Attachment A

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					                                          Attachment A
                                         COVER SHEET
                                           Page 1 of 1

Legal Name of Proposer

Name of Contact Person                                Title of Contact Person



Address of Contact Person

Electronic mail (E-mail) Address of Contact Person


Phone Number of Contact Person                        Fax Number of Contact Person


Name of Authorized Representative (For Non-Profit, if someone other than the Board Chairperson
is named as the Authorized Representative, a signed copy of the resolution of appointment must be
submitted.)

Title of Authorized Representative

Address of Authorized Representative

E-mail Address of Authorized Representative

Phone Number of Authorized Representative             Fax Number of Authorized Representative


Federal ID#                                           Edison Vendor ID #


Geographic Area(s) Currently Served By Proposer
(Counties in each Region are listed in Subsection 1.A.(4))
   Region 1                         Region 2                    Region 3

Geographic Area(s) Covered By The Proposal
(Counties in each Region are listed in Subsection 1.A.(4))
   Region 1                         Region 2                    Region 3


Signature of Authorized Representative                             Date




                                                                                           16
                              Attachment B
                         ORGANIZATIONAL CHART
                               Page 1 of 1

Provide an organizational chart as Attachment B for the Mental Health Agency,
demonstrating where the Peer Wellness Coach(es) and Supervisor of the Peer Wellness
Coach(es) will fit into the overall structural organization of the agency.




                                                                                17
                     Attachment C
 PROPOSED BUDGET AND BUDGET JUSTIFICATION WORKSHEET
                      Page 1 of 4

                                  PROPOSED BUDGET
                        BUDGET JUSTIFICATION WORKSHEET

Please complete the Budget Justification Worksheet. Required expenses are identified
under each category. Please leave the expenses as written and replace the example
funding with accurate numbers.

                       Period: January 3, 2012 through June 30, 2012
A. Salaries and Benefits and Taxes:
    a.      Salaries - expenditures for compensation, fees, salaries, and wages paid to Peer
            Wellness Coach(es) and Supervisor where applicable.
    b.      Benefits and Taxes- (a) expenditures for contributions to pension plans and to
            employee benefit programs such as health, life, and disability insurance: and (b)
            expenditures for payroll taxes such as social security and Medicare taxes and
            unemployment and workers’ compensation insurance.

                                                        Salary                              Benefits
                                  Percentage of
                                                     Allocated for        Benefits as a   Allocated for
                      Actual          Time
  Position Title                                       Program            Percentage of     Program
                      Salary      Dedicated to
                                                      January 3-             Salary        January 3-
                                     Project
                                                     June 30, 2012                        June 30, 2012
 Peer Wellness
                     $33,000      100%              $16,500               25%             $4,075
 Coach
 Peer Wellness
 Coach’s             $40,000      10%               $2,000                25%             $500
 Supervisor
 Totals                                             $18,500                               $4,575

JUSTIFICATION: Describe the role and responsibilities of each position.



B. Supplies: Expenditures for office supplies, housekeeping supplies, food and beverages,
   and other supplies. Materials costing less than $5,000 per unit and often having one-time
   use.

    Item(s)                                           Rate                                  Cost
    Laptop Computer                                   $1,200 per person                     $1,200.00
    Blackberry® (or other suitable device)            $200 per month per person             $2,400.00
    Portable Printer                                  $150 per person                       $150.00
    Scanner                                           $150 per person                       $150.00
    Digital Camera                                    $200 per person                       $200.00
    Office Supplies                                   $900 per person                       $500.00
                                                                             Total          $4,600.00
JUSTIFICATION: Describe need and include explanation of how costs were estimated.


                                                                                                   18
                     Attachment C
 PROPOSED BUDGET AND BUDGET JUSTIFICATION WORKSHEET
                      Page 2 of 4

                                 PROPOSED BUDGET
                       BUDGET JUSTIFICATION WORKSHEET
                                 (CONTINUED)

Please complete the Budget Justification Worksheet. Required expenses are identified
under each category. Please leave the expenses as written and replace the example
funding with accurate numbers.

