OFFICE of Medical Director BUREAU of Health Promotion

ALL APPLICATIONS MUST BE SUBMITTED VIA THE INTERNET

OHIO DEPARTMENT OF HEALTH

OFFICE OF Medical Director BUREAU OF Health Promotion

Community Cessation Initiative SOLICITATION FOR FISCAL YEAR 2017 (11/1/17 – 10/31/18)

Local Public Applicant Agencies Non-Profit Applicants

COMPETITIVE GRANT APPLICATION INFORMATION

___Base Only Funding ___Base and Deliverable Funding _X_100% Deliverable Funding

Revised 06/19/2017 For grant starts 4/1/2018 and thereafter

Table of Contents I. APPLICATION SUMMARY and GUIDANCE A. Policy and Procedure ...... 1 B. Application Name ...... 2 C. Purpose ...... 2 D. Qualified Applicants ...... 2 E. Service Area ...... 2 F. Number of Grants and Funds Available ...... 2 G. Due Date ...... 3 H. Authorization ...... 3 I. Goals ...... 3 J. Program Period and Budget Period...... 4 K. Public Health Accreditation Board Standards………………………………………4 L. Public Health Impact Statement...... 5 M. Incorporation of Strategies to Eliminate Health Inequities...... 5 N. Human Trafficking...... 7 O. Appropriation Contingency ...... 7 P. Programmatic, Technical Assistance and Authorization for Internet Submission .... 7 Q. Acknowledgment ...... 8 R. Late Applications ...... 8 S. Successful Applicants ...... 8 T. Unsuccessful Applicants ...... 8 U. Review Criteria ...... 8 V. Freedom of Information Act ...... 9 W. Ownership Copyright ...... 9 X. Reporting Requirements ...... 9 Y. Special Condition(s)...... 11 Z. Unallowable Costs ...... 11 AA. Client Incentives and Enabler ...... 12 AB. Audit ...... 12 AC. Submission of Application ...... 13

II. APPLICATION REQUIREMENTS AND FORMAT A. Application Information...... 14 B. Budget ...... 14 C. Assurances Certification ...... 16 D. Project Narrative ...... 16 E. Civil Rights Review Questionnaire – EEO Survey ...... 20 F. Federal Funding Accountability and Transparency Act (FFATA) Requirement .... 20 G. Public Health Impact...... 21 H. Attachment(s) ...... 21

III. APPENDICES

A. Notice of Intent to Apply for Funding B. GMIS Training Request Form C1. Scope of Work C2. Deliverables Budget Overview D. County Specific Tobacco Need Score E. Community Cessation Initiative Grantee Application Weighting F. Community Cessation Initiative Reviewer Evaluation Form G. Evaluation Requirements and Performance Measures H. Work Plan Template

I. Applicant Funding Table J. Medicaid Billing for Tobacco Cessation Treatment K. CCI Budget Justification Example L. Community Inventory Sample M. Ohio + Local Data N. Suggested Items for Partner Agreement O. PCMH Background Information P. State Health Assessment/Community Health Assessment Background Q. Hospital Bundled Payment Background R. CCI Core Services

I. APPLICATION SUMMARY and GUIDANCE

An application for an Ohio Department of Health (ODH) grant consists of a number of required components including an electronic portion submitted via the Internet website “ODH Application Gateway” and various paper forms and attachments. All the required components of a specific application must be completed and submitted by the application due date. If any of the required components are not submitted by the due date indicated in sections D, G and R, the entire application will not be considered for review.

This is a competitive Solicitation; a Notice of Intent to Apply for Funding (NOIAF – Appendix A) must be submitted by, August 10, 2017 so access to the application via the Internet website “ODH Application Gateway” can be established. Early submission is encouraged.

NEW AGENCIES ONLY or if UPDATES are needed: Applicants must submit proof of liability coverage. Request for Taxpayer Identification Number and Certification (W-9), and Authorization Agreement for Direct Deposit of EFT Payments Form (EFT).

The above-mentioned forms are located on the Ohio Department of Administrative Services website at: http://ohiosharedservices.ohio.gov/SupplierOperations/Forms.aspx

or directly at the following websites:

• Request for Taxpayer Identification Number and Certification (W-9), http://www.irs.gov/pub/irs-pdf/fw9.pdf?portlet=103 • Authorization Agreement for Direct Deposit of EFT Payments Form (EFT) http://www.ohiosharedservices.ohio.gov/SupplierOperations/doc/EFT_Payment_Authorization_OBM4310.pdf • Supplier Information Form http://www.ohiosharedservices.ohio.gov/SupplierOperations/doc/Supplier_Information_Form_OBM5657.pdf

The application summary information is provided to assist your agency in identifying funding criteria:

A. Policy and Procedure: Uniform administration of all the ODH grants is governed by the ODH Grants Administration Policies and Procedures (OGAPP) manual. This manual must be followed to ensure adherence to the rules, regulations and procedures for preparation of all Subrecipient applications. The OGAPP manual is available on the ODH website: http://www.odh.ohio.gov. (Click on Grant/Contracts, ODH Grants, Grants Administrative Policies and Procedures Manual (OGAPP)) or copy and paste the following link into your web browser: http://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/funding%20opportunities/OGAPP% 20Manual%20V100-2%20Rev%2010-1-2014.ashx

Please refer to Policy and Procedure updates found on the GMIS bulletin board.

All budget justifications must include the following language and be signed by the agency head listed in GMIS. Please refer to the budget justification examples listed on the GMIS bulletin board.

• Subrecipient understands and agrees that costs may be disallowed if deemed unallowable or in violation of OGAPP and federal rules and regulations. • The appropriate programmatic and administrative personnel involved in this application are aware of agency policy in regard to subawards and are prepared to establish the necessary inter- institutional agreements consistent with those policies. • Subrecipient agrees and understands that costs incurred in the fulfillment of the Deliverables must be allowable under OGAPP and federal rules and regulations to qualify for reimbursement.

B. Application Name: Community Cessation Initiative – Year 1

C. Purpose: The Ohio Department of Health (ODH) will make an investment to develop capacity to provide local tobacco cessation services to all Ohioans. Selected entities will work with local health departments, community organizations and health care providers to assess existing community tobacco cessation assets and services. Based on identified gaps, selected entities will adopt and implement evidence-based interventions aimed at disparate populations. The selected entity will coordinate and promote services, refer individual patients to interventions and follow up to manage relapses after treatment is completed. Existing ODH resources will be leveraged for community outreach (particularly to disparate populations) and health care provider training.

An entity representing a single county or a group representing a consortium of counties will be responsible for the initiative. Coalitions, including members such as community based organizations, hospitals, and other health care providers will be necessary for success.

In collaboration with the selected entities, using the insight and data learned from the grants, ODH will develop a business case for Ohio Medicaid and other payers to continue and/or consider reimbursing for tobacco cessation services.

D. Qualified Applicants: Ohio Local Health Departments and other nonprofit entities are eligible to apply. Applicants must attend or document in writing prior attendance at Grants Management Information System (GMIS) training and must have the capacity to accept an electronic funds transfer (EFT). If an applicant agency needs GMIS training prior to the establishment of access to the application, then a GMIS training form must be submitted (Appendix B).

The following criteria must be met for grant applications to be eligible for review: 1. Applicant does not owe funds to ODH and has repaid any funds due within 45 days of the invoice date. 2. Applicant has not been certified to the Attorney General’s (AG’s) office. 3. Applicant has submitted application and all required attachments by 4:00 p.m. on Tuesday, September 5, 2017.

E. Service Area: Applicants must apply for funds to cover an entire county in the state of Ohio. Consortium bids for multiple counties must still include the entire counties for which they are bidding.

