RFA # 18152 / Grants Gateway # DOH01-MFPNHT-2019

New York State Department of Health

Division of Long Term Care
Money Follows the Person Program

Request for Applications

Money Follows the Person Nursing Home Transition

Assistance, Support, and Education

KEY DATES:

Release Date: June 6, 2019

Questions Due: June 20, 2019

Questions, Answers and

Updates Posted (on or about): July 10, 2019

Applications Due: July 25, 2019 by 4:00 PM

DOH Contact Name & Address: Stacey Agnello, Project Advisor

Division of Long Term Care
New York State Department of Health
One Commerce Plaza
16th Floor, Room 1601
Albany, NY 12210
[email protected]
 Table of Contents
I. Introduction ...................................................................................................................... 3
A. Background ..................................................................................................................... 3
B. Description of Program ................................................................................................... 3
C. Available Funding and Anticipated Award ....................................................................... 4
II. Who May Apply ................................................................................................................ 4
A. Minimum Eligibility Requirements.................................................................................... 4
B. Preference Factors.......................................................................................................... 4
III. Project Narrative/Work Plan Outcomes ............................................................................ 5
A. Program Expectations ..................................................................................................... 5
B. Core Functions................................................................................................................ 5
C. Program Goals ................................................................................................................ 6
IV. Administrative Requirements ......................................................................................... 10
A. Issuing Agency.............................................................................................................. 10
B. Question and Answer Phase ......................................................................................... 10
C. Letter of Interest ............................................................................................................ 11
D. Applicant Conference .................................................................................................... 11
E. How to file an application .............................................................................................. 11
F. Department of Health’s Reserved Rights ...................................................................... 13
G. Term of Contract ........................................................................................................... 14
H. Payment & Reporting Requirements of Grant Awardees ............................................... 14
I. Minority & Woman-Owned Business Enterprise Requirements ..................................... 15
J. Limits on Administrative Expenses and Executive Compensation ................................. 17
K. Vendor Identification Number ........................................................................................ 17
L. Vendor Responsibility Questionnaire............................................................................. 17
M. Vendor Prequalification for Not-for-Profits ..................................................................... 17
N. General Specifications .................................................................................................. 19
V. Completing the Application............................................................................................. 20
A. Application Format/Content ........................................................................................... 20
1. Pre-Submission Uploads (Not Scored) .......................................................................... 20
2. Program Summary (Maximum Score: Not Scored)........................................................ 20
B. Freedom of Information Law ......................................................................................... 25
C. Review & Award Process .............................................................................................. 26
VI. Attachments ................................................................................................................... 27

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I. Introduction
A. Background

New York State’s Money Follows the Person (MFP) program has been a pinnacle in shifting health
care priorities away from institutional care and rebalancing them toward long term care provided in the
community. It has served as a focal point to increase access to home and community-based services
for eligible Medicaid recipients, older adults and individuals with physical and developmental
disabilities in New York State. The MFP program works to assure that residents1 of nursing homes2
throughout the State are provided with objective information to overcome challenges in accessing
alternatives to unwanted institutional placement and to assist in facilitating transition back to a
community of choice.

New York is one of 44 states nationally that have participated in MFP and have provided assistance to
over 75,0003 inviduals to facilitate transitions from nursing homes back to living and receiving services
in their communities of their choice. Between 2008 and June 2018, over 4,097 individuals have
transitioned from institutions back into community settings through New York State’s MFP program.

B. Description of Program

The MFP program supports a number of rebalancing activities, including the operation of a statewide
network of regionally based Transition Centers, which identifies potential participants in long-term
care facilities, provides them with education on return-to-community options, and facilitates their
transition from institutional to community-based care. Transition specialists work to resolve barriers to
discharge and remove obstacles to achieve successful living in the community, provide community re-
entry education and facilitate successful transitions to participants’ communities of choice. Additional
support is provided to those interested in transitioning to the community through coordinated
statewide Peer Outreach and Support. Trained peers assist in identifying individuals who express a
desire to leave institutional settings and provide support throughout the transition process. Targeted
Education and Outreach is provided to all nursing homes in New York State on a bi-annual basis by
trained educators. These education and outreach presentations reinforce compliance with MDS
Section Q referrals to the Local Contact Agency, provide information about the referral process, and
raise awareness of the availability of transition assistance and peer support.

Current partnerships with the following constituent programs assure that members of vulnerable
populations (e.g., older adult individuals with physical, intellectual, and/or developmental disabilities;
and individuals with traumatic brain injury) have access to home and community-based services:
• New York State Nursing Home Transition and Diversion (NHTD) waiver,
• New York State Traumatic Brain Injury (TBI) waiver,
• New York State Office of People with Developmental Disabilities (OPWDD) Home and
Community-Based waiver,
• Medicaid Managed Care,
• Medicaid Managed Long Term Care, and
• Health Homes.

The intent of this Request for Applications (RFA) is to procure a single vendor to administer a
statewide Transition Center infrastructure, which will provide education about community living

1
The terms “resident” and “participant” also refers to family member, significant other, legal guardian or legally authorized
representative.
2
Currently MFP focuses on residents of nursing homes and intermediate care facilities.
3
Mathematica Policy Research analysis of State MFP Grantee Semi annual Progress Reports, 2008-2016.

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options, transition assistance, peer outreach and support, and education and outreach to nursing
homes to support the transition of individuals from institutional to community-based settings.

C. Available Funding and Anticipated Award

It is anticipated that $5.4 million per year ($27,000,000 total) will be available to award one contract to
a not-for-profit organization (501(c)3) over a five-year period to deliver the Transition Center program
statewide, including the core functions of transition assistance, peer outreach and support, and
education and outreach to nursing homes, as described in Section III. Project Narrative/Work Plan
Outcomes; B. Core Functions. This initative will be supported by a combination of federal and state
funding.

II. Who May Apply

Eligible applicants must have a statewide presence that can adequately address all the the Program
Expectations and Goals listed in Section III: Project Narrative/Work Plan Outcomes and meet at
least the the minimum eligbility requirements listed below.

A. Minimum Eligibility Requirements

Applicants must:

1. Be a not-for-profit organization as indicated by a current 501(c)3 status located in New York

State.
2. Have an organizational structure that supports a statewide presence that can arrange for the
required services either directly or through subcontract(s), in all 62 NYS counties.
3. Have a minimum of three (3) years of experience working with individuals with disabilities4 and
the elderly within the long-term care service delivery system.
4. Be pre-qualified in the New York State Grants Gateway, if not exempt.

Applicants who are unable to demonstrate fulfillment of the minimum eligibilty requirements will not be
considered for a contract award. A completed, signed Application Cover Page and Attestation of
Minimum Eligibility (Attachment 1) must be uploaded into the Pre-submission Upload section in the
Grants Gateway. Failure to upload the required Attachment 1 will result in disqualification and your
application will not be reviewed.

B. Preference Factors

Applicants that can demonstrate the following preferred experience will be awarded additional points.

1. Two (2) or more years of experience working with Home and Community Based waivers and
Medicaid Managed Care plans regarding community transitions, including working with service
coordinators and care managers.
2. Two (2) or more years of experience administering a health and/or human services related
program with statewide reach.
3. Two (2) or more years of experience facilitating the transition of individuals from institutional
care to the community.
4. Two (2) or more years of experience operating peer support services.
5. Two (2) or more years of experience providing education and outreach to health care
professionals.

4
Disabilities include physical disabilities, intellectual/developmental disabilities and traumatic brain injury.

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 6. Two (2) or more years of experience assisting to repatriate New York State residents residing
in out of state long-term care facilities back to community settings in New York State.

III. Project Narrative/Work Plan Outcomes

A. Program Expectations

Successful applicants will administer a statewide Transition Center infrastructure that adheres to the
principles of the most integrated setting mandate of Title II of the Americans with Disabilities Act
(ADA) of 1990, the Olmstead decision, and the independent living concepts of personal choice and
control as well as the dignity of risk, and includes the following core program functions.

B. Core Functions

Transition Assistance – As the New York State Department of Health’s (DOH) designated Local
Contact Agency, the Transition Center program will receive referrals for education on community
supports and services, identify eligible individuals in nursing homes and provide transition assistance
to individuals wishing to transition to the community.

Utilizing a regional/local approach, successful applicants will be expected to provide education to

interested nursing home residents on available community options for Home and Community-Based
Services and assist participants to identify and access needed supports, benefits, and services in their
local communities of choice. Successful applicants will provide community preparedness education to
participants and transition planning in collaboration with the participant and the nursing home.

Transition specialists will collaborate with nursing home staff, Medicaid Managed Care plans,
Medicaid Managed Long Term Care plan care managers, local Departments of Social Services,
1915(c) Waiver providers and Regional Resource Development Centers (RRDCs), OPWDD’s State
Operations Office and Regional Office’s Front Door staff and community-based service providers as
needed, to identify and address barriers to a safe transition back to the community. In addition, they
will establish linkages and work collaboratively with Transition Center peers, as indicated.

Transition specialists will be responsible for conducting the DOH-prescribed Quality of Life (QoL)
survey to all participants on a DOH prescribed timeline (baseline and at 11 months post transition)
and monitoring continuation of 365 days of eligible home and community-based services through
monthly follow up for one year post transition.

The successful applicant will establish and implement MFP data collection and reporting mechanisms
necessary for DOH to fulfill federal and State MFP reporting requirements, and support ongoing
program analysis.

Peer Outreach and Support – Using a peer-based approach, successful applicants will train and
deploy peers to provide outreach in nursing homes. Peers will provide information to interested
individuals and families about available home and community-based services and opportunities for
community living. For individuals who wish to begin transition planning, peers will create linkages to
transition specialists and will work collaboratively with transition specialists, discharge planners and
others to support participants to successfully transition to the community. Peers will also be enlisted
to assist transition specialists in post-transition follow-up activities.

Peers will be individuals who are successfully living independently in the community and reflect the
characteristics and life experiences of the individuals that wish to transition back to the community
and, where possible, have themselves transitioned from an institutional setting into the community.

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Nursing Home Education and Outreach – Dedicated Education and Outreach staff will provide
targeted education to all nursing homes throughout the State on a bi-annual cycle, to encourage
referrals and support compliance with the Section Q process. Topics will include the identification of
potential referrals, best practices for the the MDS Section Q assessment process, availability of
transition assistance and peer support, and the process for referral to the Local Contact Agency.

Applicants may subcontract components of the scope of work. Applicants that plan to subcontract
are expected to state in the application the specific components of the scope of work to be
performed through subcontracts. Letters of commitment from each subcontractor are
strongly recommended and should be uploaded under the Pre-Submission Upload section in
the Grants Gateway as Attachment 12. Applicants should note that the lead organization
(contractor) will have overall responsibility for all contract activities, including those performed by
subcontractors, and will be the primary contact for the DOH.

