Item No. 1604
May 27, 2008
Page 3 of 31
PLAN Health Care Access for the Uninsured
Collier County Government, Florida
Housing and Human Services
3301 East Tamiami Trail
Building H
Naples, FL 34120
239-252-2273 (voice) 239-252-2638 (fax)
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Abstract
Collier County Government proposes to expand and develop a full access
program with a complete continuum of services for a population of approximately 35,000
low income uninsured residents. Requesting an amount of $327,000, Collier County
Government will implement a Health Information Technology project by creating an
information network system linking data from the hospitals' systems, the community's
clinics that serve as access to care for the poor and the private practice participating
healthcare providers into PLAN. Once the infOImation network is operational, the
project plans to develop and implement a marketing plan for full penetration of the
population of individuals who are uninsured.
Collier County is located on the southern gulf coast of the Florida peninsula, due
west of the Miami- Ft. Lauderdale area. Naples, located in the western and coastal area of
Collier County, is the largest of the 3 incorporated cities in Collier County. Everglades
City, lies south and east of Naples and recently incorporated City of Marco Island lies
south along the Gulf of Mexico. Collier County contains approximately 2,025.45 square
miles ofland area with a population of approximately 339,000.
Housing and Human Services (HHS) serves Collier County's very low, low and
moderate income residents, including the senior population by providing access to health
care, developing volunteer services with retirees, assisting with affordable
homeownership and other housing opportunities, maintaining safe and decent housing
and independent living for seniors, utilizing federal and state grants to build safe, livable
and healthy communities and to meet the local government mandates of human services
in Collier County. HHS will contract with the Physician Led Access Network (PLAN) to
meet the needs of health care access for the uninsured. PLAN is the community-based
referral network that coordinates volunteer medical care for eligible low-income,
uninsured adults in need of health services in Collier County. Led by our physicians, it is
a community partnership that brings together our physicians, community clinics,
hospitals, diagnostic and laboratory facilities, and other healthcare providers through an
integrated delivery system of volunteer care. PLAN is an initiative launched by the
Collier County Medical Society.
Add a summary of project goals, objectives and activities here.
I
Agenda Item No. 16D4
May 27, 2008
Page 4 of 31
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FISCAL YEAR 2008 ApPROPRIATIONS
PROJECT QUESTIONNAIRE
Please use this form only for projects for which you are seeking federal funding for a direct
line item in an appropriations bill. Only answer sections A and B. If you have an EP A,
Transit, Federal Highway or Economic Development project, please fill out the Section that
corresponds to that type of project as well.
Please use Microsoft Word to ensure our work is compatible with documents used by
congressional offices. The format of the questionnaire allows you to click on a question and
answer in the appropriate field. You will also be able to "check" a box by clicking on the
box with the cursor.
A. Backeround Information
1. What is your name, job title, and coutact informatiou (including emaiI, fax, aud
phone)?
Marcy Krumbine, Director of Human Services; email: marcykrumbine@colliergov.netPhone
(239) 774-8442; Fax (239) 732-2638.
Dr. Joan Colfer, Director, email: Joan_Colfer@doh.state.fl.us; (239) 774-8200
2. What is the name of the project?
Physician Led Access Network of Collier County
3. Where is the project located?
Collier County a collaborative arrangement between a non-profit organization, local
government, and the Department of Health.
4. Which Congressional District(s) does this project fall within?
14th & 25th Congressional District--Connie Mack IV and Mario Diaz-Balart are the current
congressmen for the district.
5. Please describe any special characteristics of the site. For example, current and past
uses or historic significance of the site.
6. Briefly describe the project (4-5 sentences). For example, describe the physical
characteristics of the project, the population to be served, and the purpose of the
project.
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Agenda Item No. 1604
May 27, 2008
Page 5 of 31
The project seeks to develop a health care access program for individual's who are
under/uninsured in Collier County. Using volunteer physicians, the project connects
individuals who require specialty health care to free services donated by local health care
providers. The project seeks to expand, organize, and develop a full access program with a
full continuum of services for a population of approximately 35,000 identified as needing
health care
7. Describe any in-kind contributions to your project (architectural work, land, staff
hours, etc.) aud an approximate value of these contributions.
Department of Health provides support in paying for the Executive Director of this
organization. Collier County Government pays for the Patient Coordinator. Volunteer
physicians and health care providers contribute over $1 million towards donated health care
per year.
8. Does this project have a regional impact?
In this program, we will see individuals who can prove Collier County residency for 30 days.
Therefore, we may be diminishing the impact of significant medical problems burden
communities who are home to the migrant population just like Collier County
9. How will this project benefit the community?
Developing a full access, marketed program with complete penetration of the
under/uninsured can eliminate overuse of emergency health facilities, lack of attention to
medical issues that develop with this population, and provides a local solution to the number
of immigrants in the community, both documented and undocumcnted that require health
care.
10. Does the project address an immediate need or is it related to future growth and! or
development?
This project solves both the problems associated with the current growth in the community
with the projected expanded growth in Collier County. The numbers of
uninsured!underinsured will remain constant as the job growth in the area continues to be tied
to low paying jobs, which do not typically produce jobs that also include health insurance.
11. What is the timeline for the project? Specifically, when will the project begiu and end?
Currently PLAN has been in operation for approximately three years, but with federal
funding to expand and fully operationalize this model, it is anticipated that the timeline for
expansion would begin with the initial funding and be fully realized within 36 months.
12. Are there multiple phases to this project? Yes ~ No 0
a. If yes, for which phase are you requesting funds?
Initial phase would be in adopting a shared informational database between the portals of
entry for the poor into the system. This shared database would be created and established
throughout multiple locations in Collier County. In addition to the shared database, we
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Agenda Item No. 1604
May 27, 2008
Page 6 of 31
expect to develop a marketing plan for full penetration of the population of individuals
who are under and uninsured. Finally, additional protocols related to disease management
would be placed on the population with outcome measures that demonstrate increase in
the quality of health of the members.
b. Please describe auy future phases of the project.
Future phases include expansion of this three pronged effort: informational/technical
database, marketing and outreach and increase of health care services for various ages
and expanded services.