F. Number of Grants and Funds Available: Up to six grants may be awarded in this first round of funding, totaling $3,000,000. No more than one grant will be provided to a lead LHD or nonprofit entity from each 2015 Ohio Medicaid Assessment Survey (OMAS) county type (Non-

Appalachian Rural and Suburban). Up to two OMAS Urban counties and up to two OMAS Appalachian counties may be selected. Proposals will be evaluated in comparison to other applicants of the same county type. If a consortium of entities wishes to bid, the consortium must pick a lead entity. The location of the lead will determine OMAS county type; the lead will also serve as the primary point of contact with ODH for this grant.

Table 1: Definition of County Type for the 2015 OMAS

County Counties Type Appalachian Adams, Ashtabula, Athens, Belmont, Brown, Carroll, Clermont, Columbiana, Coshocton, Gallia, Guernsey, Harrison, Highland, Hocking, Holmes, Jackson, Jefferson, Lawrence, Meigs, Monroe, Morgan, Muskingum, Noble, Perry, Pike, Ross, Scioto, Trumbull, Tuscarawas, Vinton, Washington Urban Allen, Butler, Cuyahoga, Franklin, Hamilton, Lorain, Lucas, Mahoning, Montgomery, Richland, Stark, Summit Non- Ashland, Champaign, Clinton, Crawford, Darke, Defiance, Erie, Fayette, Appalachian Hancock, Hardin, Henry, Huron, Knox, Logan, Marion, Mercer, Morrow, Rural Ottawa, Paulding, Preble, Putnam, Sandusky, Seneca, Shelby, Van Wert, Warren, Wayne, Williams, Wyandot Suburban Auglaize, Clark, Delaware, Fairfield, Fulton, Geauga, Greene, Lake, Licking, Madison, Medina, Miami, Pickaway, Portage, Union, Wood

Each applicant should refer to the Applicant Funding Table (see Appendix I) to determine the maximum amount available to the agency/ies for year one. The maximum amounts for a single county are between $175,000 and $576,000 depending on the county’s population, Medicaid enrollment, smoking prevalence, need for programs to serve disparate populations and existing referral capabilities. The applicant may apply for any amount up to and including the maximum. A consortium of applicants may request up to the combined total for the counties represented, although some consideration of economies of scale should be made.

No grant award will be issued for less than $30,000. Applications submitted for less than the minimum amount will not be considered for review.

G. Due Date: All parts of the application, including any required attachments, must be completed and received by ODH electronically via GMIS or via ground delivery by 4:00 p.m. by Tuesday, September 5, 2017. Applications and required attachments received after this deadline will not be considered for review.

Contact Amy Gorenflo at 614.466.1717 or email at [email protected] with any questions.

H. Authorization: Authorization of funds for this purpose is contained in ORC 3701.04 (A)(5).

I. CCI Program Goals:

1. Provide tobacco cessation interventions within communities to which health care providers may refer all citizens (including the uninsured, Medicaid enrollees, and

Ohioans insured by commercial carriers and other payers). CCI interventions should be expected to achieve higher quit rates than those that are currently available due to statewide buy-in, increased promotion, awareness, coordination, utilization of evidence-based services and follow up to address relapse. 2. Support counties as the central point of coordination and connection between public and private cessation services. County LHDs or applicant entities will not be required to provide all interventions directly, but rather to ensure local availability in partnership with other community agencies, referral to appropriate sources of services. As necessary and appropriate, applicant may directly provide services. 3. Evaluate efficacy and cost-effectiveness of CCI to facilitate the program’s goals for support and reimbursement from payers as a path to sustainability for local tobacco cessation services. The applicant’s role as connector and facilitator of community-clinic integration is fundamental to long-term success. 4. Create a replicable CCI process between ODH and counties to support statewide adoption. 5. Create a more integrated health planning process between state agencies, LHDs and Ohio’s nonprofit hospitals. The benefits of integrated planning will extend beyond tobacco cessation.

Three critical components will drive successful outcomes: 1. Appropriate state and local infrastructure and capability to develop, coordinate and/or deliver comprehensive tobacco cessation interventions. 2. Health care provider buy-in and expanded referral to/utilization of interventions. 3. Payer buy-in and support of long-term sustainability, assuming the initiative achieves and documents efficacy and cost-effectiveness. Payers include: Medicaid fee for service, Medicaid Managed Care Plans (MCPs), commercial insurance carriers providing private coverage and others (including self-insured employers and possibly the federal Medicare program).

J. Program Period and Budget Period: The three-year program period will begin (November 1, 2017) and end on (October 31, 2020). Funding amounts for years two and three are contingent upon availability of funds for this purpose, as well as successful grantee performance, and will be communicated by ODH prior to the application for year two. The budget period for this application is (November 1, 2017) through (October 31, 2018).

K. Public Health Accreditation Board (PHAB) Standard(s) that will be addressed by grant activities:

Inform and Educate: Inform and educate about public health issues and functions 3.1: Provide Health Education and Health Promotion Policies, Programs, Processes, and Interventions to Support Prevention and Wellness Standard

Community Engagement: Engage with the Community to identify and address health problems 4.1: Engage with the Public Health System and the Community in Identifying and Addressing Health Problems through Collaborative Processes

Policies and Plans: Develop public health policies and plans 5.1: Serve as a Primary and Expert Resource for Establishing and Maintaining Public Health Policies, Practices, and Capacity 4

Access to Care: Promote strategies to improve access to health care services 7.1: Assess Health Care Capacity and Access to Health Care Services 7.2: Identify and Implement Strategies to Improve Access to Health Care Services

Contribute to and apply the evidence base of public health 10.1: Identify and Use the Best Available Evidence or Making Informed Public Health Practice Decisions

L. Public Health Impact Statement: All applicant agencies that are not local health districts must communicate with local health districts regarding the impact of the proposed grant activities on the PHAB Standards.

1. Public Health Impact Statement Summary - Applicant agencies are required to submit a summary of the proposal to local health districts prior to submitting the grant application to ODH. The program summary, not to exceed one page, must include:

The Public Health Accreditation Board (PHAB) Standard(s) to be addressed by grant activities: - A description of the demographic characteristics (e.g., age, race, gender, ethnicity, socio-economic status, disability status, educational levels) of the target population and the geographical area in which they live (e.g., census tracts, census blocks, block groups; - A summary of the services to be provided or activities to be conducted; and, - A plan to coordinate and share information with appropriate local health districts.

The applicant must submit the above summary as part of the grant application to ODH. This will document that a written summary of the proposed activities was provided to the local health districts with a request for their support and/or comment about the activities as they relate to the PHAB Standards.

2. Public Health Impact Statement of Support - Include with the grant application a statement of support from the local health districts, if available. If a statement of support from the local health districts is not obtained, indicate that point when submitting the program summary with the grant application. If an applicant agency has a regional and/or statewide focus, a statement of support should be submitted from at least one local health district, if available.

M. Incorporation of Strategies to Eliminate Health Inequities

The ODH is committed to the elimination of health inequities. Racial and ethnic minorities and Ohio’s economically disadvantaged residents experience health inequities and, therefore, do not have the same opportunities as other groups to achieve and sustain optimal health. Throughout the various components of this application (e.g., Program Narrative, Objectives) applicants are required to:

1. Explain the extent to which health disparities and/or health inequities are manifested within the problem addressed by this funding opportunity. This includes the identification of specific group(s) who experience a disproportionate burden of disease or health condition (this information must be supported by data). 5

2. Explain and identify how specific social and environmental conditions (social determinants of health) put groups who are already disadvantaged at increased risk for health inequities.

3. Explain how proposed program interventions will address this problem.

4. Link health equity interventions in the grant proposal to national health equity strategies using the GMIS Health Equity Module.

The following section will provide basic framework, links and guidance to information to understand and apply health equity concepts.