Note: To ensure the integrity, security, and confidentiality of information contained in the Minimum
Data Set (MDS), contractor(s) selected under this RFA must comply with New York State’s MDS Data
Use Agreement with CMS (Attachment 7: Data Use Agreement). Applicants should familiarize
themselves with the requirements of the Data Use Agreement as the selected contractor(s) will be
held to the same standards as the Department regarding data security and confidentiality that are set
forth in the Data Use Agreement. In addition, a copy of a MDS Data Use Agreement Addendeum
template can be found in Attachment 8: Data Use Agreement Addendum. This MDS Data Use
Agreement Addendum template is for informational purposes only. Contractor(s) selected through
this RFA will be required to sign an Addendum to New York State’s current MDS Data Use Agreement
so that the State can request an addendum from CMS.

C. Program Goals

I. Program Infrastructure and Oversight: Ensure the statewide Transition Center

Infrastructure, including all three core program functions (Transition Assistance, Peer
Outreach and Support, and Nursing Home Education and Outreach), meets high quality
contract standards in a cost-effective manner.

1. Track and accurately report activities as directed by DOH.

i. Maintain complete information regarding participants served and services
delivered, as directed by DOH, and make all case information available and
accessible to DOH.
ii. Report on services delivered and goals achieved on a monthly and semi-annual
basis.
iii. Submit accurate vouchers within 60 days of the end of the month.
iv. Respond to ad-hoc reporting requests as directed by DOH.

2. Provide oversight and conduct quality assurance activities to ensure that contract activities
occur as directed by DOH.
i. Ensure that contract activities meet contract deliverables.
ii. Ensure the accuracy of all information maintained by the Contractor and provided
to DOH.
iii. Ensure that information related to quality assurance and improvement is provided
to DOH as directed by DOH.
iv. Ensure that the confidentiality of personally identifiable information is protected.

3. Ensure that all individuals who enter areas where patients/clients/residents might be
present, are either vaccinated for the current influenza season or wear a face mask.

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 i. Provide documentation of flu shot.
ii. Provide education related to universal precautions.

II. Transition Assistance: Provide information about options for community-based care and
facilitate transitions of older adults and individuals with physical and/or developmental
disabilities who express a desire to leave an institutional setting to return to the community.

1. Develop and implement strategies to identify individuals residing in nursing homes who are
interested in receiving information regarding the options for transitioning to a community
setting with home and community-based services.
i. Develop an outreach and marketing plan involving multiple media strategies to
generate referrals.
ii. Develop and distribute objective outreach material, with DOH approval, related to
transitioning from a nursing home to the community.
iii. Develop and implement strategies to build and maintain relationships with nursing
home discharge planners, managed long term care managers, ombudspersons,
and others related to generating referrals of individuals who wish to pursue home
and community-based service options.
iv. Coordinate all referrals as the State-designated Local Contact Agency for MDS
Section Q referrals and other referrals for transition assistance.

2. Provide objective information about options for home and community-based services for
older adults and individuals with physical and/or developmental disabilities who express a
desire to leave institutional settings and return to the community.
i. Build and maintain knowledge about available home and community-based
supports and services in each region.
ii. Ensure consistent messaging and information is provided by transition specialists
to nursing home residents interested in community transition.
iii. Make initial visit to a potential participant no more than 10 days from receipt of a
referral.
iv. Collaborate with peers to provide transition support.

3. Develop strong collaborative relationships with long-term care stakeholders to support

successful transitions to community settings.
i. Develop collaborative relationships with Regional Resource Development Centers
(RRDCs), Office for People with Development Disabilities (OPWDD)’s State
Operations Office and Regional Office’s Front Door staff, county Department of
Social Services staff, local Area Agencies on Aging, nursing home discharge
planners, home and community-based service providers, managed long term care
(MLTC) plans/MCOs, and Health Homes/Care Management Agencies in each
county and region through education and outreach.
ii. Engage with NY Connects’ Local Long Term Care Council activities to support a
coordinated local approach to community transitions.
iii. Develop and implement strategies to address identified barriers to building and
maintaining relationships with nursing home discharge planners, ombudspersons,
other long-term care community-based stakeholders, and RRDCs, MLTC
plans/MCOs, and Health Homes/Care Management Agencies and other entities
that authorize or provide home and community-based services.

4. Facilitate transition of individuals into community settings with appropriate home and
community-based services and supports to enable them to remain in the community.
i. Ensure that informed consent and release of information forms are signed by
potential participants or their legal guardians.

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 ii. Increase participant community readiness skills necessary for successful
community living.
iii. Assist facility discharge planners with the coordination of home and community-
based services and supports so that all the necessary service elements are in
place for a successful transition. Please note that this program will not supplant
any existing responsibility that the discharge planner has for assisting their
interested nursing home residents with transitioning into the community.
iv. Ensure that necessary referrals are made timely to Regional Resource
Development Centers, the Conflict Free Evaluation and Enrollment Center
(CFEEC), Managed Care Organizations (MCOs), Health Homes/Care Management
Agencies, OPWDD Front Door, etc., to begin assessment and enrollment
processes for home and community-based services.
v. Coordinate transition activity with RRDCs, OPWDD’s State Operations Office and
Regional Office’s Front Door staff, county Department of Social Services staff,
MLTC plans/MCOs, and Health Homes/Care Management Agencies.
vi. Collaborate with local Departments of Social Services to ensure steps related to
community budgeting, immediate need, etc., are occurring as needed.
vii. Link individuals with, and collaborate with, peers to support community transitions
for participants who are interested in pursuing a community transition and would
benefit from peer support to achieve a successful community transition.
viii. Follow-up with RRDCs and CFEEC/MCOs to ensure progress towards enrollment
(waiver/managed care) is being made and to resolve barriers.
ix. Ensure referrals are made to needed housing services and subsidies to support
participants’ access to accessible and affordable housing to support their
transitions.
x. Identify and work to resolve barriers to successful transition. Bring all unresolvable
barriers and systemic barriers to the attention of DOH.

5. Follow-up with participants to identify and resolve barriers to successful community

functioning to prevent reinstitutionalization post-transition.
i. Identify and assist participants to access community services and supports that
may be needed by individuals to sustain living in the community.
ii. Provide intensive follow up in the first 30 days with participants, home and
community-based service providers, RRDCs, CFEEC/MCOs, and Health
Homes/Care Management Agencies to ensure enrollment and service provision are
occurring as needed from Day 1 following discharge, and to work to resolve any
barriers to waiver/MLTC enrollment and service provision, as they arise, to prevent
reinstitutionalization.
iii. Follow-up with participants, at a minimum, monthly for the first 31-365 days in the
community to identify and assist with the resolution of barriers to successful
maintenance in the community.
iv. Identify, track, and work to resolve barriers to successful community living in the
immediate post-transition period. Bring unresolvable barriers and systemic barriers
to the attention of DOH.

6. Work to repatriate NYS residents who are living in out-of-state nursing homes to their
home communities in NYS.

7. Evaluate the quality of life of individuals transitioning to the community by administering the
QoL survey, as prescribed by DOH.
i. Administer QoL baseline and 11-month QoL surveys according to standards
developed by DOH.

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III. Peer Outreach and Support: Provide information and support to individuals in nursing homes
to support successful community transitions.

1. Recruit and train paid peers that have characteristics (i.e., physical and developmental
disabilities and/or age) that approximate those characteristics of individuals requesting
peer services, and where possible, who have themselves transitioned from a nursing home
setting into the community.
i. Develop and implement a recruitment plan for peers that ensures coverage across
all regions in New York State. This plan will be reviewed and approved by DOH.
ii. Provide comprehensive training for peers related to skills necessary to provide
outreach and support to individuals who are transitioning from a nursing home and
returning to the community, including, but not limited to, reflective listening, problem
solving, time management, professionalism, and documentation.
iii. Provide the necessary skills training for peers to accomplish successful outreach.

2. Provide Peer Outreach to older adults and individuals with physical and/or developmental
disabilities in nursing homes to identify nursing home residents who wish to leave the
institutional setting to return to the community.
i. Develop a strategy for Peer Outreach, including developing relationships with
nursing home discharge planners and ombudspersons to support outreach by
peers in the nursing homes.
ii. Identify and work to resolve barriers to conducting outreach within nursing homes.
Develop outreach materials, with DOH approval, for use as part of Peer Outreach.
iii. Provide objective information about options for home and community-based
services to older adults and individuals with physical and/or developmental
disabilities who express a desire to leave an institutional setting and return to the
community.
iv. Ensure consistent messaging and information is provided by peers to nursing home
residents interested in community transition.
v. Link nursing home residents who wish to pursue home and community-based
options with transition specialists and collaborate for transition planning with
transition specialists and nursing home discharge planners/social workers.

3. Provide Peer Support to individuals who are engaged in transitioning from facilities to
homes in the community to support successful transitions.
i. Provide one-on-one meetings between peers and nursing home residents who are
transitioning from nursing home to community. Meetings should be face-to-face
unless extenuating circumstances are prohibitive. Initial meetings should occur
within 10 days of referral.
ii. Schedule a peer to accompany a transition specialist on initial transition specialist
visits to individuals with intellectual/developmental disabilities.
iii. Ensure peers assist nursing home residents to identify and resolve their concerns
relating to the community transition.
iv. Provide peer follow-up contact during the first 60 days post transition to identify
barriers and collaborate with transition specialists to resolve issues and prevent
avoidable reinstitutionalization.

IV. Nursing Home Education and Outreach: Provide objective information to nursing home staff
to facilitate referrals to the Local Contact Agency, and support collaboration between the
nursing home staff and the Transition Centers.

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 1. Increase the knowledge of nursing home staff regarding availability of Transition
Assistance, Peer Outreach and Support, and requirements related to the Minimum Data
Set (MDS) Section Q referral to the Local Contact Agency.
i. Develop education and outreach presentation materials, for approval by DOH, to
guide the presentations.
ii. Provide intensive training to Outreach Educators to ensure they are well-versed in
the requirements related to administration of Section Q of the Minimum Data Set
(MDS) and referral to the Local Contact Agency, including the barriers and
misconceptions that inhibit compliance.
iii. Provide education and outreach presentations to all New York State skilled nursing
homes on a bi-annual basis.
iv. Summarize presentation evaluations on a semi-annual basis for submission to
DOH.
v. In collaboration with DOH, monitor nursing home compliance with MDS Section Q
information and referral processes.
vi. Modify and update presentation materials and contents based on presentation
evaluation results, new developments, and the experience of transition specialists
and peers in the field.

2. Establish outreach activities and collaborative relationships with statewide provider

associations, consumer organizations, and nursing homes to provide information about the
program, the referral process, and the assistance available for individuals to transition.
i. Foster collaborative relationships between nursing homes and the Transition
Center program.
ii. Offer presentations to the membership of the nursing home provider associations
on at least an annual basis.
iii. Seek opportunities to present at conferences, trade shows, agencies and other
venues to introduce relevant parties to the program.

IV. Administrative Requirements

A. Issuing Agency

This RFA is issued by the New York State Department of Health (DOH), Division of Long Term
Care, Bureau of Community Integration and Alzheimer’s Disease, Money Follows the Person
program. The Department is responsible for the requirements specified herein and for the
evaluation of all applications.

