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Nurse-Family Partnership Grant Program Request for Proposals April 1, 2016 – December 31, 2020 Application Information and Materials February 2016
Nurse-Family PartnershipGrant Program Request for Proposals
April 1, 2016 – December 31, 2020Application Information and Materials
February 2016
Minnesota Department of HealthDivision of Community and Family HealthFamily Home Visiting SectionP.O. Box 64882St. Paul, Minnesota 55164-0882
Nurse-Family Partnership Grant Program Request for ProposalsApril 1, 2016 – December 31, 2020Information and Materials
February 2016
Community and Family Health Division Family Home Visiting SectionNurse-Family Partnership Program ApplicationP. O. Box 64882St. Paul, MN 55164-0882
Phone: 651-201-4090http://www.health.state.mn.us/fhv/
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Table of ContentsProgram Overview.......................................................................................................4
Program Description.....................................................................................................5
Program Summary........................................................................................................8
Project Narrative and Work Plan..................................................................................9
Budget Section...........................................................................................................12
Form Instructions and Required Forms.......................................................................14
A. Grant Application Face Sheet Form...........................................................................15
B. Grant Application Checklist Form..............................................................................16
C. Nurse-Family Partnership Project Planning Work Plan Form....................................17
D. Nurse-Family Partnership Project Expansion Work Plan Form..................................18
E. Budget Justification Instructions & Budget Justification Form...................................20
F. Budget Summary Instructions & Budget Summary Form..........................................25
G. Indirect Cost Questionnaire Form.............................................................................27
Appendices.................................................................................................................28
Appendix A Criteria for Scoring NFP Grant Applications..............................................29
Appendix B EXAMPLE Nurse-Family Partnership Project Planning Work Plan.............31
Appendix C EXAMPLE Nurse-Family Partnership Project Expansion Work Plan...........32
Appendix D Nurse-Family Partnership Expansion Information Form...........................34
Appendix E 2015 MN Session Law Chapter 71, Article 14, Section 3, Subdivision 2....35
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Program OverviewIntroduction
This Request for Proposal (RFP) document provides the forms and information needed to complete the Nurse-Family Partnership (NFP) grant application. These documents are available on the Minnesota Department of Health (MDH) Family Home Visiting (FHV) website, http://www.health.state.mn.us/fhv/grant.cfm.
The MDH will be available to provide consultation and guidance during the application process. For assistance, please contact [email protected]. Please note that MDH staff will not be able to help with writing the application.
MDH will maintain an “Answers to Grant Application Questions” link on the Family Home Visiting web site: http://www.health.state.mn.us/fhv/grant.cfm. Questions and Answers will be updated regularly before the application deadline.
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Program DescriptionBackgroundThe 2015 Minnesota Legislature authorized $575,000 in state fiscal year 2016 and $2,000,000 in state fiscal year 2017 and thereafter to provide grants for new Nurse-Family Partnership (NFP) programs or to expand existing programs. Eligible applicants are Community Health Boards and Tribal Nations.
Purpose of the FundingFunding is to support Community Health Boards and Tribal Nations to begin a new NFP program or to expand an existing NFP program. The NFP program serves first-time mothers. Women must be enrolled in the home visiting program prenatally by 28 weeks gestation with services continuing until the child is two years of age. Families served must be eligible for Medical Assistance (MA) under Minnesota Statutes, Chapter 256B or the federal Special Supplemental Nutrition Program for Women, Infants and Children (WIC), 7 Code of Federal Regulations, Part 246. Families do not have to be enrolled in MA or WIC but must meet eligibility criteria if not enrolled. Funding is to supplement, not replace, funds being used for NFP programs as of June 30, 2015.
Priority will be given for grant proposals that:1. Provide services through a Minnesota Health Care Programs (MHCP) enrolled provider
that accepts MA. 2. Expand regional partnerships that provide the NFP program in rural areas.
Nurse-Family PartnershipNFP is an evidence-based, community health program that helps transform the lives of vulnerable mothers pregnant with their first child. Each mother served by NFP is partnered with a registered nurse early in her pregnancy and receives ongoing nurse home visits that continue through her child’s second birthday. Independent research proves that communities benefit from this relationship — every dollar invested in NFP can yield more than five dollars in return.
NURSE-FAMILY PARTNERSHIP GOALS1. Improve pregnancy outcomes by helping women engage in preventive health practices,
including prenatal care from their healthcare providers, improving diets and reducing use of cigarettes, alcohol and illegal substances;
2. Improve child health and development by helping parents provide responsible and competent care; and,
3. Improve the economic self-sufficiency of the family by helping parents develop a vision for their own future, plan future pregnancies, continue their education and find work.
For information about becoming a new NFP replication site in Minnesota contact:Chelsea Pearsall, MA | Business Development Manager
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For information about expanding a current NFP program in Minnesota contact:Amy Goodhue, PHN | Nurse [email protected]
Current Nurse-Family Partnership Implementing SitesThe legislation funding this grant award requires that funds be used only to supplement, not to replace current funds being used for NFP home visiting services as of June 30, 2015.