                      Period: January 3, 2012 through June 30, 2012

C. Travel/ Conferences and Meetings: Expenditures for transportation, meals, and
   lodging, per diem payments including travel expenses for meetings and conferences, gas
   and oil, repairs, licenses and permits, and leasing costs for vehicles, and expenditures for
   conducting or attending meetings, conferences, and conventions including rental of
   facilities, speakers’ fees and expenses, printed materials, and registration fees.

 Purpose of Travel         Location          Item                     Rate               Cost
  My Health, My
                           Nashville,                        8 trips x 400 miles x
  Choice, My Life                           Mileage                                   $1,472.00
                             TN                                  $0.46 per mile
     Training
  My Health, My                                              $66 per day x 30 days
                           Nashville,
  Choice, My Life                          Per Diem            (first and last day    $1,740.00
                             TN
     Training                                                    at 75% ($42))
  My Health, My
                           Nashville,                         $130 per night x 15
  Choice, My Life                            Hotel                                    $1,950.00
                             TN                                     nights
     Training
                            East             Local            3000 miles at $0.46
     Local Travel                                                                     $1,380.00
                          Tennessee          Travel                per mile
                                                             $30 per workshop x 6
                                                                 sessions x 3
 Healthy Snacks for                                          workshops and $230
                            East            Healthy
      program                                                   per graduation          $1,000
                          Tennessee         Snacks
    participants                                                celebration x 2
                                                                  graduation
                                                                 celebrations
      TOTAL:                                                                          $7,542.00

JUSTIFICATION: Describe the purpose of travel and how costs were determined.




                                                                                             19
                     Attachment C
 PROPOSED BUDGET AND BUDGET JUSTIFICATION WORKSHEET
                      Page 3 of 4

                                 PROPOSED BUDGET
                       BUDGET JUSTIFICATION WORKSHEET
                                 (CONTINUED)

Please complete the Budget Justification Worksheet. Required expenses are identified
under each category. Please leave the expenses as written and replace the example
funding with accurate numbers.

                      Period: January 3, 2012 through June 30, 2012

D. Other Non-Personnel: Note: expenses reported on budget line 1- 17 should not be
   included on this line. Allowable expenditures are advertising, bad debts, contingency
   provisions, fines and penalties, independent research and development, organization,
   page changes in professional journals, rearrangement and alteration, recruiting, taxes,
   membership dues in association and professional societies, and fees for the
   organization’s licenses, permits, and registration.


    Expense Description                               Cost
    Incentive for participants completing             $225.00
    discharge assessments ($5.00 each x 45
    participants)
                                                      $
    Total                                             $225.00

JUSTIFICATION: Describe need and include explanation of how costs were estimated.




G. Indirect Cost: (a.k.a. Administrative Expense) proportional amount in accordance
   with an allocation plan approved by the cognizant state agency. The indirect cost may
   not exceed 20% of the total budget.

    Indirect Cost Rate                                Cost
                                                      $




                                                                                             20
                              Attachment C
          PROPOSED BUDGET AND BUDGET JUSTIFICATION WORKSHEET
                               Page 4 of 4
                           PROPOSED BUDGET
   AGENCY:
   PROGRAM NAME: My Health, My Choice, My Life
  APPLICABLE PERIOD: The grant budget line-item amounts below shall be applicable only to expense incurred during the period
beginning January 3, 2012, and ending June 30, 2012.


 POLICY 03             EXPENSE OBJECT LINE-ITEM
                                       1
   Object                    CATEGORY                                                                   GRANTEE
  Line-item         (detail schedule(s) attached as applicable)
 Reference                                                           GRANT CONTRACT                   PARTICIPATION                  TOTAL PROJECT
                                                                                $                                $                             $
     1                Salaries

                                                                                     $                                $                              $
     2                Benefits & Taxes

                                                                 2
                                                                                     $                                $                              $
    4, 15             Professional Fee/ Grant & Award

                                                                                     $                                $                              $
     5                Supplies

                                                                                     $                                $                              $
     6                Telephone

                                                                                     $                                $                              $
     7                Postage & Shipping

                                                                                     $                                $                              $
     8                Occupancy

                                                                                     $                                $                              $
     9                Equipment Rental & Maintenance

                                                                                     $                                $                              $
     10               Printing & Publications

                                                                                     $                                $                              $
   11, 12             Travel/ Conferences & Meetings

