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Exhibit F
Updated 7/1/2017
PROGRAM DESCRIPTIONS
The Network Service Provider shall prepare and submit the following Program Description(s) via SurveyMonkey for each program that is funded within this contract and/or for approval prior to the start of a contract or a new program. A Prevention Program Description is required to be submitted if the Network Service Provider is contracted for prevention services. If the Network Service Provider modifies an existing program, a revision to the Program Description is required via SurveyMonkey.
1. Program Description
LSF Health Systems Program Description
1. Provider Name:
2. Provider Representative Name:
3. Program Name:
4. Select one (1) program area:*
Adult Mental Health
Children Mental Health
Adult Substance Abuse
Children Substance Abuse
5. Provide a brief (500 words or less) overview of the program in narrative form.
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EXHIBIT F
Updated 07/01/2017
6. Will the program utilize funding from or offer any of the following?
TANF (Temporary Assistance for Needy Families)
SAPTBG Set Aside for Women
SAPTBG HIV Set Aside
FIS Appropriation
PATH Grant Award
Indigent Drug Program
Forensics / Community Forensic Beds
Title XXI
Purchase of Therapeutic Services
Roll-Over Funds (Integrated Care Teams)
None (General Revenue Funding only)
Title XXI Children's Health Insurance Program (BNet)
Florida Assertive Community Treatment (FACT)
