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HomeMy WebLinkAboutbocc.con.073.2005 P1TKIN COIJNTY CLFRK'S OFFICE CHECK LIST FOR CONTRACTS SUBMITTED TO CLERK AND RECORDER FOR SCANNING/ARCHIVING Originating Department/Division: Pitkin County Public Works - Project Management Contact Person: _Jodi Smith. proiect Mgr .~ Phone #: 970-920-5396 Project Name ~ 5~_/~O , 5Z~'l/l~,o ~ (.~/yZ~ Contract #: BOCC AGENDA ITEM (BOCC signature required) Check Contract Type: /~ Services Maintenance Lease Construction Grant Agreements (Requires BOCC Action) __ Change Order/Contract Amendment Other ~)( STAFF AUTHORIZED SIGNATURE (per Revised Procurement Code7/2005) Dollar Amount: $ ~q 9/~ ~ __.Purchas~ ~ _ Employment __Intergovernmental Agreement (Requires BOCC Action) Non Profit ___Quasi-Public STAFF AUTHORIZ]E~ SIGN~,~RE Signatures Required: Under 25K - Department Head 25-50K - Department Head (if appropriate), Section Leader Over 50 K - Department Head (if appropriate), Section Leader, County Manager Contractor/Business (Complete Name): ,,~J0,~9 ~,t/'~(~r~.',~ t ~ C*~d Contract Start Date: ~/~1.~/Og" Contract EndDate: ~/a2o7,/ ~. Automatic Renewal (Y/~N): ~___~__ / All Contracts should be proofed for the following: · / No Pages Missing · " If a Page is Left Intentionally Blank - Note on Page ~' Page numbered consecutively ,," All Signatures Affixed ,/ All Dates Filled In v' All Other Blanks Filled In v' All Exhibits Attached ,/ All Legal Descriptions Attached (if appropriate) ~" Notice of Award/Proceed Attached (if appropriate) Sent to Clerk and Recorder for Scanning/Archiving (~ ,6tSE ~5;~M~ Date: ~/2 2/o~--~' Jodi Sn~l~' Projec~'r~anager Signature of authorized staff person indicates that document has been proofed and ready for scanning. Note: Clerk's Office will keep original documents in compliance with Colorado State Archives retainage schedule. pcjmj\ww~gkscannning~couniy contracts~narrative~checklistsheet Rcvt~ d t I' lodi 6/12/05 CONTF,;,-, ~' STAFF AUTHORIZED SIGNATURE Date: June 10, 2005 TO: John Lutgring, LCSW 21 S. Meadow View Court NOTICE OF AWARD CONTRACT # ' 2. STAFF AUTHORIZED SIGN~RE Glenwood Springs, Colorado 81601 (970) 928-8275 The Owner, having duly considered the Proposal submitted on June 1, 2005, for the work covered by the Contract Document titled Pitkin Count5, Senior Care Coordination in the amount of $34,400.00, and it appearing that the Price and other information in your Proposal Form is fair, equitable and to the best interest of the Owner, the offer in your Proposal Form is hereby accepted. In accordance with the terms of the Contract Documents, you are required to execute the Agreement in three copies within ten (10) consecutive days from and including the date of this Notice of Award. In addition you are required to furnish in the said time Certificates of Insurance evidencing compliance with the requirement for insurance as stated in the Contract Documents to Marty Ames, Senior Services Director, 0275 Castle Creek Road, Aspen, Colorado 81611, Fax (970) 920-5708. PITKIN COUNT,Y/ ~t~i ~nith ~'oor'Marty Ames :ACCEPTANCE OF NOTICE Receipt of the above Notice of Award is hereby acknowledged ~ ,'~' ~ I~ ,, ' ],v y ~.JttN~ 2005. By ~ ~~ thzs * da of~ Rev. 8/2004 CONTRACT FOR PROVISION OF SERVICES THIS CONTRACT is made and entered by and between the Pitkin County Board of County Commissioners ("County") and John Lutgring, LCSW, 21 S. Meadow View Court, Glenwood Springs, Colorado 81601, (970) 928-8275 (hereinafter "Contractor"). 1. Term. The term of this contract is from June 15, 2005 to December 31, 2006. At the expiration of the initial term, the contract may be extended for an additional term of one (1) gear by the express written consent of both parties pending budget approval. 2. Contractor's Obligations. Contractor shall provide professional services for the Pitkin County Senior Care Coordination per scope of work below and Exhibit A - proposal form dated: May 25, 2005. SCOPE OF WORK An experienced Care Coordinator will meet with seniors in their homes to create an individualized care plan including: · An assessment of service needs · Identification of resources to meet those needs · Referrals and assistance with implementation of services · Ongoing monitoring of care · Periodic reassessment of needs The goal of the Senior Care Coordinator is to assist each senior to maintain a quality of life consistent with his or her personal abilities and expectations. Community Need: For the purposes of this project, the most significant statistic is the growth in the 75+ population from 1990-2010. This is the group we don't necessarily "see" in the community - those with chronic health conditions and increasing frailty who are typically alone and most in need of services. There are also some younger seniors who are unable to manage dally life effectively due to social, financial, mental and physical health issues. We currently have 10-12 seniors in critical need of case management and this number grows each month. In the last 5 years, the complexity of problems facing this small but growing group of seniors has reached a critical level, beyond the scope of Senior Services staff to handle effectively. These individuals tend to bounce from agency to church to program, seeking help for their 2 current health or financial crisis. The need is for comprehensive case management and long- term solutions. For years we have tried to address this growing need by squeezing it into other initiatives, like palliative care. We have learned that this is a specific need requiring professional expertise to spend adequate time with the senior client, deal with complicated family issues, analyze problems and create solutions. Senior Care Coordinator Qualifications Licensed Clinical Social Worker or Licensed Nurse or Gerontology degree preferred. Significant Experience - This position requires geriatric education and/or significant experience with older people including understanding and working with family dynamics, assessment of physical and emotional needs, collaborative problem solving, and resource identification and referral. Organization and self-motivation - This is a contract position which will require setting up and adhering to standards, setting up service arrangements/contracts for clients, keeping impeccable records, billing for services, regular follow-up with clients, etc. Interpersonal - This person will work productively