Understanding Health Disparities, Health Inequities, Social Determinants of Health & Health Equity:

Certain groups in Ohio face significant barriers to achieving the best health possible. These groups include Ohio’s poorest residents and racial and ethnic minority groups. Health disparities occur when these groups experience more disease, death or disability beyond what would normally be expected based on their relative size of the population. Health disparities are often characterized by such measures as disproportionate incidence, prevalence and/or mortality rates of diseases or health conditions. Health is largely determined by where people live, work and play. Health disparities are unnatural and can occur because of socioeconomic status, race/ethnicity, sexual orientation, gender, disability status, geographic location or some combination of these factors. Those most impacted by health disparities also tend to have less access to resources like healthy food, good housing, good education, safe neighborhoods, freedom from racism and other forms of discrimination. These are referred to as social determinants of health. Social determinants are the root causes of health disparities. The systematic and unjust distribution of social determinants resulting in negative health outcomes is referred to as health inequities. As long as health inequities persist, those aforementioned groups will not achieve their best possible health. The ability of marginalized groups to achieve optimal health (like those with access to social determinants) is referred to as health equity. Public health programs that incorporate social determinants into the planning and implementation of interventions will greatly contribute to the elimination of health inequities.

Tobacco-related disparities can be demonstrated in terms of various domains of health inequity – including differences in the patterns, prevention, and treatment of tobacco use; differences in access to and the use of cessation resources; differences in risk, incidence, morbidity, mortality and burden of tobacco-related illness; or differences in exposure to secondhand smoke. In Ohio, priority populations for tobacco interventions are those that exhibit higher prevalence of tobacco use, secondhand smoke exposure, and/or greater incidence of tobacco related death and disease. Based on tobacco surveillance and health outcomes data, these priority populations may include, but are not limited to: a. People of low socioeconomic status; b. People with limited education (high school education or less); c. Lesbian, gay, bisexual and transgender (LGBT) people; d. People with mental health and/or substance abuse disorders; e. People with disabilities; f. Certain occupational groups (e.g., food services, hospitality industry, construction) 6

g. Pregnant women and women with infants or young children; h. African American residents or other racial/ethnic minorities with emerging tobacco- related disparities (e.g., those that identity as multiracial); i. Communities in geographical areas with a high prevalence of multiple risk factors (e.g., low income urban areas, rural communities with high poverty, Appalachian counties); j. Other with demonstrated tobacco-related disparities.

GMIS Health Equity Module:

The GMIS Health Equity Module links health equity initiatives in grant proposals to national health equity strategies such as those found in Healthy People 2020 or the National Stakeholder Strategy for Achieving Health Equity. Applicants are required to select the goals and strategies from the module which best reflect how their particular grant proposal addresses health disparities and/or health inequities. Applicants can choose more than one goal and/or strategy.

For more resources on health equity, please visit the ODH website at: http://www.healthy.ohio.gov/healthequity/equity.aspx.

N. Human Trafficking: The ODH is committed to the elimination of human trafficking in Ohio. If applicable to the Subrecipient program, ODH will give priority consideration to those Subrecipients who can demonstrate the following: 1) Victims of human trafficking are included in your agency’s target population; a. At-risk population b. Mental health population c. Homeless population 2) Agency promotes the expansion of services to identify and serve those affected by human trafficking.

Applicable to Community Cessation Initiative.

O. Appropriation Contingency: Any award made through this program is contingent upon the availability of funds for this purpose. The subrecipient agency must be prepared to support the costs of operating the program in the event of a delay in grant payments.

P. Programmatic, Technical Assistance and Authorization for Internet Submission: Initial authorization for Internet submission, for new agencies, will be granted after participation in the GMIS training session. All other agencies will receive their authorization after the posting of the Solicitation to the ODH website and the receipt of the NOIAF. Please contact Amy Gorenflo at 614.466.1717 or email at [email protected]

Applicant must attend or must document in the NOIAF prior attendance at GMIS training in order to receive authorization for internet submission.

Q. Acknowledgment: An Application Submitted status will appear in GMIS that acknowledges ODH system receipt of the application submission.

R. Late Applications: GMIS automatically provides a time and date system for grant application 7

submissions. Required attachments and/or forms sent electronically must be transmitted by the application due date. Required attachments and/or forms mailed that are non-Internet compatible must be postmarked or received on or before the application due date of Tuesday, September 5, 2017 at 4:00 p.m.

Applicants should request a legibly dated postmark, or obtain a legibly dated receipt from the U.S. Postal Service or a commercial carrier. Private metered postmarks shall not be acceptable as proof of timely mailing. Applicants can hand-deliver attachments to ODH, Grants Services Unit (GSU), via the front desk at 246 N. High St., Columbus, Ohio; but they must be delivered by 4:00 p.m. on the application due date. Fax attachments will not be accepted. GMIS applications and required application attachments received late will not be considered for review.

S. Successful Applicants: Successful applicants will receive official notification in the form of a Notice of Award (NOA). The NOA, issued over the signature of the Director of the Ohio Department of Health, allows for expenditure of grant funds.

T. Unsuccessful Applicants: Within 30 days after a decision to disapprove or not fund a grant application, written notification, issued over the signature of the Director of Health, or his designee, shall be sent to the unsuccessful applicant.

U. Review Criteria: All proposals will be judged on the quality, clarity and completeness of the application. Applications will be judged according to the extent to which the proposal:

1. Contributes to the advancement and/or improvement of the health of Ohioans through increased local tobacco cessation support; 2. Is responsive to policy concerns and program objectives of the Community Cessation Initiative and the Tobacco Use Prevention and Cessation Program; 3. Is well executed and is capable of attaining program objectives; 4. Describes Specific, Measurable, Attainable, Realistic & Time-Phased (S.M.A.R.T.) objectives, activities, milestones and outcomes with respect to time-lines and resources; 5. Estimates reasonable cost to the ODH, considering the anticipated results; 6. Indicates that program personnel are well qualified by training and/or experience for their roles in the program and the LHD or applying entity has adequate facilities and personnel and a willingness to participate in shared learning activities such as technical assistance training and sharing ideas and progress with other grantees; 7. Provides required support to ODH’s evaluation plan/data collection/business case for third party reimbursement; 8. Is responsive to the special concerns and program priorities specified in the Solicitation; 9. Has demonstrated acceptable past performance in areas related to programmatic and financial stewardship of grant funds; 10. Has demonstrated compliance to OGAPP; 11. Explicitly identifies specific groups in the service area who experience a disproportionate burden of tobacco use or who are at an increased risk for problems associated with tobacco use; and, 12. Describes activities which support the requirements outlined in sections I. thru M. of this Solicitation; 13. Need-based priority points will be awarded to applicants in each OMAS county type (See I.E. above). Need scores are identified in Appendix D. Consortium applicants will receive the highest priority points assigned for any of the counties included in the proposal. The 8

applicant representing the county with the highest need does not have to be the lead county in the proposal. 14. Five additional bonus points will be awarded to each consortium bid received. Further information about program specific review criteria for grantees are included in the Application Review Form (Appendix E). Information about how the reviewers of grant applications will evaluate each section is provided in Reviewer Evaluation Form (Appendix F).

The ODH will make the final determination and selection of successful/unsuccessful applicants and reserves the right to reject any or all applications for any given Solicitations; there will be no appeal of the Department's decision.

V. Freedom of Information Act: The Freedom of Information Act (5 U.S.C.552) and the associated Public Information Regulations require the release of certain information regarding grants requested by any member of the public. The intended use of the information will not be a criterion for release. Grant applications and grant-related reports are generally available for inspection and copying except that information considered being an unwarranted invasion of personal privacy will not be disclosed. For guidance regarding specific funding sources, refer to: 45 CFR Part 5 for funds from the U.S. Department of Health and Human Service; 34 CFR Part 5 for funds from the U.S. Department of Education or, 7 CFR Part 1 for funds from the U.S. Department of Agriculture. Select only the appropriate reference.

