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DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />FY18 -19 Application <br />Work Statement <br />(Page 11) <br />Goals: Duke Hospice Bereavement Services (DHBS) offers bereavement support to bath hospice and community clients <br />1) DHBS will schedule 200 community adult client encounters in FY18 <br />2) DHBS will schedule 64 community child /teen encounters in FY18 <br />3) DHBS will schedule 345 hospice adult client encounters in FY18 <br />4) DHBS will schedule 26 hospice child /teen encounters in FY18 <br />5) Camp ReLEAF will provide an overnight camp experience for children K -81' grade <br />6) DHBS will provide grief education and support to local educational and civic organizations as requested <br />Goal # <br />Actual 15 -16 <br />Actual 16 -17 <br />Estimated 17 -18 <br />1 <br />277 <br />205 <br />179 <br />2 <br />24 <br />33 <br />32 <br />3 <br />446 <br />491 <br />533 <br />4 <br />38 <br />47 <br />31 <br />5 <br />10 = .334 of total <br />16 = .381 of total <br />15 = .31 of total <br />6 <br />17 <br />18 <br />16 <br />Performance measures for all of the listed activities will be through service evaluation requested at the time of the event <br />or at the conclusion of a series of related events. Related events would be ongoing individual or group counseling. <br />Goal 5 Camp ReLEAF: each camper provides feedback regarding likes and dislikes of camp activities and overall <br />participation. Each activity scored well in different age groups. There are no numbers associated with the scoring of <br />satisfaction. Parents provide feedback about their children's reported experience with approximately 30% of campers <br />requesting to come back the next year. 42 campers FY17 out of 48 FY17 total campers completed a group evaluation <br />with 96% responding favorably to the camp experience, Predominant responses from campers indicated the <br />importance of meeting other children their age who had experience something similar which reduces the isolation, <br />loneliness and sense of being different. <br />Goal # <br />3 98% satisfaction <br />100 refer services <br />4 95% satisfaction <br />98% refer services <br />6 94% satisfaction <br />100% refer <br />Actual <br />96% <br />97% refer services <br />96% satisfaction <br />100% refer services <br />95% satisfaction <br />92% refer <br />Estimated <br />95% <br />95% refer services <br />95% satisfaction <br />95% refer services <br />95% satisfaction <br />95% refer `services <br />