with personnel from established agencies in the valley and also assist clients to locate and determine qualifications of individual service providers. The Care Coordinator will help identify gaps in resources that need to be addressed. This person must be able to work knowledgeably and fluidly within systems, and creatively outside systems when appropriate. Flexibility -This position will work on-call so it will be important to be flexible with hours and schedule. It may be necessary to meet with seniors or family members on their schedules, or respond to emergency issues. Financial Remuneration - This is a contract position. All costs of doing business should be considered and included in the fee. 3. Compensation and Expenses, Invoicing, Payment and Offset. The County shall compensate Contractor for its services in accordance with the Project Budget and Schedule set out in Paragraph 2. It is expressly understood and agreed that in no event will the total compensation and reimbursement to be paid hereunder exceed the sum of Thirty Five Thousand Dollars and Zero Cents ($35,000.00) for all services rendered. By contract or amendment, the County and Contractor may reallocate the budget among project tasks if the total budget amount remains unchanged. Contractor shall invoice for the project monthly based on hours worked, with payment expected within thirty (30) days of invoice, but any payment by the County may be offset by any amount the Contractor owes the County for any reason. In the event the Contractor incurs time and expenses in excess of the total compensation stated above, no compensation for said additional time and expenses shall be required to be paid by the County without written amendment to this contract executed by the County. 4. County's Exclusive Ownership of Work Product. Specifications, guidelines, case records and other documents prepared by Contractor in connection with this contract shall be the property of the County. However, Contractor shall have the right to utilize such documents in the course of its marketing, professional presentations, and for other business purposes. Contractor assigns to County the copyrights to all work prepared, developed, or created pursuant to this contract. 5. Pitkin County's Obligations. Pitkin County shall administer this contract through a County Representative. Marty Ames, Senior Services Director will manage the project as the County's Representative. In the event that Marty Ames is not available, Mary Barbour shall assume the County Representative's duties. The services provided and products delivered by the Contractor under this contract will be subject to review by the County's Representatives, or a designee, for compliance with Contractor's obligations prior to final payment. 6. Termination Prior to Expiration of Contract Term. The County has the right to terminate this contract, with or without cause, by giving written notice to the Contractor of such termination and specifying the effective date thereof. Such notice shall be given at least ten (10) days before the effective date of such termination. In such event all finished or unfinished documents, data, studies and reports prepared by the Contractor pursuant to this contract shall become the County's property. Contractor shall be entitled to receive compensation in accordance with the contract for any satisfactory work completed pursuant to the terms of this contract prior to the date of termination. Not withstanding the above, Contractor shall not be relieved of liability to the County for damages sustained by the County by virtue of any breach of the contract by the Contractor. 7. Independent Contractor Status. A. The parties to this contract intend that the relationship between them contemplated by the contract is that of independent Contractor. Contractor, and any agent, employee, or servant of Contractor shall not be deemed to be an employee, agent, or servant of Pitkin County. B. Contractor is not required to offer his services exclusively to Pitkin County under this contract. Contractor may choose to work for other individuals or entities during the term of this contract, provided that the basic services and deliverable products required under this contract are submitted in the manner and on the schedule defined under this contract. C. Contractor warrants that all work produced will conform to all applicable industry standard of care, skill and diligence in the performance of Contractor's obligations under this contract. D. Contractor shall not attempt to oversee or supervise the work or actions of any Pitkin County employee, servant or agent in the course of completing work under this contract. 4 E. Contractor is not entitled to any Workers' Compensation benefits through Pitkin County and is responsible for payment of any federal, state, FICA and other income taxes. 8. Assignabliliw. This contract is not assignable by either party. Any use of subcontractors by the Contractor for performance of this contract must be accepted in writing by the County. 9. Binding Arbitration. Any disputes arising out of this contract shall be subject to binding arbitration. The parties agree that any disputes concerning the terms and conditions of this contract shall be submitted and finally settled by arbitration. Arbitration shall be conducted pursuant to the roles of the American Arbitration Association and shall be presided over by the Pitkin County Hearing Officer appointed to arbitrate Pitkin County contract disputes. Costs of the arbitration shall be awarded to the substantially prevailing party. 10. Severability. In the event that any provision of this contract shall be held to be invalid or unenforceable, the remaining provisions of this contract shall remain valid and binding upon the parties hereto 11. Integration and Modification. A. This contract represents the entire and integrated contract between the County and the Contractor and supersedes all prior negotiations, representations, or contract, either written or oral. This contract may be amended only by written contract signed by both the County and the Contractor. B. The County may, from time to time, request changes in the scope of services of the Contractor to be performed hereunder. Such changes, including the increase or decrease in the amount of the Contractor's compensation, which are mutually agreed upon between the County and the Contractor, shall be in writing and upon execution shall become part of this contract. 