13. Is there public and/ or private support ofthis project? Yes ~ No 0
a. If yes, who are these supporters?
Collier County Government
Community Foundation, Inc.
Senior Friendship Center
Florida Department of Health
Collier County Medical Society
Collier Health Services, Inc.
Collier Regional Medical Center
Naples Community Hospital
Physician's Regional Medical Center
Neighborhood Health Clinic, Inc.
David Lawrence Center. Inc.
United Way of Collier County
b. Would these supporters be willing to publicly support the project by writing letters
or passing resolutions? Yes ~ No 0
14. Are you aware of any other counties/cities who are in favor of or opposed to this
project?
The State Volunteer Health Care Provider Program, across the State of Florida, are in support
of the PLAN program in Collier County.
15. Please describe how this project serves the County's goals and/or relates to the
Commission's long-range planning goals.
In Strategic Focus Area III, the County seeks to improve the quality of life and promote
personal self-reliance and independence through improved access to community health care and
human services for those most in need. One of the key goals in this area is to improve access to
primary and specialty medical and dental care for the working poor and indigent populations.
Additionally, another goal is to participate in community alliances and partnerships to coordinate
the provision of human services.
16. Please provide the names of state or federal agency staff that are familiar with and you
believe would advocate for your project.
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Agenda Item No. 1604
May 27, 2008
Page 7 of 31
17. Does this project require environmental review? Yes D
No [8J
a. If yes, what level of review is required?
b. Have you started environmental review? If yes, describe the review status?
18. Are you aware of any pending or past legislation which addresses this issue?
19. Have you previously discussed this project with any congressional offices?
~[8J No D
a. If yes, whom did you contact? Please provide the staff members' names if possible.
For Congressman Diaz-Ballart - Stephen Hart
For Congressman Connie Mack - Kara Moore
For Senator Martinez - John Little and Tczaziel Hernandez
B. Financial Information
1. How much funding is sought for federal fiscal year 2008 (October 1, 2007 - September
--... 30, 2008)?
$1 million
2. Is this the total amount you will request from the federal government for this project?
Yes D No [8J
a. If not, what is the total amount you will request from the federal government?
3. Including non-federal funding, what is the total cost of the project?
$5 million
4. Has your project ever been included in the President's budget request?
Yes D No [8J
a. Is it included in the President's fiscal year 2008 budget request? Yes D No [8J
5. Has the project received federal funding in the past? Yes D No [8J
a. If yes, how much? Please detail by year. (NOTE: This information is not needed for
projects previously worked on by TFG. Please continue to 17b.)
Fiscal Conference Pnrpose Committee Report
Year Allocation Langnage
($)
1999
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Agenda Item No. 1604
May 27, 2008
Page 8 of 31
Fiscal Conference Purpose Committee Report
Year Allocation Langnage
($)
2000
2001
2002
2003
2004
2005
2006
2007
Total Includes FY 2007
b. Has the federal funding from prior years been spent? Yes 0
No 0 n/a
c. If the federal fnnding has not been spent, when do you expect to spend it?
6. Has the project received state funding in the past? Yes 0 No ~
a. If yes, how much? Please detail by year.
Year
Amount ($)
b. Has the state funding been spent? Yes 0 No 0
c. Ifthe state funding has not been spent, when do you expect to spend it?
7. Has the project received funding from private sources? Yes ~ No 0
a. If yes, how much and from whom?
$50,000 - Cleveland Clinic
$35,000 - United Way of Collier County
$25,000 - Community Foundation
$ 8,000 - League Club
$1,000,000 - in donated care from health care providers per year
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Agenda Item No. 1604
May 27, 2008
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b. Has the private funding been spent? Yes ~
NoD
c. If the private fuuding has not been spent, when do you expect to spend it?
8. Are local matching funds available for the project? Yes ~ No D
a. If yes, from what source or sources?
Collier County Government matches $65,000 in salaries for one staff person
Department of Health matches $55,000 in salaries for the Executive Director.
9. Can the amount requested be spent in Fiscal Year 2008? Yes ~ No D
a. If the entire amount cannot be spent, how much can be spent in FY 2008?
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Agenda Item No. 1604
May 27,2008
Page 10 of 31
C. For EPA Proiects
1. Is the proposed project eligible for a loau from its state's Clean Water or Drinking
Water State Revolving Fund? Yes 0 No 0
a. If the project is eligible, have you applied for a SRLF loan? Yes 0 No 0
b. What priority did the state assign this project as a result of the application?
c. What size of loan did the state determine the project was eligible to receive?
2. If you do not receive the requested funding, wonld the cost of the project be fuuded
through user fees or tax increases? Yes 0 No 0
a. On average, how much would each household pay in annual user fees if you do not
receive the requested funds?
3. What is the estimated average annual user fee as a percent of the estimated median
annual income of households that will be served by the project if the community
constructs the proposed project without the requested grant funds?
a. With an SRF loan?
b. With municipal funding at market rates?
4. What is the current market rate for municipal funding?
5. How will the requested funds benefit low or moderate-income communities?
6. Is your Water Management District aware of and supportive of the project and who is
your contact at the Water Management District?
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Agenda Item No. 1604
May 27, 2008
Page 11 of 31
D. For Hi!!hwav Proiects
1. What, if any, federal-aid highway discretionary programs is the project eligible under?
2. Is the project on the State's Transportation Improvemeut workplan?
3. Are there any pending issues with the project, such as litigation or environmental
problems? Yes D No D
a. Please provide a brief description of the problem and timing for a resolution.
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Agenda Item No. 1604
May 27, 2008
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E. For Transit Proiects
1. Has the project been discussed with FTA? Yes D No D
a. If yes, please provide the name and contact information of the FTA official
contacted.
2. Is there a public transportation component of this project? Yes D No D
a. If yes, please explain.
3. Please provide the contact name and phone number for the area transit operator?
4. Is the area's transit operator involved in the project? Yes D No D
5. Has the requested earmark been discussed with the transit operator? Yes D No D
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Agenda Item No, 1604
May 27, 2008
Page 13 of 31
F. For Economic and Community Development Proiects
1. Does the project create jobs? Yes 0 No 0
a. If yes, please explain.
