850-Comprehensive Class Member Transition Program
CSFA Number: 444-22-2211
Agency Name
Department Of Human Services (444)
Agency Identification
DMH
Agency Contact
Barb Roberson
217-557-5876
barb.roberson@illinois.gov
Short Description
Scope of Services

Under the Comprehensive Class Member Transition Program, Grantees will be responsible for providing oversight and care management of the entire process entailed with transitioning Class Members to Community-Based Settings, including ensuring adequate supports are in place post-transition for the Class Member to safely and successfully remain in the community. The Grantees will be responsible and accountable for the entirety of the transition process for Class Members from Outreach through Transition and beyond, including that it will be seamless, with limited handoffs and safe.

Grantees will be responsible for orchestrating the necessary resources, building organizational capacity, entering into partnerships with subgrantees, if needed, and developing efficient processes to mitigate unnecessary delays and effectuate safe transitions for Class Member. Under the Program, Grantees are required to provide a broad array of services/activities and supports that are essential to timely and efficiently facilitating a Class Member's move from the Nursing Facilities (NFs) or Specialized Mental Health Rehabilitation Facilities (SMHRFs)/Institutions for Mental Disease (IMDs) to the community. Grantees may either directly provide all activities, services, and supports, or utilize subgrantee relationships, either in whole or in part, but Grantees will remain responsible for ensuring all activities, services, and supports are provided in a seamless manner. These transitional activities complement the treatment support and services that Class Members will be provided to move toward individual recovery and to live successfully in the community.
Subject Area
Human Services
Program Function
Health
Enabling Legislation
Mental Health Community Services Act (405 ILCS 30/)

20 ILCS 1705 Sect. 73(a)
Objectives and Goals
Scope of Services

Under the Comprehensive Class Member Transition Program, Grantees will be responsible for providing oversight and care management of the entire process entailed with transitioning Class Members to Community-Based Settings, including ensuring adequate supports are in place post-transition for the Class Member to safely and successfully remain in the community. The Grantees will be responsible and accountable for the entirety of the transition process for Class Members from Outreach through Transition and beyond, including that it will be seamless, with limited handoffs and safe.

Grantees will be responsible for orchestrating the necessary resources, building organizational capacity, entering into partnerships with subgrantees, if needed, and developing efficient processes to mitigate unnecessary delays and effectuate safe transitions for Class Member. Under the Program, Grantees are required to provide a broad array of services/activities and supports that are essential to timely and efficiently facilitating a Class Member's move from the Nursing Facilities (NFs) or Specialized Mental Health Rehabilitation Facilities (SMHRFs)/Institutions for Mental Disease (IMDs) to the community. Grantees may either directly provide all activities, services, and supports, or utilize subgrantee relationships, either in whole or in part, but Grantees will remain responsible for ensuring all activities, services, and supports are provided in a seamless manner. These transitional activities complement the treatment support and services that Class Members will be provided to move toward individual recovery and to live successfully in the community.

Transition Services and the ancillary services outlined under this grant, are the means to ensure that all efforts necessary to facilitate transitions to the community occur and that they occur under a vision of unified and/or coordinated attention. The services that Grantees will be required to deliver under this grant include, but are not limited to, the following:

Primary Services:
•Outreach to Class Members still residing in Nursing Facilities (NFs) or Specialized Mental Health Rehabilitation Facilities (SMHRFs) to inform them of their rights to seek transition services under both the Williams and Colbert Decrees;
•Resident Reviews/Evaluations of Class Members to determine appropriateness for transition to a Community-Based Setting based on Consent Decrees' mandates;
•Transition coordination, including: ?Provision of transition-related services to Class Members still residing in SMHRF/NF as identified in their Comprehensive Service Plan, including but not limited to skill building for Activities of Daily Living and treatment interventions (i.e. Substance Use, trauma, individual therapy treatments);
?The ability to interface with landlords and/or property management entities, who may have potential rental properties available;
?Conducting preliminary visits across vast geographic areas as a means of scouting appropriate rental units;
?Travel to a NF or SMHRF/IMD and transport of Class Members as they navigate housing searches;
?Accompanying Class Members as they make decisions to purchase household needs;
?Facilitating moving furniture and setting up the household are all necessary and functional resource requirements to make the transition from the NFs or SMHRFs/IMDs possible; and
Assuring continuity of Health Care/Services and doctors' appointments;
Timely transfer of benefits/entitlements, accompanying class members to the Social Security Administration (SSA) to change payee status and Local Offices to activate Medicaid.


Ancillary Services:
•SSI/SSDI Outreach Access and Recovery (SOAR);
•Integrated Healthcare (including nursing care and occupational therapy);
•Transition Fund availability and administration;
•Flexible funding; and
•Medicaid Spenddown buy-in capability for Class Members with a Spenddown.

Capacity & Quality Assurance Services:
•Quality Assurance staff to serve as a liaison to IDHS to monitor and report quality of care and outcomes.
•Secure adequate service capacity to support safe and successful Class Member transitions and tenure in the community, by any means appropriate, including, but not limited to staff retention bonuses/incentives.
•Use of grant funds to cover costs not covered by Medicaid to create new or expand existing ACT or CST teams for Class Members requiring these levels of care, this includes start-up costs for these Medicaid-billable services.

Services That Are Not Delivered, But Still Must Be Coordinated Under the Grant:

There are multiple support services that are funded outside of this grant but may be necessary for Class Member transitions and community living. Grantees will be responsible for coordinating delivery of any such services to Class Members. The potential services that grantees will be expected to coordinate but which are not covered under this grant include, but are not limited to, the following:
•Medicaid-billable services, including but not limited to: ?Case management transition and linkage activities, case management mental health, ACT, CST, etc. (as appropriate for class members with serious mental illness);
?In-Home waiver services; and/or
?Substance use waiver services.

Regardless of the funding source for the multiple supports necessary for Class Member success, Grantees will provide care coordination for the full array of complimentary services provided to the Class Member.

Deliverables

Outreach Deliverables

Outreach services are required to educate and inform each Class Member of their rights under the Williams and/or Colbert Consent Decrees and the opportunities and resources available to them should they explore transition to a Community-Based Setting. The Grantee will deliver the following Outreach services (of which there is a preference for peer-based provision of such, i.e. individuals with lived recovery experience and/or individuals who have successfully transitioned from a SMHRF or NF to a Community-Based Setting):
1.Schedule and hold at least one initial, individual face-to-face meeting with each consenting resident of the Nursing Facility (NF) or Specialized Mental Health Rehabilitation Facility (SMHRF)/Institute for Mental Disease (IMD) to: (1) Provide literature and brochures on integrated Community-Based living options and support services; (2) Show videos about prior SMHRF/NF residents who have successfully transitioned into the community; and (3) Identify relevant services and supports available to the Class Member to encourage the Class Member to explore transition options and to ensure safe and successful transitions. Repeat meetings will be held if requested by the Class Member, as often as desired;
2.Provide information to residents of NFs or SMHRFs/IMDs during the first face-to-face meeting, or as requested, on the array of Health Services and supports, by defining and explaining terms such as (but not limited to) ACT, CST, medication administering and monitoring, representative payee services, supportive employment, adaptive equipment, housing modification, peer support, physical wellness, and Psycho-Social Rehabilitation
3.Build rapport with facility staff to facilitate Class Member access and engagement;
4.Use innovative ways to engage populations outside of these deliverables;
5.Take Class Members into the community to observe different settings, such as housing options or Drop-In Centers, as appropriate;
6.At least quarterly (once every three months), re-engage Class Members who decline outreach or consent for the Resident Review/Evaluation assessment or who decline to consider moving forward with transition, if found appropriate for community re-integration;
7.Hold informational question and answer sessions with Class Members as often as requested to address the array of community resources for living in the community and how they are obtained;
8.Convene quarterly community meetings and/or community forums in the NFs or SMHRFs/IMDs to share information on transition options with larger audiences;
9.Engage Class Members' family members and/or guardians in ongoing discussions about transition/moving from NF or SMHRF/IMD to the least restrictive Community-Based Setting; Discussions should include providing information regarding housing options, available services and supports and other transition information, and addressing family/guardian concerns about the process;
10.Explain to Class Members and family or guardians the "Next Steps" in the ongoing implementation processes of the Williams and Colbert Consent Decrees, as requested;
11.For those Class Members who express an interest in transition, provide a warm hand-off to the Resident Review/Evaluation staff to obtain consent for Evaluation;
12.Document the outcome of each outreach interaction with Class Members;
13.Provide a written "menu" of services, supports, and housing that Class Members are eligible to be considered for.

Resident Review/Evaluation Deliverables

Any Class Member who consents to the transition process during Outreach will be provided with a Resident Review/Evaluation to determine their appropriateness for transition. Resident Reviews/Evaluations are thorough clinical and functional assessments of a Class Member's appropriateness for transition to a Community-Based Setting.

Initial Resident Review/Evaluations take place once a Class Member has agreed to explore transition. In addition, all Class Members must be offered the opportunity for a Resident Review/Evaluation or have an updated Resident Review/Evaluation completed annually. Class Members may also request additional Resident Review/Evaluations up to four times each year (quarterly).

In order to effectuate Evaluations, the Grantee will ensure the availability (including through existing staff or through hiring) of a full complement of licensed, clinical professionals to conduct (i) a designated target number of initial Resident Review/Evaluations, (ii) required annual Resident Review/Re-Evaluations of previously evaluated Class Members residing in the SMHRFs/NFs served by Grantee, and (iii) quarterly Resident Review/Evaluations upon request.

The Grantee will:
1.Maintain a full array of LPHAs, LCSW/LCPCs, RNs, and other clinically-trained staff with expertise in Health Care/Services to conduct the Resident Reviews/Evaluations;
2.Complete medical record reviews of Williams and Colbert Class Members for initial and annual/quarterly Resident Review/Evaluations;
3.Approach Williams and Colbert Class Members to obtain consent to conduct Resident Review/Evaluations through warm hand-off from Outreach staff;
4.Conduct and complete strengths-based Resident Review/Evaluations on consenting Class Members (initially, annually, and/or quarterly upon request);
5.Submit full, completed Resident Review/Evaluation to IDHS for data input within 7 business days, post-completion; and
6.Ensure staff participate in hosted/scheduled training sessions, webinars, and/or teleconferences.

Resident Review/Evaluations will include:
1.Preparation time to review the medical record;
2.Phone or face-to-face discussions with collateral contacts (family, friends, and/or guardians), as well as key facility staff (Director of Nursing, Social Services, administrator, etc.) to obtain information about the Class Member;
3.Face-to-face interviews with Class Members, using the established Resident Review/Evaluation tool; and
4.Complete full clinical write-ups with transition-related recommendations. Each reviewer is expected to produce (at a minimum) one completed, full Resident Review/Evaluation, per business day.

SSI/SSDI Outreach, Access, and Recovery (SOAR) Deliverables

Class Member income required to maintain community tenure is largely through SSI/SSDI. As such, it is imperative that Class Members are provided resources for SSI/SSDI applications to increase the likelihood of eligibility approval. Each Grantee will designate Social Security Specialists (SSS) through hiring or redistribution of staffing, who will facilitate full activities of Social Security benefits applications.

The Grantee will:
1.Hire or identify existing SSS staff who meet the following qualifications: (1) 21 years of age or older; (2) have a valid Driver's License; and (3) have a BA/BS from an accredited institution of higher learning.
2.All SSS staff must complete SOAR training within 40 days of full execution of the grant agreement or individual hire date, whichever is later.
3.All SSS staff will be required to participate in a statewide learning collaborative to share ideas and successful strategies with other SOAR providers.
4.Determine the exact case load volume for each SSS, using the formula of an estimated 40 hours for completion of one SSA application. At a minimum, each SSS will have no less than a caseload of 7-10 cases.
5.In the event the number of Class Members in a SSS caseload drops below the threshold of 7-10 cases and there are not existing Class Members in need of SSS services, the SSS will be used to perform other functions/duties (non-Medicaid billable) related to transitioning Class Members from SMHRF/NF, including but not limited to providing assistance with Housing Search, purchasing household items, and assisting with actual transition and apartment set up.

Transition Coordination Activity Deliverables

Once a Class Member has been approved for transition through a Resident Review/Evaluation, the Grantee will be required to engage in Transition Coordination Activities to enable the Class Member to transition to a Community-Based Setting. Certain of these Activities are universal for all transitions, and others are specific to individual Class Member needs. Activities range from skill building and treatment interventions to housing searches, coordination of ongoing services and supports and any other activity to assist the Class Member in a successful transition.