12. Indemnity. A. The Contractor (including, by definition here and hereinafter, its officials, employees, agents and representatives, subcontractors and suppliers), shall and hereby does release, discharge, indemnify and hold harmless the County of Pitkin and its officials, employees, agents and representatives from and against liability for any claim, demand, loss, damages, penalty, judgment, expenses, costs (including costs of investigation and defense), fees (including reasonable attorney and expert witness fees) or compensation in any form or kind whatsoever for any bodily injury, death, personal injury or property damage arising out of or in connection with any negligent act, intentional act, error or omission by the Contractor, and for any consequential liability alleged to accrue against the County on account of the Contractor's acts, errors or omissions; provided, however, that such indemnity shall not be construed as an indemnity for bodily injury or property damage arising from the sole negli- gence of the County or its employees. B. The Contractor further shall investigate, process, respond to, adjust, provide defense for and defend, pay or settle all claims, demands, or lawsuits related hereto at its sole expense and shall bear all other costs and expenses related thereto, even if the claim, demand or lawsuit is groundless, false or fraudulent. 13. Insurance. A. In whole or in part, the Contractor shall secure and maintain for the term of its contractual relationship with the County such insurance policies, from companies licensed in the State of Colorado, as will protect itself, the County and others as specified, from claims for bodily injuries, death, personal injury or property damage, which may arise out of or result from the Contractor's acts, errors or omissions. The following insurance coverage, at or above the limits indicated and including such endorsements as are indicated by an "X", are required: 1. Professional Liability Insurance a. Each Occurrence Limit $1,000,000.00 2. Auto Liability Insurance a. Each Occurrence Limit $1,000,000.00 B. Proof of Insurance: 1. To provide evidence of the required insurance coverage, copies of Certificates of Insurance in a form acceptable to the County shall be filed with the County through the representative identified in Paragraph 5, no later than ten (10) calendar days prior to commencement of operations affecting the County. Failure to file or maintain acceptable Certificates of Insurance with the County is agreed to be a material breach of any contract. These Certificates of Insurance shall contain a provision that coverage afforded under the policies will not be canceled or materially altered unless at least thirty (30) calendar days prior written notice by certified mail, return receipt requested (effective upon proper mailing), has been sent to the Procurement Officer. (For purposes of this provision, "materially altered" shall mean a change affecting the coverage's required herein, including a change to policy limits as set out in the then-current policy declarations page). Simultaneously with the Certificates of Insurance, the Contractor shall file with the Procurement Officer a statement as to claims pending against the required coverages, reserves established on account of such claims, defense costs expended and amounts remaining on policy limits. In addition, these Certificates of Insurance shall contain the following clauses: a. The clause "other insurance provisions," in a policy in which the County of Pitkin holds a Certificate, shall not apply to the County of Pitkin. b. The insurance companies issuing the policy or policies hereunder shall have no recourse against the County of Pitldn for payment of any premiums or for assessments under any form of policy. 6 c. Any and ail deductibles in the above-described insurance policies shail be assumed by and be for the amount of, and at the sole expense of the Contractor. d. Location of operations shail be: "ail operations and locations at which work for the referenced Project is being done." 3. Certificates of Insurance for all renewai policies shail be delivered to the County's Representative at least fifteen (15) days prior to a policy's expiration date except for any policy expiring on the expiration date of this contract or thereafter. 4. The County reserves the right to request and receive a copy of any policy and any policy endorsement at any time during the term of this contract. 14. Exemptions and Preferences. All purchases of construction or building or any other materiais for this contract shall not include Federai Excise Taxes or Colorado State or local sales or use taxes. Pitkin County is exempt from such taxes under registration numbers 98-02624 and 84- 78000-5K. 15. Records. The Contractor shail maintain comprehensive, complete and accurate books, records, and documents concerning its performance relating to this contract for a period of three (3) years after finai payment under the contract and the County shail have the right within the three (3) year period to inspect and audit these books, records and documents, upon demand, in a reasonable manner and at reasonable times, for the purpose of determining, by accepted accounting and auditing standards, compliance with ail provisions of the contract and applicable law. 16. Contract Made in Colorado. The parties agree that this contract was made in accordance with the laws of the State of Colorado and shail be so construed. Venue is agreed to be exclusively in the courts of Pitkin County, Colorado. 17. Attorney's Fees. In the event that legal action is necessary to enforce any of the provisions of this contract beyond the arbitration described in Paragraph 9, the substantially prevailing party shail be entitled to its costs and reasonable attorney's fees. 18. Governmental Immunity. Contractor agrees and understands that Pitkin County is relying on and does not waive, by any provision of this contract, the monetary limitations or terms (presently $150,000.00 per person and $600,000 per occurrence) or any other rights, immunities, and protections provided by the Colorado Governmentai Immunity Act, 24-10-101, et. Seq., C.R.S., as from time to time amended, or otherwise available to Pitkin County or any of its officers, agents or employees. Further, nothing in this contract shail be construed or interpreted to require or provide for indemnification of the Contractor by the County for any injury to any person or any property damage whatsoever which is caused by the negligence or other misconduct of the County or its agent or employees. 