W. Ownership Copyright: Any work produced under this grant, including any documents, data, photographs and negatives, electronic reports, records, software, source code, or other media, shall become the property of ODH, which shall have an unrestricted right to reproduce, distribute, modify, maintain, and use the work produced. If this grant is funded in whole, or in part, by the federal government, unless otherwise provided by the terms of that grant or by federal law, the federal funder also shall have an unrestricted right to reproduce, distribute, modify, maintain, and use the work produced. No work produced under this grant shall include copyrighted matter without the prior written consent of the owner, except as may otherwise be allowed under federal law.

ODH must approve, in advance, the content of any work produced under this grant. All work must clearly state:

“This work is funded in whole by a grant awarded by the Ohio Department of Health, Bureau of Health Promotion, Tobacco Use Prevention and Cessation Program.”

X. Reporting Requirements: Successful applicants are required to submit Subrecipient program and expenditure reports. Reports must adhere to the requirements of the OGAPP manual. Reports must be received in accordance with the requirements of the OGAPP manual and this Solicitation; before the department will release any additional funds.

Note: Failure to ensure the quality of reporting by submitting incomplete and/or late program or expenditure reports will jeopardize the receipt of future agency payments.

Reports shall be submitted as follows:

1. Program Reports: Subrecipients Program Reports must be completed and submitted via GMIS, as required by the subgrant program by the following dates: 1st Report for 9

November 1, 2017-January 31, 2018 will be due February 6, 2018; 2nd Report for February 1, 2018 thru April 30, 2018 will be due May 6, 2018; 3rd report for May 1, 2018 thru July 31, 2018 will be due August 5, 2018; 4th and final report for August 1, 2018 – October 31, 2018 will be due November 5, 2018. Associated deliverable documents must be submitted with each expenditure report. Any paper non-Internet compatible report attachments (deliverable documents) must be submitted to GSU Central Master Files by the specific report due date. Program Reports that do not include required attachments will not be approved. All program report attachments must clearly identify the authorized program name and grant number.

Submission of Subrecipient Program Reports via GMIS indicates acceptance of the OGAPP. Applicants must maintain regular contact with TUPCP assigned technical assistant, must be present at scheduled monthly learning collaborative calls, must provide a representative to participate in the State Evaluation Team, and must attend up to three scheduled training events in the Columbus area. Please note evaluation requirements and performance measures in Appendix G.

2. Subrecipient Reimbursement Expenditure Reports: Subrecipients can choose monthly or quarterly reimbursement (expenditure report submission) from ODH (please check the reimbursement type on the attached NOIAF). Please note that no changes can be made to the reimbursement type once the project numbers have been established in GMIS. Subrecipient Monthly Reimbursement Expenditure Reports must be completed and submitted via GMIS by the following dates:

Period Report Due Date November 1 – 30, 2017 December 10, 2017 December 1 – 31, 2017 January 10, 2018 January 1 – 31, 2018 February 10, 2018 February 1 – 28, 2018 March 10, 2018 March 1 – 31, 2018 April 10, 2018 April 1 – 30, 2018 May 10, 2018 May 1 – 31, 2018 June 10, 2018 June 1 – 30, 2018 July 10, 2018 July 1 – 31, 2018 August 10, 2018 August 1 – 31, 2018 September 10, 2018 September 1 – 30, 2018 October 10, 2018 October 1 – 31, 2018 November 10, 2018

Subrecipient Quarterly Reimbursement Expenditure Reports must be completed and submitted via GMIS by the following dates: (please see example below)

Period Report Due Date November 1, 2017 – January 31, 2018 February 10, 2018 February 1, 2018 – April 30, 2018 May 10, 2018 May 1, 2018 – July 31, 2018 August 10, 2018 August 1, 2018 – October 31, 2018 November 10, 2018

Note: Obligations not reported on the final monthly or 4th quarter expenditure report will not be considered for payment with the final expenditure report. 10

3. Final Expenditure Reports: A Subrecipient Final Expenditure Report reflecting total expenditures for the fiscal year must be completed and submitted via GMIS by 4:00 p.m. on or before (December 5, 2018). The information contained in this report must reflect the program’s accounting records and supportive documentation. Any cash balances must be returned with the Subrecipient Final Expense Report. The Subrecipient Final Expense Report serves as an invoice to return unused funds.

Submission of the Monthly/Quarterly and Final Subrecipient Expenditure reports via the GMIS system indicates acceptance of OGAPP. Clicking the “Approve” button signifies authorization of the submission by an agency official and constitutes electronic acknowledgment and acceptance of OGAPP rules and regulations.

4. Inventory Report: A list of all equipment purchased in whole or in part with current grant funds (Equipment Section of the approved budget) must be submitted via GMIS as part of the Subrecipient Final Expenditure Report. At least once every two years, inventory must be physically inspected by the Subrecipient. Equipment purchased with ODH grant funds must be tagged as property of ODH for inventory control. Such equipment may be required to be returned to ODH at the end of the grant program period.

Y. Special Condition(s): A Special Conditions link is available for viewing and responding to special conditions within GMIS. The 30 day time period, in which the subrecipient must respond to special conditions will begin when the link is viewable. Subsequent payments will be withheld until satisfactory responses to the special conditions or a plan describing how those special conditions will be satisfied is submitted in GMIS.

Z. Unallowable Costs: Funds may not be used for the following:

1. To advance political or religious points of view or for fund raising or lobbying; 2. To disseminate factually incorrect or deceitful information; 3. Consulting fees for salaried program personnel to perform activities related to grant objectives; 4. Bad debts of any kind; 5. Contributions to a contingency fund; 6. Entertainment; 7. Fines and penalties; 8. Membership fees -- unless related to the program and approved by ODH; 9. Interest or other financial payments (including but not limited to bank fees); 10. Contributions made by program personnel; 11. Costs to rent equipment or space owned by the funded agency; 12. Inpatient services; 13. The purchase or improvement of land; the purchase, construction, or permanent improvement of any building; 14. Satisfying any requirement for the expenditure of non-federal funds as a condition for the receipt of federal funds; 15. Travel and meals over the current state rates (see OBM website: http://obm.ohio.gov/MiscPages/Memos/default.aspx for the most recent Mileage Reimbursement memo.) 16. Costs related to out-of-state travel, unless otherwise approved by ODH, and described in the budget narrative; 11

17. Training longer than one week in duration, unless otherwise approved by ODH; 18. Contracts for compensation with advisory board members; 19. Grant-related equipment costs greater than $1,000, unless justified in the budget narrative and approved by ODH; 20. Payments to any person for influencing or attempting to influence members of Congress or the Ohio General Assembly in connection with awarding of grants; 21. Promotional Items; 22. Office Furniture (including but not limited to desks, chairs, file cabinets)

Subrecipients will not receive payment from ODH grant funds used for prohibited purposes. ODH has the right to recover funds paid to Subrecipients for purposes later discovered to be prohibited.

TUPCP has a limited amount of promotional materials available upon request.

AA. Client Incentives and Client Enablers: Client incentives are an allowable cost for programs related to disparate populations, if ODH gives prior approval.

Client enablers are an allowable cost. The following client enablers may be allowed: transportation, childcare and cell phone minutes.

Recipients of incentives must sign a statement acknowledging the receipt of the incentive and agreeing to the purpose(s) of the incentive. Subrecipients are required to maintain a log of all client incentives and enablers purchased and distributed. These files must be readily available for review during your programmatic monitoring visit.

