The Application
Part I - Coversheet
Name of Health Center
Mailing Address (no P.O.
Tax ID Number
Boxes, please)
City
State
Title:
Zip Code
Project Director
Name:
Phone Number:
Fax Number:
Medical Director
Name:
Email Address:
Board Chair
Name:
Signature:
Email Address:
CEO/Executive Director
Name:
Signature:
Email Address:
Amount of Request
$
Part II – Project Abstract. Briefly state the:
 Need that will be addressed:
 Population targeted:
 Outcomes to be achieved:
 Related interventions proposed:
 Evaluation plans:
 Cost of the project:
Part III - About the Applicant Organization. Address the following:
 Brief History:
 Size of Organization:
Staff:
Budget:
 Number of sites:
 Patient Demographics:
 Leadership/Management Structure:
 Other Relevant Information:
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Email Address:
Part IV – About the Clinical Practice. Describe the following:
 Staffing:
 Process and result of patient impanelement:
 Process and result of interdisciplinary team designation, including a pharmacist:
 Electronic Medical Record – when fully implemented:
 Where the organization is in seeking Patient Centered Medical Home designation:
 Other Relevant Information:
Part V – Statement of Need. Address:
 The number of the Health Center’s patients who have heart disease, diabetes, hypertension and
asthma:
 Whether the organization has implemented special intervention program(s) for these or other
chronic conditions affecting seniors. If yes, describe the interventions, and outcome(s). Be
specific:
 Other Relevant Information:
Part VI – The Proposed Project Description
A. General
Applicant must specify the following.
 On which chronic condition(s) this project will focus and why:
 Qualifications of personnel chosen to work on this project:
 Proposed collaborations with outside organizations (e.g physician offices, school
systems, YMCAs). Explain how these collaborations will positively impact the
proposed outcomes and documentation thereof:
 If applicable, how technology-enabled interventions will be employed (e.g. virtual
care, remote disease management, Health technology, web-based medication
adherence, digital support groups, home-based management/monitoring):
 Clinical and cost saving goals:
B. Operationalizing the Project – Explain the project plan, highlighting four essential
components; goals, objectives, actions and timelines:
 Goals are broad, general statements of what you plan to achieve – the long range
results/benefits to be realized:
 Objectives are statements that specify what steps must be taken, who will take
them and when they will be taken in order to achieve a goal. There should be at
least two objectives for each goal:
 Actions are specific activities that will be undertaken in order to achieve each
objective. In describing the activities, provide the rationale and indicate the
sequence:
 Timelines should indicate when the activities will take place and when the objectives
will be met:
Note: The clinical metrics should reflect the CMS’s Meaningful Use Stage 1
Clinical Quality Measures related to the morbidities of focus.
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The cost saving metric areas may include, but are not limited to:
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Decreased hospitalizations
Decreased emergency room visits
Decrease in unnecessary primary care provider visits
Decreased rate(s) of institutionalization
Decreased cost to health center
Compare clinical and cost saving outcomes to the year prior to funding.
C. The Evaluation Plan should identify the metrics that will be used to determine if the
goals and objectives have been met. The plan must specify the metrics to be used to
evaluate each goal and objective, as well as the source(s) of the data:
D. The Budget and Narrative – Include a line item budget that reflects the grant amount
requested, inkind contribution (specify dollar value) and any cash contribution to the
project. The narrative must explain the rationale for the request. The budget and
narrative must reflect the scope of the project:
E. Sustainability Plan – Indicate how you will continue the implementation of a successful
model after this funding ends:
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