Embed Size (px)
Citation preview
2008-2009 Minnesota e-Health Grant Program
Applications Due: September 5, 2008
Estimated Notice of Awards: October 17, 2008
Estimated Grant Agreement Start: December 1, 2008
Grant Agreement End: April 30, 2010
TABLE OF CONTENTS
GENERAL INFORMATION……………………………………………………...…….1-5BackgroundProject overviewGoals and desirable outcomesTotal available funding Estimated amount of grant awardsMatching funds requirementsGrants timeline Minnesota Electronic Health Record (EHR) Loan ProgramEligible applicants and activitiesApplication filing requirementsContact informationApplication review process
APPLICATION INSTRUCTIONSReadiness Assessment and Planning Grants…………………………………..………..6-7Implementation Grants………………………………………………………………...8-10
OTHER INFORMATIONFrequently Asked Questions……………………………………………………………..11Grant Writing Tips……………………………………………………………………….12
ATTACHMENTSApplication Cover FormSuggested Budget FormAccounting System and Financial Capability QuestionnaireGrant Application Checklist
GENERAL INFORMATION
BACKGROUNDThe adoption and effective use of electronic health information systems can play a significant role in transforming the health care system and in supporting healthier communities. New tools are bringing the power of information systems to the practice of medicine and public health, improving both quality and safety.
Minnesota policymakers recognize that more effective use of information—including the timely exchange of information—will be needed to improve the quality and safety of care. Several significant mandates were enacted in the 2007 and 2008 legislative sessions that impacts all health care providers in Minnesota (see Minnesota Statutes, sections 62J.495-497):
A mandate that all health care providers and hospitals have an interoperable electronic health record (EHR) system by 2015. All newly acquired electronic health record (EHR) products must be certified by the Certification Commission for Healthcare Information Technology (CCHIT) or its successor. Applies to settings covered by CCHIT certification.
A requirement to develop a statewide implementation plan to meet the 2015 interoperable EHR mandate. http://www.health.state.mn.us/ehealth/ehrplan2008.pdf
A requirement that all health care providers and payers establish and use an e-prescribing system by January 1, 2011.
PROJECT OVERVIEWUnder the authority of Minnesota Statutes Section 144.3345, the Commissioner of Health is authorized to award grants to support the adoption and use of interoperable electronic health record systems in rural and underserved urban areas. The grant program goals include adoption and use of interoperable electronic health record systems (EHRs), as well as electronic health information exchange among different health and health care organizations within a community.
GOALS AND DESIRABLE OUTCOMES The goals of this grant program are to:
1. Support expanded adoption and effective use of interoperable electronic health record (EHR) systems and electronic health information exchange, in rural and underserved areas to:a. improve health care outcomes and the provider-patient relationshipb. increase health service delivery efficiencies in rural and underserved areas.
2. Encourage collaboration to leverage resources and expand/standardize health information technology
3. Support improvements in prevention services and population health.
TOTAL AVAILABLE FUNDING: $3.5 million
ESTIMATED AMOUNT OF GRANT AWARDS1. Readiness Assessment and Planning: up to $50,000 2. Implementation: up to $750,000
MATCHING FUNDS REQUIREMENTA one-to-three match is required. Applicants must provide one dollar in the form of cash or in-kind services for every three dollars provided by the grant program.Minnesota e-Health Grant Program Page 1 of 12Grant Application Revised 7/14/2008
GRANT TIMELINE
Announcement of Funding Opportunity July 14, 2008 Applications Due September 5, 2008Estimated Notice of Awards October 17, 2008Estimated Grant Agreement Start December 1, 2008Grant Agreement End April 30, 2010
MINNESOTA ELECTRONIC HEALTH RECORD (EHR) LOAN PROGRAMIn addition to the Grant Program, there is also a $3.15 million no-interest loan program. This EHR Loan Program is available on a first come-first served basis. Contact Anne Schloegel at (651) 201-3850 or [email protected] for more information. Web site: http://www.health.state.mn.us/divs/orhpc/funding/index.html#ehrloan
ELIGIBLE APPLICANTS AND ACTIVITIES
A. Community e-Health collaborativesEligible organizations. Two or more health care organizations that are distinct corporate or governmental entities, representing at least two of the following types of health care settings:
Community clinics as defined in Minnesota Statutes, section 145.9268 Hospitals eligible for Rural Hospital Capital Improvement Grants as defined in
Minnesota Statutes, section 144.148 Physician clinics located in communities with populations of less than 50,000
according to U.S. Census Bureau statistics and outside the seven-county metropolitan area
Nursing facilities licensed under Minnesota Statutes, sections 144A.01 to 144A.27 Community health boards or boards of health as established in Minnesota Statutes,
chapter 145A Nonprofit entities with a purpose to provide health information exchange coordination
governed by a representative, multi-stakeholder board of directors Other providers of health or health care services approved by the Commissioner of
Health for which interoperable electronic health records would improve quality of care, patient safety, or community health.