Each Grantee will designate transition coordination staff through hiring or redistribution of staffing, who will facilitate full activities of transition coordination for the agency as a supplement to the job duties of direct care clinicians. Such activities include:

Pre-Transition
1.Provision of transition-related services to Class Members still residing in SMHRF/NF as identified in their Comprehensive Service Plan, including but not limited to skill building for Activities of Daily Living and treatment interventions (i.e. Substance Use, trauma, individual therapy treatments);
2.Identify and navigate affordable housing stock through relationship building with landlords and property management companies (Note: Not more than 25% of the units in a multi-unit building can be identified for use by Williams or Colbert Class Members and not more than 50% of the units in a 4-5-unit building can be identified for use by Williams or Colbert Class Members);
3.Maintain an update an active listing of available property listings for Class Member utilization;
4.Identify appropriate housing options in the area of Class Member's geographical preference;
5.Accompany Class Members on housing searches for potential apartments. Transition staff are required to show Class Members no less than 3 separate units to choose from during the housing search process;
6.Complete other related activities associated with securing independent housing;
7.Arrange for durable medical equipment and home and Community-Based waiver services with Medicaid Managed Care health plan support, as appropriate;
8.Facilitate transfer of medications and linkages with primary healthcare, medical specialists, pharmacies, managed care organizations, and ancillary services/supports, as appropriate;
9.Facilitate service planning, completion of transition checklist activities, and transition update meetings with the Class Member and key stakeholders and transfer the service plan of care to the post-transition team;
10.Assist with the purchase of household items to facilitate independent living in the community;
11.Provide Transition Assistance Funds up to $2,800 per Williams Class Member and $4,000 per Colbert Class Member. Purchases may include items such as apartment application fees, security deposits/move-in fees, utility connections, furniture, linens, bedding, dishes, household essentials, etc. (this should be built into proposed budget);
12.Provide transition fund administration activities and tracking associated with purchases to ensure accountability. Each item purchased must be tracked for each Class Member, for both Williams and Colbert Consent Decrees:
13.Provide Transition Flexible Funds to purchase interim expenses on behalf of transitioning Class Members until approved Medicaid and SSI/SSDI benefits are active. Purchases may include (but are not limited to) temporary medications, medical and testing supplies, non-covered medical equipment, past unpaid utility bills, Class Members' rent portions, food, landlord mitigation funds, and transportation expenses;
14.Provide administration activities and tracking associated with Transition Flex Fund purchases to ensure accountability. Transition Flex Fund purchases must be tracked separately from other Transition Assistance Funds for evaluation purposes. It is estimated that these funds will average $1,000 per Class Member;
15.Facilitate discharge planning with the Class Member, the staff of the NF/SMHRF, Medicaid Managed Care health plan care coordinator, and key stakeholders; and
16.Assist Class Members' actual moves from the NFs or SMHRFs/IMDs to the community.

Post-Transition
17.Facilitate the transfer of benefits and entitlements within 5 days of transition into the community;
18.Assist with Class Members applications for Supplemental Nutrition Assistance Program (SNAP) within 7 days of transitioning into the community;
19.Assist with Class Member applications for transportation assistance within 7 days of transitioning into the community.

Integrated Health Care (Nursing & Occupational Therapy) Deliverables

Registered Nurse Deliverables
1.RNs must review Class Member's medical, clinical charts and/or other pertinent documents made available by the nursing facility (NF/SMHRF/IMD) and documentation from the community health center, as appropriate for input into both Class Member Resident Review/Evaluation and Service Plan Development;
2.RNs must conduct interviews with Class Member's family members, guardians, and/or significant others, as appropriate, about the Class Member's past and present functional levels, capabilities and performances, including prior Community-Based experiences and circumstances of admissions to SMHRF/NF;
3.RNs must conduct a face-to-face interview with the Class Member, using state-of-the art batteries or appropriate assessment tools;
4.RNs must complete narrative reports on assessment outcomes with recommendations and deliver any intervention and/or skill building as needed for the Class Member to transition;
5.As appropriate, all Class Members must have a follow up visit by an RN within 7 days of an unscheduled ER visit or hospitalization while in the community;

General Health Care Deliverables
6.All Class Members must have a routine annual medical evaluation conducted by a Primary Care Physician in the community;
7.As appropriate, all Class Members scheduled for specialty Health Care visits must continue to be seen as scheduled while in the community;

Occupational Therapy Deliverables
8.Occupational Therapy Assessments must be provided for any Class Member for whom such an Assessment is recommended by the Evaluation/Resident Review;
9.Occupational Therapists must review medical, clinical charts, and/or other pertinent documents for the Class Member made available by the nursing facility (NF/SMHRF/IMD) and documentation from the Community Mental Health Center, as appropriate;
10.Occupational Therapists must conduct interviews with family members, guardians, and/or significant others, as appropriate, about the Class Member's past and present functional levels, capabilities, and performances;
11.Occupational Therapists must conduct a face-to-face interview with the Class Member using state-of-the art batteries or appropriate assessment tools; and
12.Occupational Therapists must complete narrative reports on assessment outcomes with recommendations and deliver any intervention and/or skill building as needed for the Class Member to transition.

Care Management Deliverables

Care Management staff coordinate the care and services at each step of the process for class members transitioning to the community. Grantee will maintain a full array of LPHAs-LCSW/LCPCs, RNs, and other clinically-trained staff with expertise in Health Care/Services for class member Care Management. Care Management staff must demonstrate leadership and accountability in managing a Class Member's transition. This includes but is not limited to being able to navigate changes at the system or individual level, the ability to clearly communicate with the interdisciplinary team, Class Member, supports and providers, and the ability to advocate for Class Members and resolve conflicts. Care Management staff must engage in ongoing learning and professional development and seek appropriate certifications as needed. Coordination activities include, but are not limited to the following:

Service Plans
1.Development of Comprehensive Service Plans. These plans must be developed and updated at specific intervals: a.Initial Service Plans must be completed within 45 days of a Resident Review/Evaluation. A Service Plan is required whether or not the Class Member is recommended for transition;
b.Service Plan updates are required every 180 days to identify and address any changes in the Class Member's clinical, medical or behavioral status, change in Class Member preferences and desires and any other updates related to the Class Member's transition to the Community; an
c.An update prior to transition to a Community-Based Setting must also be completed (within 14 days prior to the Class Member's move) to encompass the services and supports that will be necessary for the Class Member to successfully transition and maintain tenure in the Community.

2.The Service Plan must be person-centered, and focus on the Class Member's needs, desires and preferences. Service Pans must be based on input from both the Class Member, SMHRF/NF staff, family and guardians as appropriate, and others involved in either the care or support network of the Class Member. Documentation of the involvement of these individuals must be clearly documented in the Service Plan and be accompanied by signatures were possible.
3.Content of Comprehensive Service Plans: Comprehensive Service Plans and updates must be based on the clinical outcomes identified in the Resident Review/Evaluation, and contain information documenting the specific service, support and education needs of the Class Member necessary to prepare the Class Member for transition to a Community-Based Setting. In addition, if the Class Member was not recommended for transition, the Service Plan must identify and address the reasons transition was not recommended. Information in a Service Plan must include, but is not limited to the following: i.Functional status-the functional abilities of the Class Member, including their ability to independently perform the Activities of Daily Living, identifying any deficits and creation of a person-centered plan for improving autonomy
ii.Health status 1.Psychosocial status: the context of the combined influence that psychological factors and the surrounding social environment have on the Class Member's physical and mental wellness and their ability to function
2.Risk of harm: the likelihood and level of harm that could be caused by Class Member; factors that may mitigate against risk of harm;
3.Medication status (including medication management): Class Member's level of ability to self-manage medication regime and/or utilize added supports to manage medication regime. Requires the following: a.Listing of all medications and supplements, both prescription and non-prescriptio
b.b. Identification of barriers to Class Member adherence to their medication regime and identification of a plan to increase Class Member's ability to maintain medication regime

4.Healthcare utilization: Class Member's ability to fully utilize healthcare services in plan and being delivered; an
5.Community engagement: Class Member's ability to meaningfully engage in their social environment.
6.To ensure the Service Plans meet the standards required by the Williams and Colbert Decrees, all Service Plans must be reviewed by the Care Management staff's supervisor.

Implementation of Service Plans
5.Care Management staff are responsible for monitoring and implementing Class Member Services Plans. This requires continuous assessment of the effectiveness of the Service Plan as well as the Class Member's status, needs and preferences, to ensure changes are made where necessary to benefit the Class Member.
6.Implementation of the Service Plan requires Care Management staff conduct the following activities: a.Coach and Educate Class Member in areas identified in the Service Plan, including but not limited to the following: i.Medication management and how to adhere to a medication plan
ii.Healthy lifestyle
iii.Psychosocial needs
iv.Self-Management skills, including independently performing Activities of Daily Living;
v.Condition-specific risk reduction, management, and red flags;
vi.Understanding of provider guidelines and recommendations.

b.Collaborate with the Class Member, the interdisciplinary team, provider, health plan, and other supports to ensure the Service Plan is being appropriately followed, including but not limited to the following: i.Coordinate needed services, resources, medication and supplies;
ii.Facilitate obtaining needed supports;
iii.Manage transition planning;
iv.Facilitate provider visits and attend with the member when indicated;
v.Obtain previous health records and discharge summaries.
vi.Refer Class Member, family and other individuals to appropriate community resources and supports

c.Advocate for Class Member i.Advocate for needed services and supports;
ii.Advocate for changes to Class Member medication plan;
iii.Advocate for appropriate level of care;
iv.Educate clinicians and interdisciplinary team on Class Member needs and preferences.

Transition

Prior to a Class Member's transition from a SMHRF/NF, the Care Management staff must ensure the Service Plan, Risk Assessment and Mitigation Strategy needs for the Class Member have been appropriately provided/addressed.

In addition, the Care Management staff must complete a Transition Checklist to ensure all required activities have been completed. The Transition Checklist contains items in each of the following categories, to which the Care Management staff must document completion of pre-transition actions:
1.Personal Identification/Address Change;
2.Finances;
3.Housing/Environment;
4.Caregiver Services;
5.Diagnosis and Illnesses;
6.Providers;
7.DME/Medical Supplies;
8.Medical/Pharmacy;
9.Transportation;
10.Advance Directives/POA/Guardian;
11.Williams/Colbert Process Requirements;
12.Discharge; and
13.Other.

Post-Transition Care Monitoring

Care Management staff continue to provide services to Class Members post-transition through monitoring multiple aspects of the transition, Health Services, and supports as detailed and planned in the individual's Comprehensive Service Plan (inclusive of Health Services and supports beyond just mental health services). Monitoring is expected to include in-person visits. The minimum monitoring schedule is as follows (more frequent visits may be required based on Class Member needs): at least weekly for four weeks from initial transition;
a.at least every other week for the second- and third-months post-transition; and
b.at least monthly for the remaining nine months post-transition.

Care Management staff must document post-transition monitoring of the transition, Health Services, and supports received by Class Members, as well as the quality of the Health Services. Monitoring is to be conducted by:
a.Attendance at wholistic Health Service planning meetings (care planning, discharge planning), including Health Service team meetings;
b.Review of clinical record documentation; and
c.Through direct interview and observation of the Class Members in their living environment or other chosen location.

Incident Reports

Care Management staff are responsible for creating and transmitting to IDHS Incident Reports, to identify and report on adverse incidents involving Class Members post-transition. The reporting requirements are as follows (see Incident Report documentation for definitions):
1.Level I Incidents: Level I, or "Critical" incidents, must be reported within 24 hours.
2.Level II Incidents: Level II, or "Serious" incidents, must be reported within 48 hours.; and
3.Level III Incidents: Level III, or "Significant" incidents, must be reported within 72 hours.

Quality Assurance Deliverables

The QA staff are responsible for ensuring delivery of high-quality services and the provision of reports and data to IDHS.

Grantee will maintain LPHAs, LCSW/LCPCs with expertise in Health Care/Services for Quality Assurance. Reports and data shall be separated by consent decree and/or program. Services and reporting to IDHS will include (but not be limited to):
1.Oversight to ensure Comprehensive Service Plans are thoroughly completed, reviewed by the respective supervisors, based on the individualized needs of the respective Class Member, and include appropriate signatures demonstrating participation of appropriate individuals.
2.Monitoring the multiple aspects of the transition planning, provision of Health Services, and supports as detailed and planned in the Class Member's Comprehensive Service Plan (inclusive of Health Services and supports beyond just mental health services) for assigned Class Members.
3.Oversight of required pre-transition quality reports, including but not limited to the following: a.The completed Transition Checklist for each Class Member placed in the community; and
b.Documentation demonstrating completion of Comprehensive Service Plans and Risk Assessment and Mitigation Strategies for Individuals Transitioning into the Community, were completed prior to transition.

4.Review of documentation of the Care Coordinator's monitoring of the post-transition, Health Services, and supports received by Class Members, as well as the quality of the Health Services. Monitoring is to be conducted by: a.Attendance at Health Service planning meetings, including Health Service team meetings;
b.Review of clinical record documentation
c.Through direct interview and observation of the Class Members in their living environment or other chosen location.

5.Identify sentinel indicators for all incident reports to provide a quantitative basis for quality improvement by identifying incidents of care that trigger further investigation. Assessment of aspects of the structure, process, or outcome of health care must be completed upon notification of a Reportable Incident, within 24 hours.
6.Notification to IDHS when Class Members encounter barriers or other problems accessing or continuing to receive needed Health Services and supports.

Medicaid Spenddown Deliverables

Medicaid Spenddown is a category of eligibility; it is the process by which providers enable Class Members to meet any Medicaid spenddown.

The Grantee will facilitate completion of all necessary paperwork and supporting activities to establish the spenddown deductible prior to the Class Member moving from the NF/SMHRF/IMD. The Grantee's contract will be adjusted by the number of Class Members' monthly spenddown amounts over the HFS established threshold of $1041 (subject to change in CY 2020).

The Grantee shall, for each Class Member with a spenddown:
1.Complete the spenddown enrollment form and mailing and send to the Illinois Department of Healthcare and Family Services (HFS);
2.Obtain a signed agreement from the Class Member that designates the Grantee agency as the authorized representative payee;
3.Assist the Class Member in applying for Affordable Care Act (ACA) Adult Medicaid to determine Medicaid eligibility, if not completed by the NF/SMHRF/IMD;
4.Monitor monthly Medicaid allowable bills incurred to determine if these bills are sufficient to meet spenddown; and
5.Make payment to HFS no later than the 20th day of the month to ensure continuation of spenddown.