Available FundingGrant awards are for:
New NFP Replication Sites – Six months (4/1/16 through 10/31/16) for planning, training and model related fees. These are planning grants. In planning for implementation of this legislation, MDH has allocated funding to be able to support up to two (2) awarded planning grantees to move forward with implementation after successful completion of planning and approval for implementation by the NFP National Service Office. It is anticipated that there would be a modified application process for awarded planning sites to demonstrate their capacity for implementation for the period January 1, 2017 through December 31, 2020.
Expansion of existing NFP Replication Sites – four year nine month award time period (4/1/16 through 12/31/20). This funding is available to sites expanding a current NFP program and would support expansion needs including training, staff, and reflective practice.
Required Application ComponentsSee Form B, Grant Application Checklist for required application components.
Application Submission Requirements Narrative portions of the application should be written in 12-point font, single spaced
with one-inch margins. The Work Plan (Form C (Planning) or D (Expansion)) can be in 11 point font.
All pages should be numbered consecutively. Submit the entire application as one PDF document including the required forms in the
order listed on Form B Grant Application Checklist Form by email to [email protected].
The deadline for submission of applications is 4:00 PM on April 8, 2016. No application will be accepted for consideration after this time.
Application Review and Award ProcessThis is a competitive grant application. Applications will be reviewed and scored according to the Criteria for Scoring NFP Grant Applications (Appendix A).
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Reviewers may include staff from the MDH, the NFP National Service Office, developers of other models, and staff from state agencies with experience related to early childhood or family services, or individuals who are familiar with or who have provided home visiting services. Reviewers will be required to identify any conflicts of interest and will not review an application if they have a direct relationship with the applicant.
Final funding recommendations will be based on the scores and comments from reviewers. When making awards, consideration will be given to distributing funding throughout the state and/or regions and meeting the funding priorities identified in the legislation. It is anticipated that grant award decisions will be made in April 2016. Applicants will be notified whether or not their grant application was funded.
All materials submitted in response to this RFP will become property of the State and will become public record in accordance with Minnesota Statutes, section 13.599 after the evaluation process is completed. Pursuant to the statute, completion of the evaluation process occurs when the government entity has completed negotiating the grant agreement with the selected grantee. If the Responder submits information in response to this RFP that it believes to be trade secret materials, as defined by the Minnesota Government Data Practices Act, Minnesota Statute §13.37, the Responder must: Clearly mark all trade secret materials in its response at the time the response is submitted; Include a statement with its response justifying the trade secret designation for each item;
and, Defend any action seeking release of the materials it believes to be trade secret, and
indemnify and hold harmless the State, its agents and employees, from any judgements or damages awarded against the State in favor of the party requesting the materials, and any and all costs connected with that defense. This indemnification survives the State’s award of a grant contract. In submitting a response to this RFP, the Responder agrees that this indemnification survives as long as the trade secret materials are in possession of the State.
Applications are nonpublic until opened. Once opened, the name of the applicant, the address of the applicant, and the amount the applicant requested is public. All other data in an application is nonpublic data until completion of the evaluation process. After the evaluation process has been completed, all data submitted by the applicant is public.
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Program Summary
Eligibility for Grant Funds Community Health Boards, Tribal Nations
Total Funds Available
$8,575,000 for SFY16 - SFY20. It is anticipated that there will be three opportunities for funding as follows:1. Opportunity 1: SFY16 (up to 3 planning grants and 5 expansion grants)2. Opportunity 2: SFY17 (up to 2 planning grants and 2 implementation grants)3. Opportunity 3: SFY18 (up to 1 implementation grant and 1 expansion grant)
Grant Cycle New (Planning) NFP Replication Sites: 04/1/2016 – 10/31/2016Expansion Sites: 4/1/16 – 12/31/20
Grant Purpose To plan and prepare for implementation of a new NFP program, or to expand an existing NFP program.
Application Requirements
Narrative portions should be in at least 12-point font with one-inch margins All pages should be numbered consecutively Submit the entire application as one PDF document including the required
forms in the order listed on Form B Grant Application Checklist Form by email to [email protected]
Application Deadline All applications must be received electronically by MDH no later than 4:00 p.m. (CST) on Friday, April 8, 2016. Late applications will not be considered for review.
Applications Sent: Electronic Delivery Address: [email protected]
Beginning Grant Agreement Date
April 1, 2016, or date upon which all signatures to the agreement are obtained, whichever is later.
Statutory Authority 2015 MN Session Law, Chapter 71, Article 14, Section 3, Subd. 2
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Project Narrative and Work PlanThe project narrative and work plan describes the applicant’s organization and what is intended to be accomplished. To assist applicants, MDH has provided detailed instructions on what information should be included and what grant reviewers will be reviewing in each application.
The Project Narrative is divided into distinct sections and should be submitted in the sequence as below:
A. Applicant InformationB. Linkages and CollaborationC. Statement of NeedD. NFP National Service Office CoordinationE. Work Plan: Goals, Objectives, and Strategies (Form C (Planning) or D (Expansion))F. Challenges to Expansion and Plan for Resolution
A. Applicant Information (All applicants)
Please keep this section to two or fewer pages. If an applicant submits a joint application, the limit is two pages per organization. Applicants should use 12-point font with one-inch margins for this portion.
Background Information1. Briefly summarize the applicant’s history related to family home visiting and if
applicable, NFP.
