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1.
Need
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How will
you addressDescribe
the need to
expand or begin providing the proposed service(s), and how
this proposal will respond to thefor
health services in the community andcare
needs of the
target population
(with
reference to relevants),
including the needs of special populations,
demographic characteristics
(migrant and seasonal farm workers, people experiencing
homelessness, and/or access
to care/health status indicatorsresidents
of public housing) and the uninsured? (Explain within 2,000
characters
maximum – about
one page)
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2.
Project Types
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How do you plan to use IDS
funds? (Check all that apply)
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[_] Increase
health center staffing (i.e., full-time equivalents)
[_] Extend
hours of operations
[_] Expand
existing services
[_] Other
If ‘Other’,
please specify:
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3.
DescriptionResponse
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1.
An appropriate timeline for project implementation that
demonstrates operational readiness within 120 days of award
for the provision of new and expanded existing services.
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(1,000
characters maximum – about half of a page)
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2. How the health center
will ensure that all proposed services are or will be
integrated into the existing service delivery model.
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(1,000
characters maximum – about half of a page)
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3. How the health center
will ensure that all proposed services are accessible
without regard to ability to pay through a sliding fee
discount program.
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(1,000
characters maximum – about half of a page)
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4. How
the health center plans to ensure that all patients will have
reasonable access to any proposed new How will you implement
the IDS project(s) in a manner that is appropriate and
responsive to the identified community and target population
health care needs? Include a description of the types of
services, as appropriate. impacted as well as
strategies/methods for expanding access to primary care
services and increasing capacity. (Explain within 2000
characters)
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(1,000
characters maximum – about half of a page)
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5. If any services will be
provided by a Formal Written Agreement (via Column II on Form
5A), describe how the health center maintains oversight over
all services provided via contracts/agreements or
sub-recipient arrangements in accordance with Health Center
Program requirements. If services are not provided via Formal
Written Agreement, indicate that this question is not
applicable.
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(1,000
characters maximum – about half of a page)
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4.
Impact
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Describe the following:
TheHow
will the proposed IDS project(s) impact of the proposed
project, including the number of 1)proposed new patients, 2)
existing patients with increased access toeeds for health
services (as applicable), in the community and 3) new
providers. Include a detailed explanation for how the
projections were calculated target population as well as the
uninsured? (including data sourcesExplain within 2000
characters).
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(2,000
characters maximum – about half of a page)
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Patient Impact Questions
5. IDS Projections
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As a direct result of this
funding, how many
NEW
patients do you predict will access services at your health
center?Total
New Patients (Unduplicated)
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Total New Uninsured Patients
Total Retained Jobs
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