AB. Audit: Subrecipients currently receiving funding from the ODH are responsible for submitting an independent audit report. Every Subrecipient will fall into one of two categories which determine the type of audit documentation required.

Subrecipients that expend $750,000 or more in federal awards per fiscal year are required to have a single audit which meets OMB’s Federal Uniform Administrative Requirements. The Subrecipient must submit, a copy of the auditor’s management letter, a corrective action plan (if applicable) and a data collection form (for single audits) within 30 days of the receipt of the auditor’s report, but no later than nine months after the end of the Subrecipient’s fiscal year. The fair share of the cost of the single audit is an allowable cost to federal awards provided that the audit was conducted in accordance with the requirements of OMB’s Federal Uniform Administrative Requirements.

Subrecipients that expend less than the $750,000 threshold require a financial audit conducted in accordance with Generally Accepted Government Auditing Standards. The Subrecipient must submit a copy of the audit report, the auditor’s management letter, and a corrective action plan (if applicable) within 30 days of the receipt of the auditor’s report, but no later than nine months after the end of the Subrecipient’s fiscal year. The financial audit is not an allowable cost to the program.

Once an audit is completed, a copy must be sent via e-mail to [email protected] or to the ODH, Grants Services Unit, (GSU) within 30 days. Reference: OGAPP and OMB’s Omni Circular Federal Uniform Administrative Requirements regarding Audits of States, Local Governments, and Non-Profit Organizations for additional audit requirements. 12

Subrecipient audit reports (finalized and published, and including the audit Management Letters, if applicable) which include internal control findings, questioned costs or any other serious findings, must include a cover letter which:

• Lists and highlights the applicable findings; • Discloses the potential connection or effect (direct or indirect) of the findings on subgrants passed through the ODH; and, • Summarizes a Corrective Action Plan (CAP) to address the findings. A copy of the CAP should be attached to the cover letter.

AC. Submission of Application

Formatting Requirements: • Properly label each item of the application packet (e.g., Budget Narrative, Program Narrative). • Each section should use 1.5 spacing with one-inch margins. • Program and Budget Narratives must be submitted in portrait orientation on 8 ½ by 11 paper. • Number all pages (print on one side only). • Program Narrative should not exceed 30 pages (excludes appendices, attachments, budget and budget narrative, and work plan). • Use a 12-point font. • Forms must be completed and submitted in the format provided by ODH

The GMIS application submission must consist of the following: 1. Application Information Complete 2. Project Narrative & Submit 3. Project Contacts Via Internet 4. Budget

- Primary Reason - Funding - Justification - Personnel - Other Direct Costs - Equipment - Contracts - Compliance Section - Summary 5. Civil Rights Review Questionnaire 6. Assurances Certification 7. Federal Funding Accountability and Transparency Act (FFATA) reporting form 8. Change request in writing on agency letterhead (Existing agency with tax identification number, name and/or address change(s).) 9. Health Equity Module 10. Public Health Impact Statement Summary (non-health department only)

11. Statement of Support from the Local Health Districts (non-health department only) 12. Attachments as required by Program A. Community Inventory PDF(s) B. Resumes/Job Descriptions for Assigned Staff C. Work Plan (see Appendix H) D. Letters of Commitment

One copy of the following document(s) must be e-mailed to [email protected] or mailed to the address listed below:

Current Independent Audit (latest completed organizational fiscal Complete period; only if not previously submitted) Copy & E-mail or Ohio Department of Health Mail to Grants Services Unit ODH Central Master Files, 4th Floor 246 N. High Street Columbus, Ohio 43215

II. APPLICATION REQUIREMENTS AND FORMAT

GMIS access will be provided to an agency after it has completed the required ODH sponsored training. Agencies who have previously completed GMIS training will receive access after the Solicitation is posted to the ODH website.

All applications must be submitted via GMIS. Submission of all parts of the grant application via the ODH’s GMIS system indicates acceptance of OGAPP. Submission of the application signifies authorization by an agency official and constitutes electronic acknowledgment and acceptance of OGAPP rules and regulations in lieu of an executed Signature Page document.

A. Application Information: Information on the applicant agency and its administrative staff must be accurately completed. This information will serve as the basis for necessary communication between the agency and the ODH.

B. Budget: Prior to completion of the budget section, please review page 11 of the Solicitation for unallowable costs. Also please refer to Appendix I (Applicant Funding Table) for further detail regarding budget assumptions and to determine the maximum amount of funding which may be requested. Appendix J provides information on allowable Medicaid Billing for Tobacco Cessation Treatment.

The model for reimbursement for this funding opportunity is a deliverables-based model. Reimbursement will be made based on progress toward, and achievement of, units of deliverables that include outcome measures as well as outputs. The budget narrative should be based on the costs to complete each deliverable. While payments may be made throughout the budget period for activities leading to a deliverable, no less than 30% of the cost for a deliverable will be reserved for payment upon completion of the deliverable. Refer to the Scope of Work in Appendix C1 for a listing of each deliverable. The budget associated with each deliverable should be delineated in the “Other Direct Costs” category in GMIS; no line items should be creased in the “Personnel”, “Equipment” or “Contracts” categories in GMIS. 14

An example of a budget for this project can be found in Appendix K.

Match or Applicant Share is not required by this program. Do not include Match or Applicant Share in the budget and/or the Applicant Share column of the Budget Summary. Only the narrative may be used to identify additional funding information from other resources.

1. Primary Reason and Justification Pages: Provide a detailed budget justification narrative that follows Scenario 3 of the Budget Justification Template found in the Grants Management Information System (GMIS). This grant is entirely deliverables-based so all budget items must be attributed to the list of Deliverables and Activities described in the Scope of Work. A CCI-specific Budget Justification example can be found in Appendix K (a GMIS standard budget justification example can be found on GMIS).

2. Personnel, Other Direct Costs, Equipment and Contracts: Submit a budget to support costs for the period (November 1, 2017) to (October 31, 2018). Personnel, Equipment, Contracts and Direct Costs must be contained within Deliverables in the Other Direct Costs category. This is a deliverables-based grant and CCA’s are not required. Contracts should be attached in GMIS within 30 days of signing.

Funds may be used to support personnel, their training, required technical assistance phone calls and grantee collaborative learning forums, up to three in-person meetings with ODH each year, other travel (see OBM website http://obm.ohio.gov/TravelRule/default.aspx), and supplies directly related to planning, organizing and conducting the initiative described in this announcement.

The applicant shall retain all original fully executed contracts on file. A completed “Confirmation of Contractual Agreement” (CCA) must be submitted via GMIS for each contract once it has been signed by both parties. All contracts must be signed and dated by all parties prior to any services being rendered and must be attached to the CCA section in GMIS. The submitted CCA and attached contract must be approved by ODH before contractual expenditures are authorized. CCAs and attached contracts cannot be submitted until the first grant payment has been issued.

Please refer to the memorandum issued by the Director on November 26, 2013 Subject: Contracts. The memorandum was posted on the GMIS Bulletin Board on November 27, 2013.

The applicant shall itemize all equipment (minimum $1,000, unit cost value) to be purchased with grant funds in the Equipment Section.

3. Indirect (Facilities and Administration): Note to Applicant- please select one of the 3 options that apply.

Use the indirect cost rate included in the agency’s Indirect Cost Rate Agreement as negotiated with and approved by the cognizant federal funder. If the applicant chooses this option, then the agreement must be submitted in GMIS as an attachment to the application

If the subrecipient has not executed a federally approved Indirect Cost Rate Agreement, 15

the subrecipient may elect to charge a de minimis rate of 10% of modified total direct costs (MTDC) which may be used indefinitely.

Base the budget solely upon direct costs.

For further information please see section B2.10 of OGAPP.

4. Compliance Section: Answer each question on this form in GMIS as accurately as possible. Completion of the form ensures your entity’s compliance with the administrative standards of ODH and federal grants.