Insuring individuals have health care leads directly to their maintaining or obtaining
employment
2. Does this project meet a compelIiug human need? Yes ~ No 0
a. If yes, please explain.
Access to health care eliminates an individual's personal suffering, allowing them to
pursue housing, employment, etc. Improved health can also improve family relations,
diminish depression and increase the functionality of the individual. In turn, our
workforce is strengthened.
3. Does the project benefit low or moderate-income neighborhoods? Yes ~ No 0
a. If yes, please explain.
Individuals served by such a project would be those from low or moderate income
neighborhoods, maintaining the health of these communities.
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4. Does the project eliminate physical or economic distress? Yes ~ No 0
a. If yes, please explain.
Health access equals diminished physical and economic distress and improves the quality of
life for individuals who are in the most need.
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Agenda Item No. 1604
May 27,2008
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G. For Labor. Health & Human Services. and Education Proiects
1. If the request is for health-related construction, please identify the activity or activities
that will be carried out in the facility.
2. Please include a break down of the requested funding? (For example, salary $40,000;
computers $3,000, etc.)
Salary & Benefits $300,000
Information Technology and Services $250,000
Marketing and Outreach $250,000
Operating Expenses related to network $200,000
3. Is this project nationally significant? If so, please describe.
In providing an integrated network of care for the under/uninsured in the community not only
are individuals who lack health care access assisted, including individuals who are citizens,
but also addresses the lack of access for undocumented individuals in the community. Given
the large migrant population in Collier County, this program has implications for replication
amongst other communities that have large undocumented populations. Ready access for
health care to this population is debated regarding whether it should be provided due to the
individuals who are guest workers; however, this population does exist in communities and
does burden existing health care resources--structuring a program that provides outreach and
access will help communities to share the burden of these individuals. PLAN is also part of a
national, physician driven initiative to provide access to low income and under insured
citizens.
4. What specific federal responsibility does the funding of this project or activity further?
For example, what measurable improvements in health status, educational
achievement, or similar outcomes will result from this project?
Increased access for individuals who lack access to health care.
Improved health outcomes for individuals served.
Ability to assist individuals in returning to work after successfully.
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Opportunity Title:
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CFOA Description:
Opportunity Number:
Competition 10:
Opportunity Open Date:
Opportunity Close Date:
Agency Contact:
Grant ApP1i'e~lij~rrf.'~ge
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This opportunity Is only open to organizations. applicants who are submitting grant applications on behalf of a company, state, local or tribal
government, academia. or other type of organization.
* A.pplication Filing Name:
Mandatory Documents
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Application Submission Verification and Signature
Opportunity Title:
Health Information Technology Special Congressionallnltiath
Offering Agency:
Health Resources & Services Administration
CFDA Number:
93.888
CFDA Description:
Specially Selected Health Projects
Opportunity Number;
HRSA-08~128
Competition 10:
3156
Opportunity Open Date:
04/29/2008
Opportunity Close Date:
05129/2008
Application Filing Name:
PLAN Healthcare Access for the Uninsured
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Fl: Florida
--~--~~-------I
:'~'-]
USA: UNITED STATES
~=:==:=:~=]
J
Division Name:
Prefix:
f. Name and contact information of person to be contacted on matters Involving this application:
J ~liC Services
Middle Name:
[~.~~".,----
c--~'
.. Last Name:
1["Krumbine
--_..._..._.~._..,.-
[
Suffix'
Title: Director
,
Organizational Affiliation:
I....
L
.,. ~,Telephone Number: l.:.:.? 252~2273
I Email:
[" "_..:.~. .
i ~arcYk~Umbl.ne~colllergo_v ,nel
.. First Name: Marcy
.._------]
l
-
J
l
..J
I
_.______,__.___~_----.l
~ Fax Number: 1239252-2638
- .
LJ
J
Ag"nrl~ Item ~ 1604
DMlrN'IlI'IlVLr~'ZIl~
ExP"aHo~ ~Wffl'QP1J
Application for Federal Assistance SF-424 Version 02
9. Type of Applicant 1: Select Applicant Type:
I ---..--- -----,-. -.-- _.~---,.. ---..-J
B County Government
_._....__.._-~~- ._--~._-~-,~.
Type of Applicant 2: Select Applicant Type'
r----- --,--~-~- 1
-------.------.--- -~---- .--
Type of Applicant 3' Select Applicant Type:
1 --'---....------.----- .. "'.'.-----
- -_..~- --'---_.... --.J
. Other (specify):
1-- - -.........-.--.- -----.-.----.---'.--. . -.. "-J
. 10. Name of Federal Agency:
! Health Resou~ces & Services Administration ~--_.,._"_._~~. ~
... .--....- ..
11. Catalog of Federal Domestic Assistance Number:
93,888 ..J
L_
CFDA Title:
[speciallY Selected .----.-------.. ........,
Health Projects
I
"
. 12. Funding Opportunity Number:
--.--------,---.-.-.---- --~-i
iHRSA-08-128
L......:.....
"Title'
r....-.--~.--..---._----------"-,.-.. .. --".-..-- .. ,
I Health Information Technology Special Congressional Initiative I
I
I j
I ." ". ____m._ _.,---
13. Competition Identification Number:
-. .-.-..-- ,-- I
i,315~___~__ -----~.-._...----_._--- .__....----J
Tille:
..._._---_..._~--- -----.-----------------.1
1
i
i I
I. u , _"_'0_-
14. Areas Affected by Project (Cities, Counties, States, etc.):
,-,,~. ~...._..._--_._-_._-_.__..._-_._----~_._--~-------- ..---- ,._--"-"--1
I
I
!
L.._ ..u .. -. " -_._- "
. 15. Descriptive Title of Applicant's Project:
IPLAN ,
Heallh Care Access for the Uninsured I
I
i
I " ,.. ,
Attach supporting documents as specified in agency instructions.
t,,~~d. Att~~~~ I,!?,el~~~, ~~~ch~~n~~! IYJewf._tta-~h,Ill~~EJ
,,<,:;.,
",
Application for Federal Assistance SF.424 Version 02
" ,
Congressional Districts Of:
- a. Applicant ~4r25 I .. b. Program/Project 1'~125 I
Attach an additional list of Program/Project Congressional Districts if needed.
