Application: MMHU

1

Legal organization name

2

Common name (doing business as [DBA])

3

Address line 1

4

Address line 2

5

City

6

State

7

ZIP

8

County

9

Public health region

• Bellwood
• West Chicago
• Champaign
• Marion
• Metro East
• Peoria
• Rockford
• Multiple [logic, answer 9a]

Select the public health region (s) where you primarily provide services or that pertains to this application per the IDPH Health Regions map.

9a

If you chose multiple, please briefly describe which regions will be served by the strategies funded under this award.

Text

10

Organization phone

11

Organization website address (optional)

12

Type of organization

• Nonprofit
• For profit
• Tax exempt

Select your organization type.

13

Year founded/incorporated

14

IDHS /SUPR licenses, if any

15

Primary contact name

16

Primary contact title

17

Primary contact email address

18

Primary contact phone

19

Alternative contact name

20

Alternative contact title

21

Alternative contact email address

22

Alternative contact phone

23

Indirect cost election

• Federally negotiated rate
• 10% de minimis
• No indirect costs election

Select your indirect cost election.

If you select “Federally negotiated rate,” continue to item 24.

If you select “10% de minimis” or “No indirect costs election,” skip item 24 and continue with item 25.

24

Negotiated Indirect Cost Rate Agreement (NICRA) letter

Document upload (if applicable)

Upload as Attachment A (if applicable).

25

Current or planned organizational chart

Document upload (required)

Upload as Attachment B.

26

Current fiscal year organizational budget or, if you are a new organization, your planned budget for the upcoming fiscal year

Document upload (required)

Upload as Attachment C.

27

Federal or State Employer Identification Number (FEIN/EIN)

Indicate your FEIN/EIN.

28

Form W-9, Request for Taxpayer Identification Number and Certification

Document upload (required)

Upload as Attachment D.

29

Unique Entity Identifier (UEI)

Indicate your UEI.

30

Illinois Secretary of State File ID

Indicate your File ID.

31

Do you attest that your organization is not on the Federal Excluded Parties List?

Yes

No

32

Do you attest that your organization is not on the Illinois Stop Payment list? 

Yes

No

33

Do you attest that your organization is not on the Department of Healthcare and Family Services Provider Sanctions list? 

Yes

No

34

Do you attest that your organization is in good standing with the Illinois Secretary of State?

Yes

No

35

What type of accounting system does the organization use? (2.01)

• Manual and/or spreadsheet-driven
• Automated - off the shelf
• Automated - written in-house or by consulting firm
• Not Applicable

Select the response that best describes your accounting system.

36

Does the accounting system require users to have separate sign in/log on credentials for access and approval? (2.02)

• Yes
• No

37

Have any new accounting systems been implemented during the last fiscal year? (2.03)

• Yes
• No

38

Does the accounting system or related written policies and procedures separate the receipt and expenditure of grant funds at the grant level? (2.04)

• Tracked outside of the accounting system with spreadsheets
• Tracked in the accounting system

Select the response that best describes how receipt and expenditure of grant funds are tracked.

39

Does the accounting system or written policies and procedures include a formal chart of accounts that allows users to record transactions by the categories of the approved budget? (2.05)

• Yes
• No

40

How often are the general ledger accounts reconciled? (2.06)

• Monthly
• Quarterly
• Semi-annually
• Annually
• Not applicable

Select the response that best describes how often the general ledger accounts are reconciled.

41

Does the organization require monthly bank reconciliations? (2.07)

• Yes
• No

42

Does the organization have written policies and procedures regarding proper segregation of duties for fiscal activities that include, but are not limited to, a) authorization of transactions, b) recordkeeping for receipts and payments, and c) cash management? (2.08)

• Yes
• No

43

Does the organization have written review and approval processes for financial and program-related reporting? (3.01)

• Yes
• No

44

Are the annual financial statements prepared in accordance with Generally Accepted Accounting Principles (GAAP) or on a basis acceptable by the regulatory agency? (3.02)

• Yes
• No

45

Does the organization have written policies and procedures to ensure program performance measures and deliverables align with the program spending plan? (3.03)

• Yes
• No

46

Has the organization taken steps to ensure the individuals who prepare, review, and approve reports have the financial and/or program-related required knowledge, skills, and abilities? (3.04)

• Always
• Sometimes
• Never
• Not applicable

47

Who prepares the organization’s financial statements? (3.05)

• Trained staff who work for the organization
• Financial consultants who are not part of the organization’s audit firm
• Independent auditors who conduct the financial statement audit

Select the response that best describes who prepares the organization’s financial statements.