C. Assurances Certification: Each Subrecipient must submit the Assurances (Federal and State Assurances for Subrecipients) form within GMIS. This form is submitted as a part of each application via GMIS. The Assurances Certification sets forth standards of financial conduct relevant to receipt of grant funds and is provided for informational purposes. The listing is not all-inclusive and any omission of other statutes does not mean such statutes are not assimilated under this certification. Review the form and then press the “Complete” button. By submission of an application, the Subrecipient agency agrees by electronic acknowledgment to the financial standards of conduct as stated therein.

D. Project Narrative:

Before completing the project narrative, please complete the Community Inventory (an electronic link will be sent after you submit your Notice of Intent to Apply for Funding, (Appendix A); in the meantime, Appendix L provides a hard copy for your reference) and refer to Appendix I (Applicant Funding Table). Appendix M, Ohio + Local Data, provides a hard copy source of the reference information and data needed to complete the Community Inventory. The responses to each of these are necessary to complete the narrative. Consortium applicants must complete a Community Inventory for each participating county. Submit a copy of your completed Community Inventory(ies) as Attachment 1.

This grant opportunity enables applying entities to hire CCI Staff and develop a sustainability plan for community cessation services, as described in the Scope of Work (Appendix C1).

All cessation services supported by the CCI are required to be certified by the Ohio Department of Health’s Tobacco Program. Information about the certification process and specific requirements will be shared with funded communities.

1. Executive Summary: Provide a brief, one-page synopsis of the applicant(s)’ Community Cessation Initiative proposal including identification of disparate populations, services and programs to be developed and offered and what agency or agencies will provide those services, refer to services and bill for services. Please also include whether applicant(s) have an existing billing system or will partner to develop/share a system during the grant period.

2. Description of Applicant Entity/Documentation of Eligibility/Personnel: Briefly discuss the applicant entity(ies)' structure and staffing as it relates to this program 16

and, if the applicant will serve as the sole or lead entity, how it will manage the program. Resumes for existing staff, qualification requirements for new staff and position descriptions for all staff assigned to CCI project must be included with the program proposal as Attachment 2. Also, include a copy of the following table:

Position Name Percent Dedicated to CCI Duties

Describe the capacity of your organization, its personnel or contractors to communicate effectively and convey information in a manner that is easily understood by diverse audiences. This includes persons of limited English proficiency, those who are not literate, have low literacy skills, and individuals with disabilities.

Note any personnel or equipment deficiencies that will need to be addressed in order to carry out this grant. Describe plans for hiring and training, as necessary. Delineate all personnel who will be directly involved in program activities. Include the relationship between staff members of the applicant agency and other partners and agencies that will be working on this program. Include position descriptions for these staff.

3. Problem/Need: Identify and describe the local health status concern(s) that will be addressed by the program. For a consortium proposal, ensure that each county is addressed. Only restate national and state data if local data is not available. The specific health status concerns that the program intends to address may be stated in terms of health status (e.g., morbidity and/or mortality) or health system (e.g., accessibility, availability, affordability, appropriateness of health services) indicators. The indicators should be measurable in order to serve as baseline data upon which the evaluation will be based. Clearly identify the target population.

Explicitly describe segments of the target population who experience a disproportionate burden for the health concern or issue; or who are at an increased risk for the problem addressed by this funding opportunity.

Include a description of other agencies/organizations, in your area, also addressing this problem/need.

Although no single characteristic fully explains an individual’s risk for tobacco use or related health impacts, tobacco surveillance data show that the populations in Ohio at highest risk for smoking include residents that are socioeconomically disadvantaged, those with disabilities or mental health challenges, and those that identify as LGBT. African 17

American Ohioans and women who are pregnant are also populations of special interest for intervention efforts in Ohio due to tobacco-related health consequences. These groups represent current priority populations for tobacco-related prevention and cessation interventions in Ohio. Following submission of the NOIAF, the applicant agency will receive demographic and market research data from Nielsen at the census tract level in tabular form. This data will be specific to the area served and will enable identification of areas where households are most likely to purchase and use tobacco products. The Nielsen data will be reviewed at the Bidders’ Conference. Appendix M, used for the Community Inventory will also provide useful insight.

Ohio’s very high rate of smoking correlates to a very high incidence of infant mortality. In 2014, Governor Kasich convened a Tobacco Cessation Workgroup which selected CCI as an initiative to focus evidence-based strategies to reduce maternal smoking. Each successful applying entity that participates in CCI will focus on neighborhoods identified by ODH as most at risk for poor birth outcomes and work with community partners to target cessation messages, health related activities and grassroots engagement in cessation. Pregnant women are a REQUIRED disparate population to address in each CCI grant.

Methodology: In addition to describing the Problem/Need, please respond (in narrative form) to the following specific tobacco cessation issues in this section:

a. Specify how tobacco disparities and health inequities will be addressed as they relate to the applicant’s county(ies) and also how data, including Nielsen Market Research Data, was used to inform program interventions in priority areas. Based on both the completed Community Inventory(ies) and the Nielsen Market Research Health Equity Data provided after the NOIAF is received, please do the following:

i. Identify the census geography and the demographic characteristics of the population most likely to smoke and or less likely to engage in smoking cessation behaviors. Include pregnant women.

ii. Describe strategies that will be used to reach these populations and explain how these strategies will be culturally and linguistically appropriate. Please provide the rationale for this/these selection(s). Include pregnant women.

iii. Describe community partners who will collaborate on this cessation program and the role each partner will play. Include a program for pregnant women.

iv. Describe the evidence-base for the service and give a general description of methodology, location, duration, etc. Note: details may change based on later planning (justification will be requested).

b. Describe the community coalition(s) that will engage with CCI in the county(ies). Consortium proposals may include a coalition specific to each county, but must also address how those coalitions will coordinate efforts (for example, a meeting of representatives of each coalition on a regular basis). Consortium proposals may also develop a multi-county coalition, but must include representatives of each county. Discuss which partners are willing to participate. Give a description of each including their mission, target audience, services provided and role in tobacco cessation. Provide website addresses if applicable. Please also note which of these 18

partners were willing to provide an individualized letter of commitment describing the proposed partnership, or give an explanation for those that did not provide a letter of commitment. Please provide these letters as part of Attachment 4. Which partners have experience with data sharing agreements? A list of suggested items to include in an agreement is included as Appendix N.

i. Identify mature PCMH practices in the county(ies) and give a brief description of collaboration to date (see Appendix O). Note: if no PCHM practices are located in a county, there will be no reduction in scoring of the proposal; however, applicant must specifically identify and indicate if there are no PCMH practices in the county(ies). ii. Identify local Community Health Assessment/Community Health Needs Assessments that have identified tobacco cessation as priorities and how efforts will be leveraged (see Appendix P). iii. Identify local hospitals working on bundled payment/discharge follow up and give a brief description of collaboration (see Appendix Q). iv. Describe applicant’s participation in health information exchange and use of CliniSync or Health Bridge for referral or billing purposes, if any. v. Identify entities in the county(ies) receiving Infant Mortality funding and if/how these grants will be leveraged. As noted, programs to support pregnant women using tobacco are a mandatory disparate population program in CCI. c. How will individual counseling (as described in “Core Services,” Appendix R) be offered/ promoted/accessible in the county(ies)? In consortium proposals, address each county individually. d. How will group counseling (as described in “Core Services,” Appendix R) be offered/ promoted/accessible in the county(ies)? In consortium proposals, address each county individually. e. Describe plans to promote the Ohio Tobacco Quit Line as part of the CCI project. f. Describe plans to promote pharmacotherapy availability (through Medicaid, commercial insurers or the Ohio Tobacco Quit Line) as part of the CCI project. Medicaid allows provider type 50 – clinic to bill pharmacy claims. Please identify whether the applicant or relevant county LHD(s) is/are provider type 50. If so, please indicate if pharmacotherapy will be dispensed to tobacco users. If applicant or relevant county LHD is provider type 50 and does NOT intend to dispense pharmacotherapy, please explain why not. If applicant or relevant county LHD is not provider type 50, please indicate if it is planning on pursuing this classification for purposes of dispensing pharmacotherapy. g. What experience does the applicant have with referring patients to services? Describe any existing programs and technology. If the applicant does not have experience with referrals to services, please describe what technical assistance the applicant needs to ensure its role as central Connector and coordinator of services for health care providers that ask, advise and refer patients and for patients who contact the applicant directly. Be aware that this capacity is not a requirement for funding under this grant. h. What experience do(es) the applicant or relevant county LHD(s) have with billing 19