Community Crisis Prevention Team
Crisis Stabilization Proviso Award
Central Receiving System or Facilities
Primary Care Services Proviso Award
SOAR
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EXHIBIT F
Updated 07/01/2017
Adult Mental Health - Program Description
2. AMH
LSF Health Systems Program Description
7. What individuals will be served by this program?
Adults with Severe and Persistent Mental Illness
Adults with Serious and Acute Episodes of Mental Illness
Adults with Mental Health Problems
Adults with Forensic Involvement
Adults with Co-Occurring Disorders
8. Which covered services will be billed under this program?
Assessment
Case Management
Crisis Stabilization
Crisis Support/Emergency
Day Care
Day/Night
Drop-in/Self Help Centers
In-Home and On-Site Services
Inpatient
Intensive Case Management
Intervention
Medical Services
Outpatient - Individual
Outreach
Prevention
Residential, Level 1
Residential, Level 2
Residential, Level 3
Residential, Level 4
Respite Services
Sheltered Employment
Supported Employment
Supported Housing/Living
Incidental Expenses
Aftercare/Follow-up
Information and Referral
FACT Team
Outpatient - Group
Room and Board, Level 1
Room and Board, Level 2
Room and Board, Level 3
Short-Term Residential Treatment
Mental Health Clubhouse
Project Recovery
Intervention - Group
Aftercare - Group
Comprehensive Community Service Team - Individual
Comprehensive Community Service Team - Group
Recovery Support - Individual
Recovery Support - Group
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EXHIBIT F
Updated 07/01/2017
9. What is the service capacity for this program?
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EXHIBIT F
Updated 07/01/2017
Children Mental Health - Program Description
3. CMH
LSF Health Systems Program Description
10. Which individuals will be served by this program?
Children with Serious Emotional Emotional Disturbance
Children with Emotional Disturbance
Children at Risk of Emotional Disturbance
Children at Risk of Residential Services
Children with Juvenile Justice Involvement
Children at Risk of Juvenile Justice involvement
Children with Co-Occurring Disorders
11. What is the service capacity for this program?
5
EXHIBIT F
Updated 07/01/2017
12. Which covered services will be billed under this program?
Assessment
Case Management
Crisis Stabilization
Crisis Support/Emergency
Day/Night
In-Home and On-Site Services
Inpatient
Intensive Case Management
Intervention
Medical Services
Outpatient - Individual
Outreach
Prevention
Prevention/Intervention Day
Residential, Level 1
Residential, Level 2
Residential, Level 3
Residential, Level 4
Respite Services
Supported Employment
Supported Housing/Living
Incidental Expenses
Aftercare/Follow-Up
Information and Referral
Behavioral Health Overlay Services
Outpatient - Group
Room and Board, Level 1
Room and Board, Level 2
Room and Board, Level 3
Project Recovery
Intervention - Group
Aftercare - Group
Comprehensive Community Service Team - Individual
Comprehensive Community Service Team - Group
Recovery Support - Individual
Recovery Support - Group
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EXHIBIT F
Updated 07/01/2017
Adult Substance Abuse - Program Description
4. ASA
LSF Health Systems Program Description
13. Which individuals will be served by this program?
Adults at Risk of Substance Abuse (Prevention)
Adults with Substance Abuse
Adults who are Pregnant or Postpartum
Adults with Forensic Involvement
Adults with HIV
Adults with Co-Occurring Disorders
14. What is the service capacity for this program?
7
EXHIBIT F
Updated 07/01/2017
15. What covered services will be billed under this program?
Assessment
Casement Management
Crisis Support/Emergency
Day Care
Day/Night
In-Home and On-Site Services
Intervention
Medical Services
Methadone Maintenance
Outpatient - Individual
Outreach
Prevention
Residential, Level 1
Residential, Level 2
Residential, Level 3
Residential, Level 4
Respite Services
Substance Abuse Detoxification
Supported Employment
Supported Housing/Living
TASC
Incidental Expenses
Aftercare/Follow-Up
Information and Referral
Outpatient Detoxification
FACT Team
Outpatient - Group
Room and Board, Level 1
Room and Board, Level 2
Room and Board, Level 3
Intervention - Group
Aftercare - Group
SA Recovery Support - Individual
SA Recovery Support - Group
8
EXHIBIT F
Updated 07/01/2017
Children Substance Abuse - Program Description
5. CSA
LSF Health Systems Program Description
16. Which individuals will be served by this program?
Children at Risk of Substance Abuse (Prevention)
Children with Substance Abuse
Children at Risk of Residential Services
Children with Juvenile Justice Involvement
Children at Risk of Juvenile Justice Involvement
Children with HIV
Children with Co-Occurring
17. What is the service capacity for this program?
9
EXHIBIT F
Updated 07/01/2017
18. Which covered services will be billed under this program?
Assessment
Case Management
Crisis Support/Emergency
Day/Night
In-Home and On-Site Services
Intervention
Medical Services
Outpatient - Individual
Outreach
Prevention
Prevention/Intervention Day
Residential, Level 1
Residential, Level 2
Residential, Level 3
Residential, Level 4
Respite Services
Substance Abuse Detoxification
Supported Employment
Supported Housing/Living
TASC
Incidental Expenses
Aftercare/Follow-up
Information and Referral
Outpatient Detoxification
Outpatient - Group
Room and Board, Level 1
Room and Board, Level 2
Room and Board, Level 3
Intervention - Group
Aftercare - Group
SA Recovery Support - Individual
SA Recovery Support - Group
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EXHIBIT F
Updated 07/01/2017
6. Number of FTEs required for this program:
LSF Health Systems Program Description
19. Position Title:
Other (please specify)
20. Minimum Credentials for the Position
High School Diploma
AA
BA
Masters
PhD
0-3 years
4-5 years
6-8 years
10+ years
21. Minimum Credentials for the Position - Number of Years of Experience
Number of Supervisory FTEs for this Position
Number of Direct Service FTEs for this Position
Number of Support FTEs for this Position
22. FTEs Information
23. Position Title:
Other (please specify)
24. Minimum Credentials for the Position
High School Diploma
AA
BA
Masters
PhD
0-3 years
4-5 years
6-8 years
10+ years
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EXHIBIT F
Updated 07/01/2017
Number of Supervisory FTEs for this Position
Number of Direct Service FTEs for this Position
Number of Support FTEs for this Position
25. FTEs Information
Number of Supervisory FTEs for this Position
Number of Direct Service FTEs for this Position
Number of Support FTEs for this Position
26. FTEs Information
27. Position Title:
Other (please specify)
28. Minimum Credentials for the Position
High School Diploma
AA
BA
Masters
PhD
0-3 years
4-5 years
6-8 years
10+ years
Number of Supervisory FTEs for this Position
Number of Direct Service FTEs for this Position
Number of Support FTEs for this Position
29. FTEs Information
30. Position Title:
12
EXHIBIT F
Updated 07/01/2017
Other (please specify)
31. Minimum Credentials for the Position
High School Diploma
AA
BA
Masters
PhD
0-3 years
4-5 years
6-8 years
10+ years
Number of Supervisory FTEs for this Position
Number of Direct Service FTEs for this Position
Number of Support FTEs for this Position
32. FTEs Information
33. Position Title:
Other (please specify)
34. Minimum Credentials for the Position
High School Diploma
AA
BA
Masters
PhD
0-3 years
4-5 years
6-8 years
10+ years
Number of Supervisory FTEs for this Position
Number of Direct Service FTEs for this Position
Number of Support FTEs for this Position
35. FTEs Information
36. Position Title:
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EXHIBIT F
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Other (please specify)
37. Minimum Credentials for the Position
High School Diploma
AA
BA
Masters
PhD
0-3 years
4-5 years
6-8 years
10+ years
Number of Supervisory FTEs for this Position
Number of Direct Service FTEs for this Position
Number of Support FTEs for this Position
38. FTEs Information
39. Position Title:
Other (please specify)
40. Minimum Credentials for the Position
High School Diploma
AA
BA
Masters
PhD
0-3 years
4-5 years
6-8 years
10+ years
Number of Supervisory FTEs for this Position
Number of Direct Service FTEs for this Position
Number of Support FTEs for this Position
41. FTEs Information
14
EXHIBIT F
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42. Provide any additional or supplementary information regarding staffing of the program.