19. Current Year Obligations. The parties acknowledge and agree that any payments provided for hereunder or requirements for future appropriations shall constitute only currently EXHIBIT A Marty Ames Director Pitkin Co. Senior Services May25,2005 Dear Marry, I have enclosed 3 copies of the RFP for Senior Care Coordinator and look forward to the process of selecting a candidate for this important position. Pitkin County can be proud of the enhancements for their senior population. Ifanythlng is missing in my information, my cell is 970 319 8850 while traveling until Sunday June 5. Congrats on your fine work, John Lutgri~g PITKIN COUNTY SENIOR CARE COORDINATOR-RFP (John Lutgring, LCSW) SUMMARY: Pitkin County seniors experiencing difficulty in managing their health, psychosocial needs, and navigating accessible resources, can now be referred by the Pitkin County Senior Services to the new contract position of the Senior Care Coordinator (SCC). The SCC will assess the needs of the senior in their home or a convenient community locale. The assessment will include input from concemed family and relevant community members (medical, psycho- social, spiritual, and legal/financial resources). A plan of care will be developed with seniors and their family. The plan will guide the recommended steps, services, and responsibilities. Implementing the plan involves the SCC in coordinating and guiding the senior to needed services, and facilitating a smooth process through agency resources. Services and equipment needs beyond the financial means of the senior will be brokered and paid through this program. Once seniors are engaged with services, which add balance to their health, the SCC will provide monitoring and reassessment until systems are in place to maintain their progress. Disengagement would include discharge planning and client satisfaction/evaluation, which will occur in writing. Desired outcomes will include more seniors remaining in their homes without threat of unneeded hospitalizations or nursing home placements and greater autonomy in late life challenges. The SCC with Pitldn County resources may enhance the accessibility of all senior services and identify gaps which can be part of future planning. STRUCTURE: The SCC would obtain a referral list from Pitkin Senior Services and prioritize seniors in greatest need and risk of tmdesirable consequences. Linking with services most knowledgeable of the senior would start a preassessment. Meeting with senior, family, and or caregivers would occur and engagement/relationship building would begin. Formal assessment would continue over several meetings until a plan of care is written and agreed upon by all. Written steps would be addressed and the SCC would guide, counsel, and advocate for the needed services. Ongoing monitoring and problemsolving continues until disengagement. Senior Services would be given monthly updates and quarterly meetings would occur to discuss progress toward goals. Record keeping would include assessments, contacts, visits, hours, meetings, training attended, and satisfaction/outcomes. CASE WORK EXPERIENCE: John has worked as a clinical Social Worker doing gero care management with Pitkin Senior Services in 2001-2002. The work was similar to the role of the SCC. My first job following my MSW was Intensive Caseworker with families and juvenile delinquents to provide services to reduce residential placements and incarceration. This role allowed networking with services, churches, schools, and counseling, to jointly serve high risk teens. Later I supervised our chronically mentally ill case manager who coordinated care and problem solving to allow patients to remain in their community and avoid hospitalizations. In Colorado I performed home health case management at Columbine Home Health and left my mental health career to focus on keeping elderly clients in their home as long as possible. I learned about Colorado resource access and barriers to necessary services. Columbine used the MSW when the client did not follow the care plan or when client safety was going to be compromised. Home health was an optimal environment to mediate client, family, physican, and home health team collaboration. Hospice and Palliative Care has further allowed case management when patients and family members are in medical crisis, and often are at cross purposes with medical teams and or family members. Valley View Hospital Cancer Center has patients and families in need of resources, brief cotmseling, and preparation for long medical demands. I have assisted the medical team for two years. John's mental health, interviewing, crisis intervention, long term care planning, and knowledge of seniors' developmental stages allow a mature joining and respecting the dignity of seniors in distress. My mental health skills and knowledge of seniors in crisis allows care management to succeed when traditional referral to resources may be insufficient. I carry auto insurance recommended at a high level for work with seniors and I have always carried personal liability insurance for private practice level for Social Workers. As a Licensed Clinical Social Worker, I can practice without supervision. CLIENTS SERVED The number of seniors served in 2005 is projected to be 4-6 due to their high acuity and need for intense case management. In 2006 an additional 10-12 seniors can be served as their needs may be less demanding and the resources and systems in place can accommodate the senior needs more efficiently. The time required for face to face and network contacts is expected to be 8 hours weekly with an additional 2 hours by phone and communication exchange. Ten hours weekly is planned as an average throughout the 18 month period. Projected time for 2005 period of 28 weeks is (280 hours) and 2006 of 52 weeks is (520 hours) for a total of 800 hours in the 18 months. COST I used my current salary of $30 per hour, and added in FICA, transportation, cell phone, computer costs, supplies, health care increases from less existing employer benefits, and education and training cost. I am using $43 an hour as the total cost and a maximum hourly projection