Medicaid or commercial health plans for health care services? Please describe existing programs (including tobacco), services, payers and revenue achieved. If applicant does not have experience with billing, please describe how it will acquire this expertise (e.g. by partnering with an LHD or entity that does) and what technical assistance the applicant may need to ensure its role as central coordinator of services for health care providers that do not have this capability and to bill for services offered directly by the applicant. Be aware that this capacity must be in place by the time services are provided and Deliverable Objective 2 – Objective D is met.

i. Based on the Funding Table in Appendix I, what percent FTE will be reimbursed by the grant? How will the applicant recruit staff with experience and knowledge of the community(ies), preferably with experience with other local stakeholders? Who will supervise these staff?

4. Work Plan: Using the template provided in Appendix H, identify the program activities, staff, timing and evaluation measures. In order to meet the objective (receive a “3” or above as described in Appendix F) you will need to provide a description of how the activities will be conducted. Submit completed work plans as Attachment 3. a. Please develop utilization assumptions for each of the reimbursed services (individual counseling and group counseling). Over the course of three years, CCI assumes a 10% increase in users that attempt to quit, and a 10% increase in utilization of services. Additional assistance/guidance on utilization assumptions will be provided at the bidders’ conference.

E. Civil Rights Review Questionnaire - EEO Survey: The Civil Rights Review Questionnaire Survey is a part of the Application Section of GMIS. Subrecipients must complete the questionnaire as part of the application process. This questionnaire is submitted automatically with each application via the Internet.

F. Federal Funding Accountability and Transparency Act (FFATA) Requirements: All applicants applying for ODH grant funds are required to complete the FFATA reporting form in GMIS. Applicants must ensure that the information contained in SAM.gov, DUN & Bradstreet and the FFATA reporting form match. ODH will hold all payments if an applicant’s information does not successfully upload into the federal system.

All applicants for ODH grants are required to obtain a Data Universal Number System (DUNS), register in SAM.gov and submit the information in the grant application. For information about the DUNS, go to http://fedgov.dnb.com/webform. For information about System for Award Management (SAM) go to www.sam.gov.

Information on Federal Spending Transparency can be located at www.USAspending.gov or the Office of Management and Budget’s website for Federal Spending Transparency at www.whitehouse.gov/omb/open.

(Required by all applicants, the FFATA form is located on the GMIS Application page and must be completed in order to submit the application.)

G. Public Health Impact: Applicants from counties with more than one LHD or applicants that are not an LHD are to attach in GMIS the Letters(s) of Commitment from the other local health district(s) regarding the impact of your proposed grant activities on the PHAB Standards. If a 20

Letter of Commitment from the local health district is not available, indicate that and submit a copy of the program summary that your agency forwarded to the local health district(s). These are provided as Attachment 4. Please note that the RFP also requests Letters of Commitment from local partners and collaborators. These should also be provided as Attachment 4.

H. Attachment(s): Attachments are documents which are not part of the standard GMIS application but are deemed necessary to a given grant program. All attachments must clearly identify the authorized program name and program number. All attachments submitted to GMIS must be attached in the “Project Narratives” section and be in one of the following formats: PDF, Microsoft Word or Microsoft Excel. For the Community Cessation Initiative – Year 1 Grant, the following Attachments are required:

1. Community Inventory PDF(s) 2. Resumes/job descriptions for all assigned staff and table illustrated under C3. Description of Applicant Agency/Documentation of Eligibility/Personnel 3. Work Plan 4. Letters of Commitment for community coalitions as well as from LHD if applicant is not an LHD or represents a county with multiple LHDs.

For the CCI Grant, a PDF copy of the report(s) generated after the applicant submits the Community Inventory(ies) is required to make the proposal responsive to the solicitation. The link for the Community Inventory will be sent after ODH receives your NOIAF.

Please see the GMIS bulletin board for instructions on how to submit attachments in GMIS. An original and the required number of copies of non-Internet compatible attachments must be received by the ODH, Grants Services Unit, Central Master Files address by 4:00 p.m. on or before September 5, 2017.

A minimum of an original and the indicated number of copies of non-Internet attachments are required.

III. APPENDICES A. Notice of Intent to Apply for Funding B. GMIS Training Request Form C1. Scope of Work C2. Deliverables Budget Overview D. County Specific Tobacco Need Score E. Community Cessation Initiative Grantee Application Weighting F. Community Cessation Initiative Reviewer Evaluation Form G. Evaluation Requirements and Performance Measures H. Work Plan Template I. Applicant Funding Table J. Medicaid Billing for Tobacco Cessation Treatment K. CCI Budget Justification Example) L. Community Inventory Sample M. Ohio + Local Data N. Suggested Items for a Partner Agreement O. PCMH Background Information P. State Health Assessment/Community Health Assessment Background Q. Hospital Bundled Payment Background 21

R. CCI Core Services

Reimbursement Type NOTICE OF INTENT TO APPLY FOR FUNDING – Appendix A Select one of the options below: Ohio Department of Health Office of Medical Director Monthly Bureau of Health Promotion OR Quarterly Community Cessation Initiative – Year 1 ALL INFORMATION REQUESTED MUST BE COMPLETED.

County of Applicant Agency Federal Tax Identification Number

NOTE: The applicant agency/organization name must be the same as that on the IRS letter. This is the legal name by which the tax identification number is assigned.

Type of Applicant Agency County Agency Hospital Local Schools (Check One) City Agency Higher Education Not-for Profit

Applicant Agency/Organization

Applicant Agency Address

Agency Contact Person Name and Title

Telephone Number E-mail Address______

______Agency Head (Print Name) Agency Head (Signature) Please note that the agency head listed above must match the agency head listed in GMIS. Unless a new agency, NOIAF’s will not be accepted if name doesn’t match what is listed in GMIS.

Does your agency have at least two staff members who have been trained in and currently have access to the ODH GMIS system? YES NO

If yes, no further action is needed.

If no, at least two people from your agency are REQUIRED to complete the training before you will be able to access the ODH GMIS system and submit a grant proposal. Complete the GMIS training request form in the Request for Proposal.