Note: Eligible applicant organizations must represent collaborative partnerships formalized through written agreements that, if funded, commit to meaningful contributions of personnel, expertise, money, equipment or other resources, as well as the eventual and appropriate sharing of clinical data.
Eligible activities. Projects may include but are not limited to: collaborative efforts to host and support fully functional interoperable electronic health
records in multiple care settings electronic medication history and electronic patient medical history information electronic personal health records for persons with chronic diseases and for prevention
services rural and underserved community models for electronic prescribing (e-prescribing)
Minnesota e-Health Grant Program Page 2 of 12Grant Application Revised 7/14/2008
modernization of local public health information systems to electronically exchange information needed to participate in community e-Health collaboratives or for public health emergency preparedness and response
implementation of regional or community-based health information exchange.
B. Community clinics
Eligible organizations. Defined under section 145.9268, to be (1) a nonprofit clinic that is established to provide health services to low income or rural population groups; provides medical, preventive, dental, or mental health primary care services; and utilizes a sliding fee scale or other procedure to determine eligibility for charity care or to ensure that no person will be denied services because of inability to pay; (2) a governmental entity or an Indian tribal government or Indian health service unit that provides services and utilizes a sliding fee scale or other procedure as described under clause (1); (3) a consortium of clinics comprised of entities under clause (1) or (2); or (4) a nonprofit, tribal, or governmental entity proposing the establishment of a clinic that will provide services and utilize a sliding fee scale or other procedure as described under clause (1).
Eligible activities. Community clinic projects may include but are not limited to the following: efforts to plan for and implement fully functional, standards-based interoperable
electronic health records; and purchases and implementation of computer hardware, software and technology to fully
implement interoperable electronic health records.
C. Regional or community-based health information organizations
Eligible organizations. Health information exchange is defined as a legal arrangement between health care providers and group purchasers to enable and oversee the business and legal issues involved in the electronic exchange of health records among entities for the delivery of patient care (M.S. 144.291).
Eligible activities. Projects to connect and facilitate the exchange of health information among eligible health care entities may include but are not limited to the development, testing and implementation of:
data exchange standards, including data, vocabulary and messaging standards, for the exchange of health information, provided that such standards are consistent with state and national standards
security standards necessary to ensure the confidentiality and integrity of health records
computer interfaces and mechanisms for standardizing health information exchanged among eligible health care entities
a record locator service for identifying the location of patient health records interfaces and mechanisms for implementing patient consent requirement.
The legislation allows the Commissioner of Health to give preference to projects benefiting providers located in rural and underserved areas of Minnesota that are determined to have an unmet need for implementing interoperable electronic health records.
NOTE: Grant funds may not be used for construction of buildings or facilities. Minnesota e-Health Grant Program Page 3 of 12Grant Application Revised 7/14/2008
APPLICATION FILING REQUIREMENTSApplicants must:
1. Meet the minimum requirements of eligible applicants and activities (see Eligible Applicants and Activities above).
2. Designate whether applying for funding for either Readiness Assessment and Planning or Implementation.
3. Include all required elements as detailed for each particular grant type set forth in the application instructions beginning on page 6.
4. All proposals must be typed, using a single-spaced 12-point font. See specific grant type application instructions for page limits.