B. Question and Answer Phase

All substantive questions must be submitted in writing or via email to:

Justin Seastrum, HPA

New York State Department of Health
Office of Health Insurance Programs
One Commerce Plaza, Room 1450
Albany, NY 12210
[email protected]
Phone: (518) 408-6634

To the degree possible, each inquiry should cite the RFA section and paragraph to which it refers.
Written questions will be accepted until the date posted on the cover of this RFA. This includes

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 Minority and Women Owned Business Enterprise (MWBE) questions and questions pertaining to
the MWBE forms.

Questions of a technical nature can be addressed in writing or via telephone by contacting Justin
Seastrum at (518) 408-6634 or [email protected]. Questions are of a technical
nature if they are limited to how to prepare your application (e.g., formatting) rather than
relating to the substance of the application.

Some helpful links for questions of a technical nature are below. Questions regarding specific
opportunities or applications should be directed to the DOH contact listed on the cover of this
RFA.

• https://grantsmanagement.ny.gov/resources-grant-applicants

• Grants Gateway Videos: https://grantsmanagement.ny.gov/videos-grant-applicants

• Grants Gateway Team Email: [email protected]

Phone: 518-474-5595
Hours: Monday thru Friday 8am to 4pm
(Application Completion, Policy, Prequalification and Registration questions)

• Agate Technical Support Help Desk

Phone: 1-800-820-1890
Hours: Monday thru Friday 8am to 8pm
Email: [email protected]
(After hours support w/user names and lockouts)

Prospective applicants should note that all clarifications and exceptions, including those relating to
the terms and conditions of the contract, are to be raised prior to the submission of an application.

This RFA has been posted on the NYS Grants Gateway website at:
https://grantsgateway.ny.gov/IntelliGrants_NYSGG/module/nysgg/goportal.aspx and a link
provided on the Department's public website at: https://www.health.ny.gov/funding/. Questions
and answers, as well as any updates and/or modifications, will be posted on the Grants Gateway.
All such updates will be posted by the date identified on the cover of this RFA.

C. Letter of Interest

Letters of Interest are not a requirement of this RFA.

D. Applicant Conference

An Applicant Conference WILL NOT be held for this project.

E. How to file an application

Applications must be submitted online via the Grants Gateway by the date and time posted on the
cover of this RFA. Reference materials and videos are available for Grantees applying to funding
opportunities on the NYS Grants Gateway. Please visit the Grants Management website at the
following web address: https://grantsmanagement.ny.gov/ and select the “Apply for a Grant” from
the Apply & Manage menu. There is also a more detailed “Grants Gateway: Vendor User Manual”
available in the documents section under Training & Guidance; For Grant Applicants on this page

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as well. Training webinars are also provided by the Grants Gateway Team. Dates and times for
webinar instruction can be located at the following web address:
https://grantsmanagement.ny.gov/live-webinars.

To apply for this opportunity:

1. Log into the Grants Gateway as either a “Grantee” or “Grantee Contract Signatory”.
2. On the Grants Gateway home page, click the “View Opportunities” button.
3. Use the search fields to locate an opportunity; search by State agency (DOH) or enter the
Grant Opportunity name: Money Follows the Person Nursing Home Transition
Assistance, Support, and Education.
4. Click on “Search button to initiate the search.
5. Click on the name of the Grant Opportunity from the search results grid and then select the
“APPLY FOR GRANT OPPORTUNITY” button located bottom left of the Main page of the
Grant Opportunity.

Once the application is complete, prospective grantees are strongly encouraged to submit their
applications at least 48 hours prior to the due date and time. This will allow sufficient opportunity
for the applicant to obtain assistance and take corrective action should there be a technical issue
with the submission process. Failure to leave adequate time to address issues identified
during this process may jeopardize an applicant’s ability to submit their application. Both
DOH and Grants Gateway staff are available to answer applicant’s technical questions and
provide technical assistance prior to the application due date and time. Contact information for the
Grants Gateway Team is available under Section IV. B. of this RFA.

PLEASE NOTE: Although DOH and the Grants Gateway staff will do their best to address
concerns that are identified less than 48 hours prior to the due date and time, there is no
guarantee that they will be resolved in time for the application to be submitted and, therefore,
considered for funding.

The Grants Gateway will always notify applicants of successful submission. If a prospective
grantee does not get a successful submission message assigning their application a unique ID
number, it has not successfully submitted an application. During the application process, please
pay particular attention to the following:

• Not-for-profit applicants must be prequalified on the due date for this application
submission. Be sure to maintain prequalification status between funding opportunities.
Three of a not-for-profit’s essential financial documents - the IRS990, Financial Statement
and Charities Bureau filing - expire on an annual basis. If these documents are allowed to
expire, the not-for-profit’s prequalification status expires as well, and it will not be eligible
for State grant funding until its documentation is updated and approved, and prequalified
status is reinstated.
• Only individuals with the roles “Grantee Contract Signatory” or “Grantee System
Administrator” can submit an application.
• Prior to submission, the system will automatically initiate a global error checking process to
protect against incomplete applications. An applicant may need to attend to certain parts
of the application prior to being able to submit the application successfully. Be sure to
allow time after pressing the submit button to clean up any global errors that may arise.
You can also run the global error check at any time in the application process. (see p.63 of
the Grants Gateway: Vendor User Manual).
• Grantees should use numbers, letters and underscores when naming their uploaded files.
There cannot be any special characters in the uploaded file name. Also be aware of the
restriction on file size (10 MB) when uploading documents. Grantees should ensure that

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 any attachments uploaded with their application are not “protected” or “pass-worded”
documents.

The following table will provide a snapshot of which roles are allowed to Initiate, Complete, and
Submit the Grant Application(s) in the Grants Gateway.

Create and Only View

Initiate Complete Submit
Role Maintain the
Application Application Application
User Roles Application
Delegated Admin X
Grantee X X
Grantee Contract X X X
Signatory
Grantee Payment X X
Signatory
Grantee System X X X
Administrator
Grantee View Only X

PLEASE NOTE: Waiting until the last several days to complete your application online can
be dangerous, as you may have technical questions. Beginning the process of applying as
soon as possible will produce the best results.

Late applications will not be accepted. Applications will not be accepted via fax, e-mail, hard
copy or hand delivery.

F. Department of Health’s Reserved Rights

The Department of Health reserves the right to:

1. Reject any or all applications received in response to this RFA.

2. Withdraw the RFA at any time, at the Department’s sole discretion.

3. Make an award under the RFA in whole or in part.

4. Disqualify any applicant whose conduct and/or proposal fails to conform to the requirements of
the RFA.

5. Seek clarifications and revisions of applications.

6. Use application information obtained through site visits, management interviews and the
State’s investigation of an applicant’s qualifications, experience, ability or financial standing,
and any material or information submitted by the applicant in response to the agency’s request
for clarifying information in the course of evaluation and/or selection under the RFA.

7. Prior to application opening, amend the RFA specifications to correct errors or oversights, or to
supply additional information, as it becomes available.

8. Prior to application opening, direct applicants to submit proposal modifications addressing

subsequent RFA amendments.

9. Change any of the scheduled dates.

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 10. Waive any requirements that are not material.

11. Award more than one contract resulting from this RFA.

12. Conduct contract negotiations with the next responsible applicant, should the Department be
unsuccessful in negotiating with the selected applicant.

13. Utilize any and all ideas submitted with the applications received.

14. Unless otherwise specified in the RFA, every offer is firm and not revocable for a period of 60
days from the bid opening.

15. Waive or modify minor irregularities in applications received after prior notification to the
applicant.

16. Require clarification at any time during the procurement process and/or require correction of
arithmetic or other apparent errors for the purpose of assuring a full and complete
understanding of an offerer’s application and/or to determine an offerer’s compliance with the
requirements of the RFA.

17. Negotiate with successful applicants within the scope of the RFA in the best interests of the
State.

18. Eliminate any mandatory, non-material specifications that cannot be complied with by all
applicants.

19. Award grants based on geographic or regional considerations to serve the best interests of the
State.

G. Term of Contract

Any contract resulting from this RFA will be effective only upon approval by the New York State
Office of the Comptroller.

It is expected that contracts resulting from this RFA will have the following time period: March 1,
2020 through February 28, 2025.

Continued funding throughout this this five (5) year period is contingent upon availability of funding
and State budget appropriations. DOH also reserves the right to revise the award amount as
necessary due to changes in the availability of funding.

A sample New York State Master Contract for Grants can be found in the Forms Menu once an
application to this funding opportunity is started.

H. Payment & Reporting Requirements of Grant Awardees

1. The Department may, at its discretion, make an advance payment to not-for-profit grant
contractors in an amount not to exceed 25%.

2. The grant contractor will be required to submit invoices and required reports of expenditures to
the State's designated payment office (below) or, in the future, through the Grants Gateway:

14
 NYS Department of Health
Money Follows the Person Program
One Commerce Plaza
16th floor, Room 1601
Albany, NY 12210

Grant contractors must provide complete and accurate billing invoices in order to receive
payment. Billing invoices submitted to the Department must contain all information and
supporting documentation required by the Contract, the Department and the Office of the State
Comptroller (OSC). Payment for invoices submitted by the CONTRACTOR shall only be
rendered electronically unless payment by paper check is expressly authorized by the
Commissioner, in the Commissioner's sole discretion, due to extenuating circumstances.
Such electronic payment shall be made in accordance with OSC’s procedures and practices to
authorize electronic payments. Authorization forms are available at OSC’s website at:
http://www.osc.state.ny.us/epay/index.htm, by email at: [email protected] or by
telephone at 855-233-8363. CONTRACTOR acknowledges that it will not receive payment on
any claims for reimbursement submitted under this contract if it does not comply with OSC’s
electronic payment procedures, except where the Commissioner has expressly authorized
payment by paper check as set forth above.

Payment of such claims for reimbursement by the State (NYS Department of Health) shall be
made in accordance with Article XI-A of the New York State Finance Law.
The Contractor will be reimbursed for actual expenses incurred as allowed in the Contract
Budget and Workplan.

3. The grant contractor will be required to submit the following reports to the Department of
Health at the address above or, in the future, through the Grants Gateway:

• Monthly data reports as defined by DOH due the last business day of the month following
the reporting month.
• Semi Annual data report and narrative summary of progress toward goals and objectives
due:
- Last business day of July for the period January 1- June 30.
- Last business day of January for the period July 1- December 31.
• Ad Hoc Reports as requested by DOH.

All payment and reporting requirements will be detailed in Attachment D of the final NYS Master
Contract for Grants.

I. Minority & Woman-Owned Business Enterprise Requirements

Pursuant to New York State Executive Law Article 15-A, the New York State Department of Health
(“DOH”) recognizes its obligation to promote opportunities for maximum feasible participation of
certified minority- and women-owned business enterprises and the employment of minority group
members and women in the performance of DOH contracts.

In 2006, the State of New York commissioned a disparity study to evaluate whether minority and
women-owned business enterprises had a full and fair opportunity to participate in state
contracting. The findings of the study were published on April 29, 2010, under the title "The State
of Minority and Women-Owned Business Enterprises: Evidence from New York" (“Disparity
Study”). The report found evidence of statistically significant disparities between the level of
participation of minority- and women-owned business enterprises in state procurement contracting
versus the number of minority- and women-owned business enterprises that were ready, willing

15
and able to participate in state procurements. As a result of these findings, the Disparity Study
made recommendations concerning the implementation and operation of the statewide certified
minority- and women-owned business enterprises program. The recommendations from the
Disparity Study culminated in the enactment and the implementation of New York State Executive
Law Article 15-A, which requires, among other things, that DOH establish goals for maximum
feasible participation of New York State Certified minority- and women-owned business
enterprises (“MWBE”) and the employment of minority groups members and women in the
performance of New York State contracts.