48

Who prepares the organization’s program performance reports? (3.06)

• Trained staff who work in the specific program
• Grant managers or program directors
• Organizational management outside of the program

Select the response that best describes who prepares the organization’s performance reports.

49

Does the organization have written policies and procedures that support compliance with cost principles? (4.01)

• Yes
• No

50

Does the organization have written policies and procedures for allocating costs? (4.02)

• Yes
• No

51

Are costs recorded consistently with regulations and written policies and procedures to address uniformity both in grant awards and in the organization’s other activities? (4.03)

• Yes
• No

52

Does the organization charge indirect costs? (4.04)

• Yes
• No

53

Does the organization keep adequate documentation to support all costs charged to its grant awards? (4.06)

• Yes
• No

54

Does the organization have a governing body (for example, Board of Directors, Board of Trustees, City Council, County Board, Leadership, Legislature, Governor’s Office)? (4.07)

• Yes
• No

55

Is financial information, including budget to actual revenue and expenditure reports, provided to leadership or the governing body members? (4.08)

• Always
• Sometimes
• Never

Select the response that best describes how often financial information is provided to leadership or governing body members

56

Is the governing body engaged in audit function activities such as selection of an audit firm, the audit firm’s presentation of audit results, or follow-up on corrective action of audit findings? (4.09)

• Engaged in all audit function activities
• Engaged in some audit function activities
• Not involved in audit activities

Select the response that best describes how often the governing body is engaged with audit function activities.

57

Does the organization make purchases of equipment of $5,000 or more with grant funding? (4.10)

• Yes
• No

58

Is a control system in place with adequate safeguards to prevent loss, damage, theft, or unauthorized use of property? (4.13)

• Yes
• No

59

Does the organization have written policies and procedures for proper authorization of property disposals? (4.14)

• Yes
• No
• Not applicable

60

Does the organization have written policies and procedures for purchasing goods and services with grant funds? (4.15)

• Yes
• No

61

Does the organization have written policies and procedures that forbid employees, management officers, or agents from participating in the selection, award, or administration of a contract supported by a grant award if there is a real or apparent conflict of interest? (4.16)

• Yes
• No

62

Does the organization have written policies and procedures that forbid contractors who develop or draft specifications, requirements, statements of work (scope of services), or requests for proposals from competing for such procurements? (4.17)

• Yes
• No

63

Does the organization have written policies and procedures that document subrecipient and contractor determinations? (4.18)

• Yes
• No

64

In those determinations, has the organization identified any subrecipients? (4.19)

• Yes
• No

65

Does the organization have written policies and procedures for assessing subrecipient risk and monitoring program implementation? (4.20)

• Yes
• No

66

Does the accounting system or do related written policies and procedures identify expenses in excess of available budget? (4.21)

• Yes
• No

67

Are adequate controls in place to ensure that necessary budget revisions receive prior approval from the grantor when applicable? (4.22)

• Yes
• No

68

Does the organization have written policies and procedures for allocating personnel time and effort by funding source? (4.23)

• Yes
• No

69

Does the organization have written policies and procedures to ensure that all salaries and wages charged to grants accurately reflect work performed (i.e., time and effort or after-the-fact payroll verification)? (4.24)

• Yes
• No

70

Does the organization have written policies and procedures to ensure accurate tracking of grant deliverables and performance measures? (4.25)

• Yes
• No

71

Does the organization have written policies and procedures to make sure program activities are allowable under the grant agreement and state and federal regulations? (4.26)

• Yes
• No

72

Are the terms of the executed agreement and budget shared with the performance or program management staff? (4.28)

• Yes
• No

73

Does the organization have written policies and procedures for documenting participant eligibility determinations? (4.29)

• Yes
• No

74

Have there been any changes in key organizational personnel since the last audit, such as changes to Fiscal and Administrative Management, the Executive Director, and/or Program Management? (5.01)

• Yes
• No

75

Has a financial statement audit of the organization been conducted in the past year? (5.02)

• Yes
• No

If “no” is selected, skip items 77–80, continuing with item 81.