15
EXHIBIT F
Updated 07/01/2017
7. Matching Funds
LSF Health Systems Program Description
43. Which sources will you employ to raise match funding?
Private Grants
Local Government Grants
Charitable Contribution
Volunteer Services
Fees
In-Kind Contributions
Other (please specify)
44. Indicate the percentage of Matching Funds each of those selections will constitute:
16
EXHIBIT F
Updated 07/01/2017
45. How will Matching Funds for this program be used?
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EXHIBIT F
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8. Identification and Engagement Strategies
LSF Health Systems Program Description
46. Describe the source of your referrals
47. Detail how your program's screening and intake practices ensure that individuals receive prompt responsive accessto appropriate services
18
EXHIBIT F
Updated 07/01/2017
48. Detail your process for referred priority consumers (special populations)
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EXHIBIT F
Updated 07/01/2017
For the purposes of this form, the definition of Evidence-Based Practice (EBP) shall be governed byIncorporated Document 2 of the Network Service Provider’s Contract with LSF Health Systems.
9. Service Delivery Strategies
LSF Health Systems Program Description
49. Describe the admission criteria for General Populations:
50. Describe the admission criteria for Special Populations:
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EXHIBIT F
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51. Describe the disqualifying criteria for services
52. Describe the process to ensure services provided are an appropriate level and intensity to meet the needs of theservice recipient for General Populations:
21
EXHIBIT F
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53. Describe the process to ensure services provided are an appropriate level and intensity to meet the needs of theservice recipient for Special Populations:
54. Describe how each individual and family participate in the development, ongoing review of an assessment andservice plan that is the basis for delivery of appropriate services and support.
22
EXHIBIT F
Updated 07/01/2017
55. EBP - Detail evidence-based models utilized (enter each on a separate line)
56. EBP - Describe in detail how the program carries out the practices established by the evidence-based practicemodel(s) utilized as indicated above:
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EXHIBIT F
Updated 07/01/2017
57. EBP - Describe the process utilized to maintain fidelity to the evidence-based practice model(s) indicated above:
58. Describe any enhanced services offered/utilized for special populations
59. Describe discharge criteria for services for General Populations:
24
EXHIBIT F
Updated 07/01/2017
60. Describe discharge criteria for services for Special Populations:
25
EXHIBIT F
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10. Continuing Care Strategies
LSF Health Systems Program Description
61. Describe how your continuing care/after care planning strategies reduce recidivism for General Populations:
62. Describe how your continuing care/after care planning strategies reduce recidivism for Special Populations:
26
EXHIBIT F
Updated 07/01/2017
63. Describe how your program takes initiative to explore suitable resources to facilitate an appropriate discharge forGeneral Populations:
64. Describe how your program takes initiative to explore suitable resources to facilitate an appropriate discharge forSpecial Populations:
27
EXHIBIT F
Updated 07/01/2017
11. Authorization
LSF Health Systems Program Description
By submitting this survey, I acknowledge that any changes shall be reported to LSF Health Systems and that I am theauthorized representative of the Provider named above.
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EXHIBIT F
Updated 07/01/2017
This survey will collect planning information for prevention programs in the LSFHS Network. Please use aseparate survey for each prevention program operated by your agency.