Business Participation Opportunities for MWBEs

For purposes of this solicitation, the New York State Department of Health hereby establishes a
goal of 30% as follows:

1) For Not-for Profit Applicants: Eligible Expenditures include any subcontracted labor or
services, equipment, materials, or any combined purchase of the foregoing under a
contract awarded from this solicitation.

The goal on the eligible portion of this contract will be 15% for Minority-Owned Business
Enterprises (“MBE”) participation and 15% for Women-Owned Business Enterprises (“WBE”)
participation (based on the current availability of qualified MBEs and WBEs and outreach efforts to
certified MWBE firms). A contractor (“Contractor”) on the subject contract (“Contract”) must
document good faith efforts to provide meaningful participation by MWBEs as subcontractors or
suppliers in the performance of the Contract and Contractor agrees that DOH may withhold
payment pending receipt of the required MWBE documentation. For guidance on how DOH will
determine “good faith efforts,” refer to 5 NYCRR §142.8.

The directory of New York State Certified MWBEs can be viewed at:
https://ny.newnycontracts.com. The directory is found on this page under “NYS Directory of
Certified Firms” and accessed by clicking on the link entitled “Search the Directory”. Engaging
with firms found in the directory with like product(s) and/or service(s) is strongly encouraged and
all communication efforts and responses should be well documented.

By submitting an application, a grantee agrees to complete an MWBE Utilization plan as directed

in Attachment 6: Minority & Women-Owned Business Enterprise Requirement Forms of this RFA.
DOH will review the submitted MWBE Utilization Plan. If the plan is not accepted, DOH may issue
a notice of deficiency. If a notice of deficiency is issued, Grantee agrees that it shall respond to
the notice of deficiency within seven (7) business days of receipt. DOH may disqualify a Grantee
as being non-responsive under the following circumstances:

a) If a Grantee fails to submit a MWBE Utilization Plan;

b) If a Grantee fails to submit a written remedy to a notice of deficiency;
c) If a Grantee fails to submit a request for waiver (if applicable); or
d) If DOH determines that the Grantee has failed to document good-faith efforts to meet the
established DOH MWBE participation goals for the procurement.

In addition, successful awardees will be required to certify they have an acceptable Equal
Employment Opportunity policy statement.

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J. Limits on Administrative Expenses and Executive Compensation

On July 1, 2013, limitations on administrative expenses and executive compensation contained

within Governor Cuomo’s Executive Order #38 and related regulations published by the
Department (Part 1002 to 10 NYCRR – Limits on Administrative Expenses and Executive
Compensation) went into effect. Applicants agree that all state funds dispersed under this
procurement will, if applicable to them, be bound by the terms, conditions, obligations and
regulations promulgated by the Department. To provide assistance with compliance regarding
Executive Order #38 and the related regulations, please refer to the Executive Order #38 website
at: http://executiveorder38.ny.gov.

K. Vendor Identification Number

Effective January 1, 2012, in order to do business with New York State, you must have a vendor
identification number. As part of the Statewide Financial System (SFS), the Office of the State
Comptroller's Bureau of State Expenditures has created a centralized vendor repository called the
New York State Vendor File. In the event of an award and in order to initiate a contract with the
New York State Department of Health, vendors must be registered in the New York State Vendor
File and have a valid New York State Vendor ID.

If already enrolled in the Vendor File, please be sure the Vendor Identification number is included
in your organization information. If not enrolled, to request assignment of a Vendor Identification
number, please submit a New York State Office of the State Comptroller Substitute Form W-9,
which can be found on-line at: http://www.osc.state.ny.us/vendor_management/forms.htm.

Additional information concerning the New York State Vendor File can be obtained on-line at:
http://www.osc.state.ny.us/vendor_management/index.htm, by contacting the SFS Help Desk at
855-233-8363 or by emailing at [email protected].

L. Vendor Responsibility Questionnaire

The New York State Department of Health strongly encourages that vendors file the required
Vendor Responsibility Questionnaire online via the New York State VendRep System. To enroll in
and use the New York State VendRep System, see the VendRep System Instructions available at
http://www.osc.state.ny.us/vendrep/index.htm or go directly to the VendRep system online at
https://portal.osc.state.ny.us.

Vendors must provide their New York State Vendor Identification Number when enrolling. To
request assignment of a Vendor ID or for VendRep System assistance, contact the Office of the
State Comptroller's Help Desk at 866-370-4672 or 518-408-4672 or by email at
[email protected].

Applicants should complete and upload the Vendor Responsibility Attestation (Attachment 5:
Vendor Responsibility Attestation) of the RFA. The Attestation is located under Pre-Submission
uploads and once completed should be uploaded into the same section.

M. Vendor Prequalification for Not-for-Profits

All not-for-profit vendors subject to prequalification are required to prequalify prior to grant
application and execution of contracts.

Pursuant to the New York State Division of Budget Bulletin H-1032, dated July 16, 2014, New
York State has instituted key reform initiatives to the grant contract process which requires not-for-

17
profits to register in the Grants Gateway and complete the Vendor Prequalification process in
order for applications to be evaluated. Information on these initiatives can be found on the Grants
Management Website.

Applications received from not-for-profit applicants that have not Registered and are not
Prequalified in the Grants Gateway on the application due date listed on the cover of this
RFA cannot be evaluated. Such applications will be disqualified from further
consideration.

Below is a summary of the steps that must be completed to meet registration and prequalification
requirements. The Vendor Prequalification Manual on the Grants Management Website details
the requirements and an online tutorial are available to walk users through the process.

1) Register for the Grants Gateway

• On the Grants Management Website, download a copy of the Registration Form for
Administrator. A signed, notarized original form must be sent to the NYS Grants
Management office at the address provided in the submission instructions. You will be
provided with a Username and Password allowing you to access the Grants Gateway.

If you have previously registered and do not know your Username, please email
[email protected] . If you do not know your Password, please click the Forgot
Password link from the main log in page and follow the prompts.

2) Complete your Prequalification Application

• Log in to the Grants Gateway. If this is your first time logging in, you will be prompted
to change your password at the bottom of your Profile page. Enter a new password and
click SAVE.

• Click the Organization(s) link at the top of the page and complete the required fields
including selecting the State agency you have the most grants with. This page should be
completed in its entirety before you SAVE. A Document Vault link will become available
near the top of the page. Click this link to access the main Document Vault page.

• Answer the questions in the Required Forms and upload Required Documents. This
constitutes your Prequalification Application. Optional Documents are not required unless
specified in this Request for Application.

• Specific questions about the prequalification process should be referred to your agency
representative or to the Grants Gateway Team at [email protected].

3) Submit Your Prequalification Application

• After completing your Prequalification Application, click the Submit Document Vault Link
located below the Required Documents section to submit your Prequalification Application
for State agency review. Once submitted the status of the Document Vault will change to
In Review.

• If your Prequalification reviewer has questions or requests changes you will receive email
notification from the Gateway system.

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 • Once your Prequalification Application has been approved, you will receive a Gateway
notification that you are now prequalified to do business with New York State.

Vendors are strongly encouraged to begin the process as soon as possible in order to
participate in this opportunity.

N. General Specifications

1. By submitting the "Application Form" each applicant attests to its express authority to sign on
behalf of the applicant.

2. Contractors will possess, at no cost to the State, all qualifications, licenses and permits to
engage in the required business as may be required within the jurisdiction where the work
specified is to be performed. Workers to be employed in the performance of this contract will
possess the qualifications, training, licenses and permits as may be required within such
jurisdiction.

3. Submission of an application indicates the applicant's acceptance of all conditions and terms
contained in this RFA, including the terms and conditions of the contract. Any exceptions
allowed by the Department during the Question and Answer Phase (Section IV.B.) must be
clearly noted in a cover letter attached to the application.

4. An applicant may be disqualified from receiving awards if such applicant or any subsidiary,
affiliate, partner, officer, agent or principal thereof, or anyone in its employ, has previously
failed to perform satisfactorily in connection with public bidding or contracts.

5. Provisions Upon Default

a. The services to be performed by the Applicant shall be at all times subject to the
direction and control of the Department as to all matters arising in connection with or
relating to the contract resulting from this RFA.

b. In the event that the Applicant, through any cause, fails to perform any of the terms,
covenants or promises of any contract resulting from this RFA, the Department acting for
and on behalf of the State, shall thereupon have the right to terminate the contract by
giving notice in writing of the fact and date of such termination to the Applicant.

c. If, in the judgement of the Department, the Applicant acts in such a way which is likely to
or does impair or prejudice the interests of the State, the Department acting on behalf of
the State, shall thereupon have the right to terminate any contract resulting from this
RFA by giving notice in writing of the fact and date of such termination to the Contractor.
In such case the Contractor shall receive equitable compensation for such services as
shall, in the judgement of the State Comptroller, have been satisfactorily performed by
the Contractor up to the date of the termination of this agreement, which such
compensation shall not exceed the total cost incurred for the work which the Contractor
was engaged in at the time of such termination, subject to audit by the State Comptroller.

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V. Completing the Application
A. Application Format/Content

Please refer to the Grants Gateway: Vendor User Manual for assistance in applying for this
procurement through the NYS Grants Gateway. This guide is available on the Grants
Management website at: www.grantsmanagement.ny.gov/resources-grant-applicants.

Also, you must use Internet Explorer (11 or higher) to access the Grants Gateway. Using
Chrome or Firefox causes errors in the Work Plan section of the application.

Please respond to each of the sections described below when completing the Grants Gateway
online application. Your responses comprise your application. Please respond to all items within
each section. When responding to the statements and questions, be mindful that application
reviewers may not be familiar with the agency and its services. Therefore, answers should be
specific, succinct and responsive to the statements and questions as outlined.

1. Pre-Submission Uploads (Not Scored)

As a reminder, the following attachments need to be uploaded under the Pre-Submission

Uploads section of the Grants Gateway in order to submit an application in the system.

• Attachment 1: Application Cover Page and Attestation of Minimum Eligibility (refer to

RFA Section II. A. Minimum Eligibility)
• Attachment 3: Budget Forms Years 2-5
• Attachment 5: Vendor Responsibility Attestation
• Attachment 6: Minority & Women-Owned Business Enterprise Requirement Forms
• Attachment 10: Organizational Chart
• Attachment 11: Program Structure and Reporting Relationships Chart
• Attachment 12: Letters of Commitment (if applicable)

2. Program Summary (Maximum Score: Not Scored)

a. Summarize the proposed program and how it meets the Program Goals in Section III.
Project Narrative/Work Plan Outcomes; C. Program Goals of this RFA in a high quality and
cost-effective manner.