76

What type of audit was conducted? (5.03)

• Financial audit conducted in accordance with Generally Accepted Auditing Standards
• Financial audit conducted in accordance with Generally Accepted Government Auditing Standards
• Single Audit/Program Specific Audit in accordance with CFR2 200.501

Select the response that best describes the type of audit conducted within the past year.

77

Did the audit find significant deficiencies or material weaknesses? (5.04)

• Yes
• No

78

Financial Audit Report (most recent)

Document upload (optional, if available)

Upload as Attachment E, if available.

79

Has the organization submitted financial and program-related reporting in a timely manner and as required for prior grant awards?

• Always
• Sometimes
• Rarely

80

By entering my name, title, and date, I attest that I am authorized to submit the application on my organization’s behalf.

[Name]

[Title]

[Date]

Enter requested information in fields.

81

I attest that my organization is committed to processing a subaward within six (6) weeks from the Notice of Award.

• Yes
• No

82

I attest that my organization is responsible for performance and monitoring of external partners, subcontractors, and subrecipients (as allowed by the grant agreement).

• Yes
• No

83

I attest that I have reviewed the terms and conditions within this Notice of Funding Opportunity in its entirety. My organization meets the eligibility criteria and has the capacity to fulfill the scope of services described.

• Yes
• No

84

I certify that the statements herein are true, complete, and accurate to the best of my knowledge. I agree to comply, on behalf of my organization, with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)

• Yes
• No

85

I attest that my organization will adhere to applicable standards within Administrative Rule, Part 2060 pertaining to treatment off-site.

• Yes
• No

86

Conflict of Interest Disclosure

Document upload (required)

Upload as Attachment F.

87

Please list the relevant zip codes (required), Chicago Community Area(s), and/or municipalities where you will primarily provide services funded with this award.

Enter zip codes OR

Not applicable

0 points

88

Summarize the following:

• The population of focus to be served, including geographic, demographic, and other relevant characteristics.
• The reason why this population was selected.
• An overview of the services to be provided.
• Your organization’s experience providing similar services, including timeframes.
• The relevant expertise of the staff bid in the proposal.

Up to 1,500 words

(5 points)

• The response addresses all elements of the question.
• The response explains the need for the proposed program for the population of focus, and justifies the need.
• The population of focus  described in the response aligns with the program requirements.
• The services described in the response align with the program requirements.
• The response demonstrates an understanding of the expertise needed to deliver  the program,

89

What is the need to increase access to MAR in the service area?

Describe the following:

• The population of focus for services, including demographic information and other relevant characteristics
• The geographic area where services are to be provided,
• Information about opioid use disorder and trends in the service area.
• Barriers to access, including social determinants of health, lack of coverage, etc.

Please cite the source of any data included.

Up to 1,500 words

(20 points)

• The response addresses all elements of the question.
• The specific population to be served is clearly defined and in accordance with the priority population.
• The specific population experiences barriers to accessing services.
• The geographic service area is disproportionately affected by the opioid crisis, defined as including at least one of the following:
  • High opioid fatality rates per 100,000 capita
  • Concentrated poverty
  • Concentrated firearm violence
  • Other conditions that hinder the communities reaching their full potential for health and well-being
• The response includes relevant data, including sources.

90

Describe interest/acceptance of MAR in the geographic area and among the population you seek to serve.

List key stakeholders (e.g., local Recovery Oriented System of Care Councils, community groups, health care providers) and means by which you will engage and assess interest (e.g., patient feedback/focus groups, environmental scan).

Up to 1,000 words

(10 points)

• The response addresses all elements of the question.
• The response details a diverse set of stakeholders who will be engaged.
• The response describes a variety of outreach activities to be used to engage with stakeholders.

91

What is your organization’s experience working in this geographic area and with the proposed population of focus?

Up to 500 words

(5 points)

• The response addresses all elements of the question.
• The applicant’s mission and experience are consistent with the proposed program.
• The response demonstrates experience in the geographic area and with the proposed population of focus.

92

Provide up to five examples of grants or contracts that your organization has successfully managed in the past 5 years, with awarding agencies, dates, and dollar amounts.

Include any current fiscal year funding from IDHS/SUPR or IDPH.