5. Applicants are encouraged to be concise and to closely follow the grant application outline and guidance. Limit any additional documentation to information relevant to the specific scope and purpose of your proposed project. Do not include a description of the importance of electronic health records.
SUBMISSIONOne unbound single-sided original and four plain white paper copies of the application, along with an electronic version (MS Word, Excel or pdf only) on disc must be received by 4:30 p.m. on September 5, 2008, at the following address:
Anne SchloegelOffice of Rural Health and Primary CareMinnesota Department of Health
Applications must be mailed or delivered. No e-mailed or faxed applications will be accepted.
CONTACT INFORMATIONQuestions about these grants and the proposal process should be directed to:
Anne SchloegelOffice of Rural Health & Primary CarePhone: (651) 201-3850E-mail: [email protected]
For more information: http://www.health.state.mn.us/divs/orhpc and http://www.health.state.mn.us/e-health
APPLICATION REVIEW PROCESSMinnesota e-Health Grant Program Page 4 of 12Grant Application Revised 7/14/2008
Courier Address: Mailing Address:85 East Seventh Place, Suite 220Saint Paul, Minnesota 55101
P.O. Box 64882Saint Paul, Minnesota 55164-0882
Applications will be reviewed by a panel familiar with program criteria, which will recommend selections to the Commissioner of Health. In addition to panel recommendations, the Commissioner may also take into account other relevant factors in making final awards.
Scoring CriteriaThe grant applications will be scored on a 100-point scale, as follows:
Award ProcessApplicants awarded a grant contract will be expected to:
1. Submit a final work plan and budget, if requested, to the Minnesota Department of Health (MDH).
2. Execute the original and four copies of the grant agreement and return to the MDH for final signature.
3. Upon receipt of fully executed grant agreement, begin work. Note: Projects cannot be funded for work completed before the grant contract is fully executed.
4. Participate in up to two site visits or conference calls to report on progress, barriers, plans and lessons learned.
5. Submit midpoint narrative progress and expenditure reports.6. Submit final written narrative progress and expenditure reports for the grant period within
30 days of the grant contract expiring.
A final 10 percent of the total grant award will be withheld until duties listed above are completed.
APPLICATION INSTRUCTIONS:
Minnesota e-Health Grant Program Page 5 of 12Grant Application Revised 7/14/2008
Criteria Maximum Points
Needs Assessment: Clear description of the context and need for project 20 points
Project Description: Proposed project addresses the grant program purpose 20 points
Work plan and Evaluation: Work plan that clearly indicates how a successful outcome will be achieved and how this will be measured
30 points
Project Team/Resources: - Project personnel are qualified by training and/or
experience to implement and carry out the projects- Evidence of collaboration with other community
partner organizations
20 points
Budget: Clear and realistic budget for the proposed project 10 points
Total 100 points
READINESS ASSESSMENT AND PLANNING GRANTS (limit $50,000)
Required Elements Applications for these grants must not exceed 10 pages of single-spaced 12-point type. The 10-page limit includes only items 2-6 below.
1. Application Cover Form (see Attachments)2. Project Summary
Brief summary of the project including major goals, desired outcomes, the areas/populations served, and any collaborating organizations.
3. Needs Assessment a. Problem statement of unmet need.b. Brief organizational descriptions, including current use of health information
technology within each organization.c. Geographic area and demographics of population(s) served.d. Financial considerations of organizations and community including the reason(s)
why grant funds are needed.e. For e-Health collaborative and health information exchange projects only:
1) history as collaborators on previous projects, if any (can be other than health information technology projects)
2) current examples of health information exchange among the collaborators, whether on paper, by phone or fax, or electronically
3) organization that will serve as the collaborative’s fiscal agent for project.4. Project Description
a. Describe how this project meets the needs in rural and/or underserved areas. b. Clearly identify the target population. c. State reason(s) the project could not occur without grant funds.
