HSTP PROPOSAL TEMPLATE Revised February 23, 2018

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1 HSTP PROPOSAL TEMPLATE Revised February 23, 2018 Contents Tab 1: Cover Sheet Tab 2: Eligible HSTP Expenditures Tab 3: Funding Proposal COVER SHEET [Tab 1] I. APPLICANT INFORMATION DSHP funds may only be allocated directly to the eligible categories of organizations listed below (which may, with approval, subcontract for approved activities from other organizations). Indicate below which eligible category best describes the applicant. Participating Institution of Higher Education (i.e., URI, RIC, or CCRI) Vital State Health Programs Specifically defined to include: Tuberculosis Clinic, Center for Acute Infectious Disease Epidemiology, Rhode Island Child Audiology Center at the RI School for the Deaf, Consumer Assistance Programs (Office of the Child Advocate and Commission on the Deaf and Hard of Hearing), Wavemaker Fellowship ORGANIZATION/AGENCY BUDGET REQUEST PROPOSAL TITLE CONTACT PHONE DATE II. ELIGIBLE HSTP EXPENDITURE CATEGORY Permissible HSTP expenditures must be attributable to the establishment of Accountable Entities. 1 In addition, they must fit within one of the two categories identified below. 2 Please indicate below the specific eligible HSTP expenditure category(ies) for this proposal> Category 1: Healthcare Workforce Transformation (see Attachment R of the CMS Special Terms and Conditions) Category 2: Vital State Health Programs (see above definition) 1 Permissible HSTP expenditures as defined in the CMS agreement also includes One-time transitional funding to support hospitals & nursing facilities ; however, the agreement limits this program to be one-time only and to not exceed $20.5 M, paid on or before Dec 31, As such, no new projects shall be HSTP-eligible related to this specific use of funds. 2 In accordance with the CMS agreement as defined in the Special Terms and Conditions of RI Medicaid s 1115 Waiver and attachment N, there are two additional categories of permissible expenditures that are attributable to the establishment of Accountable Entities : (1) Incentive based infrastructure funding provided to AEs via the state s managed care contracts; and, (2) HSTP design, implementation and evaluation. These permissible HSTP expenditures are not applicable to this template.

2 ELIGIBLE HSTP EXPENDITURES [Tab 2] Instructions: All applicants must complete Section 1 and 3 below. Section 2 must be completed if applicable. 1. Accountable Entities All eligible HSTP expenditures (other than one-time transitional funding to support hospitals and nursing facilities) must be attributable to the establishment of Accountable Entities (AE). Indicate below the goal(s) and/or objective(s) of AEs that will be addressed by the proposed activity. (See the RI Medicaid Accountable Entity Roadmap for additional information.) Goals Develop new business models and operational changes that facilitate the transition from fee for service to value based purchasing A focus on total cost of care and accountability of an attributed population, health and healthcare Build interdisciplinary care capacity that extends beyond traditional health care providers with a particular focus on integration of physical, behavioral health, and social determinants of health Deploy new forms of organization to support improved care coordination and delivery and create shared incentives across a common enterprise Apply emerging data capabilities to refine and enhance care management, pathways, coordination, and timely responsiveness to emergent needs Objectives Improvements in the balance of long term care utilization and expenditures, away from institutional and into community-based care Decreases in readmission rates, preventable hospitalizations and preventable ED visits Increase in the provision of coordinated primary care and behavioral health services in the same setting Identifying social support needs of attributed population and establishing referral management to community partners Increased numbers of Medicaid members who choose or are assigned to a primary care practice that functions as a patient centered medical home (as recognized by EOHHS) 2. Alignment with healthcare workforce transformation priorities HSTP funds may be used to support the Healthcare Workforce Transformation (HWT) priorities and strategies identified in Attachment R of the CMS Special Terms and Conditions and summarized below. See the EOHHS Healthcare Workforce Transformation Report for additional information. Please Indicate below the healthcare workforce transformation strategy(ies) that will be addressed by the proposed activity. Priority 1: Healthcare Career Pathways Prepare Rhode Islanders from culturally and linguistically diverse backgrounds for existing and emerging good jobs and careers in healthcare through expanded career awareness, job training and education, and advancement opportunities. Support the Entry-Level Workforce Increase Diversity and Cultural Competence Develop Youth Initiatives to Expand the Talent Pipeline Address Provider Shortages

