Community Wellness
CSFA Number: 444-80-1489
Agency Name
Department Of Human Services (444)
Agency Identification
Agency Contact
Karrie Rueter
Short Description
The Community Wellness In-Home Visitation Project will provide coordinated non-clinical, in-home wellness visits and case management services for 750 seniors and single parent households who are residents of Chicago living within a 50 block radius of zip code 60651. This program seeks to ensure that the health and social needs of these at-risk individuals isolated in their homes and at risk for increased morbidity are being adequately addressed by qualified health and social service providers, and are connected to their communities.

Using existing community and faith-based infrastructure, provider will recruit, hire, and train individuals from targeted communities to provide follow up through periodic visits to clients living in the service area. Community Wellness Workers will demonstrate a familiarity and sensitivity to the targeted client populations, and the ability to communicate and relate in a culturally competent manner.

A database will be created/maintained that will document the process of both identifying and serving these individuals. Data will assist with outreach, case management, evaluation and reporting.

Additionally, the project will provide case management services to support targeted individuals in conjunction with DHS to address any unmet social and other needs identified during the observation process.
Subject Area
Human Services
Program Function
Income Security and Social Services
Enabling Legislation
Not Applicable
Objectives and Goals
Exhibit E – Performance Measures

1. # of eligible households receiving a wellness visit check-up
2. # of eligible households assisted direct (by provider) or referral to other community resource
3. # of eligible households connected to church or neighbor network
4. # of mobilized events to reduce violence/improve safety on blocks occupied by eligible households
5. # of eligible households connected to benefits through ABE and DHS Local Offices.
6. # of single parent households with increased employment
Types of Assistance
Project Grants
Uses and Restrictions

Provider will utilize and build upon the Westside Health Authority 2015 Wellness Assessment to meet the following objectives:
1. Provide in home non-clinical direct care to 750 seniors and single parent households who are isolated in their homes at risk for increased morbidity within fifty blocks of the 60651 zip code.
2. Assist with nonclinical care and support through referral and follow-ups.
3. Assist in stabilizing the care through organizing caregiving among neighbors and churches.
4. Reduce violence and other threats by mobilizing neighbors, churches and agencies.
5. Connect eligible individuals to needed benefits through ABE and DHS Local Offices.
6. Connect clients assessed to need increased employment to employability providers / employment.

Eligible clients/households:
1. Households existing within the defined zip code 60651; and
2. Household includes a senior occupant over the age of 65 or a single parent with children occupants; and
3. Household/family identified as low-income.

1. Executive Director and Wellness Coordinator will establish protocols for quality assurance and accountability, set up offices set up offices, develop contracts for staff; and hire and orientate six community wellness workers, three case managers and two community organizers.

2. Consultant and coordinator will train staff, develop outreach brochures and assessment forms for documentation, resource guides for case managers and other materials for outreach and case management.

3. Wellness workers will utilize the previous assessment forms to target blocks for outreach; outreach will be initiated by the outreach worker under the supervision of an organizer.

4. Coordinator and other staff will develop outreach activities appropriate for church participation in developing and sustaining wellness outreach activities for seniors and single parents on their block.

5. Convene block meeting with residents on blocks to build relationships between seniors, single parents and neighbors

6. Provide case management and follow up to households.

7. Identify at least two neighbors on the fifty blocks, who will agree to provide weekly caregiving visits to the targeted senior and/or single parents on a voluntary basis.

8. Provide outreach to ten churches to solicit ongoing aid for isolated seniors and/or single parents, with targeting five blocks for each church.

9. Provide each church with training and materials related to the resources available and the assets on the blocks.

10. Organize meetings among neighbors and officials to address violence and other external threats, (i.e. drug dealing, abandoned houses, etc.). Mobilize the assets among neighbors, churches, police and other agencies to address their concerns.

11. Provide ongoing follow-up.

12. Manage data and provide required documentation

13. Connect eligible individuals to needed benefits through ABE and DHS Local Offices

14. Conduct focus groups of clients and trained community workers to evaluate the program and the collection of the data.

In-Home Visitation & Case Management Services

Six community wellness workers will conduct nonclinical in-home visits to 750 seniors and single parent households who are residents of Chicago living within a 50 block radius of zip code 60651. Each wellness worker will be assigned 100 individuals previously identified with unmet needs who they will visit approximately 3 times during a 9-month period. During each in-home wellness visit, wellness workers will refer to checklist that details the services requested and checklist of services previously developed in conjunction with DHS. The purpose of the visit will be to determine whether the needs previously identified have been met, evaluate the quality of the services, and provide assistance to unaddressed concerns. The visits are also designed to provide community support for persons who are isolated. A program director will be identified and other staff as necessary to provide supervision, support and coordination for the wellness workers.

Wellness workers will be recruited through existing community and faith-based collaborations. They will consist of individuals who currently reside in the target communities. Background checks will be administered prior to hiring. All wellness workers will participate in training prior to engaging in any in-home wellness observation visits. The training will cover various subject matters to enable them to fulfill their duties effectively and will also include elements of the community health work curriculum.

Unmet needs identified that were not resolved by referral through the community wellness worker will be directed to Case Management staff for additional assistance. The project will hire 2 case managers for the population of 750 clients. Case managers may have a caseload of up to 500 clients. The role of the case manager is to work with existing programs and resources, including DHS, to ensure that unmet needs and unaddressed concerns are being addressed.