Introduction
LSF Health Systems Prevention Program Description
Name of the IndividualCompleting the Survey
Agency Name
Program Name
Email Address
1. Address
Adult Substance Abuse -Indicated Prevention
Adult Substance Abuse -Selective Prevention
Adult Substance Abuse -Universal Direct
Adult Substance Abuse -Universal Indirect
Children SubstanceAbuse - IndicatedPrevention
Children SubstanceAbuse - SelectivePrevention
Children SubstanceAbuse - Universal Direct
Children SubstanceAbuse - UniversalIndirect
2. Indicate the level of programming and population to be served by this program. For eachpopulation, enter the number of individuals to be served. If a population will not be served by theprogram, enter "N/A" in that field.
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EXHIBIT F
Updated 07/01/2017
LSF Health Systems Prevention Program Description
3. Indicate the counties in which the program will be administered.
Alachua
Baker
Bay
Bradford
Brevard
Broward
Calhoun
Charlotte
Citrus
Clay
Collier
Columbia
DeSoto
Dixie
Duval
Escambia
Flagler
Franklin
Gadsden
Gilchrist
Glades
Gulf
Hamilton
Hardee
Hendry
Hernando
Highlands
Hillsborough
Holmes
Indian River
Jackson
Jefferson
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EXHIBIT F
Updated 07/01/2017
Lafayette
Lake
Lee
Leon
Levy
Liberty
Madison
Manatee
Marion
Martin
Miami-Dade
Monroe
Nassau
Okaloosa
Okeechobee
Orange
Osceola
Palm Beach
Pasco
Pinellas
Polk
Putnam
Santa Rosa
Sarasota
Seminole
St. Johns
St. Lucie
Sumter
Suwannee
Taylor
Union
Volusia
Wakulla
Walton
Washington
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EXHIBIT F
Updated 07/01/2017
LSF Health Systems Prevention Program Description
4. Indicate the type of program.
Replication
Validation
Provisional validation
Innovation
Provisional innovation
5. Identify the risk factors addressed by the program.
Abuse victims
Academic failure beginning in the late elementary school
Already using substances
Availability of drugs
Children of substance abusers
Community laws and norms favorable to drug use, firearms & crimes
Dropouts
Early and persistent antisocial behavior
Early and persistent antisocial behavior
Early initiation of the problem behavior
Economically disadvantaged
Family conflict
Family history of problem behavior
Family management problems
Favorable attitudes toward the problem behavior
Favorable parental attitudes & involvement n the problem behavior
Friends who engage in problem behavior
Lack of commitment to school
Low neighborhood attachment & community disorganization
Mental health problems
Physically disabled
Transitions and mobility
Violent and delinquent behavior
Other (please specify)
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EXHIBIT F
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6. Identify the prevention factors for the program.
Community: Bonding (opportunity, skills and recognition
Community: Bonding (opportunity, skills and recognition
Community: Healthy Beliefs and Clear Standards
Community: Healthy Beliefs and Clear Standards
Family: Bonding (opportunity, skills, and recognition
Family: Healthy Beliefs and Clear Standards
Family: Healthy Beliefs and Clear Standards
Peer: Healthy Beliefs and Clear Standards
School: Bonding (opportunity, skills, and recognition)
School: Healthy Beliefs and Clear Standards
School: Healthy Beliefs and Clear Standards
Other (please specify)
7. Identify the specific strategies to be utilized.*
Information Dissemination
Education and Training
Alternatives
Problem Identification and Referral
Community Based Process
Environmental
Other (please specify)
8. Explain the appropriateness of the services offered by the program.
5
EXHIBIT F
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9. Describe how the effectiveness of the program will be evaluated.
10. Does the agency possess the appropriate licensure for the services offered?
Yes
No
Other (please specify)
11. How many years has the program been conducted in this circuit?
12. What is the projected length of the program?
6
EXHIBIT F
Updated 07/01/2017
LSF Health Systems Prevention Program Description
13. Identify the age of the target population for this program.
5-11
12-14
15-17
18-20
21-24
25-44
45-64
65 and over
14. Identify the ethnicity of the target population for this program.
Puerto Rican
Mexican
Cuban
Haitian
Mexican American
Spanish/Latino
Other Hispanic
None of the above
15. Identify the race of the targeted population of the program.
White
Black or African American
Native Hawaiian/Other Pacific Islander
Asian
American Indian/Alaska Native
More Than One Race (not OMB required)
Race Not Known or Other (not OMB required)