Select “not applicable” if you have not received previous grants or contracts.

Checkbox for not applicable

or

Table below

(5 points)

• The response addresses all elements of the question.
• The applicant demonstrates experience with grants management.
• The applicant demonstrates experience with services that address the opioid epidemic.
• The applicant demonstrates experience with one or more of the following:
  • Providing services like the proposed program.
  • Addressing health disparities.
  • Working with the priority populations.

93

What is your organization’s staffing plan in and off the mobile health unit (e.g., telehealth/telecounseling)?

Provide detailed information, including title for each staff member, role, and number of staff members who will be providing services in the mobile unit.

For new staff, describe your plan to hire people with the necessary qualifications and characteristics.

Describe training your organization will provide to ensure staff success.

Up to 1,500 words

(5 points)

• The response addresses all elements of the question.
• The applicant understands the experience and expertise required to implement the proposed program.

94

How does your hiring approach ensure your staffing reflects the populations you serve?

Discuss how your current staff demographics are reflective of the racial/ethnic community served and describe any changes to hiring processes necessary for ensuring cultural and linguistic appropriateness. Discuss your experience supporting peer support workers in the workforce.

Up to 1,000 words

(5 points)

• The response addresses all elements of the question.
• The response includes relevant data regarding staff diversity, which corresponds to the population the applicant serves.
• The applicant understands how to staff the proposed program to meet the needs of the population of focus.

95

Describe how you will make sure services are culturally and linguistically appropriate based on the diversity of the population to be served.

• What types of policies and procedures exist to ensure you are identifying the service needs of your service population?
• How do you incorporate the the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care into your organization’s practice and procedures?

Up to 1,000 words

(5 points)

• The response addresses all elements of the question.
• The applicant has policies and procedures in place to identify the service needs of the population of focus, including disparities in access related to cultural and linguistic barriers.
• The applicant follows the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care.
• The applicant is prepared to provide interpreters and other accommodations.

96

Identify the community partners and stakeholders needed to ensure the success of the program and describe your organization’s experience with these partners.

Include information about partnerships that exist and community involvement.

Up to 1,000 words

(5 points)

• The response addresses all elements of the question.
• The response identifies a sufficient range of partners to support the proposed program.
• The applicant has existing connections to community partners.

200 characters

200 characters

[Drop Down choices—federal, state, local government, other]

Currency, whole dollar only

200 characters

Date

Date

[same]

[same]

[same]

[same]

97

Describe the  goals, objectives, and projected outcomes based on your organization’s specific services and patient population.

The following can be used as an example format:

Goals, Objectives, and Projected Outcomes

Outcome Statement: The primary outcome for this program is increased access to MAR through the number of patients cared for, medication dispensed/prescribed, and connection to treatment/recovery support services.  Secondary outcomes include treatment retention, identification of OUD-related symptoms, decreased overdose mortality, and increase in treatment of comorbid Hepatitis C or HIV.  Program outcomes will be monitored through MMHU logs and patient level data documented in electronic health records (EHR).

Goal 1 (G1): Provide van-based MAR services and referral to treatment for patients on the south and west sides of Chicago.

• G1 Objective 1: Within the first year of MMHU operation, 500 people will have received harm reduction services and screening for MAR.
• G2 Objective 2: Within the first year of MMHU operation, 200 people will have received MAR or a referral to an organization for methadone.
• G3 Objective 3: Within the first year of MMHU operation, outcome data will be collected for at least 75% of patients to determine if patients followed up with clinic appointments after engagement in mobile unit-based inductions.

Goal 2 (G2): Connect patients to additional medical services in the mobile unit including HIV and Hepatitis C testing and treatment, wound care, and basic primary care services.

• G2 Objective 1: Within the first year of MMHU operation, 90% of patients will be offered HIV and HCV testing.
• G2 Objective 2: Within the first year of MMHU operation, all patients who test positive for HIV and/or HCV will be offered connection to treatment either on the MMHU or through the West Side Field Station COIP clinic.

Goal 3 (G3): Develop an education immersive training program for trainees (residents, DNP students, medical students) focused on harm reduction, substance use disorder treatment, and MOUD in a MMHU setting.