of 800 for the 18 months. The SCC cost would be $34,400 for salary, thus leaving at least $15,600 for purchase of services. I had planned on submitting a monthly hourly total for reimbursement throughout the 18 months. AVAILABILITY I am available Monday, Wednesday, and Friday for 10 hours per week, and I can be more flexible as needed. I can be reached by cell at 319 8850, pager at 1 800 2129026, and I have fax and home phone. IfI am selected for the SCC position I am available June 2005 and welcome the opportunity to enhance the senior experience in Pitkin County. JOHN LUTGRING'S REFERENCES-PITKIN SENIOR CARE COORDINATOR Judy Kelly, BSW, Director of Acute Rehabilitation Unit, Valley View Hospital, 1906 Blake Ave. GWS, Co. 81601 9456535x4280. Judy oversees all aspects of this inpatient program for predominately seniors experiencing stroke, fractures, and chronic medical conditions. Program goals are to remm patients to optimal functioning at home or appropriate setting. MSW role is to assist patients and their families to develop a plan for appropriate services and safety in their community. Dee Morals, RN, Acting Director of Roaring Fork Hospice. Box 1970, GWS, Co. 81602 384 7534. Dee and John do most hospice admissions jointly and she provides medical intervention/assessment with palliative referrals(life threatening illness and ongoing treatment) while John manages the psychosocial needs of palliative referrals who do not need hospice service. Prior to Dee's hospice work, she was night supervisor at Valley View Hospital for 12 years. Celynn Kruegger, MSW, Social Worker at Columbine Home Health, Box 2024, GWS, Co. 81602 ;9458050, C-9488867. I have supervised Celynn's homehealth clinical work and briefly when she did case management with Caring Connections palliative care project. Celynn is PRN MSW at hospice and has coshared client work with John. Tina Staley, MSW, Aspen Valley Hospital Cancer Care Guide-Pathfinders. 5447343 Tina did several years of bereavement volunteer work with John prior to her AVH role. John and Tina co facilitate Aspen's Grief and Loss Support Group, and I have provided informal supervision for her. Alan Saliman, MD, Medical Director, Roaring Fork Hospice since 1997. John has staffed all challenging hospice, palliative care, and ethical issues. Dr. Saliman refers palliative patients and their families in need of case management. Glenwood Medical Associates, GWS, Co. 9458503 or Debi,RN at 384 5055 Robert Derkash, MD, Medical Director, Acute Rehabilitation Unit. John has coordinated all discharge planning, family conferences, and difficult facilities placements with Dr. Derkash since 2001. Orthopaedic Associates of Aspen/Glenwood Springs, 1906 Blake Ave. GWS, Co. 816019458683 *I can facilitate a call back to the Selection Committee for anyone above not responding. John-319 8851or 1-800 212 9026. John Lutgring 21 S. Meadowview Glenwood Springs, Co. 81601 928 8275 Page 800 212 9026 RESUME Valley View Hospital/Roaring Fork Hospice (.5 fie) 1997-Charent Licensed Clinical Social Worker-completes psychosocial assessments with 100 patients/families each year, links to resources, brief counseling, provide bereavement care, community education, volunteer training. Provide palliative care to prehospice clients and families to open communication, problem solving, guide community resources, and facilitate multiple medical professionals toward a plan of care. Valley View Hospital/Acute Rehabilitation Unit ( .25-.5 fie) 2001-Current Clinical Social Worker-guide patient and family toward a workable plan of care for discharge with interdisciplinary team of MD, RN, PT, OT ,ST, MSW. Pitkin County Senior Services 2001-2002 Gero casemanagement for seniors facing challenges navigating resources and challenged by health, mental health, fmancial, family, and legal issues. Columbine Home Health 1997-2001 Clinical Social Worker to challenging clients to keep on the care plan, brief counseling, to access community resources, and to assist client/family with long term care planning. Colorado West Regional Mental Health Center 1995-1996 Program Director of Recovery Center (Outpatient CD, Halfway House, Detox Center, Hiv Education, and Youth Detention Program). Management and supervision of staff. Community Hospitals Indianapolis-Regional Mental Health Center 1975-1995 Clinical Social Worker and County Program Director. Provided individual, family, group therapies, case management, and intensive outpatient programs to children and adults. Supervised all staff, MSW students, and consultation to jail, nursing facility, hospital, and schools. Marion County Juvenile Court/Center 1972-1974 Intensive Caseworker providing 10 clients/families ou~each services to reduce recidivism. EDUCATION Indiana University MSW 1972, BA Sociology 1970, Purdue University, Marriage and Family Therapy course work 1987-1990 Marry Ames May 9, 2005 Pitkin Co. Senior Services Dear Mart3r, I have been brainstorming with the Pitkin Caremanagement Pilot and thought I would provide you a first draft for your input. I am not aware of the time frames of the two years, thus I only foensed on June through December 2005 and all of 2006. Sample Budget of Expenses June -December 2005 Caremonager Salary and Expenses $10,000 Purchased Services for Clients Served 5,000 2005 Directs $15,000 Caremanager Salary/Expenses Jan-Dee 2006 $20,000 Purchased Services for Clients Served 7,500* *(Donated/Volunteer services reduce expense) 2006 Directs 27,500 Total Directs for June 2005 -December 2006 42,500 The number of hours for face to face and caremanagement can be managed by number of individuals served, but until there is 4-6 months of service, the sample budget is only best guess. I believe the purchased services can be reduced with greater knowledge and access to resources in 2006. I did not add in hours for meetings, education, or travel, but I did build in some expenses for all but meetings. We could consider some vacation backup expense of approximately $1,000 for 2006. Iftbe time frame extends into 2007, these estimates are too high. Please let me know other demands you are considering. John Lutgring, L~sW John Lutgring 21 S. Meadowview Glenwood Springs, Co. 81601 928 8275 Page 800 212 9026 RESUME Valley View Hospital/Roaring Fork Hospice (.5 fie) 1997-Current Licensed Clinical Social Worker-completes psychosocial assessments with 100 patients/families each year, links