3. Organizational Experience and Capacity (Maximum Score: 30 points)

a. Describe the length and breadth of the lead applicant’s relevant experience in relation to
program goals working within the field of long-term care, including experience with the
home and community-based service (HCBS) delivery system (e.g., Home and Community-
Based Waivers and Managed Long Term Care).
b. Describe the lead applicant’s experience providing health and/or human services on a
statewide basis, including length and breadth of experience.
c. Describe the lead applicant’s mission and the services it provides.
d. Describe the lead applicant’s organizational structure. If the lead applicant is part of a
larger organization, describe its relationship within the larger organization.
e. Upload an organizational chart that outlines staffing and reporting relationships within the
lead applicant’s organization to the Pre-Submission section in the Grants Gateway as
Attachment 10.
f. Describe the relevant experience of the lead applicant in performing each of the core
functions listed in Section III. Project Narrative/Work Plan Outcomes; B, Core Functions,
including length and breadth of experience:

20
 i. Transitioning individuals from facilty based care to the community;
ii. Administering Peer based support services;
iii. Delivering education and outreach to health care professionals/providers.
g. Describe the lead applicant’s experience in assisting New York State residents who are
residing in out of state nursing homes to return to community settings in New York State.
h. Describe the relevant experience of the lead applicant in working with the Minimum Data
Set and Section Q.

4. Program Design (Maximum Score: 130 points)

a. Transition Center Infrastructure

1. Describe the organizational structure of the proposed program, including program

design, essential staff and their qualifications, (i.e., appropriate qualifications, skills and
experience of the staff person(s) who will oversee and implement the project and those
who will be performing program monitoring, evaluation, and the fiscal management),
and the relationship(s) between program management and direct service, including the
role of any proposed subcontractors.

2. Upload a chart that outlines program structure and reporting relationships, including
subcontractors and/or other local entities involved in direct service delivery. Upload the
chart to the Pre-Submission section in the Grants Gateway as Attachment 11.

3. Letters of Commitment from proposed subcontractors are strongly recommended and,

if applicable, should be uploaded into the Pre-Submission section of the Grants
Gateway as Attachment 12.

4. Describe the staffing plan that will provide dedicated staff to perform the following core
functions in all regions/counties in the State:
i. transition assistance,
ii. peer outreach and support,
iii. nursing home education and outreach.

5. Describe how the lead applicant will:

i. provide oversight and conduct quality assurance activities to ensure contracted
activities occur as directed by DOH,
ii. address deficiencies. If lead applicant plans to subcontract, include the plan to
address subcontractor deficiencies.

6. Describe how the three program components will be coordinated to ensure

collaboration, consistent messaging, and an integrated approach.

7. Describe how data trends related to the implementation and ongoing operation of the
Transition Center program functions will be analyzed and used to support continuous
quality improvement.

8. Describe the Information Technology (IT) infrastructure that will be put in place to
maintain all case information in a manner that is accurate, confidential, and provides
for standard and ad hoc reporting to meet DOH’s information needs.

9. Describe how HIPAA compliance will be assured in collecting and maintaining

participant information and in sending secure, electronic reports.

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 10. Describe how timely and accurate submission of vouchers will be ensured.

11. Describe how compliance with universal precautions and flu prevention will be
addressed.

b. Core Component: Transition Assistance

1. Describe how the lead applicant and any proposed subcontractors will implement the
core component of Transition Assistance including:
i. providing information on options for receiving services in the community,
ii. facilitating transitions from institutional to community-based settings, and
iii. in all regions/counties in the State.

2. Describe the initial and ongoing training that will be provided to transition specialists.

3. Describe the strategies that will be put in place to enable collaborative working
relationships with constituent programs and other stakeholders to create linkages for
home and community-based supports and services.

4. Describe how transition specialists will ensure that interested nursing home residents
have the objective information needed to make informed choices about receiving long-
term care support and services in the community.

5. Describe the process for assisting long-term care nursing home staff involved in the
discharge planning process with coordinating transitions from nursing home to the
community.

6. Describe how the quality and effectiveness of services provided by transition

specialists to individuals interested in living in the community will be monitored and
measured.

7. Describe the strategies that will be used to help prevent reinstitutionalization.

8. Describe how barriers to transition will be identified, tracked, addressed, and resolved.

9. Describe how the lead applicant will assist to repatriate New York State residents
residing in out-of-state nursing homes back to community settings in New York State.

c. Core Component: Peer Outreach and Support

1. Describe how the lead applicant and any proposed subcontractors will implement the
core function of Peer Outreach and Support, including how peers will provide:
i. outreach to residents in nursing homes, and
ii. peer support to individuals interested in pursuing a transition to the community.

2. Describe how peers with the knowledge and experience of transitioning from nursing
homes to community living will be identified and recruited to serve all 62 counties in
New York State.

3. Describe the initial and ongoing training that will be provided to peers.

4. Describe how peers will be supervised within the Transition Center infrastructure.

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 5. Describe how the lead applicant will monitor the quality of peer services, i.e., how the
effectiveness of the Peer Outreach and Support services provided through this contract
will be measured.

6. Describe how barriers to outreach within individual nursing homes will be identified,
addressed and resolved.

7. Describe how individuals’ concerns related to community transition, community

integration, and readiness to transition will be addressed through the provision of Peer
Support.

d. Core Component: Nursing Home Education and Outreach

1. Describe how Nursing Home Education and Outreach will be implemented,

including delivering current content to all nursing homes in New York State on a bi-
annual basis.

2. Describe how appropriate content about the administration of the MDS Section Q
and referral to the Local Contact Agency, including the barriers and misconceptions
that inhibit compliance as well as the best practices, and the availability of
Transition Assistance and Peer Support, will be delivered as part of the Nursing
Home Education and Outreach plan.

3. Describe the initial and ongoing training that will be provided to Outreach
Educators.

4. Describe the outreach strategy that will be used to engage nursing homes to
participate in educational presentations and foster a relationship with the Transition
Center program.

5. Describe how the quality of the Nursing Home Education and Outreach
presentations provided to nursing homes and their staff will be monitored and
evaluated for effectiveness.

6. Describe the process for keeping outreach presentation content current, applicable,
and responsive to audience feedback.

5. Workplan (Not Scored)

Applicants must enter a one year workplan into the Grants Gateway on-line template. Successful
applicants will be required to complete workplans for years two through five in subsequent years.

Please note that the Work Plan for this RFA is limited to the following: 30 Objectives, 60 Tasks,
and 90 Performance Measures. The Grants Gateway does not keep a running count of these;
applicants will be responsible for ensuring that they stay within these limits. If you exceed these
limits it will jeopardize your ability to submit your application.

The workplan should include objectives, tasks, and performance measures which coincide with
the Core Functions listed in Section III. Project Narrative/Work Plan Outcomes; B. Core Functions
and Section III. Project Narrative/Work Plan Outcomes; C. Program Goals. Instructions for
completing the Workplan can be found in Attachment 4: Workplan Instructions.

23
Describe tasks related specifically to the program activities that will occur during the initial year in
sufficient detail. This will enable the reviewers who score your application to gauge how well you
understand what must be done to implement your project, and in what order you need to complete
the tasks.

When constructing your workplan, please ensure that:

▪ The workplan includes goals and objectives; a description of activities to reach each objective;
the specific quarter(s) in which each activity will be conducted; and the staff person/position
who will be responsible for conducting it.

▪ All objectives are written in a SMART format: specific, measurable, achievable, realistic and
time-specific.

▪ Each objective includes the communities and populations that will be targeted.

▪ Each task includes the exact nature of the activity.

▪ Where appropriate, tasks should include community service organizations and other entities
with whom the lead agency will collaborate in reaching the proposed objective.

6. Budget (Maximum Score: 40 points)

Budgets must include detailed narrative justifications. If subcontracting for services, applicants
must include the name of each subcontractor, what services the subcontractor will provide and in
what counties those services will occur. The applicant must include an explanation of how the
amount of funding for each subcontractor was determined.

The budget for year one (March 1, 2020 – February 28, 2021) must be entered into the Grants
Gateway on-line template.

The template for budget years two through five (Attachment 3: Budget Forms for Years 2-5
Template) is found in the Pre-Submission upload section of the Grants Gateway. Budgets for
years two through five should be labeled as listed below, combined into one PDF document and
then uploaded under the Pre-Submission upload section of the Grants Gateway. Refer to
Attachment 2: Budget Data Entry Guidelines. Years 2-5 budgets should be labeled as follows:

Budget Year 2: March 1, 2021 – February 28, 2022

Budget Year 3: March 1, 2022 – February 28, 2023
Budget Year 4: March 1, 2023 – February 29, 2024
Budget Year 5: March 1, 2024 – February 28, 2025

All costs must be related to the provision of services outlined in this RFA, as well as be consistent
with the scope of services, reasonable and cost effective. Justification for each cost should be
submitted in narrative form. For all existing staff, the Budget Justification must delineate how the
percentage of time devoted to this initiative has been determined. THIS FUNDING MAY ONLY BE
USED TO CONTINUE EXISTING ACTIVITIES OR CREATE NEW ACTIVITIES PURSUANT TO
THIS RFA. THESE FUNDS MAY NOT BE USED TO SUPPLANT FUNDS FOR CURRENTLY
EXISTING STAFF ACTIVITIES.

Any ineligible budget items will be removed from the budget prior to contracting. The budget
amount requested will be reduced to reflect the removal of the ineligible items.

24
Administrative costs will be limited to a maximum of 10% of total direct costs.

In year one of the awarded agreement(s), start-up costs will be allowed subject to a 15% limit;
these costs may include, but are not limited to, recruitment costs, supply and equipment
purchases, and network expansion.

Expenditures will not be allowed for the remodeling or modification of structure or purchase of
major pieces of depreciable equipment (although limited computer/printing equipment may be
considered). General office furniture (chairs, desks, cabinets, cubicles, etc.) are not allowable
costs under federal MFP program funding. This applies to the awarded grantee, subawardees or
subcontractors.

It is the applicant’s responsibility to ensure that all materials to be included in the application have
been properly prepared and submitted. Applications must be submitted via the Grants Gateway
by the date and time posted on the cover of this RFA. The value assigned to each section is an
indication of the relative weight that will be given when scoring your application.

7. Preference Factors

Please respond to the following. If not applicable, please type N/A for your response in the Grants
Gateway.

a. Describe/demonstrate how your organization has two (2) or more years of experience
working with Home and Community Based waivers and Medicaid Managed Care plans
regarding community transitions, including working with service coordinators and care
managers.
b. Describe/demonstrate how your organization has two (2) or more years of experience
administering a health and/or human services related program with statewide reach.
c. Describe/demonstrate how your organization has two (2) or more years of experience
facilitating the transition of individuals from institutional care to the community.
d. Describe/demonstrate how your organization has two (2) or more years of experience
operating peer support services.
e. Describe/demonstrate how your organization has two (2) or more years of experience
providing education and outreach to health care professionals.
f. Describe/demonstrate how your organization has two (2) or more years of experience
assisting to repatriate New York State residents residing in out of state long-term care
facilities back to community settings in New York State.

