SWP Name:
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Clinical Services Objectives / Anticipated Outcomes / Degree of Achievement / STATUS / Year-End-2 / -1 / 0 / +1 / +2 / Q1 / Q2 / Q3 / Q4
Clinical Services #1:
Clients will receive RN and/or mental/behavioral health services. (The anticipated outcome should match the Projected Performance Output Measure as stated in the grant contract.) / # unduplicated users (clients) to be reached:
Primary Care #2a:
Out of all unduplicated users, a number will receive mental/behavioral health services / # unduplicated users to be seen for mental/behavioral health services:
Primary Care #2b:
Projected number of visits with mental/behavioral health provider (using approved mental health treatment modalities) / # visits with mental/behavioral health provider:
Clinical Services #3:
Clients will have documented evidence of an up-to-date risk assessment /anticipatory guidance. / # clients that will have up-to-date risk assessment/anticipatory guidance: / 80% / 85% / 90% / 95% / 100%
Clinical Services #4:
Clients with chronic disease will have documented evidence of a case management plan. / % clients will have a case management plan: / 80% / 85% / 90% / 95% / 100%
Optional ~ Objective #5:
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Evidence-Based Intervention: / Anticipated Outcomes / Degree of Achievement / STATUS / Year-End
-2 / -1 / 0 / +1 / +2 / Q1 / Q2 / Q3 / Q4
Number of participants/clients:
Number of contact hours/sessions:
Outcome Objective #1 (required):
Outcome Objective #2 (required):
Outcome Objective #3 (optional):
Focus Area:
Evidence-Based Intervention: / Anticipated Outcomes / Degree of Achievement / STATUS / Year-End
-2 / -1 / 0 / +1 / +2 / Q1 / Q2 / Q3 / Q4
Number of participants/clients:
Number of contact hours/sessions:
Outcome Objective #1 (required):
Outcome Objective #2 (required):
Outcome Objective #3 (optional):
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Clinical Groups/Evidence-Based Intervention: / Anticipated Outcomes / Degree of Achievement / STATUS / Year-End
-2 / -1 / 0 / +1 / +2 / Q1 / Q2 / Q3 / Q4
Number of participants/clients:
Number of contact hours/sessions:
Outcome Objective #1 (required):
Outcome Objective #2 (required):
Outcome Objective #3 (optional):
Outcome Objective #4 (optional):
Medicaid Objectives / Anticipated Outcomes / Degree of Achievement / STATUS / Year-End
-2 / -1 / 0 / +1 / +2 / Q1 / Q2 / Q3 / Q4
Medicaid Outreach Area 1:
Medicaid Outreach and Public Awareness[i]
Eligible and potentially eligible clients will be informed about Medicaid to increase awareness of covered services and eligibility criteria. / # eligible/potentially eligible clients that will be informed about Medicaid:
Medicaid Outreach Area 2:
Facilitating Medicaid Eligibility Determination[ii]
MO #2-1
Insurance status of each client will be assessed at each visit to determine number of unduplicated clients without insurance that access the school wellness program throughout the year. / # unduplicated clients without insurance that access the school wellness program:
MO #2-2:
100% of clients without insurance will be offered assistance with
Medicaid enrollment application. / 100% of unduplicated, uninsured clients offered assistance with Medicaid enrollment application / 90% / 95% / 100%
MO #2-3:
The number of clients successfully enrolled in Medicaid will be verified by checking enrollment status of every client assisted or offered assistance with Medicaid enrollment. / # of unduplicated clients successfully enrolled
See page 4 for reminders on eligible Medicaid outreach activities.
[i] Medicaid Outreach and Public Awareness activities inform eligible or potentially eligible individuals about Medicaid and how to access Medicaid services; or when CAHC staff is describing the services covered under a Medicaid program as part of a broader presentation e.g., within the context of a health education program. Examples include Medicaid literature distribution; using print or electronic media, school announcements to promote Medicaid covered services; and participating in health fairs where such literature is distributed.
[ii] Facilitating Medicaid Eligibility Determination activities are those where theCAHC staff assists in the Medicaid enrollment process by enrolling clients onsite at the health center. As of October 1, 2014, report the following: 1) the number of unduplicated clients who access the center during the year, broken down by quarter; 2) the number of unduplicated clients assisted onsite with completion of the Medicaid application; and 3) the number of unduplicated clients that your health center assisted onsite with enrollment that were successfully enrolled.