Grantee Service Capacity Deliverables

The Grantee shall ensure staffing levels are adequate to transition ALL Class Members who have chosen to reside in the Grantee's geographic coverage area for Consent Decree services. This may include but is not limited to the following: provision of appropriate wages, hiring bonuses, performance-based annual bonuses, and funding non-Medicaid costs associated with ensuring appropriate Assertive Community Treatment and Community Support Team capacity.

Reporting Requirements:
1.Financial Report in accordance with Exhibit C.
2.Performance Report in accordance with Exhibit E.

Payment

For at least the initial term of the Agreement (February 1, 2020 to June 30, 2020), the Department will use an advance and reconciliation method of payment. Grantees are to begin serving individuals immediately. Expenditures are to be in accordance with the detailed budget submitted by the Grantee, as part of their response to the RFA. Subsequent to the initial advance the Grantee will receive additional prospective payments based on a reconciliation of the funds advanced to the funds being requested. Expenditures incurred for the purchase of allowable goods and services necessary for conducting program activities shall be documented in a manner prescribed by the Department. Unexpended funds will be returned to the Department, per the Grant Funds Recovery process. Grantees will be assigned a transition target based on their RFA response and Department's Consent Decree requirements. In the event these targets are not met, the Department reserves the right to withhold a proportionate amount of funding, up to and including an amount equivalent to the deficiency, based on performance requirements not being met. Providers who exceed their transition targets will be eligible for a performance-based incentive payment, and during the grant extension period additional performance-based incentives may be available to provider who demonstrate extended and continuous community tenure post-transition.

Grantees who attest that they have adequate financial management systems, pursuant to State and Federal Regulations, may continue to use an advance and reconciliation method of payment for the term extension (July 1, 2020 to June 30, 2021). Grantees whose financial management systems do not meet State and Federal Requirements will receive working capital on an ongoing basis for the term extension.

See Uniform Grant Agreement, Article IV Payment, Section 4.2 Return of Grant Funds and 4.3 Cash Management Improvement Act of 1990. Payment will be issued monthly and reconciled with reported allowable expenses. Grantee shall submit a quarterly Periodic Financial Report (GOMBGATU-4002 (N-08-17)) to the appropriate email address below no later than November 1, February 1, May 1, and August 1. Reported expenses should be consistent with the approved annual grant budget. Any expenditure variances require prior Grantor approval in accordance with Article VI of the Uniform Grant Agreement to be reimbursable.
PFR Email Address for General Grants:
IDHS.DMHQuarterlyReports@illinois.gov
PFR Email Address for Williams Consent Decree:
IDHS.DMHWilliamsInvoices@Illinois.gov
PFR Email Address for Colbert Consent Decree:
AGING.COLBERT.INVOICES@ILLINOIS.GOV

DMH reporting templates and detailed instructions for submitting reports can be found in the Provider section of the IDHS website.

Contact for Notification (Populated with contact information at time of Award)

Performance Measures and Reporting

The Grantee shall submit quarterly Periodic Performance Report (GOMBGATU-4001 (N-08-17)) and the Periodic Performance Report Template by Program (PRTP) to the appropriate email address below no later than November 1, February 1, May 1, and August 1. Reporting templates and instructions for submitting reports can be found in the Provider section of the IDHS website.
PPR and PPRT Email Address for All Grants:
IDHS.DMHQuarterlyReports@illinois.gov

The following data reporting requirements are included in the reporting template. Data reported should, unless otherwise noted, be limited to quarterly data only, not cumulative.

Outreach:

Please note, unless otherwise specified, all Outreach reporting must contain unduplicated figures for both existing Class Members (current, post 60-day SMHRF/NF residents) and new Class Members (newly admitted to a SMHRF/NF, within previous 60 days).
1.Number of unduplicated Class Members engaged at the respective NFs or SMHRFs in Outreach activities.
2.Number of interested newly admitted Class Members to SMHRFs and NFs who had a face to face contact by Outreach, within 60 days post admission.
3.Number of Class Members interested in a follow up Outreach contact.
4.Number of Class Members interested in a follow up Outreach contact in which they received the contact within 7 days.
5.Number of unduplicated Outreach Introduction Letters signed by Class Members.
6.Number of Class Members who refused to engage in Outreach discussions/refused to sign Letter of Introduction who have a documented reason for refusal.
7.Number of family members or Guardians engaged in conversation with Outreach staff about the Consent Decrees.
8.Number of Community meetings held in the NFs or SMHRFs.
9.Number of Class Members who have had a Quality of Life Survey while residing in a SMHRF/NF.

Resident Review/Evaluations:

Please note, unless otherwise specified, all Resident Review/Evaluation reporting must contain unduplicated figures for both existing Class Members (current, post 60-day SMHRF/NF residents) and new Class Members (newly admitted to a SMHRF/NF, within previous 60 days).
1.Number of full/part-time staff currently employed, who meet credentials as a Resident Review/Evaluator;
2.Number of unduplicated Class Member records reviewed in preparation for completing a Resident Review/Evaluation;
3.Number of unduplicated Class Members approached for consent for a Resident Review/Evaluation;
4.Number of unduplicated Class Members who agreed to and scheduled a Resident Review/Evaluation;
5.Number of unduplicated Class Members approached/initiated for a Resident Review/Evaluation but who refused to be assessed;
6.Number of unduplicated Class Members for whom a full Resident Review/Evaluation was completed;
7.Number of duplicated Class Members for whom a full Resident Review/Evaluation was completed;
8.Number of unduplicated Class Members who consent/begin but end the Resident Review/Evaluation before completion;
9.Number of unduplicated Class Members with a completed Resident Review/Evaluation who were recommended for transition;
10.Number of unduplicated Class Members with a completed Resident Review/Evaluation who were recommended for transition to a non-PSH setting;
11.Number of unduplicated Class Members with a completed Resident Review/Evaluation who were not recommended for transition, including identification of the reason for the not recommended outcome;
12.Number of Resident Review/Evaluation outcomes submitted to IDHS; and
13.Number of unduplicated staff participating in IDHS-hosted trainings, teleconferences, or webinars.

SSS/SOAR
1.Number (total) of Class Members on the SOAR roster as of the end of the quarter.
2.Number of Class Members referred and actively engaged with the Grantee added to the SOAR roster.
3.Number of new Class Members (i.e. not previously engaged with the Grantee) referred to SOAR.
4.Number of new referrals to SOAR, assessed and engaged by the Social Security Specialist(s) within seven (7) days of referral to SOAR.
5.Number of new referrals to SOAR, assessed and engaged by the Social Security Specialist(s) after seven (7) days of referral to SOAR.
6.Number of new SOAR applications completed and submitted by the agency to SSA within 48 hours post-completion.
7.Number of new SOAR applications completed and submitted by the agency to SSA past 48 hours post-completion.
8.Number of SOAR applications submitted for protective filing dates that are completed and submitted to SSA within 60 days of referral.
9.Number of SOAR applications which received a determination status during the quarter.
10.Number of SOAR applications approved for benefit (SSI/SSDI) during the quarter.
11.Number of SOAR applications denied benefits (SSI/SSDI) during the quarter.
12.Number of SOAR applications returned to the agency on behalf of Class Member with an SSA determination status of no documented disability/ineligible during the quarter.
13.Number of SOAR applications for which a 1st appeal was submitted to SSA within two weeks of the stamped SSA 1st denial letter date.
14.Number of SOAR applications for which a 1st appeal was submitted to SSA more than two weeks after the stamped date of the SSA denial letter.
15.Number of SOAR applications for which a 2nd appeal was submitted to SSA within two weeks of the stamped date of the SSA 1st appeal denial letter.
16.Number of SOAR applications for which a 2nd appeal was submitted to SSA more than two weeks after the stamped date of the SSA 1st appeal denial letter.
17.Number of initial applications pending as of the end of the quarter.
18.Number of 1st appeals pending as of the end of the quarter.
19.Number of 2nd appeals pending as of the end of the quarter.

Transition Coordination Activities

Pre-Transition
1.Number of unduplicated Class Members assigned to the Grantee for transition coordination during the quarter.
2.Number of unduplicated Class Members' assignments received by transition coordination staff within 14 days of intake.
3.Number of Class Members with first contact occurring within seven (7) business days of receipt of the assignment by transition coordination staff.
4.Number of Class Members with initial contact more than seven (7) business days from receipt of the assignment by transition coordination staff.
5.Number of Class Members who refuse transition coordination activities after assignment.
6.Number of Class Members whose documented refusal of transition coordination activities was transmitted to the IDHS Consent Decrees' designated contact.
7.Number of the Class Members' Comprehensive Service Plans of Care which include the findings and recommendations of the Resident Review/Evaluation assessment
8.Number of consenting Class Members engaged in a housing search during the following time frames: a.Within two weeks of initial contact;
b.Between two weeks and two months after initial contact;
c.Between two months and four months after initial contact; an
d.More than four months after the initial contact.

9.Total number of Class Members engaged in housing search as of the end of the quarter.
10.Number of Class Members assisted with transferring benefits/entitlements from the NF or SMHRF prior to transition.
11.Number of Class Members assisted with linkages to primary Health Care.
12.Number of Class Members accompanied to purchase basic household items/supplies.
13.Number of completed Transition Checklists.

Post-Transition
14.Number of Class Members assisted with moving from the NF or SMHRF to the community.
15.Number of Class Members who received flexible funding up to $1,000.
16.Number of Class Members who received flexible funding over $1,000.

Integrated Health Care (Nursing & Occupational Therapy)

Registered Nurse
1.Number of Class Member health assessments scheduled by RN.
2.Number of unduplicated Class Member health assessments which included interviews scheduled and/or completed with family and significant others.
3.Number of physical health assessments completed by RN.
4.Number of physical health assessments completed on-site by RN.
5.Number of unduplicated Class Members who refuse to complete the physical health assessment.
6.Number of Class Members whose assessment was terminated prior to completion by the clinician due to Class Member distress or other symptoms.
7.Number of Class Members assessed and recommended for community transition by RN.
8.Number of Class Members assessed and not recommended for community transition by RN.
9.Number of unduplicated Class Members seen by an RN as part of Integrated Health Care staff during the first 30 days, post-transition from the NF/SMHRF/IMD.
10.Number of Class Members who had an unscheduled ER visit seen for a follow up visit by the RN within three days of the ER visit.
11.Number of Class Members whose ER visit resulted in a Health Care hospitalization who were seen by the RN within three days, post-discharge.
12.Number of Class Members who did not consent to an RN visit after hospitalization discharge or ER visit.
13.Number of Health Care consultations attempted by RN for Class Members who did not consent to an RN visit after hospitalization or ER visit.

General Health Care
14.Number of unduplicated Class Members referred to Integrated Health Care staff.
15.Number of Class Members with high-risk health challenges (serious mental illness with a high level of acuity together with co-morbid medical condition(s) and high service needs).
16.Number of Class Members with high risk health challenges seen on a weekly basis by an RN for nursing assessments (blood pressure checks, blood sugar, weight, etc.).
17.Number of Class Members scheduled for routine annual Health Care evaluation visits.
18.Number of Class Members scheduled for specialty Health Care visits.
19.Number of Class Members scheduled for specialty Health Care visits seen in the scheduled month.
20.Number of Class Members who had an unscheduled ER visit.
21.Number of Class Members whose ER visit resulted in a Health Care hospitalization.

Reportable Incidents
22.Number of Reportable Incidents due to Class Member Health Care complications.
23.Number of Reportable Incident forms submitted for all incidents due to Health Care complications.
24.Number of Reportable Incidents due to death.
25.Number of Reportable Incident forms submitted for incidents due to death.

Occupational Therapy
26.Number of Class Members referred for an OT assessment.
27.Number of OT assessments scheduled.
28.Number of interviews scheduled with family and significant others related to OT assessments.
29.Number of OT assessments completed.
30.Number of OT assessments completed on-site.
31.Number of Class Members who ended completion of the assessment.
32.Number of Class Members whose OT assessment was stopped by the clinician due to distress or other symptoms.
33.Number of Class Members assessed and recommended for community transition by OT.
34.Number of Class Members assessed and not recommended for community transition by OT.

Care Management
1.Total Number of Class Members served by Grantee as of the end of the quarter.

Service Plans
2.Number of Comprehensive Service Plans adequately completed, reviewed by the respective supervisors, based on the individualized needs of the respective Class Member, including input from other stakeholders involved in care, and including appropriate signatures of participation.

Transition
3.Number of completed Transition Checklists for each Class Member transitioned to the community;
4.Number of Comprehensive Service Plans and Risk Assessment and Mitigation Strategies for Individuals Transitioning into the Community completed with appropriate documentation prior to the Class Member's transition to the community.
5.Number of Class Members during this quarter who were within four weeks post-transition to the community.
6.Number of Class Members who received a weekly visit from the care manager for the first four weeks, post-transition to the community.
7.Number of Class Members during this quarter who were within their second- and third-months post transition to the community.
8.Number of Class Members who received a bi-weekly visit from the care manager during the second and third months, post-transition.
9.Number of Class Members during this quarter who were within their fourth through twelfth month post-transition.
10.Number of Class Members who received a monthly care manager's visit during the fourth through twelfth month, post-transition.