1-- ] 1,~~:":Jlt.~~;':Att'~~~~'Qt IE----:-]l~=_==l
17. Proposed Project:
.. a. Start Date: 109/0112008 I .. b. End Date: 1.08/31/2010 I
18. Estimated Funding ($):
. a. Federal I 32~.911:~
.. -
I -, ..~o~
" b. Applicant
.., .. "o~
" c. Slate L
f' .-. ,,~ ------,. .. '.'0061
" d. Local L..
- e. DIner I OO~
I . . 0001
"I. Program Income
.. g. TOTAL i 323,91i~
.. 19. Is Application Subject to Review By State Under ExecutIve Order 12372 Process?
lJ a. This application was made available to the State under the Executive Order 12372 Process for review on 1.~~_J
~] b. Program is subject to E.O. 12372 but has not been selected by the State for review.
[J c. Program is not covered by E,Q. 12372.
J. ]s the Applicant Delinquent On Any Federal Debt? (If "Ves", provide explanation.)
!_J Yes [{J No I !
21. "By signing this application, I certify (1) to the statements contained in the list of certifications" and (2) that the statements
herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances.. and agree to
comply with any resulting terms If I accept an award. I am aware that any false, fictitious, or fraudulent statements Dr claims
may subject me to criminal. civil, Dr administrative penalties. (U.S. Code, Title 218, Section 1001)
::Zl .. I AGREE
.. The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency
specific instructions.
Authorized Representative:
.--- I
Prefix: L~r. i ~ First Name: i~~._____.
, _um
! . .___J
Middle Name:
- -
1 Henning , .-.---. --J
. last Name:
-~~._--,_.._---,---------~~-_.~~.~._-_._-
Suffix: i i
i Chairman. --"-"- ]
'* Title: Board of County Commissioners
L._ . -. , -
.. Telephone Number: @39 252,8097 Fax Number: 1239 252-3602 I
. . , .-. ....J
I , . ~._~.- -..-."....- ""..-. .. .~.- ~"_.- .. J
. Emai!: ~mhennlng@colllergov _net
.. ... _'n -
. Signature of Authorized Representative: [~~mPleted by Granls-g~'~--u~~n sUbrr.i~5ion] . Date Signed: @:ompi~~Qd b;"Granl~g~~ u~on~ub~ission .1
AgenMrla Item No. 1604
o ill N'M!Wif~I2\lRjl~
Expiratio~011g1Jl!'8'?
.--- ~uthorized for Local Reproduction
Standard Form 424 (Revised 10/2005)
Prescribed by OMS Circular A-102
Application for Federal Assistance SF-424
Ag~iI ~W&e~~)d~~
E,p;'al'D~ ~tJ36f'~
Version 02
.. Applicant Federal Debt Delinquency Explanation
The following field should contain an explanation if the Applicant organization is delinquent on any Federal Debt. Maximum number of
characters that can be entered is 4,000. Try and avoid extra spaces and carriage returns to maximize the availability of space.
.-------------.-
CERTIFICATION REGARDING LOBBYING
Certification for Contracts, Grants, Loans. and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid. by or on behalf of the undersigned. to any
person fOf influencing Of attempting to influence an officer or employee of an agency, a Member of
Congress, an officer or employee of Congress. or an employee of a Member of Congress in connection with
the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the
entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or
modification of any Federal contract, grant. loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency. a Member of Congress. an
officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal
contract, grant, loan, or cooperative agreement. the undersigned shall complete and submit Standard
Form-LLL, "Disclosure of Lobbying Activities," in accordance with its instructions.
(3) The undersigned shall require thalthe language of this certification be included in the award documents
for all subawards al all tiers (including subcontracts, subgrants, and contracts under grants, loans. and
cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification
is a material representation of fact upon which reliance was placed when this transaction was made or
entered into. Submission of this certification is a prerequisite for making or entering into this transaction
imposed by section 1352. title 31, U_S. Code. Any person who fails to file the required certification shall be
subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
Statement for Loan Guarantees and Loan Insurance
The undersigned stales, to the best of his or her knowledge and belief, that:
If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer
or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of
a Member of Congress in connection with this commitment providing for the United Slates to insure or
guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, "Disclosure of lobbying
Activities," in accordance with its instructions. Submission of this statement is a prerequisite for making or
entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the
required statement shall be subject to a civil penalty of not less than $10,000 and not more thall $100,000
for each such failure.
....~
[-~--___~_II
Board of County I
* APPLICANT'S ORGANIZATION
i Collier County
l.....~___.__.__._...__...._
* PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE
...-.-------.---.....1
Prefix: ~.___.J * First Name: ITom _________
... Last Name ~nning- ------------------r Suffix.
L_________ _____~______._.I
Middle Name-
___...___J
! -_==-]... Title.
~ SIGNATURE: @~;;PI~t;;d"'~~-;~b-;;!~ii~~~~~~~~~_:?~_=.J
.. DATE: Completed on submi~~i~~t~-G.r;~ts.go-~----i I
'---------'-----~----:-,~~=-j
~.
Agenda Item No. 1604
May 27, 2008
Page 21 of 31
PHS-5161.1 (7100)
CHECKLIST
Public Burden Statement:
Public reporting burden of this collection of information is estimated 10
average 4 hours per response, including the time for reviewing instructions.
searching eXisting data SO'Jrces. gathenng and maintaining the data needed,
and completing and reviewing the collection of inforl'1ation An agency may not
conduct or sponsor, and a person is nol required to respond to a collection of
Information unless It disp'ays a currently valid OMS con:rol number Send
comments regarding thiS burden estimate or any other aspect of tt1IS
collectIOn of information. including suggestions f::lr reduCing this burden to
COG,
Agenda Item ~<O. 16D4
May .:..{, .:..Uuo
OM' Ao~t!"22'e,f"3~
Clearance Officer. 1500 Clifton Road, MS 0-24. Allanta, GA 30333, ATTN PRA
(0920-0428) Do not send the completed form to this address
NOTE TO APPLICANT:
This form mus! be completed and submitted with the original of your
application, Be sure to complete both sides of this form. Check the
appropriate boxes and provide the information requested. This form should be
attached as the last age of the signed anginal of the application. This page is
reserved for PHS staff use only.