                                 2
                                                                                     $                                $                              $
     13               Interest

                                                                                     $                                $                              $
     14               Insurance

                                                                                     $                                $                              $
     16               Specific Assistance To Individuals

                                      2
                                                                                     $                                $                              $
     17               Depreciation

                                                 2
                                                                                     $                                $                              $
     18               Other Non-Personnel

                                            2
                                                                                     $                                $                              $
     20               Capital Purchase

                                                                                     $                                $                              $
     22               Indirect Cost

                                                                                     $                                $                              $
     24               In-Kind Expense

                                                                                     $                                $                              $
     25                          GRAND TOTAL

      1
         Each expense object line-item shall be defined by the Department of Finance and Administration Policy 03, Uniform Reporting Requirements and Cost
Allocation Plans for Subrecipients of Federal and State Grant Monies, Appendix A. (posted on the Internet at: www.state.tn.us/finance/rds/ocr/policy03.pdf).
      2
            Applicable detail attached if line-item is funded.


                                                                                                                                                21
                                      Attachment D
                           Peer Wellness Coach Job Description
                                       Page 1 of 3

Job Title:            Peer Wellness Coach

Purpose:              To provide the My Health, My Choice, My Life program throughout East
                      Tennessee to consumers with mental illness, substance use disorders and
                      co-occurring disorders, regardless of which agency provides the services.
                      The My Health, My Choice, My Life program consists of coaching
                      activities as well as coordinating the implementation of a six (6) session
                      workshop.

This job description is not intended to be all-inclusive; and employee will also perform other
reasonably related job responsibilities as assigned by programmatic and administrative
Supervisor and other management as required. This organization reserves the right to revise or
change job duties as the need arises. Moreover, management reserves the right to change job
descriptions, job duties, or working schedules based on their duty to accommodate individuals
with disabilities. This job description does not constitute a written or implied contract of
employment.

Qualifications:

Education/Knowledge:

       Required:      Bachelor’s degree, a Certified Peer Specialist or ability to become
                      certified within one (1) year of hire.

       Preferred:     Master’s degree, a Certified Peer Specialist.

Experience:

       Must be a person with lived experience in the mental health system. Must demonstrate a
       personal commitment to a healthy lifestyle. Experience in providing trainings is required.
       Experience in providing social and recreation activities is desirable. Experience serving
       people with mental illness and/or co-occurring disorders is desirable.

Physical:

       Hearing of normal and soft tones. Close eye work. Lifting up to 50 lbs. Pushing/pulling
       up to 150 lbs. Frequent sitting, standing, walking, bending, stooping, and reaching.




                                                                                                 22
                                       Attachment D
                            Peer Wellness Coach Job Description
                                        Page 2 of 3

Duties and Responsibilities:

Peer Wellness Coaching responsibilities include but are not limited to the following:

1.     Implements the goals in Mental Health Planning Regions (insert region numbers) of the
       My Health, My Choice, My Life program of the Tennessee Department of Mental Health,
       Office of Consumer Wellness Programs as specified in (host entity’s) contract including
       Regions (insert region numbers) as part of the statewide goal to improve the physical
       health behaviors and physical health status of 2,352 adult Tennesseans with mental
       illness, substance use disorders and co-occurring disorders by the year 2015.

2.     Completes the Chronic Disease Self-Management Program (CDSMP) training at a date
       and location to be determined.

3.     Completes the process to be certified as a Master Trainer after co-leading two (2)
       CDSMP workshops.

4.     Conducts at minimum two (2) Peer Leader trainings a year.

5.     Supervises and oversees Peer Leaders within Mental Health Planning Regions (insert
       region numbers).

6.     Delivers the six (6) session My Health, My Choice, My Life program to at minimum two
       (2) Peer Support Centers or Addictions Peer Recovery Support Centers per quarter,
       (minimum of eight (8) per year).

7.     Delivers at least one (1) outreach presentation each quarter to educate traditional and
       non-traditional community partners, including, but not limited to, group home operators;
       social service mental health providers; Federally Qualified Health Centers (FQHCs); and
       local health care and wellness providers in the assigned region. The purpose of these
       presentations shall be to educate participants on the My Health, My Choice, My Life
       program.