Reportable Incidents
11.Number of Reportable Incidents.
12.Number of completed Reportable Incident forms, within the required time frame (24 hours for Level I, 48 hours for Level II and 72 hours for Level III).
13.Number of completed Reportable Incident forms outside the required time frame (identified by Level)

Quality Assurance
1.Number of Class Members assigned to the agency.
2.Number of Class Members whose Comprehensive Service Plans were monitored in accordance with IDHS policies and expectations.
3.Number of Class Members for whom Quality Administrators have provided oversight for routine quality reports, including a completed Transition Checklist for each Class Member placed in the community, and documentation of completed Comprehensive Service Plans and Risk Assessment and Mitigation Strategies for Class Members transitioning to the Community, completed prior to transition.
4.Number of sentinel indicators reviewed and reported on within 24 hours of notification of a Reportable Incident.

Medicaid Spenddown
1.Total number of unduplicated Class Members with a current spenddown.
2.Total number of unduplicated Class Members with a current spenddown added during the quarter.
3.Total number of unduplicated Class Members requiring assistance with meeting their Medicaid spenddown.
4.Number of unduplicated Class Members requiring assistance with meeting their Medicaid spenddown who have a monthly household income of $1041 of less.
5.Number of Class Members with a monthly spenddown with deductible amounts of less than: a.$100
b.$200
c.$300
d.$400
e.$500

6.Number of Class Members whose monthly spenddown amount is between $501-600 per month.
7.Number of Class Members whose monthly spenddown amount is greater than $601.
8.Number of Class Members with sufficient expenses incurred each month that can be applied to offset the monthly spenddown amount.
9.Number of Class Members with monthly spenddown who maintain continuous engagement with mental health service.
10.Number of Class Members with monthly spenddown who may self-terminate (the spenddown advance is canceled) from mental health services in the reporting period.
11.Number of Class Members on spenddown for whom the agency is serving as their representative payee.

Grantee Service Capacity
1.Amount, if any, paid in sign-on or retention (specify which) bonuses for: a.Registered Nurses
b.Occupational Therapists
c.MHP's/QMHP's
d.LPHA's
e.SOAR Staff
f.Other


ACT
2.Current ACT capacity.
3.Number of current ACT staff.
4.Quarterly expansion of ACT capacity, if applicable.
5.Number of ACT staff added during quarter if applicable.
6.Current number of Class Members appropriate for ACT level of care.
7.Number of Class Members newly determined to be in need of ACT level of care during the quarter.

CST
8.Current CST Capacity.
9.Number of current CST staff.
10.Quarterly expansion of CST capacity, if applicable.
11.Number of ACT staff added during quarter if applicable.
12.Current number of Class Members appropriate for CST level of care.
13.Number of Class Members newly determined to be in need of CST level of care during the quarter.

Nursing
14.Current nursing capacity.
15.Number of current nursing staff.
16.Nursing capacity expansion during the quarter, if applicable.
17.Number of nursing staff added during quarter if applicable.
18.Current number of Class Members appropriate for nursing care.
19.Number of Class Members newly identified as in need of nursing care during the quarter.

Occupational Therapy
20.Current Occupational Therapy capacity.
21.Number of current Occupational Therapy staff.
22.Expansion of Occupational Therapy capacity during the quarter, if applicable.
23.Number of Occupational Therapy staff added during quarter if applicable.
24.Current number of Class Members appropriate for Occupational Therapy.
25.Number of Class Members newly determined to be appropriate for Occupational Therapy during the quarter.

SSS/SOAR
26.Current Social Security Specialty/SOAR capacity.
27.Number of current SSS/SOAR staff.
28.Social Security Specialty/SOAR capacity expansion during the quarter, if applicable.
29.Number of SSS/SOAR staff added during quarter if applicable.
30.Current number of Class Members appropriate for Social Security application support.
31.Number of Class Members newly identified as in need of SSS/SOAR services during the quarter.

Performance Standards

Performance Standards are the minimum expected grantee/subgrantee performance for each enumerated item.

Outreach
1.100% of interested, newly-admitted Class Members to NFs and SMHRFs had a face-to-face contact by Outreach within 90 days, post admission.
2.100% of unduplicated Class Members interested in a follow-up contact with an Outreach Worker were engaged by Outreach staff within 7 days of request.
3.100% of unduplicated Class Members were asked to sign an Outreach Introduction letter.
4.100% of Class Members who refuse to sign an Outreach Introduction letter had a notation on the letter identifying the reason for their refusal.
5.100% of Class Members reporting issues or concerns regarding transition had a follow up contact completed by an Outreach Worker within seven (7) days.
6.100% of guardians or family members interested in speaking with Outreach Workers were contacted/engaged by Outreach staff.
7.100% of NFs or SMHRFs had a quarterly community meeting.
8.90% of Class Members referred to for completion of a Quality of Life Survey had a Quality of Life Survey completed prior to transition.

Resident Review/Evaluations
1.90% of Resident Review/Evaluation staff will be appropriately credentialed with full/part-time employment, per contract agreement, at all times;
2.100% of records of Class Members assigned for Resident Review/Evaluation will be reviewed in preparation for the Resident Review/Evaluation;
3.100% of Class Members identified will be approached for consent to complete the Resident Review/Evaluation;
4.100% of Class Members approached for Resident Review/Evaluation after a positive Outreach response who subsequently refuse to consent to a Resident Review/Evaluation, have the refusal documented, including identifying any reason provided by the Class Member;
5.80% of consenting, unduplicated, Class Members had a Resident Review/Evaluation completed;
6.80% of consenting, duplicated, Class Members (including Class Members with multiple Resident Review/Evaluations due to a positive Appeal outcome) had a Resident Review/Evaluation completed within 14 days of the Appeal outcome or request for another Resident Review/Evaluation (subject to the quarterly limitations); and
7.100% of Resident Review/Evaluation outcomes were submitted to IDHS.

SSS/SOAR
1.100% of Class Members identified as having "no income" - SSI/SSDI - (excluding those with an undocumented status) during the quarter were assigned to the agency's SOAR roster.
2.100% of Class Members referred to SOAR were actively engaged by the Grantee during quarter.
3.100% of all new referrals to SOAR assessed (within 7 business days) and engaged by the Social Security Specialist(s).
4.100% of SOAR applications completed and submitted to SSA within 48 hours, post completion.
5.100% of SOAR applications submitted for protective filing dates completed within 60 days of referral to SSS/SOAR.
6.100% of SOAR applications submitted to and acted upon by SSA obtained a determination status (i.e. none determined to be incomplete).
7.100% of SOAR applications submitted, captured, and categorized based on SSA's final determination status, i.e., approved, denied, no documented history.
8.100% of SSA applications denied were repackaged for a 1st appeal within two weeks of the 1st SSA denial stamped letter date.
9.100% of SOAR applications have initial and outcome information entered into SOAR-OAT (national database)
10.100% of SSA applications denied after the 1st appeal was repackaged for a 2nd appeal within two weeks of the date of the SSA letter denying the 1st appeal.

Transition Coordination

Pre-Transition
1.100% of unduplicated Class Members' assignments received by transition coordination within seven (7) days of intake.
2.100% of Class Members contacted within 7 business days after receipt of assignment.
3.100% of Class Members who refuse transition coordination activities are documented and identified to the Consent Decrees' designated contact.
4.100% of the Class Members' Comprehensive Service Plans of Care will include the findings and recommendations of the Resident Review/Evaluation assessment.
5.100% of consenting Class Members are engaged in a housing search.
6.100% of Class Members are assisted in linkage to primary Health Care.
7.100% of Class Members are accompanied to purchase basic household items.
8.100% of consenting Class Members have their benefits/entitlements transferred from the facility prior to transition.

Post-Transition
9.100% of Class Members are assisted in relocation from the NF or SMHRF to the community.

Integrated Health Care (Nursing & Occupational Therapy)

Nursing
1.100% of Class Members with high risk health challenges seen weekly by RN for nursing assessments (blood pressure checks, blood sugar, weight, etc.).
2.100% of Class Members who had an unscheduled ER visit had a follow up visit by the RN within three days after the ER visit.
3.100% of Class Members whose ER visit resulted in a Health Care hospitalization were seen by the RN within three days, post discharge.
4.100% medical consultations were attempted for any Class Member who did not consent to an RN visit after hospitalization or ER visit.

General Health Care

Pre-Transition
5.100% of the Class Members referred for a physical health assessment were scheduled.
6.90% of health assessments initiated were completed.
7.50% of interviews where family or significant others were contacted.
8.100% of health assessments completed on-site.
9.No more than 20% of health assessments will be aborted by Class Members prior to completion.
10.No more than 5% of health assessments will be aborted by the clinician.

Post-Transition
11.100% of unduplicated Class Members referred to Integrated Health Care staff seen during the first 30 days, post transition from the NF/IMD.
12.100% of Class Members scheduled with Integrated Health Care had a routine annual Health Care evaluation visit.
13.100% of Class Members scheduled for a specialty Health Care visit were seen in the scheduled month.

Reportable Incidents
14.100% all incidents due to Health Care complications had Reportable Incident forms submitted within the appropriate time period (Level I-24 hours, Level II-48 hours, Level III-72 hours).
15.100% of deaths had Reportable Incident forms submitted within 24 hours.

Occupational Therapy
16.100% of the OT assessments referred for an assessment were scheduled.
17.90% of OT assessments initiated were completed.
18.50% of interviews where family or significant others were contacted.
19.100% of OT assessments completed on-site.
20.No more than 20% of OT assessments will be aborted by Class Members.
21.No more than 5% of OT assessments will be aborted by the clinician.

Care Management

Service Plans
1.1. 100% of Comprehensive Service Plans adequately completed, reviewed by the respective supervisors, based on the individualized needs of the respective Class Member, including input from other stakeholders involved in care, and including appropriate signatures of participation.

Transition
2.100% Transition Checklists completed for each Class Member placed in the community, documentation of completed Comprehensive Service Plans and Risk Assessment and Mitigation Strategies for Individuals Transitioning into the Community, prior to transition.
3.100% of Reportable Incidents, completed within the required time frame (Level I-24 hours, Level II-48 hours, and Level III-72 hours).
4.100% of Class Members received a weekly visit from the care manager for the first four weeks, post-transition to the community.
5.100% of Class Members received a bi-weekly visit from the care manager during the second and third months, post-transition.
6.100% of Class Members received a monthly care manager's visit during the fourth through twelfth month, post-transition.

Quality Assurance
1.100% of Class Members referred to the agency will be assigned to staff for transition services.
2.100% of required quality reports and supporting documents are reviewed and submitted to IDHS within the designated time frames.
3.100% of cases assigned to the agency were processed to appropriate clinical team or program within 5 business days.
4.100% of the Class Members' Comprehensive Service Plans were monitored in accordance with IDHS policies and expectations.
5.100% of Transition Checklists completed prior to transition of Class Member to the community.
6.100% of Comprehensive Service Plan and Risk Assessment and Mitigation Strategies completed with supporting documentation prior to transition of Class Member to the community.
7.100% of sentinel events reviewed, including Reportable Incidents and Root Cause Analyses, and submitted to IDHS, within 24 hours and 72 hours, respectively, of the incident.

Medicaid Spenddown
1.98% of Class Members with spenddown have monthly household incomes at or less than $1041.
2.98% of Class Members will have monthly spenddown deductible amounts less than: a.$100
b.$200
c.$300
d.$400
e.$500

3.2% of Class Members will have monthly incomes greater than $500 but not greater than $600 per month.
4.100% of Class Members will have sufficient expenses that can be applied to offset the monthly spenddown amount.
5.90% of Class Members will maintain continuous monthly engagement with health services.
6.No more than 10% of Class Members with spenddown terminated from monthly mental health services during the period.

Grantee Service Capacity
1.Provider must have sufficient ACT team capacity to serve 100% of Class Members who are identified as requiring ACT services.
2.Provider must have sufficient CST team capacity to serve 100% of Class Members who are identified as requiring CST services.
3.Provider must have sufficient RN capacity to meet the needs of 100% of Class Members who are identified is requiring RN services.
4.Provider must have sufficient OT capacity to serve 100% of Class Members who are identified as requiring Occupational Therapy.
5.Provider must have sufficient transition coordination capacity to serve 100% of Class Members who require transition support.
6.Provider must have sufficient Social Security Specialist/SOAR capacity to serve 100% of Class Members who require Social Security application support.
Types of Assistance
Direct Payments for Specific Use
Uses and Restrictions
Sectarian Issue:

Applicant organizations may not expend federal or State funds for sectarian instruction, worship, prayer, or to proselytize. If the Applicant organization is a faith-based or a religious organization that offers such activities, these activities shall be voluntary for the individuals receiving services and offered separately from the grant program.

Reporting Mandates:

Per the Abused and Neglected Child Reporting Act (ANCRA, 325 ILCS 5/4), professionals who may work with children in the course of their professional duties are Mandated Reporters. Mandated Reporters are required to report suspected child maltreatment immediately when they have "reasonable cause to believe" that a child known to them in their professional or official capacity may be an abused or neglected child" (ANCRA Sec.4). This is done by calling the Illinois Department of Children and Family Services (DCFS) Hotline at 1-800-252-2873 or 1-800-25ABUSE. Programs funded through this grant opportunity must review ANCRA and, where appropriate, have a written protocol for identifying and reporting suspected child maltreatment.

The Applicant certifies that they are in compliance with all requirements and regulations issued pursuant to the Health Care Workers Background Check Act (225 ILCS 46).
Eligibility Requirements
Eligible Applicants:

Public or private, for-profit or not-for-profit community-based agencies, hospital systems, Federally Qualified Health Centers (FQHC), Healthcare for the Homeless Centers (HHC), and Managed Care Organizations (MCOs) are all eligible to apply for funds. (If an interested potential Applicant is unclear if they are eligible to apply or whether they fall into any of the above categories, please ask as part of the Question and Answer process.)