Applicant Capacity1. Briefly describe the support the applicant has related to this grant application including
applicant or governing body support. 2. Briefly describe the applicant’s history and capacity to bill for home visiting services.
B. Linkages and Collaboration
Please keep this section to two or fewer pages.The 2015 legislation gives priority to applicants that expand services in rural areas through regional partnerships.
1. Please describe the applicant’s collaboration with community partners related to planning for or implementation of NFP.
2. Please describe any proposed or current regional partnerships including discussions that have occurred.
3. For sites expanding a current NFP program, please describe the referral process the applicant will use to assure an adequate number of referrals to reach the expansion goal.
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All applicants must identify any subcontracts that will be required to carry out the duties of this grant program as part of the Contractual Services budget line item in the proposed Budget Section 2. Subcontracts are subject to State review and approval and may change based on final work plan and budget negotiations with selected grantees.
Applicant responses must include: Description of services to be subcontracted; Anticipated subcontractor/consultant’s name (if known) or selection process to be used; Length of time services will be provided; and, Total amount to be paid to subcontractor.
C. Statement of Need
Please keep this section to two or fewer pages. Please describe the need that the applicant is addressing in the community as the applicant plans for implementation or expansion of the NFP program. Include information about target population (if known); any needs assessment that was completed by the applicant separately or in collaboration with, other community partners; waiting list for sites considering expansion, etc.
D. Nurse-Family Partnership National Service Office Coordination
Please keep this section to two or fewer pages. It is important to work with the NFP National Service Office when considering implementation or expansion of a NFP program. The applicant may contact the NFP National Service Office business development manager for Minnesota, Chelsea Pearsall, at 303-864-4330, [email protected] related to new NFP implementation. Sites considering expansion may contact Amy Goodhue, 612-214-3732, [email protected]. Please describe any contact or discussions the applicant has had with the NFP National Service Office staff. Include the applicant’s NFP Expansion Information if the applicant has submitted it for review to the NFP National Service Office and any feedback the applicant has received from the NFP National Service Office. A copy of the NFP Expansion Form is attached as Appendix D.
E. Work Plan: Goals, Objectives, and Strategies
Complete all of the following on Work Plan Form C (Planning) or D (Expansion). Please limit the entire Work Plan to two or fewer pages. The work plan has objectives that should not be changed. The dates included in the objectives are suggestions and the dates may be changed according to the specific applicant’s timeline. Note: If the application is approved and funded at the level requested, the NFP Planning or Expansion Work Plan (Form C - Planning or Form D- Expansion) will be incorporated into the grant agreement between MDH and the grantee applicant as contractor’s duties. Work Plans
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must be completed according to directions so they can be separated easily from the rest of the application. (See Appendix B and C for Work Plan examples.)F. Challenges and Plan for Resolution
Please keep this section to two or fewer pages. Please describe any challenges or barriers to planning for implementation or expansion of a current NFP program. Include any potential staffing, logistical, outreach or family engagement, community partnership challenges. Please describe potential solutions to the identified challenges.
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Budget SectionThe Budget Section of the application is composed of three items:
Budget Justification Form (Form E) Budget Summary Form (Form F) Indirect Cost Questionnaire (Form G)
The applicant will need to complete one Budget Justification Form AND one Budget Summary Form for each time period of applicant’s grant program:
Planning Grants Time Periods 4/1/16-10/31/16
Expansion Grants Time Periods 4/1/16-6/30/17 7/1/17-6/30/18 7/1/18-6/30/19 7/1/19-12/31/20
Budget Justification Instructions and Form (Form E)Please read the instructions for the Budget Justification Form carefully before completing the Budget Justification Form. For each line item on the budget, provide a rationale and details relative to how the budgeted cost items were calculated.
Each Budget Justification Form should provide the details of the applicant’s expenses and a brief description of how they support the proposed grant activity for that time period. (The full description of the purpose of each grant-funded position and the necessity of budgeted items should appear in the Project Narrative.)
Budget Summary Instructions and Form (Form F)Please read the instructions for the Budget Summary Form carefully before completing the Budget Summary Form. Expenses in the line items should match the amounts listed in the line items on the corresponding Budget Justification Form.
Each Budget Summary should be where the applicant provides the total expenses for the time periods of the proposal by adding the expenses from the Budget Justification Form.
REMINDERS: Provide one Budget Justification Form AND one Budget Summary Form for each time
period listed above. Total all lines and columns and check for mathematical accuracy. Make sure that the budget summary totals match the amount listed in number 1 on the
Grant Application Face Sheet (Form A).
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Indirect Cost Questionnaire (Form G)Please complete Form G. If the applicant will be using a Federally Negotiated Indirect Cost Rate, please include the most current Federally Negotiated Indirect Cost Rate with Form G.
Budget ScoringThe scoring of the Budget Section will be done using the Budget Justification Form and the Budget Summary Form. If supplementary information is included, it will not be taken into consideration for scoring purposes.