B. Freedom of Information Law

All applications may be disclosed or used by DOH to the extent permitted by law. DOH may
disclose an application to any person for the purpose of assisting in evaluating the application or
for any other lawful purpose. All applications will become State agency records, which will be
available to the public in accordance with the Freedom of Information Law. Any portion of the
application that an applicant believes constitutes proprietary information entitled to
confidential handling, as an exception to the Freedom of Information Law, must be clearly
and specifically designated in the application. If DOH agrees with the proprietary claim, the
designated portion of the application will be withheld from public disclosure. Blanket assertions of
proprietary material will not be accepted, and failure to specifically designate proprietary material
may be deemed a waiver of any right to confidential handling of such material.

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C. Review & Award Process

Applications meeting the guidelines set forth above will be reviewed and evaluated competitively
by the New York State Department of Health, Office of Health Insurance Programs, Division of
Long Term Care, Bureau of Community Integration and Alzheimer’s Disease, Money Follows the
Person program. Minimum eligibility qualifications (Section II. Who May Apply, A. Minimum
Eligiblity Requirements) will be evaluated on a Pass/Fail basis. Applicants who are unable to
demonstrate fulfillment of the minimum qualifications will be disqualified and not be considered for
award.

A numerical scoring system will be used to evaluate responses to organizational experience and
capacity, program design and budget questions. Up to 18 additional points MAY be awarded for
applicants who meet the preference factors. The total maximum score, not including preference
factors is 200.

The applicant with the highest total score will receive the grant award. Funding amount will not
exceed the designated total funding amount listed in this RFA and for which the applicant
requested per-year funding based on availability of funds.

Program Summary Maximum Score: Not Scored

Organizational Experience and Capacity Maximum Score: 30
Program Design Maximum Score: 130
Work Plan Maximum Score: Not Scored
Budget Maximum Score: 40

TOTAL MAXIMUM SCORE 200

Preference factors Maximum Preference Point Score: 18

The minimum passing score is 70%. In the event of a tie score, the scores on the individual
application will be compared in the following order:
• organizational experience and capacity,
• program design.

The applicant with the highest score on the first section where there is a difference will be
considered the winner of the tie. In the event that all individual sections receive identical scores,
another reviewer will be chosen to review the tied applications and rank them based on the same
criteria used in the scoring process.

Applications with minor issues (missing information that is not essential to timely review and would
not impact review scores) MAY be processed, at the discretion of the State, but all issues need to
be resolved prior to time of award. An application with unresolved issues at the time award
recommendations are made will be determined to be non-responsive and will be disqualified.

If changes in funding amounts are necessary for this initiative or if additional funding becomes
available, funding will be modified and awarded in the same manner as outlined in the award
process described above.

Once an award has been made, applicants may request a debriefing of their application (whether
their application was funded or not funded). Please note the debriefing will be limited only to the
subject application and will not include any discussion of other applications. Requests must be
received no later than fifteen (15) business days from date of award or non-award announcement.

26
 To request a debriefing, please send an email to [email protected]. In the subject line, please
write: Debriefing Request for MFP RFA.

In the event unsuccessful applicants wish to protest the award resulting from this RFA, applicants
should follow the protest procedures established by the Office of the State Comptroller (OSC).
These procedures can be found on the OSC website at
http://www.osc.state.ny.us/agencies/guide/MyWebHelp. (Section XI. 17.)

VI. Attachments
Please note that certain attachments are accessed in the “Pre-Submission Uploads” section of an
online application and are not included in the RFA document. In order to access the online application
and other required documents such as the attachments, prospective applicants must be registered
and logged into the NYS Grants Gateway in the user role of either a “Grantee” or a “Grantee Contract
Signatory”.

Attachment 1: Application Cover Sheet*

Attachment 2: Budget Data Entry Guidelines**
Attachment 3: Budget Forms Years 2-5 Template*
Attachment 4: Work Plan Instructions**
Attachment 5: Vendor Responsibility Attestation*
Attachment 6: Minority & Women-Owned Business Enterprise Requirement Forms*
Attachment 7: Data Use Agreement*
Attachment 8: Data Use Agreement Addendum*
Attachment 9: Program Goals**
Attachment 10: Organizational Chart*
Attachment 11 Program Structure and Reporting Relationships Chart*
Attachment 12: Letters of Commitment (if applicable)*

*These attachments are located / included in the Pre-Submission Upload section of the Grants
Gateway on line Application.

**These attachments are part of the RFA document and are for applicant information only. These
attachments do not need to be completed.

27
 Attachment 2
Grants Gateway Budget Data Entry Guidelines
Applications OR New Budget Periods

* An asterisk has been placed next to specific budget categories which require that additional information be provided. Refer to "Grants Gateway Budget
Instructions" under the section Required Uploads.

Grants Gateway Field Character Enter Required Information as Instructed Below

Limits
Personal Services - Salary * Refer to Grants Gateway Budget Instructions document for additional information. In the Salary section only include
staff positions related to the implementation and administration of the project. ONLY staff that are employees of the
applicant organization are to be included here. All other staff should be listed under Contractual Services. If Salary is
not applicable, leave this section blank.

Provide the position title and employee name , if known. TBH should be entered in place of the employee
Position/Title 55 name if the position is vacant at the time of budget submission.
Provide a brief narrative of how the position will contribute directly to this project, Include the percent of
time the incumbent will work on the program on a full-time basis. One (1.0) FTE is based on the number
of hours worked in one week (e.g. 40-hour workweek). To determine a % FTE, divide the hours per week
spent on the project, by the number of hours in the workweek. For example: given a 40-hour workweek,
an individual working 10 hours per week on the project spends 25 percent of his/her time on the project
(i.e. 10/40 = .25) Please show in percentage form - 25%. If TBH, also provide the anticipated start date for
Role/Responsibility 500 this position.

# in Title N/A Always enter the number 1. A separate position should be added for "each" position on the contract.
Enter the annual salary the organization will pay this employee. This figure should NOT be adjusted if a
portion of the salary will be paid with other funds. Percentage of time supported with "other funds"
Annualized Salary Per Position N/A should be entered in the PS narrative.
Enter the standard (STD) hours worked each week by the employee. This figure should NOT be adjusted
STD Work Week (hrs.) N/A for hours paid with other funds.

Enter only the percent of time this position is supported with grant funds. Do NOT include any percentage
% Funded N/A of time supported by other fund sources. Total grant funding requested divided by annual salary.
Enter the estimated number of months this position will work on this grant. If TBH, enter the number of
# Months Funded N/A months based upon the anticipated start date.
Enter the total amount of grant funds requested to support this position on the project. (Annual Salary /
Total Grant Funds N/A 12 Months x # Months Funded x % Funded).
Total Match Funds N/A Always leave blank.
Match % N/A Always leave blank.
Total Other Funds Always leave blank.
> Personal Services - Salary 4000 Program Specific Instructions / Requirements
Narrative All PS positions not directly supported with grant dollars, that work on the program should be
summarized in this section. Contracted or per diem staff are not to be included in personal services
narrative; these expenses should be shown in the contractual services narrative under non-personal
services. The budget should
contain a CCA Project Director accessible full-time for communications, including e-mail.

Personal Services - Fringe* Fringe Benefits should be budgeted in line with your organization’s Standard Fringe Benefit Policy and/or Negotiated
Bargaining Agreements. If Fringe is not applicable, leave this section blank.

Type/Description 125 Provide the requested fringe rate.

Provide all fringe benefit components included in the calculation of the fringe benefit rate. Show
breakdown of fringe benefit rate into component percentages. If additional space is needed enter details
Justification 1000 in the PS - Fringe Narrative
Total Grant Funds N/A Enter the total amount of grant funds requested to support this budget category.
Total Match Funds N/A Always leave blank.
Total Other Funds N/A Always leave blank.

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> Personal Services - Fringe 4000 Program Specific Instructions / Requirements
Narrative If additional space is needed from the justification section, specify here, the components (FICA, Health
and Life Insurance, Unemployment Insurance, Disability Insurance, Worker’s Compensation, and
Retirement) and their percentages comprising the fringe benefit rate. If different rates are used for
different positions, provide details for each rate in the space provided and specify which positions are
subject to that rate.

Grants Gateway Field Character Enter Required Information as Instructed Below

Limits
Non Personal Services Non Personal Service expenses. For each Non Personal Service expense not supported by grant funds, the applicant
should include a description in the appropriate NPS Narrative section. For example if you contract with a Pharmacist
using other funds you would list under the Contractual Narrative - Pharmacist $25/hour for 20/hours total cost
$500.00.

Contractual* * Refer to Grants Gateway Budget Instructions document for additional information.
This category should be used to budget for specific services which cannot be accomplished by existing staff as well as
for any services/expenses which will be provided by a subcontractor. Include expenses such as contracted staff, per
diem staff, bookkeeping, payroll and audit services. Include the time frame for the delivery of services. Contractors
may be required to submit subcontracts to the Department for review and approval prior to execution of the
subcontract. The contractor remains fully responsible for all work performed by the subcontractor. ALL related
expenses are to be budgeted under this section (any non-personal service costs to include travel) associated with the
staff/organizations allocated to CS. If Contractual Services are not applicable, leave this section blank.

Provide the name of the organization, company or individual and the type of service being provided. If
not known, enter TBH in place of the name of the organization, company or individual. (i.e. Pharmacist -
Type/Description 125 TBH)
Describe how this expense supports the work plan objectives of the project. Include the timeframe for
Justification 1000 delivery of services.
Total Grant Funds N/A Enter the total amount of grant funds requested to support this budget category.
Total Match Funds N/A Always leave blank.
Total Other Funds N/A Always leave blank.
> Contractual Narrative 4000 All contractual positions not directly supported with grant dollars, that are required on the program or
needed to meet program deliverables should be summarized in this section.
Travel* * Refer to funding opportunity and/or Grants Gateway Budget Instructions document for additional information.
Itemized travel estimates should be based on the lesser of the written policy of the organization, the Office of State
Comptroller (OSC) guidelines, or the United States General Services Administration (USGSA) rates. Out-of-State travel
requires prior approval by the State. Travel expenses associated with any Subcontractor, Consultant, or Vendor, must
be included in the Contractual Services budget line. If Travel is not applicable, leave this section blank.

Provide the type of travel. A separate entry should be completed for each category of travel (i.e. Client,
Type/Description 125 Staff Travel, In-State, or Out-of-State).
Describe how this expense supports the work plan objectives of the project, include the title of the
Justification 1000 position(s) traveling.
Total Grant Funds N/A Enter the total amount of grant funds requested to support this budget category.
Total Match Funds N/A Always leave blank.
Total Other Funds N/A Always leave blank.
> Travel Narrative 4000 Program Specific Instructions / Requirements
If using other funds for required travel - Provide a delineation of expenses (i.e. agency cars, tokens, taxi,
etc.), or staff travel exclusive of training/ staff development (i.e., to clinic sites, agency staff travel to
meetings). Conference Attendance – Provide a delineation of the items of expense and estimated cost.
Include travel costs associated with conferences, including transportation, meals, lodging, and
registration fees. (e.g. if the total expense is for a conference, provide location and name of conference,
# of people attending, cost breakdown per person, per item expense – train ticket, lodging, food etc.).