3 Priority 2: Expand Home and Community-Based Care Increase the capacity of community-based providers to offer culturally-competent care and services in the home and community and reduce unnecessary utilization of high-cost institutional or specialty care. Expand Community-based Health Professional Education Prepare Healthcare Support Occupations for New and Emerging Roles Priority 3: Core Concepts of Health System and Practice Transformation Increase the capacity of the current and future workforce to understand and apply core concepts of health system and practice transformation. Integrated, Team-Based Care Health System Transformation Concepts 3. Description of HSTP Eligibility Please provide a summary of 250 words or less describing how this initiative (a) clearly supports the establishment of Accountable Entities and (b) where applicable, aligns with one or more healthcare workforce transformation strategy listed above.

4 FUNDING PROPOSAL [Tab 3] I. PROJECT PLAN (75 points) A. Executive Summary (5 points) Provide an Executive Summary of 250 words or less to describe the proposal, including objectives, strategies, rationale, partner organizations, and anticipated outcomes B. SMART Goals For each proposed activity, describe the following SMART goals: Specific: State specifically what you intend to accomplish (who, what, where, why) (10 points) Measurable: Describe your evaluation plan, including the qualitative and quantitative measures you will use to demonstrate and evaluate the extent to which the goal has been met. Describe the methodology that you will use to evaluate the impact of the proposed activity. (10 points) Achievable: Describe your organizational capacity (experience, expertise, resources, leadership, staff, partners, and other factors) to successfully accomplish the proposed activity (10 points) Relevant: Describe in detail how the proposed activity is relevant to the establishment of Accountable Entities and, if applicable, to one or more healthcare workforce transformation strategy, as indicated in Tab 2 (25 points) Time-Bound: Provide a Gantt Chart or other detailed timeline that includes benchmarks and deadlines for the proposed deliverables (5 points) C. Partnerships / Leveraging (5 points) Describe how the proposed activities: i. builds or strengthens partnerships with other healthcare educators, providers, state agencies, or other stakeholders ii. builds upon other healthcare workforce and/or system transformation efforts in Rhode Island D. Sustainability (5 points) Describe how the proposed activities will develop organizational capacity, partnerships, and/or new funding sources to sustain the activities beyond the funding period. II. BUDGET & BUDGET NARRATIVE (20 points) A. Budget: Complete Budget-Payment Template and Personnel Budget Template in Tab 4. B. Budget Narrative i. Provide a narrative substantiating the personnel and other expenses included in the budget. ii. Explain of how the proposed expenditures are reasonably related to the proposed level of activity. iii. Describe how the proposed funds will leverage other funds or resources iv. Provide an attestation to the fact that the proposed funds are not duplicative of other state or federal funds

5 III. IV. COMPENSATION METHODOLOGY State the type of compensation method requested and explain the rationale and benefit to EOHHS. Compensation methods available are: 1) fee for service; 2) fee sharing through FFP sharing. DATA USE AGREEMENT Is a Data Use Agreement Required? Yes/No V. CONFLICTS OF INTEREST Explain any Conflicts of Interest presented by this Initiative.

6 Health System Transformation Program TEMPLATE C.2 Budget and Payment Request Template Complete all parts of this form. Submit to EOHHS. EOHHS will review, request additional information as necessary and submit for approval. This template is to be submitted with the initial proposal for approval and also is to be submitted with each request for payment, and the final report. SCHOOL/AGENCY/DEPT: REQUEST REQUESTOR NAME: REQUESTOR ADDRESS: REQUESTOR REQUESTOR PHONE: LEAD DEPARTMENT: PARTICIPATING DEPARTMEN PROPOSAL NAME: REQUESTED BUDGET: SUBMISSION PURPOSE: Budget for New Funding Request Interim Financial Report Final Financial Report Request for Compensation EXPENDITURES AS OF PERSONNEL: $'s Requested $'s Expended % Expended to Requested Titles of Participants (List) 1) 2) 3) #) add additional Total Salaries $ - $ - 0% Fringe Benefits 0% Other Expenses Supplies Total Salaries and Fringe $ - $ - 0% Equipment < $5000 Other (please list) 1) 2) 3) #) add additional lines Total Other Expenses $ - $ - 0% Total Budget $ - $ - 0% COMPENSATION AMOUNT REQUESTED: SIGNATURES AND APPROVALS: SCHOOL/AGENCY/DEPARTMENT REQUESTOR: AGENCY/DEPT FINANCE: DEPARTMENT HEAD: EOHHS PROJECT DIRECTOR: PROJECT FINANCE: MEDICAID (DEPUTY) DIRECTOR: EOHHS Accounting RIFANS CODE: ENTERED BY: Final HSTP Proposal Template C2 C3 C4/C.2 Budget-Payment Template version