TypeofApplicalion:
~{J NEW
Supplemental
Noncompeting Continuation
i-I
U
Competing Continuation
PART A: The following checklist is provided to assure that proper signatures. assurances, and certifications have been submitted.
Included
NOT Applicable
1 Proper Signature and Date
2 Proper Signature and Date on PHS-5161 1 "Certifications" page.
3 Proper Signature and Date on appropriate "Assurances" page. i_e.. SF-424B (Non"Construction Programs)
or SF-424D (Construction Programs) .
4. If your organization currently has on file with DHHS the following assurances, please identify which have
been filed by indicating the date of such filing on the line provided (All four have been consolidated into a
single form, HHS Form 690)
[~J Civil Rights Assurance (45 CFR 3D) .
[-,J Assurance Concerning the Handicapped (45 CFR 84) .
Assurance Concerning Sex Discrimination (45 CFR 86) .
[-I Assurance Concerning Age Discrimination (45 CFR 90 & 45 CFR 91)
5, Human Subjects Certification, when applicable (45 CFR 45) ,
[J
n
IJ
PART 8: This part is provided to assure that pertinent information has been addressed and included in the application.
YES NOT ,tl,pplicable
1, Has a Public Health System Impact Slatemenllor the proposed program/project been completed and
distributed as required? .
2. Has the appropriate box been checked on the SF-424 (FACE PAGE) regarding intergovernmental review
under EO, 12372? (45 CFR Part 100)..
3. Has the entire proposed prOject period been Identified on the SF-424?
',,.,'"
]
[J
I~J
[J
[J
C-l
LJ
4. Have biographical sketch(es) with Job description(s) been attached, when required?..
5 Has the "Budget Information" page. SF-424A (Non-Construction Programs) or SF-424C (Construction
Programs), been completed and included?
6. Has the 12 month detailed budget been provided?
7, Has the budgel for the entire proposed prOject period with sufficient detail been provided? .
8. For a Supplemental application. does the delailed budget address only the additional tunds requested?
9. For Competing Conlmuatlon and Supplemental applications, has a progress report been included?
[;
,-
_I
[1
I]
PART C: In the spaces provided below, please provide the requested information.
B'~smess Ofk~la' to. be rtolif'e;ll~ a~ awarcJ :s Ie b" made
,-"-'-~ .-----------
Name: Prefix ii' ~Irs: N"nlt' ~~~_~~__ _-' ",1:ddl'~ NO'",,,, V
, Lflst Name :M~-dd- ! S,,;fl,x r-
~_._---_._------"
~ i County Manager Oroanization: IC~II-i~7c~~~;IY"- ~_-~:]
Addre~~: ~:-~;~~':1~F=0~2~~~~~T f_a il~~] Slf€el 2- ~~=-~'".,~'-"--''' _ J
"City !~~I.~-~._,-~,~_.,_J . S~ate. i=L: Florld_~1
Province ~_~___.,..... I " Cou:'ltry IJNI1ED ~j
"Z,",I Postal Code .34112
~ Teleohone Number:
]
252-8383
E-mail Address:
Fax Number:
~~-]
APPLICANT ORGANIZf.,TION'S - 2-DIGIT DHHS EIN (If already assig'lcd)
59-6000558
l)rag'<J~n ~;rec\arfPro.lect O!'e::1UT!hI'1C~oall"'vesll~"IO' C1eslgna:ed to d,re(:t the prop;)se:: p~G;,-,cl
~me: "".1,)( 1 _! _" ~':~~_~~:~ I~-ajcy__-_=:~~l to1lddl(, NdllO [--- _I
"I as' Name :Krumbine _______________ ' SI.;'frx f-------
,-
,-----------
Qroanization: HOllsing & Human Sef':
3301 TarTli_~~ITr_aj__~~J slree.t2-1------".--~
Naples-- -- -I' St",le :=L Florid;:1
."'--....--.----..... "'I I
Pr:J",,,ce I . Coun:r,.' JN1TEO S"
-------~~~-"~--------;
. ZiP /Post",: CJJe '34112 !
Title: I Director
Address: . St'oet1
. Cily
. Telephone Number' !2~ ?_5_~!3_~~____
E-mail Address:
~_~~!::Y~~u m bin e @ co~I~~!gov . nt!
Fax Number:
252..2638
~J
HIGHEST DEGREE EARNED
SOCIAL SECURITY NUMBER
PART 0: A private, nonprofit organization must include evidence of its nonprofit status with the application. Any of the following
evidence. Check the appropriate box or complete the "Previously Filed" section, whichever is applicable.
31
U.._.., (a) A reference to the organization's listing in the Internal Revenue Service's (IRS) most recent list of tax~exempt organizations described in section
501 (c)(3) of the IRS Code.
(b) A copy of a currently valid Internal Revenue Service Tax exemption certificate.
o
o
(c) A statement from a State taxing body, State Attorney General, or other appropriate State official certifying that the applicant organization has a
nonprofit status and that none of the net earnings accrue to any private shareholders or individuals.
(d) A certified copy of the organization's certificate of incorporation or similar document if it clearly establishes lhe nonprofit status of the organization.
(e) Any of the above proof for a State or national parent organization, and a statement signed by the parent organization that the applicant organization is
a local nonprofit affiliate.
o
If an applicant has evidence of current nonprofit status on file with an agency of PHS, it will not be necessary to file similar papers again, but the place
and date of filing must be indicated.
Previously Filed with: * (Agency)
1--- -
on . (Date)
1__~____::J
--,--~
INVENTIONS
If this is an application for continued support. include: (1) the report of inventions conceived or reduced to practice required by the terms and conditions of
the grant: or (2) a list of inventions already reported, or (3) a negative certification.