29
Equipment * Refer to funding opportunity and/or Grants Gateway Budget Instructions document for additional information.
This section is used to itemize both purchased and rental equipment costs. Equipment is defined as items such as
computers, printers, phones, apparatus or fixed asset (other than land or a building) that are tangible personal
property having a useful life of more than one year and a purchase price equal or exceeding $5,000. These items must
be inventoried (tagged) and included on the annual equipment inventory form. This also includes a grouping of like
items which equals or exceeds $5,000. Item(s) not falling under this definition should be included under Operating
Expenses. If Equipment is not applicable, leave this section blank.

Type/Description 125 Provide the type of equipment and the quantity to be purchased or rented. (i.e. 3 Desk Top PCs)

Grants Gateway Field Character Enter Required Information as Instructed Below

Limits

Provide the names of the staff that will be using the equipment and provide the calculation used to
determine the allocation of this expense to the project. Reminder: staff % Funded (time and effort) must
Justification 1000 be taken into consideration when determining the appropriate allocation of the expense to the project.
Total Grant Funds N/A Enter the total amount of grant funds requested to support this budget category.
Total Match Funds N/A Always leave blank.
Total Other Funds N/A Always leave blank.
> Equipment Narrative 4000 Program Specific Instructions / Requirements
If using other funds for required equipment enter the details here.
Space/Property: Rent This section is used to itemize costs associated with Space/Property: Rent. A separate entry will be required if more
than one instance of rental property is needed. If Space/Property: Rent is not applicable, leave this section blank. The
expenses included are rent, maintenance, and insurance (property and liability). Occupancy costs must include
square foot value of space and total square footage along with methodology used to determine expense.

Type/Description 125 Provide the physical address of the rental property.

Provide details such as which project(s) operate(s) out of the space, and provide the calculation used to
Justification 1000 determine the allocation of this expense to the project.
Total Grant Funds N/A Enter the total amount of grant funds requested to support this budget category.
Total Match Funds N/A Always leave blank.
Total Other Funds N/A Always leave blank.
> Space/Property: Rent Narrative 4000 Program Specific Instructions / Requirements
If using other funds enter the details here.
Expenditures will not be allowed for the purchase of major pieces of depreciable equipment (although
limited computer/printing equipment may be considered).

Space/Property: Own This section is used to itemize costs associated with Space/Property: . If Space/Property: Own is not applicable, leave
this section blank. The expenses included are, maintenance, insurance (property and liability). Demonstrate how the
total expense being allocated to this program is calculated. Provide the allocation methodology and percent.
Occupancy costs must include square foot value of space and total square footage along with methodology used to
determine expense.
Type/Description 125 Provide the physical address of the property that is owned.
Provide details such as which project(s) operate(s) out of the space, and provide the calculation used to
Justification 1000 determine the allocation of this expense to the project.
Total Grant Funds N/A Enter the total amount of grant funds requested to support this budget category.
Total Match Funds N/A Always leave blank.
Total Other Funds N/A Always leave blank.
> Space/Property: Own Narrative 4000 Program Specific Instructions / Requirements
If using other funds enter the details here.

Utilities This section is used to itemize costs associated with Utilities. A separate entry is needed for each category of expense
relating to utilities (i.e., utilities, telephone, mobile, etc.)using other funds. If Utilities are is not applicable, leave this
section blank.
Type/Description 125 Provide the type of expense and include the property address. (i.e. Telephone - 123 Cherry Lane)
Provide details such as which project(s) share this expense, and provide the calculation used to determine
Justification 1000 the allocation of this expense to the project.
Total Grant Funds N/A Enter the total amount of grant funds requested to support this budget category.
Total Match Funds N/A Always leave blank.
Total Other Funds N/A Always leave blank.
> Utilities Narrative 4000 Program Specific Instructions / Requirements
If using other funds enter the details here.

30
Operating Expenses * Refer to funding opportunity and/or Grants Gateway Budget Instructions document for additional information.
This section is used to itemize costs associated with the operation of the project, including but not limited to
insurance/bonding, photocopying, advertising, office supplies, direct medical service supplies, program
supplies/materials, rental subsidy, security deposit, brokers fees, tenant utility allowance, furniture and contingency
funds. A separate entry for each type of expense is needed. Expenses for any costs shared across multiple projects
must be appropriately cost-allocated in accordance with the benefit received or effort provided to the project. If
Operating Expenses are not applicable, leave this section blank.

Type/Description 125 Provide the type of expense

Grants Gateway Field Character Enter Required Information as Instructed Below

Limits

Budget justifications should identify the proposed goods/services that are programmatically necessary
and describe how this expense supports the Work Plan objectives of the project. The justification should
provide sufficient detail to demonstrate that specific uses and amounts of funding have been carefully
Justification 1000 considered, are reasonable and are consistent with the approaches described in the Work Plan.
Total Grant Funds N/A Enter the total amount of grant funds requested to support this budget category.
Total Match Funds N/A Always leave blank.
Total Other Funds N/A Always leave blank.
> Operating Expenses Narrative 4000 Program Specific Instructions / Requirements
Provide a narrative description for any required items that are purchased with other funds.
Supplies/Materials – Provide justification of need and a breakdown for all items. (e.g. if the total
expense is for education materials or office supplies, in addition to providing a narrative justification of
need, provide a breakdown of each item as total # x cost per item = total expense for that item.)
Expenditures will not be allowed for remodeling or modification of structure.
Funding is expected to support one annual statewide meeting of FPP providers in Albany, NY. See Page
24 of the RFA for further instructions.

Other Expenses Detail* Only Indirect costs are to be budgeted under this section (also referred to as Administrative costs), unless determined
not to be allowed by the award. Non-profit agencies receiving federal funds are eligible to charge their federally
approved indirect cost rate. A copy of the current federal ICR agreement must be uploaded to the Grantee Document
Folder section of the application. For organizations without a federally-approved indirect cost rate, indirect costs will
be limited to no more than 10% of total direct costs. Direct costs may include Personal Service, Fringe Benefits, Space,
Program Operations, Travel, Equipment, and Other budget costs. Applicants must provide a description of costs
included in the indirect cost calculation in the Other Expenses budget narrative section of the application.

Provide the requested indirect costs rate, indicating whether it is based on a Federally Approved Rate
Type/Description 125 Agreement.
Indicate specifically that the document was uploaded to the Grants Gateway (Federally Approved Rate
Justification 1000 Agreement )
Total Grant Funds N/A Provide the requested value using the formulary provided.
Total Match Funds N/A Always leave blank.
Total Other Funds N/A Always leave blank.
> Other Narrative 4000 Program Specific Instructions / Requirements
If using other funds enter the details here.

31
 Grants Gateway Budget
Data Entry
Where to Budget

Budget Category Side-by-Side – use this chart to assist with aligning cost categories with the (8) defined budget categories,
labeled a through f on the budget summary. This a sample listing of those most commonly used.
Master Grant Contract Budget Categories Sample of Budget Categories
Personal Services ALL employees on payroll
Fringe Payroll Taxes, Health Insurance, Pension, Worker's Compensation, etc.
Contractual Services* Vendors*
Contractual Services** Subcontractors / Consultants / Affiliate Staff
Travel (ALL - for client, staff, and volunteers). Travel for individuals funded under the Contractual Service budget category must
Travel be included under CS.
> article of nonexpendable, tangible personal property having a useful life of more than one year and an acquisition cost which
equals or exceeds $5,000, or a grouping of like items which equals or exceeds $5,000. < $5,000 budget under Operating
Equipment Expense Expenses

Space/Property & Utility Expenses Rent, Depreciation, Maintenance & Repairs, Utilities (including electric, heat, cell phone, internet, telephone)
Operating Expense Equipment, Office Technology purchases < $5,000
Beverages, Food, Meeting Costs. Adherence to Guidelines for Healthy Meetings as adopted from National Alliance for Nutrition
and Activity (NANA) Healthy Meeting Guidelines is required:
Operating Expense https://www.health.ny.gov/prevention/healthy_lifestyles/guidelines.htm.
Operating Expense Office Supplies, Program Supplies/Materials
Conference Costs/Registration Fees. IF these costs are associated with other reimbursable travel (lodging, mileage, etc.), these
Operating Expenses costs should be budgeted under travel.
Operating Expenses Staff Training/Professional Development (for costs such as conference fee - NOT travel)
Operating Expenses Vehicle Operating Expenses
Operating Expenses Client Services (medical supplies, translation services, etc.)
Operating Expenses Direct Medical Supplies
Operating Expense unless fringe benefit related, then it is Personal Services Insurance (e.g. general liability)
Operating Expense unless it is contracted out, then it is Contractual Services Database Management, Computer/Network Maintenance
Media Placement, Advertising (e.g. recruitment ads, program promotion). ALL purchased media placement or advertising
Operating Expense unless it is contracted out, then it is Contractual Services requires prior approval.
Operating Expense unless it is contracted out, then it is Contractual Services Educational Materials, Printing, Postage
Operating Expenses any associated travel must go under travel Special Events, Workshops
Other Indirect

*Contractual Services - Vendors: include those persons or organizations that provide the same or similar services to any customer without altering its product. Examples of vendors include audit services, payroll services,
bookkeepers, laboratory services, and IT consultants.

**Contractual Services – Subcontractors / Consultants / Affiliate Staff: performs a portion of the scope of work from the lead contractor’s project, often off-site and under the direction of a third party. The subcontractor has
its performance measured against the objectives of its portion of the scope of work of the lead program.
 ATTACHMENT 4
Work Plan Instructions

A concise work plan is required to ensure that the Department and the contractor are both clear
about the expectations under the contract. The following are required elements of this RFA
designed to ensure that the minimum necessary information is obtained. DOH may require
additional information if deemed necessary. The core activities that are outlined in this RFA will
be part of the work plan and will be audited for payment.

• Program Objectives – This section defines the work of the project. This section must be
completed by the applicant.

• Tasks/Action Steps – This section defines the activities or specific tasks to meet the objectives
and defined requirements for each goal for Peer Outreach and Support, Transition Assistance
and Nursing Home Education and Outreach, as appropriate. This section must be completed
by the applicant.

• Target Date/Performance Measures/Progress to Date – This section will include the dates for
assessing progress. Timeframes should include regularly scheduled, periodic check-in points
for assessing progress in addition to start and end dates. These established timeframes must
be used to help organize activities. This section must be completed by the applicant.

The contractor’s quarterly reports detailing achievement of scheduled work plan benchmarks will
form the basis by which submitted vouchers for contracted services are evaluated for payment.

Following are snap shots of the Work Plan in the Grants Gateway.
The Work Plan is considered a “Grantee-Defined Work Plan” which means that the applicant can
create their own set of Objectives, Tasks, and Performance Measures.

To enter a Work Plan, click on the Work Plan Properties page in the Forms Menu.
1) At first, the Work Plan Properties screen will include only one item – a blank Objective. Enter
the Objective Name and Objective Description and then click the [SAVE] button.

75 characters

250 characters

2) Once the first Objective is saved, the Objective will be shown with a blank Task (1.1). Enter the
Name and Description for Task 1.1 and click the [SAVE] button.
a. NOTE: a second blank Objective will also be shown at this time.

