1. Provider Organization Information, complete Attachment A.
  2. Capability and Plans for Delivery of Community Mental Health Medicaid Services complete Attachment B.  Include in your narrative a detailed description of the capability of your organization to deliver hospital-based or community-based mental health or substance abuse services, both existing service capacity (available open "slots") as well as proposed expansion of capacity for each service. In the "notes" column please reflect any special expertise (especially languages spoken and cultural competence), and description of hours of availability for each of the services. If applicable, include the number of teams/staff providing each service, number of individuals served and locations where this service is available for each service:
  3. Development of additional service capacity, complete Attachment C.  Include in your narrative for Attachment C the expansion of capacity for exiting services and the development of any new services proposed, describe your plans and resources (head count and funding) needed to develop service and support capacity: (a) for FY 2012; and (b) in subsequent years. The narrative shall include a description of how your organization will assure that services and supports are recovery-oriented, and will be delivered in a manner that is person-centered, and respects the individual's preferences and choices.  Propose options that can build on existing staff, teams or resources and options that require totally new development. Include an anticipated time frame for new/expanded services. Your response shall include at least the following infrastructure needs:
    • Staff recruitment and selection
    • Staff training and development
    • Staff supervision
    • Staff administrative support
    • Additional office space
    • Additional equipment
  4. Capability and Plans for Securing and Maintaining Linkages with Other Necessary Supports and Services; complete Attachment D.
  5. Describe the capability of your organization to provide integrated services for individuals with the dual disorders of mental illness and substance abuse, including the degree, if any, to which your organization's service delivery model corresponds to the fidelity of the evidenced-based models for this integrated service.
  6. Describe the capability of your organization to provide integrated services for individuals with the dual disorders of mental illnesses and medical/physical problems, including all staffing, procedures, or other factors demonstrating integrated practice.
  7. Geographic coverage 
    • Community mental health service providers, please describe the geographic area currently served by your agency and any additional areas where your organization could expand geographically. Specifically list the Hospital EDs, from the Hospitals listed in Table II that you propose your agency would serve. Describe any conditions that would impact your organization's ability to expand into new areas, including but not limited to minimum number of clients in an area and resources needed to support geographic expansion.
  8. Financial stability
    • Provide a general assessment of the financial stability of your organization and its ability to sustain operations into the future of the next five years. This general assessment should be described in the context of the reality of existing rates, budget issues, and consequent payment timeliness currently being experienced in the state.
    • Provide the following indicators reflecting the financial condition of your organization:
      • Number of days of operation possible with cash on hand
      • Current total amount of available lines of credit not currently being utilized
      • Ratio of total assets to total liabilities
      • Resources of any affiliated organizations that could be available to support the services described above
  9. Capability and Plans to Assure the Ongoing Quality of Services and Continuous Improvement
    • Describe the quality improvement and quality assurance processes currently in place within your organization and any plans to adjust or further develop these processes in the immediate future. Include specific example(s) of how these processes have improved outcomes, service, and/or minimized risk;
    • Describe how your current and future quality improvement and assurance processes will benefit the Region 1 South Crisis Care recipients.
  10. Capability and Plans to Provide Individual Outcome Data
    • Describe your organization's current use or immediate future plans to obtain and utilize individual consumer outcome data.