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Form Instructions and Required FormsA. Grant Application Face Sheet Form
B. Grant Application Checklist Form
C. NFP Planning Work Plan Form
D. NFP Expansion Work Plan Form
E. Budget Justification Instructions & Form (one form for each time period)
F. Budget Summary Instructions & Form (one form for each time period)
G. Indirect Cost Questionnaire Form
All required forms can be accessed individually at http://www.health.state.mn.us/fhv/grant.cfm
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Form A: Grant Applicant Face SheetGeneral Applicant Information
Applicant’s Legal Name (do not use a “doing business as” name):
Applicant’s Business Address:
Applicant’s Minnesota Tax Identification Number:
Applicant’s Federal Tax Identification Number:
Director of Applicant AgencyName:
Business Address:
Phone Number:
Email:
Financial Contact, or Fiscal Agent, for this grantName of Financial Contact for this grant:
Name of Fiscal Agent for this grant, if applicable:
Phone Number:
Email:
Contact Person for this grantName:
Business Address:
Phone Number:
Email:
Requested FundingTotal Amount on Proposed Budget: $
I certify that the information contained above is true and accurate to the best of my knowledge; that I have informed this agency’s governing board of the agency’s intent to apply for this grant; and, that I have received approval from the governing board to submit this application on behalf of the agency.
Signature of Authorized Agent for Applicant
Date of signature
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Form B: Grant Application Checklist
Use this checklist to ensure that you have included all the required items for your grant application. Any application that does not contain all required items will be considered incomplete and will not be reviewed.
Have you included the following required items? Grant Applicant Face Sheet (Form A) Grant Application Checklist (Form B) Table of Contents Project Narrative NFP Work Plan (Form C (Planning) or D (Expansion)) Budget Justification Form (Form E) (1 for each year of the grant) Budget Summary Form (Form F) (1 for each year of the grant) MDH Indirect Cost Questionnaire (Form G)
APPLICATION DEADLINE: Not later than 4:00 PM (CST) on Friday, April 8, 2016
Delivery Address:[email protected]
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Form C: NFP Planning Work Plan-2015 Grant RFP
Community Health Board or Tribal Nation:
Counties Included in Application:
Contact Person for Work Plan including name, email, and phone no.:
Date Submitted:
Objectives ActivitiesBy May 30, 2016 develop a plan to provide a quarterly report on activities related to this work plan. By October 1, 2016 a decision will be made as to whether it is feasible to move forward with NFP implementation. By October 1, 2016 any collaborative agreements to support NFP implementation with partners will be in place. By October 1, 2016 a Nurse-Family Partnership Implementation Plan will be submitted. By October 15, 2016 MDH will receive a copy of the Nurse-Family Partnership Implementation Plan and timeline to receive approval of from Nurse-Family Partnership of the Implementation Plan.
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Form D: NFP Expansion Work Plan-2015 Grant RFPCommunity Health Board or Tribal Nation:
Counties Included in Application:
Contact Person for Work Plan including name, email, and phone no.:
Date submitted:
NFP funded capacity as of June 30, 2015 _______ Proposed expansion with this application _________ = Total NFP Capacity ______
Objectives ActivitiesBy May 1, 2016 submit an Expansion Information Form related to this grant application to the Nurse-Family Partnership National Service Office if one has not been previously submitted.By May 31, 2016 develop a plan to collect data as outlined in the Family Home Visiting Reporting Guidance for 2016 for submission to MDH via FHVRES beginning October 2016 through the entire grand period. By May 31, 2016 develop a plan for quarterly reporting to MDH related to activities of this work plan. By May 31, 2016 submit the Expansion Information Form for this project and feedback from the NFP NSO to MDH. By June 1, 2016 any additional staff needed to implement the proposed expansion are hired and trained. By July 1, 2016 begin recruiting and enrolling families to participate in the NFP expansion. By July 1, 2016 develop and begin implementing a plan related to any other support needed for this expansion including providing reflective practice.
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Objectives ActivitiesBy May 1, 2017 achieve a full case load of families to be served under this expansion grant.
By July 31, 2017 develop and submit a plan to MDH to maintain 85% of total NFP capacity for agency.
By December 31, 2020 maintain fidelity to the NFP model and 85% of total NFP capacity.
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Form E: Budget Justification Instructions and Form
Before the applicant begins writing the organization’s budget, consider the specific activity planned and the resources needed to do it. What resources does the applicant need to be able to plan for implementation of a new Nurse-Family Partnership program or expand an existing Nurse-Family Partnership program? Which items will need to be replaced during the program (grant time period)? When considering the skills needed to carry out the activity, remember to include any training that will be needed for staff.
The Budget Section of this application is composed of three items: Budget Justification Form (Form E) Budget Summary Form (Form F) Indirect Cost Questionnaire (Form G)
Applicant will need to complete Budget Justification Forms (Form E), one for each time period of applicant’s grant program listed below. The Budget Summary Form (Form F) is where the applicant will summarize each period of the grant Budget Justification Form by line item for each time period of applicant’s grant proposal.
Planning Grants Time Periods 4/1/16-10/31/16
Expansion Grants Time Periods 4/1/16-6/30/17 7/1/17-6/30/18 7/1/18-6/30/19 7/1/19-12/31/20
Each Budget Justification Form will provide the details of the applicant’s expenses and a brief description of how they support the proposed grant activity for that budget period. (A full description of how the applicant’s expenses support the proposed activities, including grant-funded positions, should appear in the Project Narrative.)