EXECUTIVE ORDER 12372
Effective September 30,1983. Executive Order 12372
(Intergovernmental Review of Federal Programs) directed OMS to
abolish OMS Circular A-95 and establish a new process for consulling
with State and local elected officials on proposed Federal financial
assistance. The Department of Health and Human Services
implemented the Executive Order through regulations at 45 CFR Part
100 (Inter-governmental Review of Department of Health and Human
Services Programs and Activities). The objectives of the Executive
r ---:;'Ire to (1) increase Stale flexibility to design a consultation
,s and select the programs it wishes to review, (2) increase the
ab",IY of State and local elected officials to Influence Federal decisions
and (3) compel Federal officials to be responsive to State concerns. or
explain the reasons.
The regulations at 45 CFR Part 100 were published in Federal Register
on June 24,1983, along with a notice identifying the
/
Department's programs thai are subject to the provisions of Executive Order
12372. Information regarding PHS programs SUbject to Executive Order 12372 is
also available from the appropriate awarding office.
States participating in this program establish Stale Single Points of Contact
(SPOCs) to coordinate and manage the review and comment on proposed Federal
financial asslstance_ Applicants should contact the Governor's office for
information regarding the SPOC, programs selected for review, and the
consultation (review) process designed by their State.
Applicants are to certify on the face page of the SF-424 (attached) whether the
request is for a program covered under Executive Order. 12372 and, where
appropriate. whether the Stale has been given an opportunity to comment.
Agenda Item No. 1604
OMS APMi>~I"'b, 4/J4{J.8007
ExpirJi1i01lEla?e40'i'kil/2008
ASSURANCES. NON-CONSTRUCTION PROGRAMS
r~~ ------~_.._----_.-.-~---
I Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing
i instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
I mformatlOn. Send comments regarding the burden estimate or any other aspect of this collection of information, Including suggestions for
'reducing this burden. 10 the Office of Management and Budget, Paperwork Reduction Project (0348-0040), Washmgton, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET.
liT TO THE ADDRESS PROVIDED BY THE_~P~~~-"~~N~AGENCY.
NOTE:
SEND
Certain of these assurances may not be applicable to your project or program If you have questions, please contact the
awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances If
such is the case, you will be notified.
As the duly authorized representative of the applicant, I certify that the applicant
1. Has the legal authority to apply for Federal assistance
and the institutional. managerial and financial capability
(including funds sufficient to pay the non-Federal share
of project cost) 10 ensure proper planning, management
and completion of the project described in this
application
2. Will give the awarding agency, the Comptroller General
of the United States and, if appropriate, the State,
through any authorized representative. access to and
the right to examine all records, books, papers, or
documents related to the award; and will establish a
proper accounting system in accordance with generally
accepted accounting standards or agency directives.
3. Will establish safeguards 10 prohibit employees from
using their positions for a purpose that constitutes or
presents the appearance of personal or organizational
conflict of interest, or personal gain.
4. Will initiate and complete the work within the applicable
time frame after receipt of approval of the awarding
agency.
5. Will comply with the Intergovernmental Personnel Act of
1970 (42 U,S.C. SS4728-4763) relating to prescribed
standards for merit systems for programs funded under
one of the 19 statutes or regulations specified in
Appendix A of OPM's Standards for a Merit System of
Personnel Administration (5 C_F.R. 900, Subpart F).
6. Will comply with all Federal statutes relating to
nondiscrimination, These include but are not limited to
(a) Title VI of the Civil Rights Act of 1964 (P_L. 88-352)
which prohibits discrimination on the basis of race, color
or national origin: (b) Title IX of the Education
Amendments of 1972, as amended (20 U,S.C, S~16B1~
1683, and 1685-1686), which prohibits discrimination on
the basis of sex; (c) Section 504 of the Rehabilitation
Previous Edition Usable
Act of 1973, as amended (29 U_S,C, S794), which
prohibits discrimination on the basis of handicaps; (d)
the Age Discrimination Act of 1975, as amended (42
U,S,C, S96101-6107), which prohibits discrimination
on the basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (P.L. 92-255), as amended,
relating to nondiscrimination on the basis of drug
abuse; (f) the Comprehensive Alcohol Abuse and
Alcoholism Prevention, Treatment and Rehabilitalion
Act of 1970 (P,L. 91-616). as amended. relating to
nondiscrimination on the basis of alcohol abuse or
alcoholism: (g) 99523 and 527 of the Public Health
Service Act of 1912 (42 US_C_ 99290 dd-3 and 290 ee-
3), as amended, relating to confidentialify of alcohol
and drug abuse patient records; (h) Title VlIl of the
Civil Rights Act of 1968 (42 U_S,C. 993601 et seq.), as
amended, relating to nondiscrimination in the sale,
rental or financing of housing; (I) any other
nondiscrimination provisions in the specific statute(s)
under which application for Federal assistance is being
made; and, (j) the requirements of any other
nondiscrimination statute(s) which may apply to the
applicalion_
7 Will comply, or has already complied, wilh the
requirements of Titles II and III of the Uniform
Relocation ASSistance and Real Property Acquisition
Policies Act of 1970 (p.L. 91~646) which provide for
fair and equitable treatment of persons displaced or
whose property is acquired as a result of Federal or
federally~assisted programs_ These requirements apply
to all interests in real properly acquired for project
purposes regardless of Federal participation in
purchases.
8. Will comply, as applicable, with provisions of the
Hatch Act (5 U_S.C. 991501-1508 and 7324-7328)
which limit the political activities of employees whose
principal employment activities are funded in whole or
in part with Federal funds
Authorized for Local Reproduction
Standard Form 4248 (Rev. 7-97)
Prescribed by OMB Circular A-'02
\
9. Will comply, as applicable, with the provisions of the Davis~
Bacon Act (40 US.C. !l!l276a to 276a-7), the Copeland Act
(40 US.C. !l276c and 18 U.SC. !l874), and the Contract
Work Hours and Safely Standards Act (40 U.S.C 39327.
333), regarding tabor standards for federally-assisted
construction subagreements.
10_ Will comply, if applicable. with flood insurance purchase
requirements of Section 102(a) of the Flood Disaster
Protection Act of 1973 (P.L. 93-234) which requires
recipients in a special flood hazard area 10 participate in the
program and to purchase flood insurance if the total cost of
insurable construction and acquisition is $10,000 or more.
