exhibit f - program descriptions - drizzy drake (1 of 3) final · exhibit f updated 7/1/2017...

Exhibit F

Updated 7/1/2017

PROGRAM DESCRIPTIONS

The Network Service Provider shall prepare and submit the following Program Description(s) via SurveyMonkey for each program that is funded within this contract and/or for approval prior to the start of a contract or a new program. A Prevention Program Description is required to be submitted if the Network Service Provider is contracted for prevention services. If the Network Service Provider modifies an existing program, a revision to the Program Description is required via SurveyMonkey.

1. Program Description

LSF Health Systems Program Description

1. Provider Name:

2. Provider Representative Name:

3. Program Name:

4. Select one (1) program area:*

Adult Mental Health

Children Mental Health

Adult Substance Abuse

Children Substance Abuse

5. Provide a brief (500 words or less) overview of the program in narrative form.

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6. Will the program utilize funding from or offer any of the following?

TANF (Temporary Assistance for Needy Families)

SAPTBG Set Aside for Women

SAPTBG HIV Set Aside

FIS Appropriation

PATH Grant Award

Indigent Drug Program

Forensics / Community Forensic Beds

Title XXI

Purchase of Therapeutic Services

Roll-Over Funds (Integrated Care Teams)

None (General Revenue Funding only)

Title XXI Children's Health Insurance Program (BNet)

Florida Assertive Community Treatment (FACT)

Community Crisis Prevention Team

Crisis Stabilization Proviso Award

Central Receiving System or Facilities

Primary Care Services Proviso Award

SOAR

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Adult Mental Health - Program Description

2. AMH


7. What individuals will be served by this program?

Adults with Severe and Persistent Mental Illness

Adults with Serious and Acute Episodes of Mental Illness

Adults with Mental Health Problems

Adults with Forensic Involvement

Adults with Co-Occurring Disorders

8. Which covered services will be billed under this program?

Assessment

Case Management

Crisis Stabilization

Crisis Support/Emergency

Day Care

Day/Night

Drop-in/Self Help Centers

In-Home and On-Site Services

Inpatient

Intensive Case Management

Intervention

Medical Services

Outpatient - Individual

Outreach

Prevention

Residential, Level 1




Respite Services

Sheltered Employment

Supported Employment

Supported Housing/Living

Incidental Expenses

Aftercare/Follow-up

Information and Referral

FACT Team

Outpatient - Group

Room and Board, Level 1



Short-Term Residential Treatment

Mental Health Clubhouse

Project Recovery

Intervention - Group

Aftercare - Group

Comprehensive Community Service Team - Individual

Comprehensive Community Service Team - Group

Recovery Support - Individual

Recovery Support - Group

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9. What is the service capacity for this program?

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Children Mental Health - Program Description

3. CMH


10. Which individuals will be served by this program?

Children with Serious Emotional Emotional Disturbance

Children with Emotional Disturbance

Children at Risk of Emotional Disturbance

Children at Risk of Residential Services

Children with Juvenile Justice Involvement

Children at Risk of Juvenile Justice involvement

Children with Co-Occurring Disorders


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Assessment

Case Management

Crisis Stabilization


Day/Night


Inpatient

Intensive Case Management

Intervention

Medical Services


Outreach

Prevention

Prevention/Intervention Day





Respite Services



Incidental Expenses

Aftercare/Follow-Up


Behavioral Health Overlay Services

Outpatient - Group




Project Recovery


Aftercare - Group

Comprehensive Community Service Team - Individual

Comprehensive Community Service Team - Group

Recovery Support - Individual

Recovery Support - Group

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Adult Substance Abuse - Program Description

4. ASA



Adults at Risk of Substance Abuse (Prevention)

Adults with Substance Abuse

Adults who are Pregnant or Postpartum

Adults with Forensic Involvement

Adults with HIV

Adults with Co-Occurring Disorders


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15. What covered services will be billed under this program?