The categories listed below (salary/fringe, contractual services, travel, supplies/expenses, other, and indirect) describe the costs that may be included in each category and correspond to the sections in both the Budget Justification Form and the Budget Summary Form.
Salary and FringeFor each proposed funded position, indicate the title, the full time equivalent (FTE) on this grant (see example below), the expected rate of pay, and the total amount applicant expects to pay the position for the year. Grant funds can be used for salary and fringe benefits for staff members directly involved in applicant’s proposed activities.
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Any salaries from the administrative, accounting, human resources, or IT support, MUST be supported by some type of time tracking, in order to be included as a direct line expense. If these salary expenses are not supported by time reporting documentation, then the expenses must be included in the indirect line.
Full time equivalent (FTE): The percentage of time a person will work on the 2016-2020 Nurse-Family Partnership Grant project. Each position that will work on this grant should show the following information:
EXAMPLE:Public Health Nurse: $30.40/hourly rate
X 2080/annual hours (or whatever your agency annual standard is)$63,232 annual salary
Multiply annual salary by your agency’s fringe rate:$63,232 annual salary* 23% fringe rate (or whatever your agency fringe rate is)$14,543 fringe amount
Now add the annual salary and the fringe amount together:$63,232 annual salary
+$14,543 fringe$77,775/annual salary and fringe total
Multiply the annual salary and fringe total by the FTE being charged to this grant:$77,775 annual salary and fringe totalX .50 FTE assigned to grant$38,888 total to be charged to grant for this position
Contractual ServicesApplicants must identify any subcontracts that will occur as part of carrying out the duties of this grant program as part of the Contractual Services budget line item in your proposed budget. The use of contractual services is subject to State review and may change based on final work plan and budget negotiations with selected grantees.
Applicant responses must include: Description of services to be contracted; Anticipated contractor/consultant’s name (if known) or selection process to be used; Length of time the services will be provided; and, Total amount to be paid to contractor.
TravelList the expected travel costs for staff working on the grant, including mileage, hotel, and meals. At a minimum, your organization must include the cost for at least one staff member to attend two MDH-sponsored statewide or regional meetings during each year. If project staff will travel during the course of their jobs or for attendance at educational events, itemize the costs, frequency, and the nature of the
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travel. Grant funds cannot be used for out-of-state travel without prior written approval from MDH. Minnesota will be considered the home state for determining whether travel is out of state.
Community Health Board applicants: Budget for travel costs using the rates listed in the State of Minnesota’s Commissioner’s Plan.
Please reference the meal allowances rates listed there. Hotel/motel expenses should be reasonable and consistent with the facilities available. Grantees
are expected to exercise good judgement when incurring lodging expenses. Mileage will be reimbursed at the current IRS rate.
Tribal Nation applicants:Budget for travel costs using the rates provided by the General Services Administration (GSA). Current lodging amounts and meal reimbursement rates vary depending on where in Minnesota
the travel occurs. Please reference the per diem rates listed there. Hotel/motel expenses should be reasonable and consistent with the facilities available. Grantees
are expected to exercise good judgement when incurring lodging expenses. A breakdown of the meals and incidental expenses can be found here. Mileage will be reimbursed at the current IRS rate.
Supplies and ExpensesBriefly explain the expected costs for items and services the applicant will purchase to run the program. These might include additional telephone equipment; postage; printing; photocopying; office supplies; training materials; and equipment. Include the costs expected to be incurred to ensure that community representatives, partners, or clients who are included in the applicant’s process or program can participate fully. Examples of these costs are fees paid to translators or interpreters. Grant funds may not be used to purchase any individual piece of equipment that costs more than $5,000, or for major capital improvements to property.
OtherInclude in this section any expenses the applicant expects to have for other items that do not fit in any other category. An example is staff training. Grant funds cannot be used for capital purchases, permanent improvements; cash assistance paid directly to individuals; or any cost not directly related to the grant.
Indirect CostsIndirect costs are expenses of doing business that cannot be directly attributed to a specific grant program or budget line item. They can include: executive and/or supervisory salaries and fringe, rent, facilities maintenance, insurance premiums, etc. These costs are often allocated across an entire agency. If you are able to do time tracking for any of these salary costs they should be included under Salary and Fringe. The total allowed for indirect costs can be either charges up to your federally approved indirect rate, or up to a maximum of 10%. To calculate indirect costs, multiply the direct expenses in the budget (Line 6. Subtotal of this form) by what you are using as your indirect cost rate.
If the applicant will be using a Federally Negotiated Indirect Cost Rate, you will need to submit with your application your most current federally approved indirect rate.
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Form E: Budget Justification Instructions and Form
Complete one form for each time period.MDH Grant Program Name:Applicant Agency:Contact Person:Phone Number:Email Address:Budget Period: ________ to ________
Revision # (MDH use only):
1. Salary and Fringe Benefits: For each proposed funded position, list the title, the full time equivalent, the expected rate of pay, and the total amount applicant expects to pay the position.
Justification: REQUESTEDDOLLARS
Total Salary and Fringe $
2. Contractual Services: List the services applicant expects to contract out, the contractor’s or consultant’s name, whether the contractor is non-profit or for-profit, the length of time the services will be provided and the total amount expected to be paid. Supplies and travel of contractor should be included, if applicable. Itemize equipment rented or leased for the project.
