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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 /> y) 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: Men's and Maggie Alvis Women's Halfway Houses <br /> (Residential Rehabilitation) <br /> 4. Program Activity Name ; Staff will work with stakeholders and community <br /> partners (UNC Hospitals, the Court system, IFC shelter, <br /> etc.) to identify referrals for individuals in our community <br /> who need long-term halfway house services. <br /> Program Goal 110 men and women receive long-term (3-6 months) <br /> recovery and community support services. <br /> Performance Measures Outcomes are evaluated using NCTOPPS tool and our <br /> EMR. <br /> Previous Year Program Results Provide services to 106 individuals and maintain a 98% <br /> utilization rate. <br /> Current Year Estimated Results Provide services to 109 individuals and maintain a 98% <br /> utilization rate. <br /> Next Year Projected Results Provide services to 110 individuals and maintain a 98% <br /> utilization rate. <br /> 5. Program Activity Name Staff develops a Person-Centered Plan for each <br /> individual, with a goal of self-sufficiency and sobriety <br /> upon graduation. <br /> Program Goal 78 % of all clients will graduate from the program and <br /> re-enter the community and/or family. <br /> Performance Measures Clinical staff will regularly monitor the case planning <br /> activities for each client during their stay in the program. <br /> Previous Year Program Results 77 % of all clients will graduate from the program and <br /> re-enter the community and/or family. <br /> Current Year Estimated Results 77 % of all clients will graduate from the program and <br /> DO NOT SUBMIT THIS PAGE 1/31/201711:11:58AMPage 23 of <br />