5. Project Work Plan - may not extend beyond April 30, 2010 The work plan may be in narrative or table/spreadsheet form or both and should include:
a. Goals/outcomes and expectations for the projectb. Time-specific objectives to achieve each stated outcome/goalc. Methods for accomplishing each objective and metrics for measuring the successful
achievement of the objectivesd. Communications plan to ensure all stakeholders are kept informed of project goals
and progress, and are engagede. For community e-Health collaborative and health information exchange projects
include a brief description of the formal process used for obtaining the governing boards of each collaborating organization’s approval to commit to the grant duties and conditions of funding. Describe how the present project will advance progress toward complete ability to exchange information.
6. Project Team a. Name(s), title(s), organization(s), and qualifications of the project lead or co-leads.b. Names, titles and organizations of primary project team members and their project roles.
Include information on the clinicians involved in the planning or implementation processes. c. Description of the source of any in-kind technical support, internal and/or
external, for the project.
Minnesota e-Health Grant Program Page 6 of 12Grant Application Revised 7/14/2008
7. Line Item BudgetAll reasonable costs for completing project are eligible. Insert a line item budget into the narrative or attach as a separate document (see Attachments).
a. Indirect charges. If requested, limited to 10 percent of the total funding request.b. In-kind match. Include the amounts and sources of financial or in-kind resources
used for the required one-to-three match. It is not necessary to have a match for each line item; however, the total match must equal at least one-third of the total grant dollars being applied for. In-kind match should be expressed in dollars, and can include, but is not limited to, staff time (the value of salaries and fringe) spent by collaborating organizations on the project (for example, staff time spent in planning, governance or IT support), communications and mileage costs related to planning or governance meetings, and equipment needed to enable health information exchange or adoption of an interoperable EHR.Note: Grant funds may not be used for construction of buildings or facilities.
8. Budget Narrative. Provide information on how each of the line items shown in the budget was calculated.
a. Salary and Fringe. For any positions funded by this grant, provide the position title, amount of salary and fringe benefits paid for by the grant, and percent of time on the project. Include a brief description of the activities of each position as it relates to the project. The budget form need only reflect the totals for salaries and fringe.
b. Travel. Include a description of the proposed travel as it relates to the completion of the project. Provide the estimated number of miles planned for project activities as well as the rate of reimbursement per mile to be paid from project funds (not to exceed the current rate established by the Internal Revenue Service).
c. Equipment. Include a description and projected costs of any proposed equipment as it relates to the completion of the project. No more than 20 percent of any grant may be used for equipment.
d. Supplies. Include a description of any supplies needed for completion of the project.e. Contracted services. Provide the name of contractors, the services to be provided,
and projected costs. Include brief background information about contractors, including how their previous experience relates to the project. If no contractor has been chosen, include a description of the availability of contractors for the services and/or products required and the method for choosing a contractor.
f. Other. If it is necessary to include expenditures in the “Other” category, include a detailed description of the proposed expenditures as they relate to the project. Add additional “Other” lines to the budget form as needed.
g. In-kind match. (See 7c and/or 8b)h. Indirect charges. If requested, may not exceed 10 percent of the total funding request.
9. Project Contact Information Name and qualifications of the person or persons leading or co-leading the project.
10. Letters of commitment and support. a. For community e-Health collaborative and health information exchange projects,
include letters of commitment from all collaborating organizations. The letter of commitment from the organization agreeing to serve as fiscal agent must state their willingness to accept and account for grant funds under this program.
b. For all projects, letters of support from other organizations are allowed but not required. 11. Accounting System and Financial Capability Questionnaire (see Attachments)
Minnesota e-Health Grant Program Page 7 of 12Grant Application Revised 7/14/2008
APPLICATION INSTRUCTIONS: IMPLEMENTATION GRANTS
Note: All newly acquired electronic health record (EHR) products must be certified by the Certification Commission for Healthcare Information Technology (CCHIT) or its successor (M.S. § 62J.495). Applies to settings covered by CCHIT certification.
Required Elements Applications for these grants must not exceed 15 pages of single-spaced 12-point type. The 15-page limit includes only items 2-6 below.
1. Application Cover Form (see Attachments)2. Project Summary
Brief summary of the project including desired outcomes, the areas/populations served, and the collaborating organizations.