Assessment

Casement Management


Day Care

Day/Night


Intervention

Medical Services

Methadone Maintenance


Outreach

Prevention





Respite Services

Substance Abuse Detoxification



TASC

Incidental Expenses

Aftercare/Follow-Up


Outpatient Detoxification

FACT Team

Outpatient - Group





Aftercare - Group

SA Recovery Support - Individual

SA Recovery Support - Group

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Children Substance Abuse - Program Description

5. CSA



Children at Risk of Substance Abuse (Prevention)

Children with Substance Abuse

Children at Risk of Residential Services

Children with Juvenile Justice Involvement

Children at Risk of Juvenile Justice Involvement

Children with HIV

Children with Co-Occurring


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Assessment

Case Management


Day/Night


Intervention

Medical Services


Outreach

Prevention

Prevention/Intervention Day





Respite Services

Substance Abuse Detoxification



TASC

Incidental Expenses

Aftercare/Follow-up


Outpatient Detoxification

Outpatient - Group





Aftercare - Group

SA Recovery Support - Individual

SA Recovery Support - Group

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6. Number of FTEs required for this program:


19. Position Title:

Other (please specify)

20. Minimum Credentials for the Position

High School Diploma

AA

BA

Masters

PhD

0-3 years

4-5 years

6-8 years

10+ years

21. Minimum Credentials for the Position - Number of Years of Experience

Number of Supervisory FTEs for this Position

Number of Direct Service FTEs for this Position

Number of Support FTEs for this Position

22. FTEs Information

23. Position Title:



High School Diploma

AA

BA

Masters

PhD

0-3 years

4-5 years

6-8 years

10+ years

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27. Position Title:



High School Diploma

AA

BA

Masters

PhD

0-3 years

4-5 years

6-8 years

10+ years





30. Position Title:

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High School Diploma

AA

BA

Masters

PhD

0-3 years

4-5 years

6-8 years

10+ years





33. Position Title:



High School Diploma

AA

BA

Masters

PhD

0-3 years

4-5 years

6-8 years

10+ years





36. Position Title:

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High School Diploma

AA

BA

Masters

PhD

0-3 years

4-5 years

6-8 years

10+ years





39. Position Title:



High School Diploma

AA

BA

Masters

PhD

0-3 years

4-5 years

6-8 years

10+ years





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42. Provide any additional or supplementary information regarding staffing of the program.

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7. Matching Funds


43. Which sources will you employ to raise match funding?

Private Grants

Local Government Grants

Charitable Contribution

Volunteer Services

Fees

In-Kind Contributions


44. Indicate the percentage of Matching Funds each of those selections will constitute:

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45. How will Matching Funds for this program be used?

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8. Identification and Engagement Strategies


46. Describe the source of your referrals

47. Detail how your program's screening and intake practices ensure that individuals receive prompt responsive accessto appropriate services

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48. Detail your process for referred priority consumers (special populations)

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For the purposes of this form, the definition of Evidence-Based Practice (EBP) shall be governed byIncorporated Document 2 of the Network Service Provider’s Contract with LSF Health Systems.

9. Service Delivery Strategies


49. Describe the admission criteria for General Populations:

50. Describe the admission criteria for Special Populations:

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51. Describe the disqualifying criteria for services

52. Describe the process to ensure services provided are an appropriate level and intensity to meet the needs of theservice recipient for General Populations:

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53. Describe the process to ensure services provided are an appropriate level and intensity to meet the needs of theservice recipient for Special Populations:

54. Describe how each individual and family participate in the development, ongoing review of an assessment andservice plan that is the basis for delivery of appropriate services and support.

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55. EBP - Detail evidence-based models utilized (enter each on a separate line)

56. EBP - Describe in detail how the program carries out the practices established by the evidence-based practicemodel(s) utilized as indicated above:

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57. EBP - Describe the process utilized to maintain fidelity to the evidence-based practice model(s) indicated above:

58. Describe any enhanced services offered/utilized for special populations

59. Describe discharge criteria for services for General Populations:

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60. Describe discharge criteria for services for Special Populations:

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10. Continuing Care Strategies


61. Describe how your continuing care/after care planning strategies reduce recidivism for General Populations:

62. Describe how your continuing care/after care planning strategies reduce recidivism for Special Populations:

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63. Describe how your program takes initiative to explore suitable resources to facilitate an appropriate discharge forGeneral Populations:

64. Describe how your program takes initiative to explore suitable resources to facilitate an appropriate discharge forSpecial Populations:

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11. Authorization


By submitting this survey, I acknowledge that any changes shall be reported to LSF Health Systems and that I am theauthorized representative of the Provider named above.