11. WHl comply with environmental standards which may be
prescribed pursuant to the following: (a) institution of
environmental quality control measures under the National
Environmental Policy Act of 1969 (P.L. 91-190) and
Executive Order (EO) 11514; (b) notification of violating
facilities pursuant to EO 11738; (c) protection of wetlands
pursuant to EO 11990; (d) evaluation of flood hazards in
floodplains in accordance with EO 11988; (e) assurance of
project consistency with the approved State management
program developed under the Coastal Zone Management
Act of 1972 (16 U.S.C. SS1451 et seq,); (f) conformity of
Federal actions to State (Clean Air) Implementation Plans
under Section 176(c) of the Clean Air Act of 1955, as
amended (42 U,S.C, 997401 et seq.); (g) protection of
underground sources of drinking water under the Safe
Drinking Water Act of 1974, as amended (Pl, 93-523);
and, (h) protection of endangered species under the
Endangered Species Act of 1973, as amended (P.l. 93.
205)
Agenda Item No. 1604
May 27, 2008
Page 25 of 31
12
Will comply with the Wild and Scenic Rivers Act of
1968 (16 U.S_C. S91271 et seq.) related to protecting
components or potential components of the national
wild and scenic rivers system.
13.
Will assist the awarding agency in assuring compliance
with Section 106 of the National Historic Preservation
Act of 1966, as amended (16 US.C. 9470), EO 11593
(identification and protection of historic properties), and
the Archaeological and Historic Preservation Act of
1974 (16 U.SC !l!l469a-1 et seq.).
14.
Will comply with PL. 93-348 regarding the protection of
human subjects involved in research, development, and
related activities supported by this award of assistance.
15.
Will comply with the Laboratory Animal Welfare Act of
1966 (P.L. 89,544. as amended, 7 USC !l!l2131 et
seq.) pertaining to the care, handling, and treatment of
warm blooded animals held for research, leaching, or
other activities supported by this award of assistance,
16.
Will comply with the lead-Based Paint Poisoning
Prevention Act (42 U.S.C. $S4801 et seq.) which
prohibits the use of lead-based paint in construcflon or
rehabilitation of residence structures.
17.
Will cause to be performed the required financial and
compliance audits in accordance with the Single Audit
Act Amendments of 1996 and OMB Circular No. A-133,
"Audits of States, local Governments, and Non~Profit
Organizations."
18.
Will comply with all applicable requirements of all other
Federal laws, executive orders, regulations, and policies
governing this program.
. SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL . TITLE
~ ~--------~~-~
Corr~rlell:'ti on "lltm,is~~lor1 10 G! ants 90V i~~airman~ B_~a~~ of Co~_~~~.~~".:~~ssioners ~m
. APPLICANT ORGANIZATION . DATE SUBMITTED
-- -- --~--- .'---.. i Completed O~l submission to Gnmt:iQov
I Collier County .J
! ,---~-----.-
.~
Standard Form 4248 (Rev. 7.97) Back
DISCLOSURE OF LOBBYING ACTIVITIES
Agenud I Lelll I'IIU. 1604
May 27 2008
APP'"'I"1l~eP~1l of 31
0348,0046
Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352
[. ,~'~YI!~~.~~~:~,~~~'~.~~~[)_i_~~~?:.i_4~~,:~~~Q~~~t,;q
1. . Type of Federal Action:
Da.contraet
[tJ b.grant
o c.cooperallvlIagreemenl
Cd.loan
C e.loangulIrantefl
o f. loan Insurance
2. " Status of Federal Action:
[] '.OId""""."II,"loo
~ b,lnltlalaward
L:I,.,o"..wu'
4. Name and Address of Reporting Entity:
~Prlme
'Name
L~ SubAwardee
i~_ollier5~~~,~y'
---- _.~--_.~
,
_I
. SIreet1 SIreel2
[3:~~~;;;;;;iTrail-E~;i----=:J [==---=--===-=--=--J
. City State Z,p
l~,~~les
]:;.;;,~
ilFL Florida
Congressional District
ilknown: !14
6. " Federal Department/Agency:
IHRSA
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Title:
Board of County Commissioners
Telephone No.: 239252-8097
'I
Date:
Authonzed lor Lo~al Reproduction
Standard Form-LLL(Rev. 7-97)
Agenda Item No. 1604
May 27, 2008
Page 27 of 31
Memorandum of Understanding
May 2008
The Memorandum of Understanding dated the _ of May, 2008 is among the Physician
Led Access Network of Collier County, Inc. (PLAN); NCH Healthcare System,
Inc.(NCH); Naples HMA, Inc. dba Physicians Regional Medical Center (PRMC); Senior
Friendship Centers, Inc. dba Senior Friendship Centers of Collier County (SFC); Collier
Health Services, Inc. (CHSI) and Collier County.
I. History of Relationship
In an effort to support not-for-profit human service agencies, Collier County Government
has adopted as one of its core missions in its Five-Year Plan, to collaborate with other
agencies to apply for and manage grants on their behalf to enhance existing service and
implement innovative progrwns. The Collier County Housing and Human Services
Department has previously collaborated with agencies to seek grant funding to address
the needs of low income citizens of Collier County in access to health care and other
health related issues.
The goal of the partnering organizations is to provide access to the full continuum of
care-primary care, specialty care, medications, and hospital care and thereby improve
the health of the low-income uninsured in our community. In addition, the organizations
commit to developing and implementing systems and procedures for electronic transfer
of medical information and developing additional outcome measurements, as well as
electronic data collection methodologies to track access and cost-savings.
II. Roles and Responsibilities
Collier County Government
Collier County will serve as the applicant and fiscal agent for the grant project.
Collier County will ensure compliance with the reporting requirements of the U.S.
Department of Health and Human Services, Health Resources and Services
Administration, Office of Health Information Technology.
Collier County will support collaboration efforts of the project by scheduling regular
partnership meetings and providing a meeting location for all partners.
Physician Led Access Network of Collier County, Ine.
PLAN will serve as the direct day to day contact for the electronic information exchange
project including the marketing and outreach elements.