If a Managed Care Organization is a successful Applicant and also receives funds from the Illinois Department of Healthcare and Family Services to coordinate care for Class Members, those services cannot be duplicated under this RFA.

The funding opportunity in this RFA is not limited to those who currently receive funding from the Illinois Department of Human Services, either generally, or to currently serve Class Members.

Successful Applicants must hold all necessary licenses for the services to be delivered and populations to be served.
Eligible Applicants
Nonprofit Organizations; Government Organizations; For-Profit Organizations;
Application and Award Processing
PART I

A. Date of Issuance:

October 21, 2019

B. Issuing Organizational Unit:

Illinois Department of Human Services, Division of Mental Health

Contact Person: Barb Roberson

600 East Ash Street

Building 500, 3rd Floor

Springfield, IL 62703

barb.roberson@illinois.gov

217-557-5876

C. RFA Availability:

Copies of this Request for Applications (RFA) may be downloaded from the Illinois Department of Human Services (IDHS or the Department) web site: http://dhs.illinois.gov/olmstead/rfa.

Date, Location and Time of RFA Opening: Applications, including Budget materials submitted through CSA Tracker or, as applicable, with the application, must be received no later than 5:00 pm Central Time on Friday, December 20, 2019. The application (other than portions submitted through CSA Tracker) must be submitted via email and the office receipt time will be determine by the time and date stamp of the received email. The Department will not accept applications submitted by mail, on disk, or by fax.

Submission Instructions - Date, Time, and Delivery:

Complete Submissions include Application Packet and CSA Budget submission.

Applications are to be submitted by EMAIL only

Proposed Budgets are to be submitted through CSA Portal

DHS is not obligated to accept applications submitted in any other manner,

Applications are due on or before: December 20, 2019 at 5:00 pm Central Time.

Budget Requirements

A budget and budget narrative need to be completed in the CSA tracking database. See section F for details on how to submit. Budget is required to be submitted by December 20, 2019 at 5:00 pm Central Time and there must be separate budgets for each consent decree.

Application Package must be one document, in Adobe (.pdf) format, in the following order:
1.Uniform State Grant Application
2.Proposal Narrative (Limited to 20 pages)
3.Attachments. This should include Linkage Agreements (if applicable) and an approved Negotiated Indirect Cost Rate Agreement (NICRA).
4.All proposals must include the following mandatory forms/attachment:

a) Uniform Grant Application for State Grant Assistance Program Plan Budget (subsequent template attachment to RFA), and

b) Copy of Currently Approved Negotiated Indirect Cost Rate Agreement (NICRA).

Email Applications pages to: DHS.GrantApp@illinois.gov

Subject line of the email MUST state: Applicant Organization Name, RFA#, Applicant Organization Contact Person (ex. Abe Frohman), Region (e.g. Cook County (North)

E. Audit Submission Requirements:

The Department reserves the right to request a copy of the Applicant's most recent audited financial statements as part of its Application. The Department will use the audit to ascertain the fiscal capacity of Applicant. Requests will be made after the Application submission date.

F. Content and Form of Application Submission:

A complete Application Submission consists of the Application Package and the CSA Budget submission.

Application Package must be one document, in Adobe (.pdf) format, in the following order:
1.Each Applicant is required to complete and submit a Uniform Application for State Grant Assistance for each Consent Decree. Each application and narrative will cover all geographic areas where the potential grantee is proposing providing services. (Form IL444-22-2211) This is a 3-page document with the first page already completed by the IDHS Division of Mental Health. One application This document must be signed and dated by the Applicant.
2.Program Proposal Narrative a.The program proposal narrative shall not exceed 20 pages, single-sided. Items included as Attachments are NOT included in the page limitations. The program proposal narrative, including Attachments, must be sequentially page numbered.
b.All documents must be typed using 12-point font size and at 100% magnification.
c.The PDF submission must be on 8 1/2 x 11-inch page size. (can include tables, charts, graphics)
d.With the exception of letterhead and stationery for letter(s) of support and linkage agreements, the entire application and program proposal packet should be in black typeface on a white background. i.The program proposal narrative must be typed single-spaced with 1-inch margins on all sides.

e.Budget Requirements


Budget Requirements for February 1, 2020 through June 30, 2020
•A Budget and budget narrative need to be completed in the CSA tracking system database. A budget template can be used as a tool to assist in determining expenses; however, the final budget must be completed in the CSA Tracking System. 1.The budget narrative should describe how the specified resources and personnel have been allocated for the services and activities described in the proposal narrative.
2.The budget should be prepared to reflect the term of February 1, 2020 through June 30, 2020.
3.IDHS/DMH anticipates that any term of the agreement resulting from this RFA will be February 1, 2020 continuing through June 30, 2020. Renewal for one year (July 1, 2020 through June 30, 2021) is at the sole discretion of IDHS and will be dependent upon multiple factors including the Grantee's performance, adherence to program requirements, and the availability of funds.

•Applicants must complete two separate budgets, one for Williams Consent Decree-related expenses and a second one for Colbert Consent Decree-related expenses. When entering these budgets in the CSA tracking system, Applicants must ensure they select the appropriate suffix (i.e., WCD, CCD). A separate budget must be submitted for each Williams and Colbert Consent Decree, as they will be separate grant awards to ensure the Department tracks expenditures as required for each consent decree.

Budget Requirements for July 1, 2020 through June 30, 2021
•A Budget and budget narrative need to be completed on the DHS fillable pdf template (subsequent template attachment to RFA) and submitted with the Application and Proposal Narrative.
•The budget should be prepared to reflect the term of July 1, 2020 through June 30, 2021.
•Applicants must complete two separate budgets, one for Williams Consent Decree-related expenses and second one for Colbert Consent Decree-related expenses. A separate budget must be submitted for each Williams and Colbert Consent Decrees as they will be separate grant awards to ensure the Department tracks expenditures as required for each consent decree.

Indirect Cost Rate Requirements

Please refer to 2 CFR 200.414 regarding Indirect (F&A) Costs. To charge indirect costs to a grant, agencies must have an annually-negotiated indirect cost rate agreement (NICRA). If the agency has multiple NICRAs, DHS/DMH will accept only the lesser rate. There are three types of NICRAs:
a.Federally-Negotiated Rate;
b.State-Negotiated Rate; and
c.De Minimis Rate

G. Eligible Applicants:

Public or private, for-profit or not-for-profit community-based agencies, hospital systems, Federally Qualified Health Centers (FQHC), Healthcare for the Homeless Centers (HHC), and Managed Care Organizations (MCOs) are all eligible to apply for funds. (If an interested potential Applicant is unclear if they are eligible to apply or whether they fall into any of the above categories, please ask as part of the Question and Answer process.)

If a Managed Care Organization is a successful Applicant and also receives funds from the Illinois Department of Healthcare and Family Services to coordinate care for Class Members, those services cannot be duplicated under this RFA.

The funding opportunity in this RFA is not limited to those who currently receive funding from the Illinois Department of Human Services, either generally, or to currently serve Class Members.

Successful Applicants must hold all necessary licenses for the services to be delivered and populations to be served.

H. Technical Assistance Conference and Questions and Answers:

Technical Assistance Conference

There will be a Technical Assistance Webinar held on Wednesday, October 30, 2019 from 10:00am until 12:00pm CT. Details regarding the Webinar will be posted to the RFA webpage. The webinar and any associated Questions and Answers will be posted on the RFA site. Attendance is not mandatory.

Questions & Answers

Submit questions relating to the RFA via email to: barb.roberson@illinois.gov. All technical questions and answers will be posted on the IDHS RFA webpage http://dhs.illinois.gov/olmstead/rfa.

The site will be updated periodically, a minimum of 2 times per week. Written answers on Question& Answer page will be considered as part of the RFA.

The last day to submit a question is: December 10, 2019.

IDHS' website will be the primary source of information concerning the RFA. It is the responsibility of each Applicant to monitor that website and to comply with any instructions or requirements relating to the RFA.

I. Award Process:

The Department anticipates the availability of approximately $12,390,558 for services in FY20 (February 1, 2020 - June 30, 2020). In the event IDHS continues this funding, the FY21 (July 1, 2020 - June 30, 2021) anticipated available funding is $29,737,340. (Note: This is the anticipated, total, available funding for the services outlined in this RFA and does not include all funding under the consent decrees.)

Separate awards will be issued for the Williams Consent Decree and the Colbert Consent Decree to ensure that the Department tracks expenditures and activities as required in each consent decree.

It is anticipated that Applicants will receive notifications by the Department regarding funding decisions by January 10, 2020. A Notice of State Award (NOSA) is not equivalent to an agreement with the Department to commence providing service. Successful Applicants will receive the Uniform Grant Agreement for their signature and return it per instructions provided at the time. Work cannot begin until an agreement is signed by both the Applicant and the Department.

J. Review Panel:

Applications will be reviewed independently by a panel established by staff from IDHS, which may include Department staff familiar with the requirements of the program, personnel from other State agencies, and individuals outside State government not affiliated in any manner with the Applicants. Panel members will read and evaluate Applications independently using guidelines set by IDHS, including the scoring rubric and application content requirements, detailed below.

Each submission reviewed will receive a score based on pre-determined criteria. The Department reserves the right to consider factors other than the Applicant's final score in determining final grant recommendations. Such factors may include (but are not limited to) geographic service area, Applicant's past performance, and degree of need for service. The Department also reserves the right to ask Applicants, subject to the Applicants' agreement, to cover geographic service areas for which the Applicant did not submit an application.

K. Estimated Length of Agreement:

The Department estimates that the initial term of the agreement resulting from this RFA will begin February 1, 2020, ending June 30, 2020. At IDHS' sole discretion, the agreement for this program may be renewed for an additional one-year period. (July 1, 2020 - June 30, 2021).

L. Withdrawal Disclaimer:

The Illinois Department of Human Services may withdraw this Request for Applications at any time.

M. Modifications to Applications by Applicants:

To make modifications to an Application after it has been submitted, the Applicant must submit a complete replacement Application package, as described above under Section F - Content and Form of Application, accompanied by a letter requesting that the replacement Application be considered. This must be received in the prescribed manner by the date and time designated under Section D.

N. Modifications to the Request for Applications:

If it becomes necessary or appropriate for IDHS to change or supplement any part of the RFA, a modification to the RFA will be available on the Department's website, found at http://dhs.illinois.gov/olmstead/rfa. See Section C. The Department will attempt to notify all interested parties and known recipients of the RFA. Upon receipt of the modification notice, prospective respondents are asked to send written acknowledgement to the Department contact person, listed above under Section B Issuing Organizational Unit Contract Person.

O. Clarifications, Negotiations, or Discussions Initiated by IDHS:

The Department may contact any Applicant prior to the final award for the following purposes:
1.As part of the Department's review process, the Department may request that an Applicant clarify its bid or Application. Applicants shall provide the names, titles, and contact information (office phone, cell phone, and email) for three individuals who are authorized to act on behalf of the Applicant during the review and negotiation process. Please list the individuals in the order you would like them contacted in the event of questions, concerns, or discussions. Due to time constraints necessary to implement the services required by IDHS, the Applicant's representatives may be contacted at any time during the process.
2.Discussions may be held to promote understanding of the Department's requirements and the Applicant's Application and to facilitate arriving at a grant agreement.
3.When the Department knows or has reason to conclude that a mistake has been made, the Department shall ask the Applicant to confirm the information. Situations in which confirmation may be requested include obvious or apparent errors on the face of the document or a price unreasonably lower than the price others submitted, or a price considerably higher than what is currently paid for similar services. If the Applicant alleges a mistake, the bid or Application may be corrected or withdrawn following the conditions to be set forth by the State of Illinois.

P. Late Applications/Responses:

The Department will attempt to notify all Applicants whose Applications were submitted if the Application will not be considered because of lateness or noncompliance with Application submission requirements.

Q. Objections:

Applicants who object to any provision of the RFA, who believe their Application was improperly rejected, who believe their Application should have been selected, or who believe that the selected Application(s) is/are not in the best interest of the Department may submit a written protest of the Department's decision(s). The Department will consider all such written protests that are submitted according to the time periods specified below. The Department will investigate and respond to all allegations.

The decision of the Department is final. Protests must be in writing via email and will be considered filed when received by the Department at the following email address.

Illinois Department of Human Services
Robert J. Grindle, Deputy General Counsel
Robert.Grindle@illinois.gov

Protests regarding RFA specifications must be filed within ten (10) calendar days after the date the RFA was issued and, in any event must be filed before the date for opening the Applications. Any protests relating to the RFA process must be received within ten (10) calendar days of receiving a notice of award or notice of non-award. The Department will not consider protests of the scores.

R. Commencement of Services:

No services can be paid for prior to the full and complete execution of the grant agreement and its filing with the Illinois Office of the Comptroller.

S. Public Information:

Portions of the information submitted pursuant to this RFA are subject to the Illinois Freedom of Information Act. The successful Applicant must recognize and accept that any material marked proprietary or confidential may still be considered open for public inspection. Price information submitted by the successful Applicants shall be considered public.

The Department may give Applicants feedback about their Application upon request and at the discretion of the Department.

T. Agreement:

The legal agreement between IDHS and the successful Applicants will be in the form and format prescribed by IDHS. Applicants should review the agreement and ensure that they meet all requirements contained therein. Applicants must note any exceptions to the agreement. All exceptions must be agreed to by IDHS before execution of the agreement.

