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DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> h) Describe what would happen if requested funding is not awarded at all or if a reduced <br /> allocation is recommended. <br /> The number of individuals served would be negatively impacted by a reduction in or <br /> absence of funding. Our licensed halfway houses are not a Medicaid billable service and <br /> are funded at a very low State rate that does not cover the cost of running the programs, <br /> making it difficult to sustain these critical treatment/housing programs which have a higher <br /> rate of success than other programs in the state and nation. Facility Based Crisis and <br /> Detox/Behavioral Health Urgent Crisis Care services are historically underfunded by State <br /> IPRS dollars, as well as Medicaid. The requirements of the Service Definitions that oversee <br /> these types of licensed programs exceed the billing rate for the service. Funding is tight for <br /> crisis services, and every dollar we receive is critical in maintaining crisis services. <br /> i) Include any other pertinent information. <br /> Freedom House tracks success through a variety of measures which relate to the quality of <br /> outcomes of our clients. Measures can include sobriety post discharge, emergency <br /> department or crisis recidivism, improvements in physical health and medication adherence, <br /> quality of life improvements such as decent housing, employment, family reunification, etc. <br /> By tracking our performance, Freedom House can monitor the effectiveness of our programs <br /> and practices and make adjustments. <br /> Program/Project Information <br /> j) Complete the Target Population and Program Beneficiary Demographics Chart <br /> k) Complete the Schedule of Positions Chart for Program Staff <br /> I) Disclosure of Potential Conflicts of Interested must be signed <br /> m) Complete the Work Statement Chart to describe the work to be performed, and be sure to <br /> attach copies of all data collection tools that will be used to verify achievement of program <br /> goals and objectives. Describe who will be responsible for monitoring progress. <br /> Information to Complete <br /> j.)Target Population <br /> Complete the following tables to the best of your ability. Show numbers of participants and <br /> percentages, as applicable, in each category. <br /> Please indicate whether this project/program will serve: II Persons E Households El Units <br /> Program: Facility-Based Crisis, <br /> Detox,and Behavioral Health Urgent <br /> Crisis Care <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Gender <br /> Male 1,123 1,363 1,410 <br /> Female 906 1,179 1,229 <br /> Total 2,029 2,542 2,639 <br /> Main Application 1/25/2016 4:55:19 PM Page 10 of 24 <br /> 1 <br />