Justification: REQUESTEDDOLLARS
Total Contractual Services $
3. Travel: Explain applicants expected instate travel costs, including mileage, hotel and meals. At a minimum, your organization must include the cost for at least one staff member to attend two MDH-sponsored statewide or regional meetings. If program staff will travel, itemize the costs, frequency and the nature of the travel.
Justification: REQUESTEDDOLLARS
Total Travel $
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4. Supplies and Expenses: Explain the expected costs for items and services the applicant will purchase to run the program. Include telephone expenses that are part of this proposal; cell phones and new telephone equipment to be purchased, if applicable. Estimate postage if part of the project. List printing and copying costs necessary for the project (other than occasional copying on an office copy machine). List office and program supplies and expendable equipment such as training materials, curriculum and software. Generally supplies include items that are consumed during the course of the project, equipment under $5,000.
Justification: REQUESTEDDOLLARS
Total Supplies and Expenses $
5. Other Expenses: Briefly describe any expenses that do not fit in any other category. An example is staff training.
Justification: REQUESTEDDOLLARS
Total Other Expenses $
6. SUBTOTAL (Enter sum of lines 1 through 5): $
7. Indirect Costs: Enter your proposed indirect cost rate below. In the box to the right, enter the amount of indirect costs being requested. Indirect costs can be up to your federally approved indirect rate, or up to a maximum of 10%, multiplied by the direct expenses in the budget (line 6 of this form).
Indirect cost rate: _____%REQUESTEDDOLLARS
Total Indirect $
8. TOTAL (sum of line 6 + line 7) $
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Form F: Budget Summary Instructions and Form
This form should be used to show the total requested budget for the applicant’s proposed grant-funded activities for each time period of the program. The budget should include funding necessary in each category for each year of the grant. The total in each category should reflect the total of that category from the corresponding Budget Justification Form.
The Subtotal (line 6) should reflect the total of all the expenses listed on each Budget Justification Form.
Please enter zero (0) in the Total Proposed Amount column if you do not propose to expend grant funds in a line item.
Please type all items on the Budget Summary Form (Form F).Name of MDH Grant Program – enter name of the grant program for which you are applyingName of Applicant Agency – Legal name of the agency applying for grant funds.Name of Contact Person for Budget – Person who may be contacted for questions related to the budget proposal.Phone – Telephone number of the person listed.Fax – Fax number of the person listed.E-Mail – E-mail address of the person listed.
1. Salary and Fringe : The total amount of grant funds that will be used during each time period on page 12 to cover salary/fringe benefits (add the figures from the “Total Salary and Fringe” box in all of the Budget Justification Forms).
2. Contractual Services : The total amount of grant funds the applicant plans to spend on contractual services (add the figures from the “Total Contractual Services” box in all of the Budget Justification Forms).
3. Travel : The total amount of grant funds that the applicant plans to spend on travel (add the figures from the “Total Travel” box in all of the Budget Justification Forms).
4. Supplies and Expenses : The total amount of grant funds that the applicant plans to spend on supplies and expenses (add the figures from the “Total Supplies and Expenses” box in all of the Budget Justification Forms).
5. Other : The total amount of grant funds that the applicant plans to spend on items that are not listed above (add the figures from the “Other Total” box in all of the Budget Justification Forms).
6. Subtotal : The sum of lines 1 through 5. This figure should match the sum of the subtotals on applicant’s Budget Justification Forms.
7. Indirect Costs : The total amount of grant funds that the applicant plans to spend for indirect costs. Indirect costs can be up to an applicant’s federally approved indirect rate, or up to a maximum of 10%, multiplied by the direct expenses in the budget (line 6 of this form). This figure should match the sum of the indirect costs on your Budget Justification Forms.
8. Total : The total in adding lines 6 and 7.
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Form F: Budget Summary Instructions and Form
Complete one form for each time period.Name of MDH Grant Program:
Name of Applicant Agency:
Name of Contact Person for Budget:
Budget Period: _____________to ______________
Phone: Fax:
E-mail:
Line Item Total Proposed Amount1) Salary and Fringe
2) Contractual Services
3) Travel
4) Supplies and Expenses
5) Other
6) Subtotal (sum of lines 1 through 5)
7) Indirect Costs (your federally approved rate, or maximum of 10%, multiplied by line 6)
8) TOTAL (sum of line 6 + line 7)
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Form G: Indirect Cost QuestionnaireApplicant’s Legal Name: _________________________________________
Program: 2016-2020 Nurse-Family Partnership Grant
Please check one of the three options below:
1. Not applicable
No charges to the grant program listed above are for indirect costs.
2. Federally Approved Indirect Cost Rate Agreement
A federally negotiated fixed rate is to be charged against all grant programs.
A copy of the federally approved Indirect Cost Rate Agreement covering the current federal fiscal year is attached.
3. No federally approved indirect cost rate – requesting up to 10% maximum
Up to 10% of the direct expenses in the budget for the grant program listed above can be used for indirect costs per CFR Part 200 - Uniform Administrative Requirements, Costs Principles, and Audit Requirements for Federal Awards.