Data Collection:

Data will be collected and managed in a provider database to assist with outreach, case management, evaluation and reporting. At a minimum, the following will be maintained per household:
1. Client demographic information (name, address, age, gender, ethnicity, race, etc.)
2. # contacts made
3. # in-home visits
4. # services requested
5. # service referral
6. # referral services received
7. Household needs assessment
a. Housing
b. Income
c. Employment
d. Education
e. Health
f. Life Skills
g. Childcare
h. Parenting
i. Food/nutrition
j. Transportation
k. Drug dependency
l. Current government benefits (disability, medical, TANF, SNAP, child care, WIC, etc.)
8. New government benefits acquired (disability, medical, TANF, SNAP, child care, WIC, etc.)
9. # of clients/households with increased employment
10. # of clients/households with increased education
11. Case Plan developed (Y/N)
12. Case Plan completed (100% / 50% or more / less than 50%)


An annual Evaluation of the project will include at a minimum, focus groups of clients and trained community workers to evaluate the program and the collection of the data.
Eligibility Requirements
Eligible Applicants are pre-identified through the budget appropriation process.

Applicant agencies may not be eligible for a grant award until they have pre-qualified through the Grant Accountability and Transparency Act (GATA) Grantee Portal,
Eligible Applicants
Application and Award Processing
a) Pre-application Coordination.
Applicant agencies are not eligible for a grant award until they have pre-qualified through the Grant Accountability and Transparency Act (GATA) Grantee Portal, During pre-qualification, Dun and Bradstreet verifications are performed including a check of Debarred and Suspended status and good standing with the Secretary of State. The pre-qualification process also includes a financial and administrative risk assessment utilizing an Internal Controls Questionnaire and a programmatic risk assessment. If applicable, the agency will be notified that it is ineligible for award as a result of the Dun and Bradstreet verification. The entity will be informed of corrective action needed to become eligible for a grant award.

b) The Application Procedure.
An Application must be submitted in the format required by the Department and in the manner dictated by the Department. Refer to NOFO for detailed information.

c) Award Procedure.
1) An award shall be made pursuant to a written determination based on the evaluation criteria set forth in the grant application. A Notice of State Award (NOSA) will be issued to enable the applicant to make an informed decision to accept the grant award. The NOSA shall include:
a. The terms and condition of the award.
b. Specific conditions assigned to the grantee based on the fiscal and administrative and programmatic risk assessments.
3) Upon acceptance of the grant award, announcement of the grant award shall be published by the awarding agency to
4) A written Notice of Denial shall be sent to the applicants not receiving awards.

d) Criteria for Selecting Proposals.
The application criteria, scoring information and details regarding the review and decision-making process can be found in the NOFO.

e) Appeals.
Refer to DHS Merit Based Review Policy - Appeals Process

f) Renewals.
If this program is renewed annually, grantees will be required to update their plan and submit a current year budget
Assistance Consideration
Administrative Costs (Direct /Indirect)
Funding allocated under this grant is intended to provide direct services to clients. It is expected that administrative costs, both direct and indirect, will represent a small portion of the overall program budget and should NOT exceed 20%. Administrative means those activities performed by staff and costs which are supportive of and required for project implementation for which there is no direct client contact such as fiscal staff; audit; clerical support; office rent, utilities, insurance; general office equipment etc. Program budgets and narratives will detail how all proposed expenditures are directly necessary for program implementation and will distinguish between Indirect/Direct Administrative and Direct Program expenses. Any budget deemed to include inappropriate or excessive administrative costs will not be approved. At no time may the approved NICRA be exceeded under this agreement – even if it is below the maximum allowed under the award. Documentation will be required to verify the approved NICRA.

Match is NOT required for this grant.

Subcontractor Agreement(s) and budgets must be pre-approved by the Department and on file with the Department. Subcontractors are subject to all provisions of this Agreement. The provider shall retain sole responsibility for the performance of the subcontractor.
Post Assistance Requirements
a) Reports.
1. Fiscal Reports / Billing Information. The Provider shall submit monthly expenditure documentation forms in the format prescribed by the Department. The Expenditure Documentation forms must be submitted no later than the 15th of each month for the preceding month.
2. Annual Application/Plan & Budget, all providers are required to submit an annual Application/Plan and detailed Budget and Budget Narrative to the Department as directed.
3. Monthly and cumulative data/performance reports will be submitted to the Department as directed on or before the 15th of each month for the preceding month. Providers must ensure all individuals referred to and served in the program are tracked by client in the providers’ data system.
4. Additional annual performance data may be collected as directed by the department and in a format prescribed by the Department.
5. Revisions to the program plan and budget may be requested in writing and must be pre-approved. Budget revisions are required if the revision exceeds 5% of the entire grant award and/or if the revision requires a shift in excess of 10% in any one line item (plus or minus).

b) Audits.
Grantee shall be subject to the audit requirements contained in the Single Audit Act Amendments of 1996 (31 USC 7501-7507) and subpart F of 2 CFR Part 200, and the audit rules set forth by the Governor’s Office of Management and Budget. See 30 ILCS 708/65©.

The Provider will provide the Department with requested monitoring and evaluation information and understands that the Department will monitor, audit, and evaluate service and records. Reporting will be as required by the Bureau. Monitoring may include but is not limited to:
1. On site visits to providers including inspection of client files, fiscal records, and interviews with program staff, contractors, etc..
2. Telephone monitoring of service via contacts with providers and a sample of clients receiving service.
3. Compliance and Performance Measure reviews.
4. Periodic audits.
5. Unannounced visits.
6. Desk Reviews.

c) Records.
Record retention requirements can be found in CFR 200.333.
Regulations, Guidelines, Literature
Funding By Fiscal Year
FY 2017 : $286,000
FY 2018 : $271,700
FY 2019 : $271,700
Federal Funding
Notice of Funding Opportunities
Agency IDGrantee NameStart DateEnd DateAmount
FCSYR04839-FCSYR04839WESTSIDE HEALTH AUTHORITY07/01/201906/30/20201,000,000