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DocuSign Envelope ID:4D553CF7-2BBD-4F4E-B84E-E6B8B077A9AB <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Work Statement <br /> I) Complete the Work Statement Chart to describe the work to be performed. <br /> This chart is used to document program activities, program goals, performance measures, <br /> and actual results. (Add more rows as needed) If this is a new program, you will only <br /> document the projected information. Every program is required to have AT LEAST 1 Program <br /> Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and Time- <br /> bound. Click on SMART Goals to learn more. <br /> • Program Activities should outline major activities the agency implements to accomplish its <br /> program goals. (i.e. Deliver meals to elderly/disabled residents.) <br /> • Program Goal should explain what the program is trying to achieve/accomplish. Goals are <br /> statements about what the program should accomplish. (i.e. Deliver 100 meals per day, <br /> Monday-Friday.) <br /> • Performance Measures describe how you will evaluate the degree in which you achieved <br /> the stated goals. (i.e. Will track the number of meals delivered each day.) <br /> • Actual Program Results use program results to indicate the actual measureable <br /> achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of <br /> 105 meals per day.) <br /> Work Statement Chart for Program: 24/365/7 Urgent Behavioral HealthCare (Facility-Based <br /> Crisis and Detox) <br /> 1. Program Activity Name Provide services to all referrals from the community that <br /> meet admission criteria. <br /> Program Goal Provide services to 3,429 individuals in need of <br /> addiction or mental health treatment. <br /> Performance Measures We will use our EMR system to track these numbers. <br /> Previous Year Program Results We served 2,064 clients served in the Crisis Unit. <br /> Current Year Estimated Results We anticipate serving 2,639 clients in the Crisis Unit. <br /> Next Year Projected Results We anticipate seeing an increase from the previous FY <br /> in clients served in the Crisis Unit which also includes <br /> walk-in crisis clients. <br /> 2. Program Activity Name Crisis staff begin discharge planning with each client in <br /> the crisis unit, using motivational interviewing <br /> techniques to incentivize clients to move into the next <br /> appropriate level of care. <br /> Program Goal Provide treatment planning to refer 100% of those <br /> served to the next appropriate level of care. <br /> Performance Measures Our EMR system tracks this information and flow of <br /> client services. <br /> DO NOT SUBMIT THIS PAGE 1/31/2017 11:11:58 AM Page 15 of <br />