3. Needs Assessment a. Problem statement of unmet need. b. Brief organizational descriptions, including current use of health information
technology within each participating organization.c. Geographic area and demographics of population(s) served.d. Financial considerations of organizations and community including the reason(s)
why grant funds are needed.e. For e-Health collaborative and health information exchange projects only:
1) history as collaborators on previous projects, if any (can be other than health IT projects)
2) current examples of health information exchange among the collaborators, whether on paper, by phone or fax, or electronically
3) organization that will serve as the collaborative’s fiscal agent on this project.4. Project Description
a. Describe how this project meets the needs in rural and/or underserved areas. Clearly identify the target population.
b. State reason(s) the project could not occur without grant funds. c. Describe how the project is expected to improve patient safety, quality of care,
consumer empowerment, and/or community health. d. Describe how the project will address patient privacy and security issues. e. Describe how the project will address interoperability with other community health
care providers such as labs, pharmacies and hospitals. 5. Project Work Plan - may not extend beyond April 30, 2010
The work plan may be in narrative or table/spreadsheet form or both and should include:a. Goals/outcomes and expectations for the projectb. Time-specific objectives to achieve each stated outcome/goalc. Methods for accomplishing each objective and metrics for measuring the successful
achievement of the objectivesd. Communications plan to ensure all stakeholders are kept informed of project goals
and progress, and are engagede. For community e-Health collaborative and health information exchange projects
include a brief description of the formal process used for obtaining the governing
Minnesota e-Health Grant Program Page 8 of 12Grant Application Revised 7/14/2008
boards of each collaborating organization’s approval to commit to the grant duties and conditions of funding. Describe how the present project will advance progress toward complete ability to exchange information
f. Evidence that project is part of the applicant’s long term business and clinical strategy (strategic plan)
g. Evidence that planning activities have been completed including due diligence, workflow analysis, clinician and consumer involvement, etc. Include a description of relevant training that has occurred
h. Information on the vendor selection process such that the product selected includes essential key features to improve patient care in a health center population. This should include registry functions, decision support tools, and population based health outcomes system reports capability
i. Plans for staff training for implementation and continuous evaluation j. Plans for system operation and maintenance and technical support resources.k. Plans to address decreased productivity during implementationl. Plans for sustainability beyond state funding.
6. Project Team a. Name(s), title(s), organization(s), and qualifications of the project lead or co-leads.b. Names, titles and organizations of the primary project team members and their roles
in the project. Include information on the clinicians involved in the planning or implementation processes.
c. Description of the source of any in-kind technical support, internal and/or external, for the project.
7. Line Item Budget All reasonable costs for completing project are eligible. Insert a line item budget into the narrative or attach as a separate document (see Attachments).
a. Indirect charges. If requested, limited to 10 percent of the total funding request.b. In-kind match. Include the amounts and sources of financial or in-kind resources
used for the required one-to-three match. It is not necessary to have a match for each line item: however, the total match must equal at least one-third of the total grant dollars being applied for. In-kind match should be expressed in dollars, and can include, but is not limited to, staff time (the value of salaries and fringe) spent by collaborating organizations on the project (for example, staff time spent in planning, governance, or IT support), communications and mileage costs related to planning or governance meetings, and equipment needed to enable health information exchange or adoption of an interoperable EHR.
Note: Grant funds may not be used for construction of buildings or facilities.8. Budget Narrative.
Provide information on how each of the line items shown in the budget was calculated. a. Salary and Fringe. For any positions proposed to be funded from this project,
provide the position title, the amount of salary and fringe benefits paid for by the grant, and percent of time on the project. Include a brief description of the activities of each position as it relates to the project. The budget form need only reflect the totals for salaries and fringe.
b. Travel. Include a description of the proposed travel as it relates to the completion of the project. Provide the estimated number of miles planned for project activities
Minnesota e-Health Grant Program Page 9 of 12Grant Application Revised 7/14/2008
as well as the rate of reimbursement per mile to be paid from project funds (not to exceed the current rate established by the Internal Revenue Service).