8.     Coordinates with the Peer Support Center Director of each site to ensure each participant
       in the My Health, My Choice, My Life program receives timely transportation to and from
       the facility where the program is being offered.

9.     Identifies participants who appear to need individualized assistance, whether due to
       cultural issues, reading difficulties, or disability, and provides the appropriate assistance.




                                                                                                   23
                                      Attachment D
                           Peer Wellness Coach Job Description
                                       Page 3 of 3
10.   Works with each program participant to identify a health care home, and if the participant
      has not had a physical within the last year, works with them to schedule an appointment
      for a physical.

11.   Provides support to members engaging with primary care physicians and/or health care
      homes as needed.
12.   Participates in a series of training sessions conducted by Centerstone Research Institute
      on program evaluation and assessments.

13.   Administers several assessment tools, including the National Outcomes Measures
      (NOMS) tool, Recovery Assessment Scale, and the CDSMP Health Survey, at baseline,
      discharge, and every six (6) months as long as the participant is receiving services as part
      of the program. Also administer the Locator Form to all participants at baseline.

14.   Tracks and monitors daily process measures of program participants.

15.   Inputs assessment data and daily process measures into an on-line project management
      dashboard.

16.   Collaborates with the Peer Support Center Director of each site to coordinate weekly
      health and wellness activities with each Peer Support Center at which the My Health, My
      Choice, My Life program is currently or has been offered.

17.   Facilitates and participates in community collaboration efforts that facilitate the
      achievement of these goals.

18.   Supervises the Peer Leaders in a manner that is consistent with (host agency’s) standards
      and that facilitates the people in those positions meeting the Peer Leaders' Guidelines.

19.   Adheres to the Certified Peer Specialist Code of Ethics.

20.   Participates in a weekly planning meeting with the State’s Director of Consumer
      Wellness Programs.

21.   Participates in monthly in-person supervision meetings with (host agency) Supervisor and
      the State’s Director of Consumer Wellness Programs.




                                                                                                  24
                                     Attachment E
                              INTENDED SCOPE OF SERVICES
                                       Page 1 of 9
A.1.   The Grantee shall provide all services and deliverables as required, described, and detailed
       herein and shall meet all service and delivery timelines as specified by this Grant Contract.

A.2.   Service Definitions:

       a.      The Tennessee My Health, My Choice, My Life program is being funded by a federal
               grant awarded to the State by the United States Department of Health and Human
               Services (HHS), Substance Abuse and Mental Health Services Administration
               (SAMHSA), Center for Mental Health Services (CMHS).

       b.      The My Health, My Choice, My Life program utilizes the statewide infrastructure of Peer
               Support and Addiction Peer Recovery Centers and Certified Peer Specialists by
               integrating a peer-led health promotion, wellness and chronic disease prevention and
               self-management program for individuals with mental illness, substance use disorders,
               and co-occurring disorders.

       c.      The purpose of this Grant Contract is for the Grantee to employ a community staff person
               who is a self-identified mental health service recipient and a Certified Peer Support
               Specialist as a Peer Wellness Coach (PWC) to assist the State in implementing a holistic
               wellness program based on the Chronic Disease Self Management Program (CDSMP)
               curriculum to participants in the Peer Support Centers (PSC) and provide continuous
               peer wellness coaching.

               NOTE: Singular/Plural changes will be made to Section A.2.c. if needed.

       d.      A Peer Support Center (PSC) is a place where persons who have received treatment for
               mental illness develop their own recovery-based programs to supplement existing mental
               health services, address issues such as social isolation and discrimination, experience
               opportunities for socialization and personal and educational enhancement, and acquire
               the necessary skills for the utilization of resources within the community.

       e.      A mental health service recipient is someone who has met at some point in his or her
               adult life the following definition: an adult with a diagnosable mental, behavioral,
               substance use or emotional disorder of sufficient duration to meet diagnosable criteria as
               specified within the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
               (DSM-IV), or current revision, that has resulted in functional impairment which has
               substantially interfered with or limited one or more major activities.

       f.      “Co-occurring disorders”, for purposes of this Grant Contract, means combined
               conditions of serious mental illness and substance use disorder.

       g.      “Serious mental illness”, for purposes of this Grant Contract, means a mental disorder
               diagnosable using Diagnostic and Statistical Manual, Fourth Edition, Text Revision
               (DSM-IV-TR) or more current edition, and of such severity and duration as to result in
               functional impairment in at least one (1) of four (4) life functioning domains as noted in
               Section A.2.i.

       h.      “Substance use disorder”, for purposes of this Grant Contract, means a substance-
               related disorder as diagnosed by the Diagnostic and Statistical Manual of Mental
               Disorders, Fourth Edition, Text Revision (DSM-IV-TR), or more current edition.