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This survey will collect planning information for prevention programs in the LSFHS Network. Please use aseparate survey for each prevention program operated by your agency.

Introduction

LSF Health Systems Prevention Program Description

Name of the IndividualCompleting the Survey

Agency Name

Program Name

Email Address

1. Address

Adult Substance Abuse -Indicated Prevention

Adult Substance Abuse -Selective Prevention

Adult Substance Abuse -Universal Direct

Adult Substance Abuse -Universal Indirect

Children SubstanceAbuse - IndicatedPrevention

Children SubstanceAbuse - SelectivePrevention

Children SubstanceAbuse - Universal Direct

Children SubstanceAbuse - UniversalIndirect

2. Indicate the level of programming and population to be served by this program. For eachpopulation, enter the number of individuals to be served. If a population will not be served by theprogram, enter "N/A" in that field.

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3. Indicate the counties in which the program will be administered.

Alachua

Baker

Bay

Bradford

Brevard

Broward

Calhoun

Charlotte

Citrus

Clay

Collier

Columbia

DeSoto

Dixie

Duval

Escambia

Flagler

Franklin

Gadsden

Gilchrist

Glades

Gulf

Hamilton

Hardee

Hendry

Hernando

Highlands

Hillsborough

Holmes

Indian River

Jackson

Jefferson

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Lafayette

Lake

Lee

Leon

Levy

Liberty

Madison

Manatee

Marion

Martin

Miami-Dade

Monroe

Nassau

Okaloosa

Okeechobee

Orange

Osceola

Palm Beach

Pasco

Pinellas

Polk

Putnam

Santa Rosa

Sarasota

Seminole

St. Johns

St. Lucie

Sumter

Suwannee

Taylor

Union

Volusia

Wakulla

Walton

Washington

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4. Indicate the type of program.

Replication

Validation

Provisional validation

Innovation

Provisional innovation

5. Identify the risk factors addressed by the program.

Abuse victims

Academic failure beginning in the late elementary school

Already using substances

Availability of drugs

Children of substance abusers

Community laws and norms favorable to drug use, firearms & crimes

Dropouts

Early and persistent antisocial behavior

Early and persistent antisocial behavior

Early initiation of the problem behavior

Economically disadvantaged

Family conflict

Family history of problem behavior

Family management problems

Favorable attitudes toward the problem behavior

Favorable parental attitudes & involvement n the problem behavior

Friends who engage in problem behavior

Lack of commitment to school

Low neighborhood attachment & community disorganization

Mental health problems

Physically disabled

Transitions and mobility

Violent and delinquent behavior


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6. Identify the prevention factors for the program.

Community: Bonding (opportunity, skills and recognition

Community: Bonding (opportunity, skills and recognition

Community: Healthy Beliefs and Clear Standards

Community: Healthy Beliefs and Clear Standards

Family: Bonding (opportunity, skills, and recognition

Family: Healthy Beliefs and Clear Standards

Family: Healthy Beliefs and Clear Standards

Peer: Healthy Beliefs and Clear Standards

School: Bonding (opportunity, skills, and recognition)

School: Healthy Beliefs and Clear Standards

School: Healthy Beliefs and Clear Standards


7. Identify the specific strategies to be utilized.*

Information Dissemination

Education and Training

Alternatives

Problem Identification and Referral

Community Based Process

Environmental


8. Explain the appropriateness of the services offered by the program.

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9. Describe how the effectiveness of the program will be evaluated.

10. Does the agency possess the appropriate licensure for the services offered?

Yes

No


11. How many years has the program been conducted in this circuit?

12. What is the projected length of the program?

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13. Identify the age of the target population for this program.