c. Equipment. Include a description and projected costs of any proposed equipment as it relates to the completion of the project. No more than 20 percent of any grant may be used for equipment. This may include hardware.
d. Software. Include a description and projected costs of any proposed software as it relates to the completion of the project.
e. Supplies. Include a description of any supplies needed for the completion of the project.
f. Consultants/Contracted services. Provide the name of contractors, the services to be provided, and projected costs. Include brief background information about contractors, including how their previous experience relates to the project. If no contractor has been chosen, include a description of the availability of contractors for the services and/or products required and the method for choosing a contractor.
g. Other. If it is necessary to include expenditures in the “Other” category, include a detailed description of the proposed expenditures as they relate to the project. Add additional “Other” lines to the budget form as needed.
h. In-kind match. (See 7c and/or 8b)i. Indirect charges. If requested, may not exceed 10 percent of the total funding request.
9. Project Contact InformationName and qualifications of the person or persons leading or co-leading the project.
10. Letters of Commitment and Supporta. For community e-Health collaborative and health information exchange projects,
include letters of commitment from all collaborating organizations. The letter of commitment from the organization agreeing to serve as fiscal agent must state their willingness to accept and account for grant funds under this program.
b. For all projects, letters of support from other organizations are also allowed but not required.
11. Accounting System and Financial Capability Questionnaire (see Attachments)
Minnesota e-Health Grant Program Page 10 of 12Grant Application Revised 7/14/2008
Frequently Asked Questions1. Are these funds for new collaboratives only? No, an existing collaborative is eligible as long as
the project being supported by the funds is consistent with grant purposes and eligible activities.
2. We are an integrated care system, with some clinics in the metro area and some in Greater Minnesota. Are we eligible as a community e-health collaborative? Yes, as long as the focus is on advancing the adoption of an interoperable EHR in your rural clinics and you partner with other rural organizations in the communities served by those clinics.
3. Can we use these grant funds to add new functionality to an existing EHR? Yes, as long as the additional functionality is for the purpose of improving data exchange among and between members of the community e-Health collaborative.
4. Can we use the implementation grant funds to support the ongoing operational costs of an existing collaborative focused (at least in part) on data exchange? The proposal must include some new exchange or other EHR related activity to be eligible for grant funds. A reasonable cost associated with governance/operation of the existing organization or collaborative may be included; however, in the narrative, address the issue of sustainability beyond grant funding.
5. We are an integrated health care system with facilities in both Minnesota and a neighboring state or states. Can we use these funds to support assessment and/or adoption across our entire system, including those facilities outside of Minnesota? Yes, as long as the following conditions are met: (1) your organization is based in Minnesota; (2) the members of your collaborative are based in Minnesota; (3) your facilities in neighboring states can or do serve Minnesotans; and (4) you meet the rural/underserved, match and other grant requirements.
6. What are “underserved areas?” “Underserved areas” are geographic locations that have received federal designation as a Health Professional Shortage Area or a Medically Underserved Area for reasons of socio-economic status, availability of adequate health insurance coverage, transportation, lack of accessible clinic facilities and services, health professionals and services, health status or indicators, age or other demographic factors, cultural and/or language barriers, or other factor(s), experience barriers to accessing health care services for preventive and acute care needs. The links to the federal Health Resources and Services Administration (HRSA) databases of shortage designations are: http://hpsafind.hrsa.gov/ and http://muafind.hrsa.gov/ .
7. How often can we invoice? Invoices can be submitted for work completed on a quarterly basis.
8. Is there a list of nationally certified EHR solutions? Yes, the list of nationally certified EHR products can be found at the Certification Commission for Healthcare Information Technology (CCHIT) Web site: http://www.cchit.org/certified/ .
Minnesota e-Health Grant Program Page 11 of 12Grant Application Revised 7/14/2008
Grant Writing Tips
Over the last two years demand for grant funds from the e-Health Grant Program has greatly exceeded the supply. Almost four times the available amount of grant funds were sought this year than were available. This intense competition has resulted in a close examination of applications by the review committee and a careful assessment of the strengths and weaknesses of the applications. Below are some observations and suggestions for grant proposals compiled from the grant programs within the Office of Rural Health and Primary Care.