75 characters
250 characters

75 characters

250 characters

3) Once the first Task (1.1) is saved, the Objective will now be shown with a blank Performance
Measure (1.1.1) under Task 1.1, and an additional blank Task (1.2).
a. Enter the Name and Description for Performance Measure 1.1.1.
b. Some Performance Measures allow the applicant to choose the Performance Measure
Capture Type. If available, choose the appropriate Capture Type.
c. Optional: Enter the Name and Description for Task 1.2
d. Optional: Enter the Name and Description for Objective 2

34
 75 characters
250 characters

75 characters
250 characters

75 characters

max. 250 characters

75 characters

250 characters

4. Continue to enter Objectives, Tasks, and Performance Measures as necessary.

NOTES:
- Use the minus and plus buttons to collapse or expand a section to make it easier to read.
- Use the up or down arrows to move sections within the Work Plan.

35
 ATTACHMENT 9

Program Goals
(matches RFA Section II. C.)

V. Program Infrastructure and Oversight: Ensure the Statewide Transition Center

Infrastructure, including all three core program functions (Transition Assistance, Peer
Outreach and Support and Nursing Home Education and Outreach), meets high quality
contract standards in a cost-effective manner.

1. Track and accurately report activities in a timely manner as directed by DOH.

i. Maintain complete information regarding participants served and services
delivered, as directed by DOH, and make all case information available and
accessible to DOH.
ii. Report on services delivered and goals achieved on a monthly and semi-annual
basis, and as directed by DOH.
iii. Submit accurate and timely vouchers within 60 days of the end of the month.
iv. Respond to ad-hoc reporting requests in a timely manner as directed by DOH.

2. Provide oversight and conduct quality assurance activities to ensure contract activities
occur as directed by DOH.
i. Ensure that contract activities meet contract deliverables.
ii. Ensure the accuracy of all information maintained by the Contractor and
provided to DOH.
iii. Ensure that information related to quality assurance and improvement is
provided to DOH as directed by DOH.
iv. Ensure that the confidentiality of personally identifiable information is protected.

3. Ensure that all individuals who enter areas where patients/clients/residents might be
present, are either vaccinated for the current influenza season or wear a face mask.
i. Provide documentation of flu shot.
ii. Provide education related to universal precautions.

VI. Transition Assistance: Provide information about options for community-based care and
facilitate transitions of older adults and individuals with physical and/or developmental
disabilities who express a desire to leave an institutional setting to return to the community.

1. Develop and implement strategies to identify individuals residing in nursing homes who
are interested in receiving information regarding the options for transitioning to a
community setting with Home and Community Based Services (HCBS).
i. Develop an outreach and marketing plan involving multiple media strategies, to
generate referrals.
ii. Develop and distribute objective outreach material, with DOH approval, related
to transitioning from a nursing home to the community.
iii. Develop and implement strategies to build and maintain relationships with
nursing home discharge planners, managed long term care managers,
ombudspersons, and others related to generating referrals of individuals who
wish to pursue home and community-based service options.
iv. Coordinate all referrals as the State-designated Local Contact Agency for MDS
Section Q referrals and other referrals for transition assistance.

36
2. Provide objective information about options for home and community-based services
for older adults and individuals with physical and/or developmental disabilities who
express a desire to leave institutional settings and return to the community.
i. Build and maintain knowledge about available HCBS in each region.
ii. Ensure consistent messaging and information is provided by transition
specialists to nursing home residents interested in community transition.
iii. Make initial visit to a potential participant no more than 10 days from receipt of
a referral.
iv. Collaborate with peers to provide transition support.

3. Develop strong collaborative relationships with long-term care stakeholders to support

successful transitions to community settings.
i. Develop collaborative relationships with Regional Resource Development
Centers (RRDCs), Office for People with Development Disabilities (OPWDD)’s
State Operations Office and Regional Office’s Front Door staff, county
Department of Social Services staff, local Area Agencies on Aging, nursing
home discharge planners, HCBS service providers, and MLTC plans/MCOs in
each County and region through education and outreach.
ii. Engage with NY Connects’ Local Long-Term Care Council activities to support
a coordinated local approach to community transitions.
iii. Develop and implement strategies to address identified barriers to building and
maintaining relationships with nursing home discharge planners,
ombudspersons, other long-term care community-based stakeholders, and
RRDCs, MLTC plans/MCOs and other entities that authorize or provide home
and community-based services.

4. Facilitate successful transitions of individuals into community settings with appropriate

home and community-based services and supports to enable them to remain in the
community.
i. Ensure that informed consent and release of information forms are signed by
potential participants or their legal guardians.
ii. Increase participant community readiness skills necessary for successful
community living.
iii. Assist nursing home discharge planners with the coordination of home and
community-based services and supports so that all the necessary service
elements are in place for a successful transition. Please note that this program
will not supplant any existing responsibility that the discharge planner has for
assisting their interested nursing home residents with transitioning into the
community.
iv. Ensure that necessary referrals are made timely to Regional Resource
Development Centers (RRDCs) and Conflict Free Evaluation and Enrollment
Center (CFEEC)/Managed Care Organizations (MCOs), Health Homes/Care
Management Agencies, OPWDD Front Door, etc., to begin assessment and
enrollment processes for HCBS services.
v. Coordinate transition activity with Regional Resource Development Centers
(RRDCs), OPWDD’s State Operations Office and Regional Office’s Front Door
staff, county Department of Social Services staff, and MLTC plans/MCOs and
Health Homes/Care Management Agencies.
vi. Collaborate with local Departments of Social Services to ensure steps related to
community budgeting, immediate need, etc. are occurring as needed.
vii. Link individuals with, and collaborate with, peers to support community
transitions for participants who are interested in pursuing a community

37
 transition and would benefit from peer support to achieve a successful
community transition.
viii. Follow-up with RRDCs and CFEEC/MCOs to ensure progress towards
enrollment (waiver/managed care) is being made and to resolve barriers.
ix. Ensure referrals are made to needed housing services and subsidies to support
participants’ access to accessible and affordable housing to support their
transitions.
x. Identify and work to resolve barriers to successful transition. Bring all
unresolvable barriers and systemic barriers to the attention of DOH.

5. Identify and follow-up with participants to resolve barriers to successful community

functioning to prevent re-institutionalization post-transition.
i. Identify and assist participant to access community services and supports that
may be needed by individuals to sustain living in the community.
ii. Provide intensive follow up in the first 30 days with participants, HCBS service
providers, RRDCs, and CFEEC/MCOs and Health Homes/Care Management
Agencies to ensure enrollment and service provision are occurring as needed
from Day 1 following discharge, and to work to resolve any barriers to
waiver/MLTC enrollment and service provision, as they arise, to prevent
reinstitutionalization.
iii. Follow-up with participants, at a minimum, monthly for the first 31-365 days in
the community to identify and assist with the resolution of barriers to successful
maintenance in the community.
iv. Identify, track, and work to resolve barriers to successful community living in
the immediate post-transition period. Bring unresolvable barriers and systemic
barriers to the attention of DOH.

6. Work to repatriate NYS residents who are living in out-of-state nursing homes to their
home communities in NYS.

7. Evaluate the Quality of Life of individuals transitioning to the community by

administering the Quality of Life survey, as prescribed by DOH.
i. Administer QOL baseline and 11-month QoL surveys according to standards
developed by DOH.

VII. Peer Outreach and Support: Provide information and support to individuals in nursing
homes to support successful community transitions.

1. Recruit and train paid peers that have characteristics (i.e., physical and developmental
disabilities and/or age) that approximate those characteristics of individuals requesting
peer services, and where possible, who have themselves transferred from a nursing
home setting into the community.
i. Develop and implement a recruitment plan for peers that ensures coverage
across all regions in New York State. This plan will be reviewed and approved
by DOH.
ii. Provide comprehensive training for peers related to skills necessary to provide
outreach and support to individuals who are transitioning from a nursing home
and returning to the community, including, but not limited to, reflective listening,
problem solving, time management, professionalism, and documentation.
iii. Provide the necessary skills training for peers to accomplish successful
outreach.

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 2. Provide Peer Outreach to older adults and individuals with physical and/or
developmental disabilities in nursing homes to identify nursing home residents who
wish to leave the institutional setting to return to the community.
i. Develop a strategy for Peer Outreach, including developing relationships with
nursing home discharge planners and ombudspersons to support outreach by
peers in the nursing homes.
ii. Identify and work to resolve barriers to conducting outreach within nursing
homes. Develop outreach materials, with DOH approval, for use as part of Peer
Outreach.
iii. Provide objective information about options for home and community-based
services to older adults and individuals with physical and/or developmental
disabilities who express a desire to leave an institutional setting and return to
the community.
iv. Ensure consistent messaging and information is provided by peers to nursing
home residents interested in community transition.
v. Link nursing home residents who wish to pursue home and community-based
options to transition specialists and collaborate for transition planning with
transition specialists and nursing home discharge planners/social workers.

3. Provide Peer Support to individuals who are engaged in transitioning from facilities to
homes in the community to support successful transitions.
i. Provide one-on-one meetings between peers and nursing home residents who
are transitioning from nursing home to community. Meetings should be face-to-
face unless extenuating circumstances are prohibitive. Initial meetings should
occur within 10 days of referral.
ii. Schedule a peer to accompany a Transition Specialist on initial Transition
Specialist visit to individuals with an Intellectual/Developmental Disability.
iii. Ensure peers assist nursing home residents to identify and resolve their
concerns relating to the community transition.
iv. Provide peer follow-up contact during the first 60 days post transition to identify
barriers and collaborate with transition specialists to resolve issues and prevent
avoidable reinstitutionalization.

VIII. Nursing Home Education and Outreach: Provide objective information to nursing home
staff to facilitate referrals to the Local Contact Agency (LCA), and support collaboration
between the nursing home staff and the Transition Centers.

1. Increase the knowledge of nursing home staff regarding availability of Transition

Assistance, Peer Outreach and Support, and requirements related to the Minimum
Data Set (MDS) Section Q referral to the LCA.
i. Develop education and outreach presentation materials, for approval by DOH,
to guide the presentations.
ii. Provide intensive training to Outreach Educators to ensure they are well-versed
in the requirements related to administration of Section Q of the Minimum Data
Set (MDS) and referral to the Local Contact Agency, including the barriers and
misconceptions that inhibit compliance.
iii. Provide education and outreach presentations to all New York State skilled
nursing homes on a bi-annual basis.
iv. Summarize presentation evaluations on a semi-annual basis for submission to
DOH.
v. In collaboration with DOH, monitor nursing home compliance with MDS Section
Q information and referral processes.

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 vi. Modify and update presentation materials and contents based on presentation
evaluation results, new developments, and the experience of transition
specialists and peers in the field.

2. Establish outreach activities and collaborative relationships with statewide provider

associations, consumer organizations, and nursing homes to provide information about
the program, the referral process, and the assistance available for individuals to
transition.
i. Foster collaborative relationships between nursing homes and the Transition
Center program.
ii. Offer presentations to the membership of the nursing home provider
associations on at least an annual basis.
iii. Seek opportunities to present at conferences, trade shows, agencies and other
venues to introduce relevant parties to the program.

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