U. Program Evaluation and Reporting Requirements:

Successful Applicants will be required to participate in assessment efforts as directed by the Department and to collect and report data accordingly. This reporting includes, but is not limited to, the reporting contained in Exhibit E: Performance Measures and Reporting to this RFA. All successful Applicants are required to utilize the Department's template, which will be provided. On a quarterly basis, successful Applicants will report data, program, and outcomes information. Additional data and information may be requested throughout the year as determined by the Department.

V. Training and Technical Assistance:

Applicants must agree to receive consultation technical assistance from authorized representatives of the Department. The funded Applicants will be required to attend any site visits performed by the Department. Successful Applicants will be required to attend regular meetings and training as provided by the Department.

W. Deliverables:

In addition to the deliverables detailed in Exhibit B, attached hereto, successful Applicants will be required to provide the following information to the Department, in a format provided by the Department:
1.Expenditure documentation,
2.Annual program plan and detailed program, including the disclosure of and responsibilities and allocation amongst any subgrantees' Agency budget in a format provided by the Department; and
3.Other reports as required by the Department.

X. Additional Information:

The Department reserves the right to request additional information that could assist with its award decision. Applicants are expected to provide the additional information within a reasonable time period. Failure to provide the information could result in the rejection of the Application.

Y. Sectarian Issue:

Applicant organizations may not expend federal or State funds for sectarian instruction, worship, prayer, or to proselytize. If the Applicant organization is a faith-based or a religious organization that offers such activities, these activities shall be voluntary for the individuals receiving services and offered separately from the grant program.

Z. Background Checks:

Background checks are required for all program staff and volunteers who have the potential for one-on-one contact with Class Members served under the Williams and Colbert Consent Decrees. Funded programs will be required to have a written protocol on file requiring background checks, as well as evidence of their completion.

AA. Reporting Mandates:

Per the Abused and Neglected Child Reporting Act (ANCRA, 325 ILCS 5/4), professionals who may work with children in the course of their professional duties are Mandated Reporters. Mandated Reporters are required to report suspected child maltreatment immediately when they have "reasonable cause to believe" that a child known to them in their professional or official capacity may be an abused or neglected child" (ANCRA Sec.4). This is done by calling the Illinois Department of Children and Family Services (DCFS) Hotline at 1-800-252-2873 or 1-800-25ABUSE. Programs funded through this grant opportunity must review ANCRA and, where appropriate, have a written protocol for identifying and reporting suspected child maltreatment.

The Applicant certifies that they are in compliance with all requirements and regulations issued pursuant to the Health Care Workers Background Check Act (225 ILCS 46).

BB. Hiring and Employment Policy:

It is the policy of the Department to encourage cultural diversity in the work environment and to promote employment opportunities through its programs. The Department philosophy is that the program workforce should appropriately reflect the populations to be served, with special attention given to hiring individuals indigenous to those communities. Consistent with Department policy, whenever a position becomes available, funded programs are encouraged to consider TANF clients and/or persons with a disability for employment, contingent upon their qualifications in the areas of education and work experience.

CC. Payment Method:

For at least the initial term of the agreement (February 1, 2020 to June 30, 2020), the Department will use an advance and reconciliation method of payment. Successful Applicants are to begin serving Class Members immediately upon the effective date of their grant agreement. Grantee shall submit a quarterly Periodic Financial Report (GOMBGATU-4002 (N-08-17)) to the appropriate email address below no later than November 1, February 1, May 1, and August 1. Reported expenses should be consistent with the approved annual grant budget. Any expenditure variances require prior Grantor approval in accordance with Article VI of the Uniform Grant Agreement to be reimbursable.

Subsequent to the initial advance the successful Applicants will receive additional prospective payments based on a reconciliation of the funds advanced to the funds being requested. Expenditures incurred for the purchase of allowable goods and services necessary for conducting program activities shall be documented in a manner prescribed by the Department. Unexpended funds will be returned to the Department, per the Grant Funds Recovery process. See the Uniform Grant Agreement, Article IV Payment, Section 4.2 Return of Grant Funds and 4.3 Cash Management Improvement Act of 1990.

Selected Applicants attesting that they have adequate financial management systems, pursuant to State and federal regulations, may continue to use an advance and reconciliation method of payment for any term extensions (July 1, 2020 to June 30, 2021) and otherwise will receive working capital on an ongoing basis.

PART II

A. Department's Need for Services:

The Illinois Department of Human Services is charged with implementing and meeting the requirements of the Williams v. Pritzker and Colbert v. Pritzker Consent Decrees. While targeted at different populations, both Decrees require the Department to evaluate individuals currently residing in institutional placements, with the end goal of transitioning them to the least restrictive Community-Based Setting appropriate to the individual's needs, e.g. fair-market subsidized rental units, permanent supported housing (including fair-market, subsidized rental units), home with family, supported/supervised residential settings, or supported living programs.

The Williams Class consists of Individuals with a serious mental illness residing in 23 Specialized Mental Health Rehabilitation Facilities (SMHRFs) in Illinois, who express desire to live in a Community-Based Setting, and for whom a Community-Based Setting is appropriate. The Colbert Class consists of all Medicaid-eligible adults with physical and/or psychiatric disabilities, who are being, or may in the future be, unnecessarily living in Nursing Facilities located in Cook County, Illinois, and who with appropriate supports and services may be able to live in a Community-Based Setting.

Additional information on Colbert can be found at https://www2.illinois.gov/aging/CommunityServices/colbert%20v.%20pritzker/Pages/Colbert%20v.%20Pritzker.aspx

Additional information on Williams can be found at http://www.dhs.state.il.us/page.aspx?item=51834

The Department envisions a person-centered, seamless experience throughout the transition process, from initial outreach to resident review/evaluation to finding and establishing housing to preparing for and enabling successful transition and community tenure and, finally, through post-transition community services. This program seeks to eliminate fragmentation in the Class Member experience and delays in the movement of Class Members from one stage of the process to the next. This new program requires that successful Applicants demonstrate capacity and expertise to offer class members the full range of transition services described above and in Attachment A. This may be accomplished independently by a single organization or through a consortium characterized by a lead provider organization (grantee) in partnership with other provider organizations (subgrantees). More specifically, IDHS recognizes that under this program, grantees may assign responsibility for serving Class Members to different staff members and/or subgrantees at different stages of the process. Program design should reflect how relationships and trust established between an individual service provider and a Class Member in one stage of the process will be preserved and transferred to the next stage, even if the individual or provider organization interacting with the Class Member changes. Applicants should explicitly describe how the respondent's proposed program will ensure a seamless experience for Class Members, paying particular attention to how the respondent will track each individual Class Member in the process and safeguard against delays and service gaps as Class Members move from one stage to the next. Tracking mechanisms are subject to IDHS' discretion and may require Grantees to utilize a data management system or other data tracking means.

The Department is issuing this RFA to contract with capable Applicants that directly, or working with subgrantees, can provide a comprehensive set of services to these individuals, including outreach and engagement; evaluation; support services, including peer-to-peer; and placement in appropriate housing. After placement of a Class Member in the community, the successful Applicants will be expected to provide, directly and/or working through subgrantees, the entire array of support services necessary for these individuals to thrive in their new living environment.

Applicant organizations can apply to deliver all the services described herein, either independently, along with subgrantees, or (other than tracking, managing, reporting, and communicating regarding the process) entirely through subgrantees, as a network of organizations responsible for delivering these services. Regardless of the method of service delivery, the Applicant must be able to successfully demonstrate their ability to fully, safely, and actively engage, evaluate, and transition individuals from their current living arrangements into community living arrangements approved under the Williams and Colbert Consent Decrees.

Attachment A to this RFA identifies, in detail, the services successful Applicants are expected to have the capacity to deliver, either directly and/or through subgrantees. While not every Class Member will need all services, the Application needs to demonstrate the Applicant's ability to deliver directly and/or through subgrantees the full spectrum of services.

Attachment B to this RFA identifies both the Colbert-covered Nursing Facilities and the Williams-covered Specialized Mental Health Rehabilitation Facilities (SMHRF)/Institutions of Mental Disease (IMD).

In your one application, you must clearly state which geographic coverage area(s) you plan to provide services consistent with the Grant. The full array of services must be offered to anyone who transitions from an SMHRF or NF from your awarded area either directly or by subgrantee/subcontractor no matter where they choose to reside in the State of Illinois. Most Class Members choose to stay within their originating county, however many from Cook County do choose to reside in the collar counties. The geographic coverage areas are:
1.Cook County (North)
2.Cook County (Central)
3.Cook County (South)
4.Northern Collar Counties (McHenry, Lake, Kane, DuPage)
5.Southern Collar Counties (Kendall, Will, Grundy, Kankakee)
6.Macon County (Decatur)
7.Peoria County (Peoria)

All organizations proposing providing services with subgrantees in their proposal must provide dual signed letters of agreement with each subgrantee/subcontractor, as evidence that the full array of services and supports listed above are available for Williams and Colbert Class Members.

B. Goals to be Achieved:

The Department is required to work with and report to a Court Monitor appointed by the Federal Judge with jurisdiction over these two cases. Each year, the Department is required to fully and safely transition, at a minimum, a targeted number of individuals from their current institutional setting to an appropriate, integrated Community-Based Setting. For FY20 (July 1, 2019 - June 30, 2020), the required number for Williams is 400 transitions and the Colbert required number is 900. The total pool of Applicants selected through this RFA are expected to work directly, or through subgrantees, with the Williams and Colbert populations to ensure that the total projected number of individuals fully and safely transitioned to the community meets or exceeds these numbers.

Attachment B identifies the current location of Class Members by facility. Also included is a chart depicting the current fiscal year required numbers v. current fiscal year transitioned to date for Williams Class Members; and the current 6-month target numbers v. previous 6-month transitioned to date for Colbert Class Members.

C. Services to be Performed/Coordination with Medicaid Managed Care Plans:

Successful Applicants are to provide, directly or through subgrantees, all of the services necessary to transition individuals covered by the Williams and Colbert Consent Decrees from their current institutional settings to an integrated community setting. This includes, but is not limited to, outreach, evaluation/resident review, and transition to appropriate integrated community settings. Post transition services are also required to stabilize and maintain the individuals in their community. Attachment A contains details on the services to be provided. Grantees under this program will be required to provide transition services, as described, to Class Members who may also separately receive care coordination services through their Medicaid managed care plan. Applications should explicitly describe how the agency will work and communicate with Class Members' separate, existing Medicaid managed care plans to ensure care coordination and avoid duplication or gaps in necessary services and supports. Applicants should highlight and provide specifics relevant experience working with care coordinators in other organizations. Applicants who are managed care organizations should describe how they will collaborate with other Medicaid managed care plans in which Class Members are enrolled.

D. Application Content and Scoring and Grantee Requirements:


Section

Applications should be formatted as follows, based on the Evaluation Factors listed.

Points



Executive Summary:

Applicants should provide a brief, but thorough, overview of their proposal along with any limitations regarding the Applicant's ability to perform the services required by the Department.

(Single Summary required, covering both Consent Decrees)
0

Agency Qualifications:

Applicants should also include a summary of their organizational background, subgrantee/subcontractor network (if applicable), and relevant experience. The Applicant should describe their incorporation status, along with all certifications and licenses held by both the agency and the key staff that will work on this project and should provide the same for any subgrantees.

(Single Summary required, covering both Consent Decrees)
20

Narrative:

This section should be composed of two parts: 1) Introduction and 2) Methodology.

The narrative should provide the Department with a detailed explanation as to how the Applicant intends to meet proposed, targeted outcomes and a timeline for the completion of the activities necessary to transition individuals from institutional setting to integrated community living. The narrative should also present a clear discussion of strategies for integrating services and minimizing service delays and discouraging siloes for direct and subgranted services. The narrative must provide details for all service areas being proposed.

Areas to address could include, but are not limited to:
1.How the Applicant will track Class Members, eliminate bottlenecks and delays, and communicate and coordinate with any subgrantees, providers of ancillary services, the MCOs, the NFs and SMHRFs, IDHS, and other entities involved in the process.
2.How the Applicant will work and communicate with Class Members' separate, existing Medicaid managed care plans to ensure care coordination and avoid duplication or gaps in necessary services and supports.
3.How the Applicant will handle each stage of the process (see Primary, Ancillary, and Capacity & Quality Services detailed in the Scope of Services (Exhibit A), including, but not limited to: Outreach, Evaluation/Resident Review, Pre-Transition, Housing, Post-Transition, ensuring a high-quality, conflict-free process.
4.How the Applicant is able to cover the geographic region(s) for which the Applicant is applying and is able to fulfill and service housing/Community-Based Settings beyond that region.

(Single Narrative required, covering both Consent Decrees)
25

Work Plan:

For this section the Applicant should provide a chart that includes:
1.Scope of Services,
2.Deliverables/Milestones,
3.Performance Measures, and
4.Performance Standards.

For each of these 4 areas the Applicant should provide both a description of what they commit to accomplish and quantifiable outcomes. This portion of the Application will be used by the Department to determine how many individuals the Applicant projects to serve and the outcomes they expect to obtain for Class Members under each consent decree (i.e. how many Class Members is the Applicant targeting to transition for Colbert Class Members and Williams Class Members, respectively, for the time period at issue).