• G3 Objective 1: Within 3 months of operation, a MMHU substance use disorder rotation will be offered to trainees.
• G3 Objective 2: Within the first year of operation, at least 20 residents, DNP students, and medical students will have completed a rotation on the MMHU.

Goal 4 (G4): Within the first two years develop a sustainability plan, evaluation report, and a MMHU toolkit

• G4 Objective 1: Monitor insurance enrollment rates, billable services, and billable medications to develop a potential business model for continued sustainability the MMHU as well as a model for sustainability for future programs.
• G4 Objective 2: Following a thorough evaluation, produce a document containing programmatic workflows, instructions, protocols, and a toolkit that can be disseminated to other programs in Illinois to initiate and support a similar model of care through shared learning.

Up to 1,000 words

(5 points)

• The response addresses all elements of the question.
• The response lists specific outcomes that are related to the proposed program requirements.
• The service projections are clear and reasonable in relation to the budget request.

98

Answer the following questions:

• What medications do you plan to offer? Why?
  • If your organization does not plan to offer all three FDA-approved medications, provide rationale for the two FDA medications that you must provide and indicate whether you have a goal of offering all three.
• Will you dispense and/or prescribe medications?
• If you do not plan to offer all three medications on the mobile health unit, how will access be ensured (e.g., referral)?
• What is your estimated timeline to initate services?

Up to 1,000 words

(5 points)

• The response addresses all elements of the question.
• The plan explains and rationalizes what medications will be dispensed and/or prescribed.
• The plan explains how access to medications not offered will be addressed.
• The response details a timeline to initiate services that meets program requirements.

99

Describe logistics of the mobile health unit, including:

• Where do you anticipate parking the vehicle?
• What days of the week will the vehicle be in operation?
• What are the proposed hours of operation per day?
• What are the proposed hours of operation per week? 

Up to 1,000 words

(5 points)

• The response addresses all elements of the question.

100

Describe the workflow of the services provided in the vehicle including MAR dispensing and/or prescribing.

Up to 500 words

(2 points)

• The response addresses all elements of the question.
• The response describes how the organization will dispense and/or prescribe medication.

Describe how your organization will ensure patients have access to the full spectrum of treatment and recovery support services, and how and when you will connect clients to “in office” care.

Describe processes for:

• Recovery support and referrals to community partners
• Higher levels of care as indicated
• Referrals for other health services

(Provide the names of the organizations and partners and describe the services provided by these organizations.)

Up to 1,000 words

(3 points)

• The response addresses all elements of the question.
• The response describes how the organization will ensure access to  recovery supports and referrals.
• The response describes how the organization will ensure access to higher levels of care as needed.
• The response describes how the organization will ensure access to referrals for other health services

102

Describe the social determinants of health assessment and assistance you plan to provide to those receiving services, including assistance with enrollment in health insurance, housing, and employment services.

(2 points)

• The response addresses all elements of the question.
• The response describes how the organization will assess social determinant of health needs.
• The response describes how the organization will support social determinants of health needs.

103

Explain how staff will engage in outreach and their outreach methods (e.g., one-on-one meetings, community forums) and type of representatives you plan to meet with (e.g., law enforcement officials, community partners, faith-based organizations). 

(3 points)

• The response addresses all elements of the question.
• The outreach plan details which staff will participate in different types of outreach activities.
• The outreach plan involves engaging with a diverse set of stakeholders.

104

Describe additional services you are proposing to provide in the MMHU (optional, but preferred).

Include:

• Harm reduction services
• Recovery support services
• Treatment services
• Community education and referral services
• Primary health services
• Other services

(5 points)

• The response describes how the organization will provide additional services.

105

Total funding requested for the period of performance

[currency]

(0 points)

• Advance Payment and Reconcile Method
• Reimbursement Method
• Working Capital Advance Method

(0 points)

The budget and narrative must tie fiscal activity to program objectives and deliverables and must demonstrate that all proposed costs are

• Reasonable and necessary,
• Allocable, and
• Allowable as defined by program regulatory requirements and Uniform Guidance (2 CFR 200), as applicable.

Upload the Budget Workbook as Attachment H to submit your project budget and advance payment request.

 (required)

(5 points)

• The budget is filled out completely.
• Salaries, benefits, and other expenditures appear reasonable for the community in which the proposed program will take place.
• All line items correspond to elements of the proposed program.