The applicant agency is requesting a rate of % for the grant program listed above.
Per MDH Policy, the applicant must inform MDH of the types of costs included in the applicant’s indirect costs. Please list below.
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AppendicesAppendix A Criteria for Scoring NFP Grant ApplicationsAppendix B NFP Planning Work Plan ExampleAppendix C NFP Expansion Work Plan ExampleAppendix D NFP Expansion Information Appendix E 2015 Minnesota Session Law, Chapter 71, Article 14, Section 3, Subd, 2
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Appendix A: Criteria for Scoring NFP Grant Applications
I. Applicant Information (all applicants)A. Does the applicant describe their agency’s history related to home visiting? B. If the applicant is intending to expand their NFP program, do they describe their history
related to NFP implementation? C. Does the applicant describe support they have received related to the application including
any governing board, advisory group or agency support? D. Does the applicant describe in some detail their capacity to bill for home visiting services for
Medicaid recipients of home visiting?
II. Linkages and CollaborationAll ApplicantsA. Does the applicant describe their collaboration with community partners especially as it
relates to home visiting or NFP? B. If applicable (a multi-site collaboration), does the applicant discuss any regional
collaborations? C. If the applicant proposed to contract out services, does the applicant:
1. Describe the services to be contracted for; 2. Provide anticipated contractor information including name and selection process to be
used; 3. Length of time the services will be provided; and,4. Total amount to be paid to the contractor.
For Applicants Proposing NFP Expansion Does the applicant describe the referral process the agency uses to assure an adequate number of referrals will be accessed to achieve the expansion goal?
III. Statement of Need (all applicants)A. Has the applicant identified the community need that the applicant hopes to address with
the application and proposed activities?B. Does the applicant include in their description of need:
1. A target population2. Waiting list for home visiting services especially for those sites considering expansion or
other information demonstrating need for expanded services.
IV. NFP National Service Office Coordination All ApplicantsDoes the applicant describe contact with the NFP National Service Office regarding this application and proposed implementation or expansion?
For Applicants Proposing NFP ExpansionA. Has the applicant included a NFP Expansion Information Form that was submitted to the NFP
National Service Office related to the proposed expansion?
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B. If an applicant has submitted a NFP Expansion Information Form did they include feedback that was received from the NFP National Service Office?
V. Work Plan: Goals, Objectives, Strategies All ApplicantsDo the proposed activities demonstrate the capacity to achieve goals/objectives in the work plan?
For Applicants Proposing NFP Expansion Has the applicant identified activities to achieve goals/objectives related to: a) Recruitment of families; b) Reflective practice; c) Need for new supervisor or other staff including hiring and training; d) Identifying current service capacity with NFP and additional capacity with expansion; e) Regional collaborations; f) Ability to submit quarterly reports to MDH; g) Ability to submit quarterly data to MDH through FHVRES; h) Ability to achieve and maintain 85% of funded NFP capacity; and i) Ability to achieve and maintain a full caseload as proposed through the expansion.
VI. Potential Challenges (all applicants) A. Does the applicant describe any challenges related to the proposed application for planning
or expansion including potential staffing, logistical, outreach and family engagement, or community partnership challenges?
B. Does the applicant describe any potential solutions to the named challenges?
VII. Budget (all applicants)A. Are the budget forms complete? B. Do the amounts in the Budget Summary and the Budget Justification match? C. Is the information contained in the budget and work plan consistent? D. Are the projected costs, reasonable, cost-effective and sufficient to accomplish the proposed
activities?
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Appendix B: EXAMPLE NFP Planning Work Plan Example – 2015 Grant RFP
Community Health Board or Tribal Nation:
Counties Included in Application:
Contact Person for Work Plan including name, email, and phone no.:
Date Submitted:
Objectives Activities: Examples only, list not all inclusive. Objectives required, local activities to meet objectives may vary.
By May 30, 2016 develop a plan to provide a quarterly report on activities related to this work plan.
Determine how to collect information on activities Identify person responsible for collecting information for quarterly reporting
By October 1, 2016 a decision will be made as to whether it is feasible to move forward with NFP implementation.
Contact the NFP National Service Office business developer of interest in becoming a replication site by June 1, 2016.
Conduct community needs assessment: review data and identify community population needs, capacity gaps, and sustainability by X________.
Conduct an assessment of organizational capacity/ies at leadership meeting on June 16, 2016.
Obtain approval by county boards to proceed with planning by X______.By October 1, 2016 any collaborative agreements to support NFP implementation with partners will be in place.
Meet with partners regarding program planning to determine requirements of collaborative agreements.
Develop collaborative agreement. Approved collaborative agreement by X______.
By October 1, 2016 a NFP Implementation Plan will be submitted.
Meet with NSO business developer monthly to work toward completion of NFP Implementation Plan.
Request letters of agreement from local partners and advocates by X______.By October 15, 2016 MDH will receive a copy of the NFP Implementation Plan and timeline to receive approval of from NFP of the Implementation Plan.
Implementation review scheduled with NSO on X______. Submit copy of revised, approved Implementation Plan to MDH when finalized
and reviewed by the NSO.