Two separate work plans should be submitted. One document should cover the period from February 1, 2020 to June 30, 2020. The second work plan should reflect the renewal period from July 1, 2020 to June 30, 2021, if it becomes available.
(Separate plans required: (1) covering 2/1/20-6/30/20 and (2) covering 7/1/20-6/30/21. Each plan must cover both Consent Decrees and give separate targets for each Consent Decree) 35

Budget and Budget Narrative:

Applicants should submit a detailed line item budget, with a separate budget for the Williams Consent Decree and for the Colbert Consent Decree, that includes all costs associated with the Application.

The narrative within each line of the budget should identify how each of the major expenditure categories relates to the work plan and expected outcomes. Vacant positions or other cost items not currently being incurred by the Applicant, but are being requested as part of this submission, should identify a timeline for filling or

acquisition by the Applicant. The budget should identify all current and anticipated costs, including costs required to serve individuals with significantly complex medical and/or behavioral needs as well as Substance Use disorders.

The budget should identify all current and anticipated costs necessary to successfully and completely accomplish the activities in the work plan. The budget and narrative should be submitted as two separate documents. The budget submitted in the CSA System should cover the period from February 1, 2020 to June 30, 2020. The second budget (not in CSA) should reflect the period from July 1, 2020 through June 30, 2021 and be completed on the DHS fillable pdf budget template and submitted with the Applications and Program Proposal Narratives as instructed in Part I, D.1.c and Part I, F.

(Separate budgets required for each Consent Decree)
20

Grantee Requirements

The following requirements must be met in order to be awarded a grant from IDHS. You must have completed all of these requirements before an award can be made. Failure to meet these qualifications will exclude any agency from receiving an award. If your agency has not received grants from IDHS in the past, it is important to note it may take time to receive the appropriate system access and you will be responsible for ensuring timely actions are completed to have all requirements met prior to the scoring and awarding of this grant.
1.Register with the Illinois Grant Accountability and Transparency Act Grantee Portal
2.Grantees must be qualified to do business with the State of Illinois. To be qualified for a grant award, a Grantee must: a.Have a current DUNS number;
b.Have a current System for Award Management account (SAM.gov);
c.Not be on the Federal Excluded Parties List;
d.Be in Good Standing with the Illinois Secretary of State, as applicable;
e.Not appear on the Department of Healthcare and Family Services Provider Sanctions list;
f.Submit an Application to DHS.GrantApp@illinois.gov. i.The Application for each Consent Decree must be sent in a separate email.
ii.A single Application must be used for all geographic areas where coverage is being proposed.
iii.The subject line of the email MUST state: Provider Organization Name, RFA Number, Contact Name, Region

g.Complete one Internal Controls Questionnaire (ICQ) as the Fiscal and Administrative Risk Assessment on an annual basis on the Governor's Office of Management and Budget (GOMB) website at https://grants.illinois.gov/portal/
h.Complete a Programmatic Risk Assessment (PRA) for each potential grant award (i.e. Williams or Colbert) on the DHSDMH webpage. Links are provided under the "PRA" column.
i.Complete a Budget for the term February 1, 2020 through June 30, 2021 for each Consent Decree grant award in the CSA tracking database: CSA Budget/Tracking System database.
Assistance Consideration
Serves as Maintenance of Effort to the Federal Substance Abuse and Mental Health Services Administration Community Mental Health Block Grant.
Post Assistance Requirements
Performance Measures and Reporting

The Grantee shall submit quarterly Periodic Performance Report (GOMBGATU-4001 (N-08-17)) and the Periodic Performance Report Template by Program (PRTP) to the appropriate email address below no later than November 1, February 1, May 1, and August 1. Reporting templates and instructions for submitting reports can be found in the Provider section of the IDHS website.
PPR and PPRT Email Address for All Grants:
IDHS.DMHQuarterlyReports@illinois.gov

The following data reporting requirements are included in the reporting template. Data reported should, unless otherwise noted, be limited to quarterly data only, not cumulative.

Outreach:

Please note, unless otherwise specified, all Outreach reporting must contain unduplicated figures for both existing Class Members (current, post 60-day SMHRF/NF residents) and new Class Members (newly admitted to a SMHRF/NF, within previous 60 days).
1.Number of unduplicated Class Members engaged at the respective NFs or SMHRFs in Outreach activities.
2.Number of interested newly admitted Class Members to SMHRFs and NFs who had a face to face contact by Outreach, within 60 days post admission.
3.Number of Class Members interested in a follow up Outreach contact.
4.Number of Class Members interested in a follow up Outreach contact in which they received the contact within 7 days.
5.Number of unduplicated Outreach Introduction Letters signed by Class Members.
6.Number of Class Members who refused to engage in Outreach discussions/refused to sign Letter of Introduction who have a documented reason for refusal.
7.Number of family members or Guardians engaged in conversation with Outreach staff about the Consent Decrees.
8.Number of Community meetings held in the NFs or SMHRFs.
9.Number of Class Members who have had a Quality of Life Survey while residing in a SMHRF/NF.

Resident Review/Evaluations:

Please note, unless otherwise specified, all Resident Review/Evaluation reporting must contain unduplicated figures for both existing Class Members (current, post 60-day SMHRF/NF residents) and new Class Members (newly admitted to a SMHRF/NF, within previous 60 days).
1.Number of full/part-time staff currently employed, who meet credentials as a Resident Review/Evaluator;
2.Number of unduplicated Class Member records reviewed in preparation for completing a Resident Review/Evaluation;
3.Number of unduplicated Class Members approached for consent for a Resident Review/Evaluation;
4.Number of unduplicated Class Members who agreed to and scheduled a Resident Review/Evaluation;
5.Number of unduplicated Class Members approached/initiated for a Resident Review/Evaluation but who refused to be assessed;
6.Number of unduplicated Class Members for whom a full Resident Review/Evaluation was completed;
7.Number of duplicated Class Members for whom a full Resident Review/Evaluation was completed;
8.Number of unduplicated Class Members who consent/begin but end the Resident Review/Evaluation before completion;
9.Number of unduplicated Class Members with a completed Resident Review/Evaluation who were recommended for transition;
10.Number of unduplicated Class Members with a completed Resident Review/Evaluation who were recommended for transition to a non-PSH setting;
11.Number of unduplicated Class Members with a completed Resident Review/Evaluation who were not recommended for transition, including identification of the reason for the not recommended outcome;
12.Number of Resident Review/Evaluation outcomes submitted to IDHS; and
13.Number of unduplicated staff participating in IDHS-hosted trainings, teleconferences, or webinars.

SSS/SOAR
1.Number (total) of Class Members on the SOAR roster as of the end of the quarter.
2.Number of Class Members referred and actively engaged with the Grantee added to the SOAR roster.
3.Number of new Class Members (i.e. not previously engaged with the Grantee) referred to SOAR.
4.Number of new referrals to SOAR, assessed and engaged by the Social Security Specialist(s) within seven (7) days of referral to SOAR.
5.Number of new referrals to SOAR, assessed and engaged by the Social Security Specialist(s) after seven (7) days of referral to SOAR.
6.Number of new SOAR applications completed and submitted by the agency to SSA within 48 hours post-completion.
7.Number of new SOAR applications completed and submitted by the agency to SSA past 48 hours post-completion.
8.Number of SOAR applications submitted for protective filing dates that are completed and submitted to SSA within 60 days of referral.
9.Number of SOAR applications which received a determination status during the quarter.
10.Number of SOAR applications approved for benefit (SSI/SSDI) during the quarter.
11.Number of SOAR applications denied benefits (SSI/SSDI) during the quarter.
12.Number of SOAR applications returned to the agency on behalf of Class Member with an SSA determination status of no documented disability/ineligible during the quarter.
13.Number of SOAR applications for which a 1st appeal was submitted to SSA within two weeks of the stamped SSA 1st denial letter date.
14.Number of SOAR applications for which a 1st appeal was submitted to SSA more than two weeks after the stamped date of the SSA denial letter.
15.Number of SOAR applications for which a 2nd appeal was submitted to SSA within two weeks of the stamped date of the SSA 1st appeal denial letter.
16.Number of SOAR applications for which a 2nd appeal was submitted to SSA more than two weeks after the stamped date of the SSA 1st appeal denial letter.
17.Number of initial applications pending as of the end of the quarter.
18.Number of 1st appeals pending as of the end of the quarter.
19.Number of 2nd appeals pending as of the end of the quarter.

Transition Coordination Activities

Pre-Transition
1.Number of unduplicated Class Members assigned to the Grantee for transition coordination during the quarter.
2.Number of unduplicated Class Members' assignments received by transition coordination staff within 14 days of intake.
3.Number of Class Members with first contact occurring within seven (7) business days of receipt of the assignment by transition coordination staff.
4.Number of Class Members with initial contact more than seven (7) business days from receipt of the assignment by transition coordination staff.
5.Number of Class Members who refuse transition coordination activities after assignment.
6.Number of Class Members whose documented refusal of transition coordination activities was transmitted to the IDHS Consent Decrees' designated contact.
7.Number of the Class Members' Comprehensive Service Plans of Care which include the findings and recommendations of the Resident Review/Evaluation assessment
8.Number of consenting Class Members engaged in a housing search during the following time frames: a.Within two weeks of initial contact;
b.Between two weeks and two months after initial contact;
c.Between two months and four months after initial contact; an
d.More than four months after the initial contact.

9.Total number of Class Members engaged in housing search as of the end of the quarter.
10.Number of Class Members assisted with transferring benefits/entitlements from the NF or SMHRF prior to transition.
11.Number of Class Members assisted with linkages to primary Health Care.
12.Number of Class Members accompanied to purchase basic household items/supplies.
13.Number of completed Transition Checklists.

Post-Transition
14.Number of Class Members assisted with moving from the NF or SMHRF to the community.
15.Number of Class Members who received flexible funding up to $1,000.
16.Number of Class Members who received flexible funding over $1,000.

Integrated Health Care (Nursing & Occupational Therapy)

Registered Nurse
1.Number of Class Member health assessments scheduled by RN.
2.Number of unduplicated Class Member health assessments which included interviews scheduled and/or completed with family and significant others.
3.Number of physical health assessments completed by RN.
4.Number of physical health assessments completed on-site by RN.
5.Number of unduplicated Class Members who refuse to complete the physical health assessment.
6.Number of Class Members whose assessment was terminated prior to completion by the clinician due to Class Member distress or other symptoms.
7.Number of Class Members assessed and recommended for community transition by RN.
8.Number of Class Members assessed and not recommended for community transition by RN.
9.Number of unduplicated Class Members seen by an RN as part of Integrated Health Care staff during the first 30 days, post-transition from the NF/SMHRF/IMD.
10.Number of Class Members who had an unscheduled ER visit seen for a follow up visit by the RN within three days of the ER visit.
11.Number of Class Members whose ER visit resulted in a Health Care hospitalization who were seen by the RN within three days, post-discharge.
12.Number of Class Members who did not consent to an RN visit after hospitalization discharge or ER visit.
13.Number of Health Care consultations attempted by RN for Class Members who did not consent to an RN visit after hospitalization or ER visit.

General Health Care
14.Number of unduplicated Class Members referred to Integrated Health Care staff.
15.Number of Class Members with high-risk health challenges (serious mental illness with a high level of acuity together with co-morbid medical condition(s) and high service needs).
16.Number of Class Members with high risk health challenges seen on a weekly basis by an RN for nursing assessments (blood pressure checks, blood sugar, weight, etc.).
17.Number of Class Members scheduled for routine annual Health Care evaluation visits.
18.Number of Class Members scheduled for specialty Health Care visits.
19.Number of Class Members scheduled for specialty Health Care visits seen in the scheduled month.
20.Number of Class Members who had an unscheduled ER visit.
21.Number of Class Members whose ER visit resulted in a Health Care hospitalization.

Reportable Incidents
22.Number of Reportable Incidents due to Class Member Health Care complications.
23.Number of Reportable Incident forms submitted for all incidents due to Health Care complications.
24.Number of Reportable Incidents due to death.
25.Number of Reportable Incident forms submitted for incidents due to death.

Occupational Therapy
26.Number of Class Members referred for an OT assessment.
27.Number of OT assessments scheduled.
28.Number of interviews scheduled with family and significant others related to OT assessments.
29.Number of OT assessments completed.
30.Number of OT assessments completed on-site.
31.Number of Class Members who ended completion of the assessment.
32.Number of Class Members whose OT assessment was stopped by the clinician due to distress or other symptoms.
33.Number of Class Members assessed and recommended for community transition by OT.
34.Number of Class Members assessed and not recommended for community transition by OT.

Care Management
1.Total Number of Class Members served by Grantee as of the end of the quarter.

Service Plans
2.Number of Comprehensive Service Plans adequately completed, reviewed by the respective supervisors, based on the individualized needs of the respective Class Member, including input from other stakeholders involved in care, and including appropriate signatures of participation.

Transition
3.Number of completed Transition Checklists for each Class Member transitioned to the community;
4.Number of Comprehensive Service Plans and Risk Assessment and Mitigation Strategies for Individuals Transitioning into the Community completed with appropriate documentation prior to the Class Member's transition to the community.
5.Number of Class Members during this quarter who were within four weeks post-transition to the community.
6.Number of Class Members who received a weekly visit from the care manager for the first four weeks, post-transition to the community.
7.Number of Class Members during this quarter who were within their second- and third-months post transition to the community.
8.Number of Class Members who received a bi-weekly visit from the care manager during the second and third months, post-transition.
9.Number of Class Members during this quarter who were within their fourth through twelfth month post-transition.
10.Number of Class Members who received a monthly care manager's visit during the fourth through twelfth month, post-transition.