5-11

12-14

15-17

18-20

21-24

25-44

45-64

65 and over

14. Identify the ethnicity of the target population for this program.

Puerto Rican

Mexican

Cuban

Haitian

Mexican American

Spanish/Latino

Other Hispanic

None of the above

15. Identify the race of the targeted population of the program.

White

Black or African American

Native Hawaiian/Other Pacific Islander

Asian

American Indian/Alaska Native

More Than One Race (not OMB required)

Race Not Known or Other (not OMB required)

16. Identify the targeted gender of the program.

Male

Female

Both

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17. Planned number of groups

Minimum

Maximum

18. Range of the number of participants in each group

19. If the number of participants exceeds guidelines for the program, provide a justification below.

20. How many sessions will be administered per group?

21. Will pre and post tests be administered?

Yes

No

22. Will supplemental activities be administered?

Yes

No

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23. Identify the number of supplemental activities to be administered.

24. Identify the supplemental services.*

STN01 Prevention Information Clearinghouse

STN03 Health Promotion

STN05 Prevention print material development

STN07 Newsletter Development

STN08 Prevention media message development

STN11 Disseminating print material

STN13 Newsletter Dissemination

STN14 Disseminating via mass media

STN15 Community resource directory dissemination

STN16 Community-wide Awareness

STN17 Speaking Engagements

STN18 Telephone Information Services

STC06 Prevention Training

STC08 Prevention Technical Assistance

STE01 Children of Substance Abusers (COSA) Groups

STE02 Drug Education - Schools

STE03S Drug Education - Youth Groups

STE04S Parenting/Family Support

STE05 Peer leader training

STE06M Mentoring

STE06S Support Group

STN06 Training curriculum development

STA01 Alcohol, tobacco and other drug-free activities

STA06 Service Learning

STA07A Recreation Support

STA07B Tutoring

STA07C Youth Group Support

STE05S Peer leader activites

STE06P Other prevention activities/ services: Prevention Counseling

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STP01 Employee Assistance

STP03 Student Assistance

STP06 Prevention Assessment and Referral

STC02 Coalition Support: Needs and Resource Assessment

STC03 Volunteer Coordination

STC04 Coalition Participation

STC05A Coalition Support: community awareness and other recognition

STC10 Coalition Support: Strategic Planning

STV01A Coalition Support: environmental strategies

STV01B Consultation on organizational environmental strategies

STV01C Environmental strategies related to illegal drug abuse prevention

STV01D Environmental strategies related to prescription or OTC drug abuse prevention

STV02 Environmental strategies related to tobacco sales prevention

STV03 Environmental Strategies related to underage alcohol sales prevention

STV06 Prevention Policy Activities

STC05C Coalition building

STC05D Coalition coordination

STC02B Community needs assessment

STC01 Community resource assessment

STC10B Strategic Planning

STC05B Community Process

STN09 Community resource directory development & maintenance

STC05 Coalition Partnership Coordination

STN16A Social Media and Networking

STN16M Media Campaigns

25. Will booster sessions be offered?

Yes

No

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Staffing Patterns


Title

Responsibility

Qualifications

Cost Center

Number of FTEs

Comments

26. Position 1

Title

Responsibility

Qualifications

Cost Center

Number of FTEs

Comments

27. Position 2

Title

Responsibility

Qualifications

Cost Center

Number of FTEs

Comments

28. Position 3

Title

Responsibility

Qualifications

Cost Center

Number of FTEs

Comments

29. Position 4

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Title

Responsibility

Qualifications

Cost Center

Number of FTEs

Comments

30. Position 5

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Using the total contracted dollars allocated to Prevention/PPG, account for 100% of the funding acrosseach of the areas identified.

Funding


48 -IndicatedPrevention(ASA)

48 -IndicatedPrevention(CSA)

49 -SelectivePrevention(ASA)

49 -SelectivePrevention(CSA)

50 -UniversalDirectPrevention(ASA)

50 -UniversalDirectPrevention(CSA)

51 -UniversalIndirectPrevention(ASA)

51 -UniversalIndirectPrevention(CSA)

31. Identify funding allocations by covered service.

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32. Provide a narrative description of the program.

33. Additional Comments

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Thank you for participating. Feedback regarding the program description submitted for prevention serviceswill be provided.


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exhibit f - program descriptions - drizzy drake (1 of 3) final · exhibit f updated 7/1/2017...

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