RFI Process and Hub Onboarding Description

1. Submit the Partner Agency Application. Applications will be reviewed by HCAN staff.􀃠
2. Interview: Selected applicants will be invited to an interview with key HCAN staff.􀃠
3. Legal agreements: Applicants selected to become a CCA will be notified and sent a HUB contract BAA.
4. HIPAA security/encryption verification: Talbert House IT will ensure all devices (phones, tablets, desktops, laptops) are password protected, encrypted, and meet HIPAA security standards.
5. CHWs and Supervisors attend required Hub trainings and meetings including: Hub Welcome, Intro to CCS Training, monthly Hub meetings.

PARTNER AGENCY APPLICATION

** Application does not save. Enter all responses then select 'Submit Application' **

Question Title

* 1. Name of Organization

Question Title

* 2. Address

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

Question Title

* 3. CEO / President

First Name

Last Name

Title

Phone Number

Question Title

* 4. Financial Contact

First Name

Last Name

Title

Phone Number

Question Title

* 5. IT Contact

First Name

Last Name

Title

Phone Number

Question Title

* 6. CHW Supervisor Contact

First Name

Last Name

Title

Phone Number

Question Title

* 7. CHW TRAINING & SUPERVISION

Confirm the willingness and availability of the supervisor and CHWs to participate in the HUB's Training sessions (2 half days); attend monthly Supervisor and CHW meetings; and monitor the CHW's work via the Care Coordination System (CCS) – the HUB's web-based electronic record and reporting system. Additional training dates may be scheduled for CHWs and Supervisors when needed.

Question Title

* 8. Agency Information

Number of CHWs

Number Certified by Ohio Board of Nursing

Total FTE (CHWs)

Number of Licensed Professionals (RN, LPN, LISW)

Total FTE (Licensure)

Narrative

Question Title

* 9. Describe the organization's history and mission including the number of years serving the community. Include any significant recent and current organizational issues/changes, current programs and activities (2000 character limit).

Question Title

* 10. Describe the population you serve. Include the number of clients served by your agency in the last calendar year including the number of pregnant women, adults, and children.
Describe your geographic footprint for clients and provide a list of the zip codes served by your organization.

Question Title

* 11. Outline the organization's experience with regard to strategies or activities related to reducing low birthweight, premature birth, infant mortality, and chronic disease among the Medicaid eligible population (2000 character limit).

Question Title

* 12. Indicate the primary reason your organization is interested in having your community health worker(s) work through the HCAN HUB (2000 character limit).

Question Title

* 13. List the organization's insurance coverage types (if available) and limits for: Professional liability, General liability, Cyber/technology, Workers Compensation.

Question Title

* 14. Document any potential issues/concerns with the expectations noted in the expectations web page for participating as a CCA with the HUB.

Attachments - PDF documents required

Question Title

* 15. Insurance Declaration Page

Question Title

* 16. Job Descriptions

Question Title

* 17. Resumes

By submitting this application, your organization and its personnel assures they can meet the HUB expectations for participating as a CCA as noted in the "Expectations" section of this
web page.

Question Title

* 18. Signature

First Name

Last Name

Title

** Application does not save. Enter all responses then select 'Submit Application' **

RFI Process and Hub Onboarding Description

Question Title

* 1. Name of Organization

Question Title

* 2. Address

Question Title

* 3. CEO / President

Question Title

* 4. Financial Contact

Question Title

* 5. IT Contact

Question Title

* 6. CHW Supervisor Contact

Question Title

Question Title

* 8. Agency Information

Question Title

* 9. Describe the organization's history and mission including the number of years serving the community. Include any significant recent and current organizational issues/changes, current programs and activities (2000 character limit).

Question Title

* 10. Describe the population you serve. Include the number of clients served by your agency in the last calendar year including the number of pregnant women, adults, and children.Describe your geographic footprint for clients and provide a list of the zip codes served by your organization.

Question Title

* 11. Outline the organization's experience with regard to strategies or activities related to reducing low birthweight, premature birth, infant mortality, and chronic disease among the Medicaid eligible population (2000 character limit).

Question Title

* 12. Indicate the primary reason your organization is interested in having your community health worker(s) work through the HCAN HUB (2000 character limit).

Question Title

* 13. List the organization's insurance coverage types (if available) and limits for: Professional liability, General liability, Cyber/technology, Workers Compensation.

Question Title

* 14. Document any potential issues/concerns with the expectations noted in the expectations web page for participating as a CCA with the HUB.

Question Title

* 15. Insurance Declaration Page

Question Title

* 16. Job Descriptions

Question Title

* 17. Resumes

Question Title

* 18. Signature

* 10. Describe the population you serve. Include the number of clients served by your agency in the last calendar year including the number of pregnant women, adults, and children.
Describe your geographic footprint for clients and provide a list of the zip codes served by your organization.