Reportable Incidents
11.Number of Reportable Incidents.
12.Number of completed Reportable Incident forms, within the required time frame (24 hours for Level I, 48 hours for Level II and 72 hours for Level III).
13.Number of completed Reportable Incident forms outside the required time frame (identified by Level)

Quality Assurance
1.Number of Class Members assigned to the agency.
2.Number of Class Members whose Comprehensive Service Plans were monitored in accordance with IDHS policies and expectations.
3.Number of Class Members for whom Quality Administrators have provided oversight for routine quality reports, including a completed Transition Checklist for each Class Member placed in the community, and documentation of completed Comprehensive Service Plans and Risk Assessment and Mitigation Strategies for Class Members transitioning to the Community, completed prior to transition.
4.Number of sentinel indicators reviewed and reported on within 24 hours of notification of a Reportable Incident.

Medicaid Spenddown
1.Total number of unduplicated Class Members with a current spenddown.
2.Total number of unduplicated Class Members with a current spenddown added during the quarter.
3.Total number of unduplicated Class Members requiring assistance with meeting their Medicaid spenddown.
4.Number of unduplicated Class Members requiring assistance with meeting their Medicaid spenddown who have a monthly household income of $1041 of less.
5.Number of Class Members with a monthly spenddown with deductible amounts of less than: a.$100
b.$200
c.$300
d.$400
e.$500

6.Number of Class Members whose monthly spenddown amount is between $501-600 per month.
7.Number of Class Members whose monthly spenddown amount is greater than $601.
8.Number of Class Members with sufficient expenses incurred each month that can be applied to offset the monthly spenddown amount.
9.Number of Class Members with monthly spenddown who maintain continuous engagement with mental health service.
10.Number of Class Members with monthly spenddown who may self-terminate (the spenddown advance is canceled) from mental health services in the reporting period.
11.Number of Class Members on spenddown for whom the agency is serving as their representative payee.

Grantee Service Capacity
1.Amount, if any, paid in sign-on or retention (specify which) bonuses for: a.Registered Nurses
b.Occupational Therapists
c.MHP's/QMHP's
d.LPHA's
e.SOAR Staff
f.Other


ACT
2.Current ACT capacity.
3.Number of current ACT staff.
4.Quarterly expansion of ACT capacity, if applicable.
5.Number of ACT staff added during quarter if applicable.
6.Current number of Class Members appropriate for ACT level of care.
7.Number of Class Members newly determined to be in need of ACT level of care during the quarter.

CST
8.Current CST Capacity.
9.Number of current CST staff.
10.Quarterly expansion of CST capacity, if applicable.
11.Number of ACT staff added during quarter if applicable.
12.Current number of Class Members appropriate for CST level of care.
13.Number of Class Members newly determined to be in need of CST level of care during the quarter.

Nursing
14.Current nursing capacity.
15.Number of current nursing staff.
16.Nursing capacity expansion during the quarter, if applicable.
17.Number of nursing staff added during quarter if applicable.
18.Current number of Class Members appropriate for nursing care.
19.Number of Class Members newly identified as in need of nursing care during the quarter.

Occupational Therapy
20.Current Occupational Therapy capacity.
21.Number of current Occupational Therapy staff.
22.Expansion of Occupational Therapy capacity during the quarter, if applicable.
23.Number of Occupational Therapy staff added during quarter if applicable.
24.Current number of Class Members appropriate for Occupational Therapy.
25.Number of Class Members newly determined to be appropriate for Occupational Therapy during the quarter.

SSS/SOAR
26.Current Social Security Specialty/SOAR capacity.
27.Number of current SSS/SOAR staff.
28.Social Security Specialty/SOAR capacity expansion during the quarter, if applicable.
29.Number of SSS/SOAR staff added during quarter if applicable.
30.Current number of Class Members appropriate for Social Security application support.
31.Number of Class Members newly identified as in need of SSS/SOAR services during the quarter.

Performance Standards

Performance Standards are the minimum expected grantee/subgrantee performance for each enumerated item.

Outreach
1.100% of interested, newly-admitted Class Members to NFs and SMHRFs had a face-to-face contact by Outreach within 90 days, post admission.
2.100% of unduplicated Class Members interested in a follow-up contact with an Outreach Worker were engaged by Outreach staff within 7 days of request.
3.100% of unduplicated Class Members were asked to sign an Outreach Introduction letter.
4.100% of Class Members who refuse to sign an Outreach Introduction letter had a notation on the letter identifying the reason for their refusal.
5.100% of Class Members reporting issues or concerns regarding transition had a follow up contact completed by an Outreach Worker within seven (7) days.
6.100% of guardians or family members interested in speaking with Outreach Workers were contacted/engaged by Outreach staff.
7.100% of NFs or SMHRFs had a quarterly community meeting.
8.90% of Class Members referred to for completion of a Quality of Life Survey had a Quality of Life Survey completed prior to transition.

Resident Review/Evaluations
1.90% of Resident Review/Evaluation staff will be appropriately credentialed with full/part-time employment, per contract agreement, at all times;
2.100% of records of Class Members assigned for Resident Review/Evaluation will be reviewed in preparation for the Resident Review/Evaluation;
3.100% of Class Members identified will be approached for consent to complete the Resident Review/Evaluation;
4.100% of Class Members approached for Resident Review/Evaluation after a positive Outreach response who subsequently refuse to consent to a Resident Review/Evaluation, have the refusal documented, including identifying any reason provided by the Class Member;
5.80% of consenting, unduplicated, Class Members had a Resident Review/Evaluation completed;
6.80% of consenting, duplicated, Class Members (including Class Members with multiple Resident Review/Evaluations due to a positive Appeal outcome) had a Resident Review/Evaluation completed within 14 days of the Appeal outcome or request for another Resident Review/Evaluation (subject to the quarterly limitations); and
7.100% of Resident Review/Evaluation outcomes were submitted to IDHS.

SSS/SOAR
1.100% of Class Members identified as having "no income" - SSI/SSDI - (excluding those with an undocumented status) during the quarter were assigned to the agency's SOAR roster.
2.100% of Class Members referred to SOAR were actively engaged by the Grantee during quarter.
3.100% of all new referrals to SOAR assessed (within 7 business days) and engaged by the Social Security Specialist(s).
4.100% of SOAR applications completed and submitted to SSA within 48 hours, post completion.
5.100% of SOAR applications submitted for protective filing dates completed within 60 days of referral to SSS/SOAR.
6.100% of SOAR applications submitted to and acted upon by SSA obtained a determination status (i.e. none determined to be incomplete).
7.100% of SOAR applications submitted, captured, and categorized based on SSA's final determination status, i.e., approved, denied, no documented history.
8.100% of SSA applications denied were repackaged for a 1st appeal within two weeks of the 1st SSA denial stamped letter date.
9.100% of SOAR applications have initial and outcome information entered into SOAR-OAT (national database)
10.100% of SSA applications denied after the 1st appeal was repackaged for a 2nd appeal within two weeks of the date of the SSA letter denying the 1st appeal.

Transition Coordination

Pre-Transition
1.100% of unduplicated Class Members' assignments received by transition coordination within seven (7) days of intake.
2.100% of Class Members contacted within 7 business days after receipt of assignment.
3.100% of Class Members who refuse transition coordination activities are documented and identified to the Consent Decrees' designated contact.
4.100% of the Class Members' Comprehensive Service Plans of Care will include the findings and recommendations of the Resident Review/Evaluation assessment.
5.100% of consenting Class Members are engaged in a housing search.
6.100% of Class Members are assisted in linkage to primary Health Care.
7.100% of Class Members are accompanied to purchase basic household items.
8.100% of consenting Class Members have their benefits/entitlements transferred from the facility prior to transition.

Post-Transition
9.100% of Class Members are assisted in relocation from the NF or SMHRF to the community.

Integrated Health Care (Nursing & Occupational Therapy)

Nursing
1.100% of Class Members with high risk health challenges seen weekly by RN for nursing assessments (blood pressure checks, blood sugar, weight, etc.).
2.100% of Class Members who had an unscheduled ER visit had a follow up visit by the RN within three days after the ER visit.
3.100% of Class Members whose ER visit resulted in a Health Care hospitalization were seen by the RN within three days, post discharge.
4.100% medical consultations were attempted for any Class Member who did not consent to an RN visit after hospitalization or ER visit.

General Health Care

Pre-Transition
5.100% of the Class Members referred for a physical health assessment were scheduled.
6.90% of health assessments initiated were completed.
7.50% of interviews where family or significant others were contacted.
8.100% of health assessments completed on-site.
9.No more than 20% of health assessments will be aborted by Class Members prior to completion.
10.No more than 5% of health assessments will be aborted by the clinician.

Post-Transition
11.100% of unduplicated Class Members referred to Integrated Health Care staff seen during the first 30 days, post transition from the NF/IMD.
12.100% of Class Members scheduled with Integrated Health Care had a routine annual Health Care evaluation visit.
13.100% of Class Members scheduled for a specialty Health Care visit were seen in the scheduled month.

Reportable Incidents
14.100% all incidents due to Health Care complications had Reportable Incident forms submitted within the appropriate time period (Level I-24 hours, Level II-48 hours, Level III-72 hours).
15.100% of deaths had Reportable Incident forms submitted within 24 hours.

Occupational Therapy
16.100% of the OT assessments referred for an assessment were scheduled.
17.90% of OT assessments initiated were completed.
18.50% of interviews where family or significant others were contacted.
19.100% of OT assessments completed on-site.
20.No more than 20% of OT assessments will be aborted by Class Members.
21.No more than 5% of OT assessments will be aborted by the clinician.

Care Management

Service Plans
1.1. 100% of Comprehensive Service Plans adequately completed, reviewed by the respective supervisors, based on the individualized needs of the respective Class Member, including input from other stakeholders involved in care, and including appropriate signatures of participation.

Transition
2.100% Transition Checklists completed for each Class Member placed in the community, documentation of completed Comprehensive Service Plans and Risk Assessment and Mitigation Strategies for Individuals Transitioning into the Community, prior to transition.
3.100% of Reportable Incidents, completed within the required time frame (Level I-24 hours, Level II-48 hours, and Level III-72 hours).
4.100% of Class Members received a weekly visit from the care manager for the first four weeks, post-transition to the community.
5.100% of Class Members received a bi-weekly visit from the care manager during the second and third months, post-transition.
6.100% of Class Members received a monthly care manager's visit during the fourth through twelfth month, post-transition.

Quality Assurance
1.100% of Class Members referred to the agency will be assigned to staff for transition services.
2.100% of required quality reports and supporting documents are reviewed and submitted to IDHS within the designated time frames.
3.100% of cases assigned to the agency were processed to appropriate clinical team or program within 5 business days.
4.100% of the Class Members' Comprehensive Service Plans were monitored in accordance with IDHS policies and expectations.
5.100% of Transition Checklists completed prior to transition of Class Member to the community.
6.100% of Comprehensive Service Plan and Risk Assessment and Mitigation Strategies completed with supporting documentation prior to transition of Class Member to the community.
7.100% of sentinel events reviewed, including Reportable Incidents and Root Cause Analyses, and submitted to IDHS, within 24 hours and 72 hours, respectively, of the incident.

Medicaid Spenddown
1.98% of Class Members with spenddown have monthly household incomes at or less than $1041.
2.98% of Class Members will have monthly spenddown deductible amounts less than: a.$100
b.$200
c.$300
d.$400
e.$500

3.2% of Class Members will have monthly incomes greater than $500 but not greater than $600 per month.
4.100% of Class Members will have sufficient expenses that can be applied to offset the monthly spenddown amount.
5.90% of Class Members will maintain continuous monthly engagement with health services.
6.No more than 10% of Class Members with spenddown terminated from monthly mental health services during the period.

Grantee Service Capacity
1.Provider must have sufficient ACT team capacity to serve 100% of Class Members who are identified as requiring ACT services.
2.Provider must have sufficient CST team capacity to serve 100% of Class Members who are identified as requiring CST services.
3.Provider must have sufficient RN capacity to meet the needs of 100% of Class Members who are identified is requiring RN services.
4.Provider must have sufficient OT capacity to serve 100% of Class Members who are identified as requiring Occupational Therapy.
5.Provider must have sufficient transition coordination capacity to serve 100% of Class Members who require transition support.
6.Provider must have sufficient Social Security Specialist/SOAR capacity to serve 100% of Class Members who require Social Security application support.

Program Evaluation and Reporting Requirements:

Successful Applicants will be required to participate in assessment efforts as directed by the Department and to collect and report data accordingly. This reporting includes, but is not limited to, the reporting contained in Exhibit E: Performance Measures and Reporting to this RFA. All successful Applicants are required to utilize the Department's template, which will be provided. On a quarterly basis, successful Applicants will report data, program, and outcomes information. Additional data and information may be requested throughout the year as determined by the Department.
Regulations, Guidelines, Literature
Title 59: Mental Health of the Administrative Code

2 CFR 200/45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements

DHS/DMH Attachment B
DHS/DMH Program Manual
Federal Funding
None
Notice of Funding Opportunities
None
Agency IDGrantee NameStart DateEnd DateAmount
45CYB04082-45CYB04082TRILOGY, INC.02/01/202006/30/20202,075,417
45CYB04072-45CYB04072TRILOGY, INC.02/01/202006/30/20201,564,850
45CYB04071-45CYB04071THE THRESHOLDS02/01/202006/30/20201,394,416
45CYB04075-45CYB04075ENVISION UNLIMITED02/01/202006/30/20201,363,048
45CYB04078-45CYB04078LUTHERAN SOCIAL SERVICES OF ILLINOIS02/01/202006/30/20201,342,432