A. Critical Need: Reviewers seek to answer the question “Is this project a CRITICAL need?” Do not offer statistics based on national studies or statewide data as part of your need or problem statement. Reviewers want to know YOUR problem and how YOUR facility proposes addressing it. Broad, general statements regarding how the project contributes to effectiveness, efficiency, accessibility, patient/staff safety, the promotion of the general health and welfare of the community are not persuasive. What is the priority of the project in your facility strategic plan? Hint: Chances are if the project is not deemed as a high priority and/or specifically identified in your strategic plan; it is not likely to be a high priority for the grant review committee either.
B. Make the Case for This Organization: Why YOU? Why does this application merit the award of limited grant resources over any other proposal for a similar or identical project elsewhere? It is not enough to simply have a fundable project (i.e., an eligible activity); you must make a compelling, convincing case that your project merits competitive selection. What is the current and projected financial status of your facility? Hint: Most electronic health record (EHR) systems comprise numerous modules and features that support clinical decision making, practice management and billing functions. While clinical functionality requires some administrative capabilities, given the limited amount of grant funding resources, projects that primarily support billing or other financial capabilities may be viewed as less competitive.
C. Budget: Review for inconsistencies between the cover page, budget form, and budget narrative regarding grant amount sought, match to be provided, and the total project cost.
D. Resources and Staff: What provision have you made for securing qualified staff or infrastructure improvements in connection with your proposed project? Do you need to train the staff on the new equipment or procedure(s) or make other facility improvements? Have you budgeted for this and is it reflected in the one page budget form and budget narrative? The grant award should not be used to replace existing institutional support for a program or staff, i.e., grant funds should supplement not substitute for or supplant an existing/ongoing institutional financial commitment.
E. Final Review: Before submission, give the final application to someone who was not deeply involved in constructing it to be reviewed for completeness, clarity, comprehension, consistency, and compelling case for the award of grant funds in a competitive environment.
Minnesota e-Health Grant Program Page 12 of 12Grant Application Revised 7/14/2008
Attachments
1. Application Cover Form2. Suggested Budget Form3. Accounting System and Financial Capability Questionnaire4. Grant Application Checklist
2008-2009 Minnesota e-Health Grant ProgramApplication Cover Form
1. Type of grant being applied for:
Readiness Assessment and Planning Implementation
2. Type of applicant: Community e-Health collaborative Community clinic Regional or community-based health information organization
3. Lead Applicant Organization (with which grant agreement is to be executed)
Legal Name Fed Tax ID # State Tax ID #
4. Names and cities of the collaborating organizations (for community e-Health collaborative and health information exchange projects):
5. Total amount of state grant funds applied for: $
Total dollar value of match (cash or in-kind): $
6. Contact Person for Further Information on Application:
Name Title
Organization:
Address:
Phone: e-mail:
I certify that the information contained herein is true and accurate to the best of my knowledge, and I have been authorized to submit this application on behalf of the applicant organizations listed above.
______________________________ Signature Title Date
2008-2009 Minnesota e-Health Grant Program
Suggested Budget FormNote: The grant narrative must include a budget justification narrative explaining each line item below.
Categories State Funding Requested
Financial Match*
In-kind match* Total
Total Personnel
Salaries
Fringe
Travel
Equipment
Software
Supplies Consultants/ Contractors** Other
Sub-Total
Indirect (no more than 10% of the sub-total)
TOTAL
* The match can be either in financial or in-kind services. It is not necessary to have either or both types of match for each line item. The only requirement is that the total of the financial match and the in-kind match must be at least one-third of the total grant dollars being applied for. In-kind match should be expressed in dollars, and can include, but is not limited to, staff time (the value of salaries and fringe) spent by collaborating organizations on the project (for example, staff time spent in planning, governance, or IT support), communications and mileage costs related to planning or governance meetings, and equipment needed to enable exchange or adoption of HIT.
** Contractors must be identified. If contractors have not yet been identified, explain the selection process your collaborative will use.