                                                                                                            25
                                      Attachment E
                               INTENDED SCOPE OF SERVICES
                                       Page 2 of 9
       i.      “Functional impairment”, for purposes of this Grant Contract, means that the individual is
               unable to perform the basic activities of daily living in at least one (1) of the following four
               (4) domains:

               (1)      Activities of daily living;

               (2)      Interpersonal functioning;

               (3)      Concentration, task performance, and pace; and

               (4)      Adaptation to change.

       j.      “Health care home”, for the purposes of this Grant Contract, means an approach to
               primary care in which primary care providers, families and patients work in partnership to
               improve health outcomes and quality of life for individuals with chronic health conditions
               and disabilities.

       k.      “Primary care physician”, for the purposes of this Grant Contract, means is a physician or
               medical doctor who provides both the first contact for a person with an undiagnosed
               health concern as well as continuing care of varied medical conditions, not limited by
               cause, organ system, or diagnosis.

       l.      An Addictions Peer Recovery Support Center is a place where persons who are
               recovering from a substance use disorder or a co-occurring disorder go to be assisted
               with their recovery process. Programming at an Addictions Peer Recovery Support
               Center includes but are is not limited to mentoring; education; and addictions disorder
               peer recovery support services including, but not limited to, peer counseling,
               transportation, and employment skills.

A.3.   Service Recipients:

       Any adult Tennessee resident of Mental Health Planning Region(s) (insert region number(s)) who
       is eighteen (18) years of age or older and who is a mental health service recipient as defined in
       Section A.2.e.

A.4.   Service Goals:

       a.      To improve the physical health behaviors and physical health status of two thousand
               three hundred fifty-two (2,352) adult Tennesseans with mental illness, substance use
               disorders or co-occurring disorders.

       b.      To empower participants in Tennessee’s My Health, My Life, My Choice program to
               improve health sustaining behaviors that will lead to increased life expectancy and a
               higher quality of life by increasing their knowledge and behaviors regarding the following:

               (1)      Techniques to deal with problems such as frustration, fatigue, pain and isolation;

               (2)      Appropriate exercise for maintaining and improving strength, flexibility, and
                        endurance;

               (3)      Appropriate use of medications;


                                                                                                             26
                                     Attachment E
                              INTENDED SCOPE OF SERVICES
                                      Page 3 of 9
               (4)     Communicating effectively with family, friends, and health care professionals;

               (5)     Nutrition;

               (6)     How to evaluate new treatments;

               (7)     Healthy weight management;

               (8)     Smoking cessation;

               (9)     Safer sex and infectious disease; and

               (10)    Alcohol and other substance use.

       c.      To increase the number of service recipients, identified in Section A.3., who have
               identified a health care home and a primary care physician, and who have received a
               physical within the last twelve (12) months.

A.5.   Structure:

       a.      The Grantee shall provide staff and resources to assist the State in the implementation of
               the My Health, My Life, My Choice program.

       b.      The Grantee shall employ and supervise (insert number of PWC) staff person(s) to work
               full time, as that is defined in the Grantee’s policy (thirty seven and one-half to forty (37.5-
               40) hours per week), as a Peer Wellness Coach (PWC). Each PWC must meet the
               following qualifications:

               (1)     Current or past recipient of mental health services, and/or co-occurring services;

               (2)     Certified Peer Specialist or if a candidate is identified who is not a Certified Peer
                       Specialist, the candidate has one (1) year from the date of hire to become a
                       Certified Peer Specialist;

               (3)     Holds at minimum a Bachelor’s Degree from an accredited institution of higher
                       education;

               (4)     Demonstrated professional written and verbal communication skills;

               (5)     Proficiency in Microsoft Word and Excel, and ability to adapt to new information
                       systems quickly;

