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DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Work Statement <br />o) 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 <br />Program Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and <br />Time - bound. Click on SMART Goals to learn more. <br />• Program Activities should outline major activities the agency implements to accomplish its <br />program goals. (Le. 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: Carrboro Community Health Center <br />1. Program Activity Name <br />Refugee Health Care Population Health Program Support <br />Program Goal <br />CCHC will be a comprehensive primary care medical home to 650 <br />refugee patients from Orange County, providing <br />culturally /linguistically appropriate care with the help of <br />Town/county-supported interpretation services. <br />Performance Measures <br /># Refugee Health Patients Served; Value of Interpretation Service <br />Provided. <br />Previous Year Program Results <br />2016 -2017 served estimated 703 Refugees. <br />Current Year Estimated Results <br />2017 -2018 6 month results; 444 <br />Next Year Projected Results <br />2018 -2019: CCHC will care for 650 refugees. <br />2. Program Activity Name <br />Affordable Medical Care for Low - income Individuals <br />Program Goal <br />CCHC will effectively reach its target low- income population with <br />comprehensive primary medical care ( >21,700 medical visits <br />( >8,400 self - pay)), serving more than 3,400 Orange County /Town <br />of Chapel Hill /Carrboro residents annually. <br />Performance Measures <br />#Individuals served medically by insurance status <br />#Individuals served medically by income status <br />#Total number of medical visits <br />Total # served and # Orange County residents served <br />Previous Year Program Results <br />2016 -2017 — 3,595 Orange County residents served at Carrboro <br />CHC <br />Current Year Estimated Results <br />2017 -2018 6 month data — 2,451 Orange County residents served <br />at Carrboro CHC. So estimate on track to achieve 3,400 Orange <br />County residents at CCHC, 3,728 across PHS. <br />Next Year Projected Results <br />PHS will serve more than 3,400 Orange County/Town of Chapel <br />Hill/Town of Carrboro residents with medical homes services (total <br />number of visits, income status, and insurance status are not <br />projected, but will be reported as descriptors of the population <br />served. <br />PROGRAM INFORMATION 1/23/2018 11 :00 :54 AM P a g e 1 9 o f 2 3 <br />