1
Agenda Item No. 1604
May 27, 2008
Page 28 of 31
PLAN will initiate, oversee and coordinate with the appropriate Information Technology
staff identified by the participating hospital systems and clinics, the development of the
necessary schemas that will facilitate transfer of data into the PLAN portal from the
hospitals' systems and clinics' systems.
PLAN will serve as the project coordinator, with partIcIpating partners in the
identification of appropriate necessary HIP AA compliant information to be collected and
disbursed as regards the targeted population.
PLAN will initiate and coordinate with the partners, the establishing of performance
measurements and outcomes.
PLAN will maintain the community's data in the health information exchange system for
PLAN participating providers and MOU participating partners.
PLAN will provide the scanning devices for the emergency departments (total of 4) of
both NCH Healthcare Systems and Physicians Regional Medical Centers for identifying
patients already in the PLAN database.
PLAN will provide Senior Friendship Center two computers to access the secured PLAN
electronic information network.
NCH Health care System, Inc.
NCH will collaborate with PLAN in the identification of appropriate necessary HIPAA
compliant information to be collected as regards the targeted population.
NCH will review the performance measurements and outcomes of this community
healthcare access project.
NCH Information Technology staff and/or other identified persons representing NCH
will consider participating in the identification and development of the necessary schema
that will extract data from the NCH existing system(s) to PLAN.
NCH will coordinate with PLAN the possibility of placement of scanning devices in the
emergency departments (2) for identifying the targeted population,
Naples HMA, Inc. dba Physicians Regional Medical Center
Physicians Regional Medical Center will collaborate with PLAN in providing staff to
participate in the identification of appropriate necessary HIP AA compliant information to
be collected and disbursed as regards the targeted population.
2
Agenda Item No. 1604
May 27, 2008
Page 29 of 31
Physicians Regional Medical Center will participate in the establishment of performance
measurements and outcomes of this community healthcare access project.
Physicians Regional Medical Center Information Technology staff and/or other identified
persons representing Physicians Regional Medical Center will participate in the
identification and development of the necessary schema that will extract or transfer data
from Physicians Medical Centers' existing system(s) to PLAN.
Physicians Regional Medical Center will coordinate with PLAN the placement and
procedures for use of scanning devices in the emergency departments (2) for identifYing
the targeted population,
Collier Health Services, Inc.
CHSI will participate in the PLAN electronic information network and as an entry access
point for primary care patients identified as low income uninsured adults,
CHSI will collaborate with PLAN in providing staff to participate in the identification of
appropriate necessary HIP AA compliant information to be collected and disbursed as
regards the targeted population.
CHSI will participate in the establishment of performance measurements and outcomes
of this community healthcare access project.
CHSI Information Technology staff and/or other identified persons representing CHSI
will participate in the identification and development of the necessary schema that will
transfer data from CHSI's existing system(s) to PLAN.
Senior Friendship Centers, Inc. dba Senior Friendship Centers of Collier County
Senior Friendship Center agrees to participate in the PLAN electronic information
network and as an entry access point for primary care patients identified as low income
uninsured adults.
Senior Friendship Center agrees to the placement of two computers in their location,
providing access to the secured PLAN system; and will provide DSL or better high speed
internet access for these two computer set ups.
Senior Friendship Center will provide data input to PLAN through the use of these two
computers, however, will not be limited to these two computers for data input to the
PLAN system.
III. Time Line
The roles and responsibilities described above are contingent on the grantee, Collier
County, receiving the funds requested for this project in the HIT grant application. The
3
Agenda Item No. 1604
May 27, 2008
Page 30 of 31
beginning and end dates of the collaborative effort would coincide with the grant period,
anticipated to be September 1, 2008 through August 31, 2010.
Approval
We the undersigned have read and agree with this Memorandum of Understanding.
Further we have reviewed the portion of the proposed budget pertaining to the
collaborative effort described herein, and approve it in its entirety.
By
By
Date
Lauren Leifer
Executive Director
Physician Led Access Network
Of Collier County, Inc.
Date
Tom Henning
Chairman
Collier County Board of Commissioners
By
By
Date
Allen Weiss, MD
Chief Executive Officer
NCH Healthcare System, Inc.
Date
Geoff Moebius
Chief Executive Officer
Naples HMA, Inc. dba Physicians Regional
Medical Center
By
By
Date
Richard Akin
Chief Executive Officer
Collier Health Services, Inc
Date
Robert Carter
Chief Executive Officer
Senior Friendship Centers, Inc., dba Senior
Friendship Centers of Collier County
4
Page I of I
Agenda Item No. 1604
May 27, 2008
Page 31 of 31
COLLIER COUNTY
BOARD OF COUNTY COMMISSIONERS
Item Number:
Item Summary:
16D4
Meeting Date:
To approve application for a Health Information Technology Special Congressional Initiative
earmark from the United States Department of Health and Human Services to develop and
implement a shared informational database between the portals of entry for the poor into the
health care system ($323,911)
5/27/200890000 AM
Prepared By
Marcy Krumbine
Director
Date
Public Services
Housing & Human Services
5/12/20089:02:23 AM
Approved By
Marcy Krumbine
Director
Date
Public Services
Housing & Human Services
5/13/2008 12:51 PM
Approved By
Marla Ramsey
Public Services Administrator
Date
Public Services
Public Services Admin.
5/13/20083:10 PM
Approved By
Marlene J. Foard
Grants Coordinator
Date
Administrative Services
Administrative Services Admin.
5/14/200810:34 AM
Approved By
Heidi F. Ashton
Assistant County Attorney
Date
County Attorney
County Attorney Office
5/16/200811:16 AM
Approved By
OMS Coordinator
OMS Coordinator
Date
County Manager's Office
Office of Management & Budget
5/16/200811 :29 AM
Approved By
Sherry Pryor
Management & Budget Analyst
Date
County Manager's Office
Office of Management & Budget
5/19120084:14 PM
Approved By
James V. Mudd
County Manager
Date
Board of County
Commissioners
County Manager's Office
5/19/20085:53 PM
file:IIC:\AgendaTest\ExDort\1 08-Mav%2027.%202008\ 16.%20CONSENT%20AGENDA \ 1... 5/21/2008