               (6)     Ability to work in an unstructured environment;

               (7)     Exceptional organizational skills;

               (8)     Demonstrated attention to detail;

               (9)     Ability to manage a group of five to ten (5-10) Peer Leaders;




                                                                                                            27
                           Attachment E
                    INTENDED SCOPE OF SERVICES
                            Page 4 of 9
     (10)    Possesses teaching and training experience and is able to effectively facilitate a
             group;

     (11)    Demonstrated ability to communicate professionally with individuals at multiple
             levels and in stressful situations;

     (12)    Valid F Endorsement Tennessee Driver’s License in good standing;

     (13)    Ability to work independently with little supervision;

     (14)    Ability to stay within a budget for expenses;

     (15)    Ability to follow-through with tasks, including preparation for tasks;

     (16)    Ability to present self in a professional manner (grooming, dressing and
             communication skills);

     (17)    Ability to manage time appropriately so all job tasks are completed in a timely
             matter; and

     (18)    Ability to receive feedback and make appropriate corrections/changes.

c.   Each PWC will implement and sustain the My Health, My Choice, My Life program
     regionally for the Mental Health Planning Region (insert region) serving the Counties
     shown in Attachment (insert number). If the staff person is not a current Certified Peer
     Specialist, the staff person must obtain state certification as a Certified Peer Specialist
     within one (1) year of hire.

d.   As noted in Section A.2.b., the My Health, My Choice, My Life program utilizes the
     statewide infrastructure of Peer Support Centers and Addictions Peer Recovery Support
     Centers and Certified Peer Specialists by integrating a peer-led health, wellness and
     chronic disease prevention and self-management program for individuals with mental
     illness, substance use disorders, and co-occurring disorders. Therefore, the Grantee
     shall ensure that all My Health, My Choice, My Life related activities at each Peer
     Support Center (PSC) are offered free of charge.

e.   The Grantee shall provide each PWC a minimum of one (1) hour of face-to-face
     supervision per month from the Agency Supervisor. The documentation of the date and
     duration of the supervision shall be kept at each PSC site and shall be made available
     upon request of the State. There must also be a minimum of three (3) documented
     contacts a week between the Agency Supervisor and each PWC.

f.   The Grantee shall ensure that each PWC has a laptop computer, a mobile phone with
     electronic mail (e-mail) capabilities, a portable printer, a scanner and a digital camera.
     The computer system shall be capable of fully accessing, downloading and using
     information from the State’s online reporting website, and other linked or referenced
     Internet sites.




                                                                                                   28
                                   Attachment E
                            INTENDED SCOPE OF SERVICES
                                    Page 5 of 9
       g.     The Grantee shall ensure that each PWC is capable of transmitting and receiving
              information through e-mail. The Grantee shall maintain, and ensure that the PWC
              maintains, an agency e-mail address and provide the State with any change in the e-mail
              address(es) within two (2) workdays of the effective date of the change.

       h.     The Grantee shall provide other services that may include, but are not limited to, the
              following:

              (1)     Preparing reports, presentations and documentation in accordance with formats
                      and timelines as directed by the State;

              (2)     Submitting to the State all required financial, statistical, program and supporting
                      documentation in the timeframe prescribed; and

              (3)     Convening and participating in scheduled meetings, workgroups, and
                      conferences as designated by the State.

A.6.   Process:

       a.     The Grantee shall ensure that each PWC performs all of the following duties related to
              becoming a PWC and conducting training and/or workshops:

              (1)     Completes the My Health, My Choice, My Life training in Nashville, Tennessee in
                      January, 2012;

              (2)     Completes the Chronic Disease Self-Management Program (CDSMP) Master
                      Training if deemed appropriate by the Director of Consumer Wellness Programs.
                      If each PWC does attend the CDSMP Master Training, each PWC will complete
                      the process to be certified as a Master Trainer by Stanford University;

              (3)     Conducts at minimum two (2) Peer Leader Trainings per year on how to co-
                      facilitate the CDSMP alongside himself/herself;

              (4)     Supervises and oversees Peer Leaders within Mental Health Planning Region
                      (insert region);