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Appendix C: Example NFP Expansion Work Plan Example – 2015 Grant RFP
Community Health Board or Tribal Nation: Counties Included in Application: Contact Person for Work Plan including name, email, and phone no.: Date submitted: NFP funded capacity as of June 30, 2015 _________ Proposed expansion with this application __________ = Total NFP Capacity ______
Objectives Activities- Examples: Examples only, list not all inclusive. Objectives required, local activities to meet objectives may vary.
By May 1, 2016 submit an Expansion Information Form related to this grant application to the NFP National Service Office if one has not been previously submitted.
Determine need for expansion, i.e., Review data, meet with partners, etc. Call with NSO Nurse Consultant to notify of interest to expand. Obtain approval by county boards to proceed with expansion by X______.
By May 31, 2016 develop a plan to collect data as outlined in the Family Home Visiting Reporting Guidance for 2016 for submission to MDH via FHVRES beginning October 2016 through the entire grand period.
Train staff in data collection. Review FHVRES Reporting Guidance with staff. Develop policy related to data collection and submission.
By May 31, 2016 develop a plan for quarterly reporting to MDH related to activities of this work plan.
Determine how to collect information on activities. Identify person responsible for collecting information for quarterly reporting.
By May 31, 2016 submit the Expansion Information Form for this project and feedback from the NFP NSO to MDH.
Submit reviewed Expansion Information Form to MDH on X_______.
By June 1, 2016 any additional staff needed to implement the proposed expansion are hired and trained.
Advertise to hire 1.0 FTE for expansion of 25 families. Interview and hire 1.0 FTE for expansion by X_____. Contact NSO Nurse Consultant for training registration for new staff.
By July 1, 2016 begin recruiting and enrolling families to participate in the NFP expansion.
Outreach to WIC staff, prenatal provider, and alternative learning centers on a quarterly basis to recruit new eligible families.
Review procedure for assigning new client referrals for new staff. Review NFP Outreach toolkit for strategies in new geographical area.
By July 1, 2016 develop and begin implementing a plan related to any other support needed for this expansion including providing reflective practice.
Schedule time to review Unit One Skills Assessment with new staff to identify training gaps/needs by X____.
Schedule weekly reflective supervision times with new staff.
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Objectives Activities- Examples: Examples only, list not all inclusive. Objectives required, local activities to meet objectives may vary.
By May 1, 2017 achieve a full case load of families to be served under this expansion grant.
Schedule time to meet with existing and new referral agencies by July 1, 2016. Screen, assign and enroll new NFP referrals by July 1, 2016 or after home visitor
completes Unit 2 training. Refer to NFP calendar/plan in team meeting module for achieving full caseload
within nine months. Supervisor to monitor caseload progress on a monthly basis.
By July 31, 2017 develop and submit a plan to MDH to maintain 85% of total NFP capacity for agency.
Review ETO quarterly reports beginning September 1, 2016to determine client attrition rates during pregnancy, infancy and toddler.
Conduct a PDSA process to address timing and reasons for client attrition. Assign new referrals to caseloads that are less than 85% capacity. Review Operational Efficiency Dashboard with NSO consultant on a monthly basis
beginning September 1, 2016 to identify opportunities for growth in enrollment and retention efforts.
By December 31, 2020 maintain fidelity to the NFP model and 85% of total NFP capacity.
Follow NFP visit guidelines on home visits and input data about all home visit activity into ETO system.
Adhere to NFP model elements 1-18. Reengage potential referral sources biannually to keep current on referral flow. Assign new referrals to caseloads that are less than 85% capacity. NFP supervisor and team will review fidelity reports on a quarterly basis
beginning September 1, 2016.
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Appendix D: Expansion Information Form
The Nurse-Family Partnership Expansion Information Form is available by contacting Amy Goodhue, Nurse-Family Partnership Nurse Consultant at [email protected].
If you are a current Nurse-Family Partnership site, you may also access the form by going to the Nurse-Family Partnership website http://www.nursefamilypartnership.org/ and logging on to the NFP Community tab.
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Appendix E: 2015 Minnesota Session Law, Chapter 71, Article 14, Section 3, Subd, 2
Targeted Home Visiting System. (a) $75,000 in fiscal year 2016 is for the commissioner of health, in consultation with the commissioners of human services and education, community health boards, tribal nations, and other home visiting stakeholders, to design baseline training for new home visitors to ensure statewide coordination across home visiting programs.
(b) $575,000 in fiscal year 2016 and $2,000,000 fiscal year 2017 are to provide grants to community health boards and tribal nations for start-up grants for new nurse-family partnership programs and for grants to expand existing programs to serve first-time mothers, prenatally by 28 weeks gestation until the child is two years of age, who are eligible for medical assistance under Minnesota Statutes, chapter 256B, or the federal Special Supplemental Nutrition Program for Women, Infants, and Children. The commissioner shall award grants to community health boards or tribal nations in metropolitan and rural areas of the state. Priority for all grants shall be given to nurse-family partnership programs that provide services through a Minnesota health care program-enrolled provider that accepts medical assistance. Additionally, priority for grants to rural areas shall be given to community health boards and tribal nations that expand services within regional partnerships that provide the nurse-family partnership program. Funding available under this paragraph may only be used to supplement, not to replace, funds being used for nurse-family partnership home visiting services as of June 30, 2015.
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