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Consolidated Agreement FYI Page 18 of 33 4. Assure that the service provider includes a copy of the county's monthly program activity and service level data to the Department's Health Director on a monthly basis. 5. Provide a clear and comprehensive description of the entire care and case management system including: a. A description of services for both the Medicaid and non -Medicaid children and Medicaid women (and also non -Medicaid women, if appropriate). Include a statement of how the county will address Agreement Addendum (AA) deliverables for the OBCM and CC4C programs and provide oversight through Executive Leadership to assure that AA deliverables are met for both programs. The Agreement Addenda for Activity 101 Maternal Health and Activity 318 Care Coordination for Children programs will be revised to reference this effort as a one-year pilot; b. A statement on how the county service system components interact; c. The staffing plan; d. Outreach strategies; e. A description of the client triage model for early childhood and maternal health programs and services for the county; f. A description of the referral system both to and from the care management systems. Develop criteria for referral of all first-time mothers to the women's and children's home visiting programs. Those not eligible for the women's and children's home visiting programs or for those who decline the services will be referred to OBCM. The plan should include a process to follow- up on referrals to assure they were successfully completed and the referral outcomes; g. Follow-up strategies; h. Accountability and monitoring plans that cover Department responsibility for all of the Title V components including non -Medicaid care management services and school nurses; i. A description detailing the overall goals and strategies of the Department's plan to develop a unique continuum of care for these populations. This should include school nurses, case management for the non -Medicaid eligible children, Nurse -Family Partnership, and other pertinent women's and children's services in the county; j. A statement on how the Department will maintain a clear audit trail for the various components of the system. 6. Describe the program monitoring process including the procedure for corrective action plans in the event they are warranted. The program monitoring process should also include analysis of county program activity reports and outcomes indicative of clients' successes based on the program evaluation criteria. 7. Provide a statement on how the Department will coordinate and transition clients in collaboration with school nurses as an extension of OBCM/CC4C/CCNC (Community Care of North Carolina) care coordination in the school setting. If so, include information about the involvement of school nurse consultants in the planning process, prior to implementing the case management system in the county schools. 8. Ensure that the service provider's CC4C coordinators complete the Life Skills Progression (LSP) assessment and focus on children with toxic stress. A strong concern is that the typical medical model of CCNC care management is very different than the medical and socioeconomic model used in public health. One of the values of the CC4C model is the additional focus on prevention and health promotion. The LSP is a tool that allows CC4C to assess, intervene and track progress of a