              (5)     Delivers the CDSMP as part of the My Health, My Choice, My Life program to at
                      minimum eight (8) Peer Support Centers, Addiction Peer Recovery Centers or
                      other mental health facilities per year, as directed by the State’s Director of
                      Consumer Wellness Programs;

              (6)     Delivers the CDSMP as part of the My Health, My Choice, My Life program to at
                      least thirty-six (36) service recipients, as identified in Section A.3.;

              (7)     Collaborates with the staff of each facility at which the CDSMP is offered to
                      coordinate weekly health and wellness activities with each Peer Support Center
                      at which the My Health, My Choice, My Life program is currently or has been
                      offered;




                                                                                                        29
                          Attachment E
                   INTENDED SCOPE OF SERVICES
                           Page 6 of 9
     (8)     Provides Peer Wellness Coaching to participants of the My Health, My Choice,
             My Life program, as directed by the State’s Director of Consumer Wellness
             Programs.

     (9)     Supplements program curriculum with appropriate materials and guest
             presenters from local resources;

     (10)    Supervises and oversees Peer Leaders within Mental Health Planning Regions
             (insert region); and

     (11)    Augments the CDSMP as directed by the State’s Director of Consumer Wellness
             Programs by offering additional sessions which may include but are not limited

             to the following: healthy weight management; smoking cessation; safer sex and
             infectious disease; and alcohol and other substance use.

b.   The Grantee shall ensure that each PWC performs the following duty related to outreach
     presentations:

     (1)     Delivers at least one (1) outreach presentation per quarter to educate traditional
             and non-traditional community partners, including, but not limited to, group home
             operators; social service mental health providers; Federally Qualified Health
             Centers (FQHCs); and local health care and wellness providers in the assigned
             region. The purpose of these presentations shall be to educate participants on
             the My Health, My Choice, My Life program and enlist their participation in
             addressing the service goals identified in Section A.4.

c.   The Grantee shall ensure that each PWC performs all of the following duties related to
     participants of the My Health, My Choice, My Life program:

     (1)     Coordinates with staff from the facility at which the program is being offered to
             ensure that each participant in the My Health, My Choice, My Life program
             receives free transportation to and from each of the six (6) My Health, My
             Choice, My Life sessions, plus the intake and discharge evaluations, as needed,
             including but not limited to vehicles or bus passes to be used by service
             recipients;

     (2)     Develops liaison relationships with local FQHCs and work with participants to
             establish a health care home;

     (3)     Ensures that each My Health, My Choice, My Life program participant identifies a
             health care home and if a participant has not received a physical within the last
             twelve (12) months, work with him/her to schedule an appointment for a physical
             and participate in subsequent follow-up appointments with, and
             recommendations from, the participants’ primary care provider;

     (4)     Provides support to members engaging with primary care physicians and/or
             health care homes as needed;




                                                                                              30
                            Attachment E
                    INTENDED SCOPE OF SERVICES
                            Page 7 of 9
     (5)     Identifies participants who appear to need individualized assistance, whether due
             to cultural issues, reading difficulties, or disability, and provides the appropriate
             assistance;

     (6)     Utilizes techniques to assist participants (probing, individualized administration,
             providing context for questionnaire items) and makes accommodations for them;

     (7)     Informs participants of their rights and responsibilities, risks, alternative
             treatments, and confidentiality (offered verbally and in writing); and

     (8)     Informs program participants about the evaluation component of the program;
             invites program participants to participate in program evaluation; and informs
             program participants that participation in evaluation activities is strictly voluntary
             and that declining to participate will not result in discontinuation of services.

d.   The Grantee shall ensure that each PWC performs all of the following duties related to
     program evaluation:

     (1)     Participates in a series of training sessions conducted by Centerstone Research
             Institute on program evaluation and assessments;

     (2)     Works with the appropriate people at Centerstone Research Institute to complete
             the following:

             i.      The collection of Informed Consent Forms and Record Locator Forms;

             ii.     Administering the National Outcomes Measures (NOMS) tool, Recovery
                     Assessment Scale, and the Physical Health Survey at baseline,
                     discharge, and every six (6) months as long as the participant is
                     receiving services as part of the program;

                     (a)      When collecting data at baseline and discharge, ninety percent
                              (90%) of required participant data shall be collected;

                     (b)      When collecting data at six (6) month follow-up as long as the
                              participant is receiving services as part of the program, eighty
                              percent (80%) of required data shall be collected; and

                     (c)      When collecting individual session process data, one hundred
                              percent (100%) of required data shall be collected; and

             iii.    Entering and submitting the data for use in performance improvement
                     efforts as well as required reporting to SAMHSA;

     (3)     Informs program participants that participation in evaluation activities is strictly
             voluntary and that declining to participate will not result in discontinuation of
             services; and

     (4)     Remunerates participants for completion of discharge and six (6) month follow-up
             evaluation activities.