to resources, brief counseling, provide bereavement care, community education, volunteer training. Provide palliative care to prehospiee clients and families to open communication, problem solving, guide community resollrees, and facilitate multiple medical professionals toward a plan of care. Valley View Hospital/Acute Rehabilitation Unit ( .25-.5 fie) 2001-Current Clinical Social Worker-guide patient and family toward a workable plan of care for discharge with interdisciplinary team of MD, RN, PT, OT ,ST, MSW. Pitkin County Senior Services 2001-2002 Gero casemanagement for seniors facing challenges navigating resources and challenged by health, mental health, financial, family, and legal issues. Columbine Home Health 1997-2001 Clinical Social Worker to challenging clients to keep on the care plan, brief counseling, to access community resources, and to assist client/family with long term care planning. Colorado West Regional Mental Health Center 1995-1996 Program Director of Recove~ Center (Outpatient CD, Halfway House, Detox Center, Hiv Education, and Youth Detention Program). Management and supervision of staff. Community Hospitals Indianapolis-Regional Mental Health Center 1975-1995 Clinical Social Worker and County Program Director. Provided individual, family, group therapies, case management, and intensive outpatient programs to children and adults. Supervised all staff, MSW students, and consultation to jail, nursing facility, hospital, and schools. Marion County Juvenile Court/Center 1972-1974 Intensive Caseworker providing 10 clients/families outreach services to reduce recidivism. EDUCATION Indiana University MSW 1972, BA Sociology 1970, Purdue University, Marriage and Family Therapy course work 1987-1990 Request for Taxpayer Identification Number and Certification Give form to the requester. Do NOT send to the IRS. Business name, if different from above. (See Specific~nstructions on page 2.) Check appropriate box: ~ Individual/Sole proprietor [] Corporation [] Partnership [] Other ~ ...................................... Requester's name and address (optional) Address (number~.street, _arid apt, pr suite, no.) City, state, and ZIP c~ ~aa Taxpayer Identification Number ~ N) List account number(s) here (optional) Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, if you are a resident alien OR a sole proprietor, see the instructions on page 2. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to pet a TIN on page 2. Note: If the account is in more than one name, see the chart on page 2 for guidelines on whose number to enter. I~ll! Certification Social security number ~R Em ~l°~r id~nti~cati~ nimbirI For Payees Exempt From Backup Withholding (See the instructions on page 2.) Under penalties of perjury, I cer~if7 that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN. (See the instructions on page 2.) He. $i~lnature , Date, Purpose of form. A person whys What is backup withholding? Persons 5. You do not certif7 to the requester required to file an information return with the IRS must get your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9, if you are a U,S. person (including a resident alien), to give your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are an exempt payee. If you are a foreign person, IRS prefers you use a Form W-8 (certificate of foreign status). After December 31, 2000, foreign persons must use an appropriate Form W-8. Note: If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9. making cer~in payments to you must withhold and pay to the IRS 31% of such payments under certain conditions. This is called "backup withholding." Payments that may be subject to backup withholding include interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. If you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return, payments you receive will not be subject to backup withholding. Payments you receive will be subject to backup withholding if: 1. You do not furnish your TIN to the requester, or 2. You do not certify your TIN when required (see the Part III instructions on page 2 for details), or 3. The IRS tells the requester that you furnished an incorrect TIN, or 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or that you are not subject to backup withholding under 3 above (for reportable interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt from backup withholding. See the Part II instructions and the separate Instructions for the Request~r of Form W-9. Penalties Failure to furnish TIN. If you fail to furnish your con-ect TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment. Misuse of TINs. If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and criminal penalties. Cat. NO. 10231X Form W-9 {Rev. 11-99) Form W-9 (Rev, 11-99) Page 2 Specific Instructions Name. If you are an individual, you must generally enter the name shown on your social security card. However, if you have changed your last name, for instance, due to marriage, without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name. If the account is injoint names, list first and then circle the name of the person or entity whose number you enter in Part I of the form. Sole proprietor. You must enter your individual name as shown on your social security card. You may enter your business, trade, or "doing business as" name on the business name line. Other entities. Enter your business name as shown on required Federal mx documents. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or "doing business as" name on the business name line. Part I--Taxpayer Identification Number (TIN) You must enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your iRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below, If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, using your EIN may result in unnecessary notices to the requester. Note: See the chart on this page for further clarification of name and TIN combinations. How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local Social Security Administration office. Get Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can get Forms W-7 and SS-4 from the IRS by calling 1-800-TAX-FORM (1-800-829-3676) or from the IRS's Internet Web Site at www.irs.gov. If you do not have a TIN, write "Applied For" in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester. Other payments are subject to backup withholding. Note: Writing "Applied For" means that you have already applied for a TIN OR that you intend to apply for one soon, Part II--For Payees Exempt From Backup Withholding Individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends. For more information on exempt payees, see the separate Instructions for the Requester of Form W-9. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding. Enter your correct TIN in Part I, write "Exempt" in Part II, and sign and date the form, If you are a nonresident alien or a foreign entity not subject to backup withholding, give the requester a completed Form W-8 (certification of foreign status). Part III--Certification For a joint account, only the person whose TIN is shown in Part I should sign (when required). 1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification. 2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form. 3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification. 4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. "Other payments" include payments made in the course of the requester's trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations). 5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified stat~ tuition program payments, IRA or USA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to give your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA or USA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry out their tax laws. You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 31% of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply. What Name and Number To Give the Requester For this type of account: Give name and SSN of: 1. Individual 2. Two of more individuals (joint account) 3. Custodian account of a minor (Uniform Gift to Minors Act) 4. a. The usual revocable savings trust (grantor is also trustee) b So-called trust a legal or valid trust 5. Sole proprietorship The individual The actual owner of the account or, if combined [und$, the first individual on the account I The owner 3 For this type of account: ire name and EIN of: Legal entity" The corporation The organization The pa~nership The broker or nominee The public entity may use either your SSN or EIN {if you have one) 4 LiSt brst and circle the name of the legal trust, estate, or pension trust. (Do not furnish the TIN of the personal name is listed, the number will be considered ro Pitkin County Risk Management Department Workers' Compensation Acknowledgment I, John Lutgrin~, as sole proprietor or partner of /, ~-~/,9 ~ct~','kgfl, ~_5~/fi(business name), represent that I have no person or persons in my employ, but that I shall obtain and maintain workers' compensation protection pursuant to those insurance requirements as set forth in the Workers' Compensation Act of Colorado (Articles 40 to 54 of Title 8 of the Colorado Revised Statutes) for any and all persons as I may employ in performing any work in the future. I shall also require any subcontractor as I may contract with or obtain for any work to maintain workers' compensation protection for its employees. Date signed o~ LCSW ~/ 9 budgeted expenditures of Pitkin County. Pitkin County's obligations under this contract are subject to Pitkin County's annual right to budget and appropriate the sums necessary to provide the services set forth herein. No provisions of the contract shall constitute a mandatory charge or requirement in any ensuing fiscal year beyond the then current fiscal year of Pitkin County. No provision of the contract shall be construed or interpreted as creating a multiple-fiscal year direct or indirect debt or other financial obligation of Pitkin County within the meaning of any constitutional or statutory debt limitation. This contract shall not directly or indirectly obligate Pitkin County to make any payments beyond those appropriated for Pitkin County's then current fiscal year. No provisions of this contract shall be construed to pledge or create a lien on any class or source of Pitkin County's moneys, nor shall any provision of this contract restrict the future issuance of Pitkin County's bonds or any obligations payable from any class or source of Pitkin County's money. 20. Notice. Any written notice required by this contract shall be deemed delivered through any of the following: (1) hand delivery to the person at the address below; (2) delivery by facsimile with confirmation of receipt to the fax number below; or (3) within three (3) days of being sent certified first class mail, postage prepaid, return receipt requested addressed as follows: A. Pitkin County with copies to: Marty Ames, Senior Services Director Pitkin County Attorney's Office 0275 Castle Creek Road 530 E. Main Street, #302 Aspen, Colorado 81611 Aspen, Colorado 81611 B. To Contractor: John Lutgring, LCSW 21 S. Meadowview Glenwood Springs, Colorado 81601 (970) 928-8275 IN W1TNESS WHEREOF, the parties have executed this contract as of the date first set out herein above. CONTRACTOR: pIT¢.~O/UNT/~'~/'--'' r Marty Ames, Senior Services Date Nan Sundeen, Community Relations Date 8 LETTER OF ENGAGEMENT June 9, 2005 John Lutgring, LCSW 21 S. Meadowview Glenwood Springs, Colorado 81601 (970) 928-8275 Re: Pitkin County Senior Care Coordination Dear John Lutgring, The purpose of this letter is to summarize the pertinent terms of Pitkin County's arrangement with you to provide the specified services enumerated in the following paragraph. The County's obligation under the Workers' Compensation Statute requires Pitkin County and you to formalize the terms of this engagement in a notarized writing. SCOPE OF WORK An experienced Care Coordinator will meet with seniors in their homes to create an individualized care plan including: · An assessment of service needs · Identification of resources to meet those needs Referrals and assistance with implementation of services · Ongoing monitoring of care · Periodic reassessment of needs The goal of the Senior Care Coordinator is to assist each senior to maintain a quality of life consistent with his or her personal abilities and expectations. 