7 Health System Transformation Program Project Plan and Periodic Reporting Template Complete all parts of this form. Submit to EOHHS for review. This template is to be submitted with the initial proposal for approval and also is to be submitted with each periodic progress report. TEMPLATE C.3 SCHOOL/AGENCY/DEPT: REQUEST REQUESTOR NAME: REQUESTOR ADDRESS: REQUESTOR REQUESTOR PHONE: LEAD DEPARTMENT: PARTICIPATING DEPTS: PROPOSAL NAME: REQUESTED BUDGET: PROGRESS REPORT Project Plan Person(s) Responsible Department(s) Responsible Start Date Due Date Status 1. Insert Activity 2. Insert Activity 3. Insert Activity 4. Insert Activity 5. Insert Activity 6. Insert Activity 7. Insert Activity 8. Insert Activity 9. Insert Activity 10. Insert Activity % complete Achievements to Date Issues Issue Resolution Deliverables Person(s) Responsible Department(s) Responsible Start Date Due Date Status 1. Insert Deliverable 2. Insert Deliverable 3. Insert Deliverable 4. Insert Deliverable 5. Insert Deliverable 6. Insert Deliverable % complete Achievements to Date Issues Issue Resolution SIGNATURES AND APPROVALS: SCHOOL/AGENCY/DEPARTMENT REQUESTOR: AGENCY/DEPARTMENT FINANCE: DEPARTMENT HEAD: EOHHS APPROVAL PROJECT DIRECTOR: PROJECT FINANCE: MEDICAID (DEPUTY) DIRECTOR: Final HSTP Proposal Template C2 C3 C4/C.3 Project Plan & Reporting version

8 Attach additional sheets as necessary. Health System Transformation Program Final Report Template TEMPLATE C.4 Complete all parts of this form. Submit to EOHHS. EOHHS will review, request additional information as necessary and submit for approval. This template is to be submitted with the final deliverable(s). SCHOOL/AGENCY/DEPT: REQUEST REQUESTOR NAME: REQUESTOR ADDRESS REQUESTOR REQUESTOR PHONE: LEAD DEPARTMENT: PARTICIPATING DEPARTMENTS PROPOSAL NAME: REQUESTED COMPENSATION: Describe the result of the initiative Describe the outcome of the initiative. Describe the goals met under this initiative Describe how the initiative achieved the goal(s). Describe how the initiative has/will impact RI Medicaid. Describe how this initiative has or will inprove the delivery of healthcare to RI's Medicaid beneficiaries, reduce costs, etc. List and describe the deliverables of this initiative Provide a final project plan using Tempate C.3 and describe the deliverables below and attach deliverables. BUDGET (complete budget template) Complete Attached Budget and Compensation Request Template (Tempate C.2). SIGNATURES AND APPROVALS: SCHOOL/AGENCY/DEPARTMENT REQUESTOR: AGENCY/DEPT FINANCE: DEPARTMENT HEAD: EOHHS PROJECT DIRECTOR: PROJECT FINANCE: MEDICAID (DEPUTY) DIRECTOR: Final HSTP Proposal Template C2 C3 C4/C.4 Final Report Template version

H 7819 S T A T E O F R H O D E I S L A N D

H 7819 S T A T E O F R H O D E I S L A N D LC00 01 -- H 1 S T A T E O F R H O D E I S L A N D IN GENERAL ASSEMBLY JANUARY SESSION, A.D. 01 A N A C T RELATING TO HEALTH AND SAFETY - THE RHODE ISLAND HEALTHCARE AUTHORITY Introduced By: Representatives