                                                                                                    31
                                     Attachment E
                             INTENDED SCOPE OF SERVICES
                                     Page 8 of 9
       e.     The Grantee shall ensure that each PWC performs all of the following duties related to
              reporting and other activities:

              (1)     Meets and complies with all federal grant requirements and reporting
                      requirements adopted by the State;

              (2)     Submits quarterly reports that describe his/her activities and successes. These
                      reports shall be due on the fifteenth (15th) of the month following the end of each
                      quarter. Reports shall be submitted to the State’s Director of Consumer
                      Wellness Programs, Division of Recovery Services and Planning, by electronic
                      means or hard copy in a format prescribed by the State. Failure to submit these
                      reports within the specified time frame could result in delay in reimbursement
                      until such time the requirement is met. It is expressly understood and agreed the
                      obligations set forth in this section shall survive the termination of this Grant
                      Contract as specifically indicated herein; and

              (3)     Assists the State as necessary with all program events and activities; and
                      participates in other activities as approved, directed, and authorized by the State.

A.7.   Outcome – Access:

       a.     Service recipients are referred to the My Health, My Choice, My Life program by mental
              health professionals from all areas in the Mental Health Planning Region assigned in
              Section A.5.b.

       b.     Attendance and participation in the My Health, My Choice, My Life program is voluntary.

       c.     Transportation to each session, including assessments and other evaluation sessions, of
              the My Health, My Choice, My Life program is offered at no cost to each service recipient
              enrolled in the program.

A.8.   Outcome – Capacity:

       a.     The Grantee shall provide the My Health, My Choice, My Life program to at least thirty-
              six (36) individuals in the region identified in Section A.3., thereby improving their
              physical health behaviors and physical health status.

       b.     The Grantee shall empower at least thirty-six (36) participants in the My Health, My
              Choice, My Life program to also increase their knowledge regarding healthy weight
              management; smoking cessation; safer sex and infectious disease; and alcohol and other
              substance use, thus improving health-sustaining behaviors that will lead to increase life
              expectancy and a higher quality of life.

       c.     The Grantee shall ensure that at least thirty-six (36) participants in the My Health, My
              Choice, My Life program identify a health care home and establish an ongoing
              relationship with a primary care physician.

A.9.   Outcome – Effectiveness:

       a.     The Grantee shall report results from the evaluation of the My Health, My Choice, My Life
              program that show that:


                                                                                                         32
                    Attachment E
            INTENDED SCOPE OF SERVICES
                    Page 9 of 9
(1)   Eighty percent (80%) of the participants who complete the My Health, My Choice,
      My Life program report that their understanding and knowledge about their
      physical health behaviors and physical health status has improved. The
      participants’ understanding and knowledge shall be measured by administering a
      test to the participants prior to their participation in the My Health, My Choice, My
      Life program (a pre-test) and administering a second test to the participants after
      completion of the program (a post-test);

(2)   Eighty percent (80%) of the participants who complete the My Health, My
      Choice, My Life program also report that their understanding and knowledge
      about healthy weight management; smoking cessation; safer sex and infectious
      disease; and alcohol and other substance use has improved. The participants’
      understanding and knowledge shall be measured by administering a test to the
      participants prior to their participation in the My Health, My Choice, My Life
      program (a pre-test) and administering a second test to the participants after
      completion of the program (a post-test);

(3)   Eighty percent (80%) of the participants who complete the My Health, My Choice,
      My Life program report that they have an identified health care home; and

(4)   Eighty percent (80%) of the participants who complete the My Health, My Choice,
      My Life program report that they have had a complete physical examination by a
      primary care physician.




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