16. Identify the targeted gender of the program.
Male
Female
Both
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EXHIBIT F
Updated 07/01/2017
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EXHIBIT F
Updated 07/01/2017
LSF Health Systems Prevention Program Description
17. Planned number of groups
Minimum
Maximum
18. Range of the number of participants in each group
19. If the number of participants exceeds guidelines for the program, provide a justification below.
20. How many sessions will be administered per group?
21. Will pre and post tests be administered?
Yes
No
22. Will supplemental activities be administered?
Yes
No
9
EXHIBIT F
Updated 07/01/2017
LSF Health Systems Prevention Program Description
23. Identify the number of supplemental activities to be administered.
24. Identify the supplemental services.*
STN01 Prevention Information Clearinghouse
STN03 Health Promotion
STN05 Prevention print material development
STN07 Newsletter Development
STN08 Prevention media message development
STN11 Disseminating print material
STN13 Newsletter Dissemination
STN14 Disseminating via mass media
STN15 Community resource directory dissemination
STN16 Community-wide Awareness
STN17 Speaking Engagements
STN18 Telephone Information Services
STC06 Prevention Training
STC08 Prevention Technical Assistance
STE01 Children of Substance Abusers (COSA) Groups
STE02 Drug Education - Schools
STE03S Drug Education - Youth Groups
STE04S Parenting/Family Support
STE05 Peer leader training
STE06M Mentoring
STE06S Support Group
STN06 Training curriculum development
STA01 Alcohol, tobacco and other drug-free activities
STA06 Service Learning
STA07A Recreation Support
STA07B Tutoring
STA07C Youth Group Support
STE05S Peer leader activites
STE06P Other prevention activities/ services: Prevention Counseling
10
EXHIBIT F
Updated 07/01/2017
STP01 Employee Assistance
STP03 Student Assistance
STP06 Prevention Assessment and Referral
STC02 Coalition Support: Needs and Resource Assessment
STC03 Volunteer Coordination
STC04 Coalition Participation
STC05A Coalition Support: community awareness and other recognition
STC10 Coalition Support: Strategic Planning
STV01A Coalition Support: environmental strategies
STV01B Consultation on organizational environmental strategies
STV01C Environmental strategies related to illegal drug abuse prevention
STV01D Environmental strategies related to prescription or OTC drug abuse prevention
STV02 Environmental strategies related to tobacco sales prevention
STV03 Environmental Strategies related to underage alcohol sales prevention
STV06 Prevention Policy Activities
STC05C Coalition building
STC05D Coalition coordination
STC02B Community needs assessment
STC01 Community resource assessment
STC10B Strategic Planning
STC05B Community Process
STN09 Community resource directory development & maintenance
STC05 Coalition Partnership Coordination
STN16A Social Media and Networking
STN16M Media Campaigns
25. Will booster sessions be offered?
Yes
No
11
EXHIBIT F
Updated 07/01/2017
Staffing Patterns
LSF Health Systems Prevention Program Description
Title
Responsibility
Qualifications
Cost Center
Number of FTEs
Comments
26. Position 1
Title
Responsibility
Qualifications
Cost Center
Number of FTEs
Comments
27. Position 2
Title
Responsibility
Qualifications
Cost Center
Number of FTEs
Comments
28. Position 3
Title
Responsibility
Qualifications
Cost Center
Number of FTEs
Comments
29. Position 4
12
EXHIBIT F
Updated 07/01/2017
Title
Responsibility
Qualifications
Cost Center
Number of FTEs
Comments
30. Position 5
13
EXHIBIT F
Updated 07/01/2017
Using the total contracted dollars allocated to Prevention/PPG, account for 100% of the funding acrosseach of the areas identified.
Funding
LSF Health Systems Prevention Program Description
48 -IndicatedPrevention(ASA)
48 -IndicatedPrevention(CSA)
49 -SelectivePrevention(ASA)
49 -SelectivePrevention(CSA)
50 -UniversalDirectPrevention(ASA)
50 -UniversalDirectPrevention(CSA)
51 -UniversalIndirectPrevention(ASA)
51 -UniversalIndirectPrevention(CSA)
31. Identify funding allocations by covered service.
14
EXHIBIT F
Updated 07/01/2017
LSF Health Systems Prevention Program Description
32. Provide a narrative description of the program.
33. Additional Comments
15
EXHIBIT F
Updated 07/01/2017
Thank you for participating. Feedback regarding the program description submitted for prevention serviceswill be provided.
LSF Health Systems Prevention Program Description
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EXHIBIT F
Updated 07/01/2017