ACCOUNTING SYSTEM AND FINANCIAL CAPABILITY QUESTIONNAIRE
This is the standard form to be used in order to determine the financial capacity of grant applicants. The creation and implementation of this form is in response to the best practices stated in the Office of Legislative Auditor’s report “State Grants to Nonprofit Organizations,” January 2007.
This form should be used for applicant agencies that: are requesting, or will receive, more than $50,000; are new to state granting; are recently incorporated (five years or less); had previous unfavorable financial performance with federal and/or state funds; had significant audit findings; or for any applicant whose financial capacity is unknown or questionable.
No applicants will be excluded from receiving funding based solely on the answers to these questions.SECTION A: APPLICANT INFORMATION
1. Organization Name and Address 2.Employer Identification Number
3.Number of EmployeesFull Time: Part Time:
4. When did the applicant receive its 501(c)3 status? (MM/DD/YYYY)?
5. Is the applicant affiliated with or managed by any other organizations (Ex. regional or national offices)? YES NO If “Yes,” provide details:
5b. Does the applicant receive management or financial assistance from any other organizations? YES NO If “Yes,” provide details:
6a. Total revenue in most recent accounting period (12 months).
6b. How many different funding sources does the total revenue come from?
7. Does the applicant have written policies and procedures for the following business processes?a. Accounting Yes No Not Sure If yes please attach a copy of the table of contentsb. Purchasing Yes No Not Sure If yes please attach a copy of the table of contentsc. Payroll Yes No Not Sure If yes please attach a copy of the table of contents
SECTION B: ACCOUNTING SYSTEM1.Has a Federal or State Agency issued an official opinion regarding the adequacy of the applicants accounting system for the collection, identification and allocation of costs for grants Yes NoNote: If a financial review occurred within the past three years, omit Questions 2 – 6 of this Section and 1-3 of Section C.a. If yes, provide the name and address of the reviewing agency: b. Attach a copy of the latest review and any
subsequent documents.
2. Which of the following best describes the accounting system? Manual Automated Combination 3. Does the accounting system identify the deposits and expenditures of program funds for
each and every grant separately? Yes No Not Sure
4. If the applicant has multiple programs within a grant, does the accounting system record the expenditures for each and every program separately by budget line items?
Yes No Not Sure Not Applicable
5. Are time studies conducted for an employee(s) who receives funding from multiple sources?
Yes No Not Sure No Multiple Sources
6. Does the accounting system have a way to identify over spending of grant funds? Yes No Not SureSECTION C: FUND CONTROL
1. Is a separate bank account maintained for grant funds? Yes No Not Sure
2. If grant funds are mixed with other funds, can the grants expenses be easily identified? Yes No Not Sure
3. Are the officials of the organization bonded? Yes No Not SureSECTION D: FINANCIAL STATEMENTS
1. Did an independent certified public accountant (CPA) ever examine the organization’s financial statements? Yes No Not Sure
SECTION E: CERTIFICATION
I certify that the above information is complete and correct to the best of my knowledge.
1. Signature 2. Date / /
3. Title
2008-2009 Minnesota e-Health Grant Program
Grant Application Checklist
This form is for your purposes only, and does not need to be submitted with your grant application.
____ Grant application cover form is completely filled out.
____ Grant application form is signed by an authorized agent of the collaborative.
____ Excluding cover form, budget forms and letters of commitment and support:Readiness Assessment and Planning grants do not exceed 10 pages of narrative. Implementation grants do not exceed 15 pages of narrative.
____ Proposal narrative is at least 12-point type.
____ Budget form is enclosed.
____ Accounting System and Financial Capability Questionnaire form is enclosed.
____ If applicant is a community e-health collaborative, letters of commitment are enclosed from each of the organizations listed.
____ One original, four plain white paper copies, and an electronic version (MS Word, Excel or pdf only) on disc, must be received before 4:30 p.m. on September 5, 2008.
Anne SchloegelOffice of Rural Health and Primary CareMinnesota Department of Health
Courier delivery: Postal address:85 East 7th Place, Suite 220Saint Paul, Minnesota 55101
P.O. Box 64882Saint Paul, Minnesota 55164-0882