10 Conununity Need: For the purposes of this project, the most significant statistic is the growth in the 75+ population from 1990-2010. This is the group we don't necessarily "see" in the comanunity - those with chronic health conditions and increasing frailty who are typically alone and most in need of services. There are also some younger seniors who are unable to manage daily life effectively due to social, financial, mental and physical health issues. We currently have 10-12 seniors in critical need of case management and this number grows each month. In the last 5 years, the complexity of problems facing this small but growing group of seniors has reached a critical level, beyond the scope of Senior Services staff to handle effectively. These individuals tend to bounce from agency to church to program, seeking help for their current health or financial crisis. The need is for comprehensive case management and long- term solutions. For years we have tried to address this growing need by squeezing it into other initiatives, like palliative care. We have learned that this is a specific need requiring professional expertise to spend adequate time with the senior client, deal with complicated family issues, analyze problems and create solutions. It is mutually agreed that the County does not have an exclusive right to your services and it is contemplated that you may provide similar work to other businesses, governments and non-profit organizations. You acknowledge that the work performed for Pitkin County will be that of an independent contractor and that no employee-employer relationship is created. You have full control over how the services are performed and it is expected that work will be conducted in accordance with industry standards by applying professional judgment. The County will provide, if necessary, documents and information to complete the work described in the preceding paragraph. The County representative signing this letter is available to you to discuss any details related to this engagement. This letter of engagement will terminate on December 31st and will require a new document in succeeding years to be effective. You acknowledge and agree that you shall not be entitled to workers' compensation benefits in connection with this project and that you shall be responsible for the payment of all state and federal income taxes. If you are in agreement with the terms of this letter, please sign below in the presence of a notary and return a copy to us for our files. We appreciate the opportunity of working with you. Sincerely, /.~ - Marry Ames, Sefiior Services Director AGREED: STATE OF COLORADO ) ) SS. COUNTY OF PITKIN ) The forgoing instrument was acknowledged before me this __~_~day of June, 2005, by Witnessed my hand and official seal. ~ My Commission F. xpima 1~/10/2005 11 JUN-16-2005 THU 05',42 ?~ ?ITKIN O0 SENIOR S~VS STATE FARiVI INSURANCE CO~PAN~S tn~ursn~a Oomp~ny Greeley CO 80638.0001 ~ZJ~ -2[86 A F~× NO, 9709205708 AUTO RENEWAL POLICY NUMBi~R 58 9297-AOB-(~6B JUL OS 2005 to dAN 08200S P, 03 LUTGRING, L JOHN & HEATHER DATI~ DUE THIS I$ NOT A BILL. PLEASE PAY THIS AMOUNT Coverages end Limits Premiums 21 s MEADOW VIEW CT GLENW00D SPGS CO 81601-9227 II,,h,.,Ihll.ll..,,lll,h.d,h,l,ll.,h,hl.,Ih.lll Your premium is based on the lollowln9. . .# not oorreOt, Gonta~t your agent. .)002 TOYOTA 4 RUNNER VIN JT3HN86RX29071217 Oleos 6A3H40F Drivers of vehicle in your household... Principal driver is age 50 - 74 and there are no unmarried drivers under 25 assigned to this car. Ordinary use oi vehicle... Pleasure or not more than 30 miles weekly to and f~om work or ashool. Driven 7,500 miles or less annually. (National average is 12,000 miles annually.) Additional Information... Your State Farm Payment Plan number is 0045946418. A Liability Bodily Injury 250,000/500,000 Property Damage 100,000 G Medical Payments 26,000 D-WG 500 Deductible Comprehensive G 500 Deductible Collision H Emergency Road Service U Uninsured Motor Vehicle [3od[ly injury 250~000/500,000 Total Premium Your premium has already been adjusted by the tollowing: Premium Reductions Multiple Line Mutt[car Vehicle Safety Accident-Free 92.09 24.97 57.81 79.04 3.20 ~2.78 ~299.89 ~6.60 75.q0 8.75 51.55 IMPORTANT: It is important that you read the enclosed explanation of SIGNIFICANT CHANGES TO YOUR POLICY. You will soon receive an updated version of your policy. The fo owing I st of drivers s shown for nformationa purposes only and does not extend or expand coverage beyond that contained in this automobile policy. Our records indicate the persons listed below are the only licensed ddvers reperted to us: L JOHN LUTGRING~ HEATHER LUTGRING, SONYA LUTGRING. If the above information is inaccurate or incomplete, please contact your agent immediately to make corrections. · ** Your policy haa the Ouarantoed Renswal Endorsement. Agent CARL J ClANI INSUR AGOY Telephone (970)945-6201 RECEIVED TIME JUN, 16, 5:31PM ~ 70 7802 7295 See reverse sids for important information. Please I~eep this part for.your record. Prepared JUN 02 2005 JUN-16-2005 THU 05:42 PM PITKIN 00 SENIOR SRVS FRX NO, 9709205708 P, 02 CERTIFICATE OF INSURANCE SUC~ ll~UI~,NCE AS RI~FECT~ T~ ~ OF ~ C~ ~ BO~ER OR OTH~WISE ~AT~ WITHOUT G~ 10 DAYS ~OR HO~D~ NA~D BE~, B~ ~ NO E~NT ~LL ~ C~CAT~ BE VAL~ M~ ~ ~ DAYS ~O~ BV ~ ~CY D~ED BE~W. ~ ~: L- JO~ ~ ~A~R L~G~G Ad~ ofN~ ~: 21 S. ~W V~W CT GL~OOD SP~Gg. CO 81~1 Signature ofAu~ori~d Repr~sent~ive Titl~ Agenf s Code Number D~ Name and Address of Ce~ifica~ Holder PIIK1N COUNTY SENIOR SERVICES FAX # 970-947-0779 158-4402 Rev. 9-94 Pr/nted/n USA Name and Add~e~ of A~r= CARL $ CIA/~ CLU 2402 SOOTH/3.RAIqD A'V~. GL~D~GS. CO gl~l (970) 945-6201 C~w.k/fz pe. rm~nent C~ifim of ]~suran~: f~a* liability coverage Check if~he Carrie,'*,,, Holder ~ be ~ as a~z Add/~onal RECEIVED TIME JUN, 16, 5:31PM T/15/O~. $OCZAL WORKER PRO'F~'-SS[ONAL LIABILITY POLICY NO~IC~ A LOW~ L~,']rT ~F MABRL~¢ APPLIE~ TO JUD~M~:N'~ OR S~LE~,ET, T~ WHEN ?H~RE ARE ALLEGATIONS OF 8~UAL MECONDU~ (gEE T~E 9~CiAL P~OVISIO~,~ "SEXUAL M~CO,~UCT" ~N THE ~OLICY), DECLARATI P:,L;OY~O: SWL--38~5256 ACCOUi'~JTi~C~: CO--LUTL4~O--O ITEM 1. {~:) NAME AND ADD~ESS OF INSURED: IT'~V: 1. (b) AD~ITiO~x~M. NAMED INSUREDS: JOHN LUTGR[NG GCENWOOO SPGSt CO 81601 [NOIVIOU&L O~l/O]./O~ 'FO: 0~'/01/05 'i 2:01 A. IVl. STANDARD TIM E AT TF]E ADDRESS OF '~'PI~ INSURED AS STATED NEREIN: (a)$ ZtO00~O00 (b) S Z~O00~O00 ,ic)~ 5~000 EACH WRONGFUL ACT OR SERIES OF CONTINUOUS. REPEATED OR INTERRELATED ;NRONGFUL ACTS OR OCCURRENCE AGGREGATE DEFENSE REIMBURSE[VJE¢-i' D[FgNS~ L/MI1 -{¸ ~. FtE'i?,OAC"¢iVE DA'i',E: 0~/01/~. TOTAL PREMIUM: AS, DJTIONAL PREMIUM (1¢ exercised): ~ ~.~ F, ":= i ANNUAL PREMIUM 1~00i 1~6a00 , 18~000 · , ,; ' ~. POLICY FORMS AND ENDO:ISEMEN'i'S ....~'~ __~,,~ /~ 6197 831gl (10/03} '- ~ ....... '" ....