The NOIAF must be accompanied by the agency’s Proof of Non-Profit status (if applicable); Proof of Liability Coverage (if applicable); Request for Taxpayer Identification Number and Certification (W-9), Authorization Agreement for Direct Deposit of EFT Payments Form (EFT), (New Agency Only) Vendor Information Form. These forms are located on the Ohio Department of Administrative Services website at: http://ohiosharedservices.ohio.gov/SupplierOperations/Forms.aspx.You can also access these forms at the following websites: • Request for Taxpayer Identification Number and Certification (W-9), http://ohiosharedservices.ohio.gov/SupplierOperations/Forms.aspx • Authorization Agreement for Direct Deposit of EFT Payments Form (EFT) http://www.ohiosharedservices.ohio.gov/SupplierOperations/doc/EFT_Payment_Authorization_OBM4310.pdf • Supplier Information Form http://www.ohiosharedservices.ohio.gov/SupplierOperations/doc/Supplier_Information_Form_OBM5657.pdf

Forms are only required for NEW AGENCIES or if UPDATES are needed for current agencies. ODH will forward the forms to Ohio Shared Services. FORMS MUST BE RECEIVED BY August 7, 2017

Amy Gorenflo (614.466.1717) Ohio Department of Health Tobacco Use Prevention and Cessation Program 246 North High Street – 8th Floor Columbus, OH 43215 E-mail: [email protected] NOTE: NOIAF’s will be considered late if any of the required forms listed above are not received by NEW AGENCIES by the due date. NOIAF’s considered late will not be accepted A-1

Appendix B

GMIS 2.0 TRAINING FORM – Appendix B

GMIS Training, User Access, Access Change or Deactivation Request

One request per person. Requests will only be honored when signed by your Agency Head or Agency Financial Head and complete. In addition, if a user leaves your agency, you are to notify ODH so that their account is rendered inactive and submit a form for the replacement. The user will receive his/her username and password via e-mail once the request is processed. Please note: GMIS Training is only required for New Agencies to ODH. If you are new to your agency someone there should train you. Refresher guides can be found on the ODH web site: http://www.odh.ohio.gov/en/about/grants/grants.aspx ODH Grants Page – “GMIS Training Resource” Section. Confirmation of your GMIS training session will be e-mailed once a date has been assigned by ODH. Also use this form when user changes are needed.

`Date: ______

Check the type of access and complete the information requested: [ ] Employee - needs GMIS Training

[ ] New Employee - needs GMIS Access. Effective Date of Activation: ______

[ ] Existing Employee - New GMIS User or GMIS User Access Change. Effective/Change Date:______

[ ] Agency Head [ ] Agency Financial Head [ ] Program Director [ ] Program Fiscal Contact [ ] User

Check the type of Deactivation and complete the information requested – [ ] User no longer needs access to ODH

Application Gateway/GMIS 2.0 Effective Date of Deactivation: ______or

[ ] User no longer needs access to GMIS 2.0 only. Effective Date of Deactivation: ______or

[ ] User no longer needs access to GMIS Project(s) listed below: Effective Date of Deactivation: ______

Agency Name & Address:______

______Employee Name (no nicknames):

Employee Job Title:

Employee Office Phone Number: Employee Office Fax Number:

Employee Office Email Address:

User Access/Change/ Deactivation Section: Please check all that applies and enter requested information:

Email Notifications: [ ] Yes [ ] No

GMIS Project Number(s) - User needs/does not need (circle the one that applies) access to: ______

B-1

Appendix B

Authorization Signature for User Access/Change/Deactivation:

______Printed Name of Agency Head or Agency Financial Head Signature of Agency Head or Agency Financial Head

To be completed by Grants System Officer ONLY - Date Received: Date Processed: Deliver Requests to Karen Tinsley, Grants System Officer, 614-644-7546 Mail: ODH/OFA, 35 E. Chestnut St.,4th Floor, Columbus, Ohio 43215 Or Scan & Email: [email protected]

B-2

Appendix C1 Appendix C1 Name of Subgrant Program: Tobacco Use Prevention and Cessation Program-Community Cessation Initiative Budget Period: November 1, 2017-October 31, 2018 # of Deliverables: 6 Use Budget Justification Scenario#: 3

_____ Base and Deliverables X Deliverables Only

Role of the Funded Grantee Organizations in Accomplishing the Goals of the CCI Initiative: As a three-year program, the activities identified below will evolve over time. The focus in the first year will be on identifying and filling gaps in infrastructure and service providers, targeting the highest need disparate populations, launching and promoting services in the community, and doing early evaluation. Year two will focus on solidifying the baseline services, expanding as necessary to serve additional disparate populations, working more closely with local and state entities on an integrated planning process, and increasing utilization of cessation services. By the end of year two grantees will be focusing on long term sustainability planning. Year three will continue the activities of the previous years but may also include mentoring other local health departments that are just starting their three-year funding cycle. A strong focus will at this point be on sustainability, billing relationships and evaluation.

Specific Activities: 1. Make an assessment of local cessation services and the populations they serve. Create a plan to develop a community coalition to fill gaps in services. Coordinate with ODH to provide training to community partners that will facilitate local services to be provided in accordance with best practices. 2. Develop a referral and billing infrastructure so community agencies are willing and able to provide local cessation services and coordinate and connect public and private cessation services with tobacco users. As necessary and appropriate, grantee may provide direct services. 3. Promote local CCI services to health care providers and track referrals. Follow up with each tobacco user to determine the success of their cessation attempt; provide encouragement and re-engage anyone who has experienced a relapse. 4. Evaluate efficacy and cost-effectiveness of CCI cessation services to facilitate ODH’s goals for support and reimbursement from payers as a path to sustainability. Provide feedback and additional training to community partners as needed. Contribute to a replicable CCI process between ODH and Ohio counties through participation in learning collaborative activities. 5. Develop and participate in a more integrated planning process locally (CHA/CHIP and CHNA) and statewide (SHA/SHIP) to coordinate and optimize local efforts for greatest impact.

C1-1

Appendix C1 Deliverable - Objective 1: By the end of Month 3 a series of planning documents to establish necessary infrastructure to execute CCI program activities will be submitted to ODH. These documents will be added to the funded entity’s overall project plan. Documents include:

Objective A: Submit Strategic Planning Document (20-page limit excluding position descriptions), which must include the following:

• Summary of the results of the Community Inventory analysis. • Identification of the gaps in cessation services. o Prioritize 3 service gaps to work on within this budget year. o Identify 3 disparate populations you will be working with during year one. • List of staff and stakeholders identified and included in workgroups. o Notes and sign-in sheets from planning meetings. • Staffing infrastructure/plan. o Positions descriptions for all program staff. (Must indicate minimum experience and project responsibilities). o Designate staff who will participate in evaluation activities. o Timeline to reach full staffing for project.

Objective B: Submit Project Implementation Plan which must include the following:

• For the 3 prioritized service gaps and 3 disparate populations identified in Strategic Planning Document develop a plan and timeline for implementation of cessation services. o How implementation of each of the three areas will be approached. . Structure services in line with Clinical Practice Guidelines and the recommendations provided by ODH. . Ensure services are included in deliverables and activities relating to Deliverable - Objective 2 (below). o Identify partners specific to each priority area and describe how those partnerships will be established and maintained and the responsibilities of each partner. o Identify what specific methods will be used to service targeted disparate populations. o Identify resources required and how they will be obtained. • Actions to support success include: o Attend training offered by ODH on Health Equity and Tobacco Control (submit certificate of completion for disparate population training or documented registration for training), as well as participate in TA meetings and information exchanges.

Deliverable - Objective 2: By the end of Month 5 develop and launch a community cessation provider network with mechanisms for service delivery, a documented referral process/system, and provider billing. Objective A: Establish of a community network system of existing service providers in place to offer essential cessation services to residents of county(ies). • Submit a list of approved existing service providers that are able to offer essential cessation services to residents of your jurisdiction. • List must be supported by what services providers offer and their methods of treatment.

C1-2

Appendix C1 • Documentation of ODH approval for each provider. • Executed Agreements for existing qualified/ODH-approved providers that include, if appropriate, how providers will be reimbursed for services that are not billable through Medicaid or other insurance provider.

Objective B: XX (to be filled in by funded entity) new providers are in place offering cessation services. (NOTE: This deliverable should only be chosen if existing services are not adequate to meet the needs of the service area.) Actions to support success include: • Summarize types of services (e.g. group, individual, referral for telephonic) to be provided and how new providers (applicant, LHD or community provider) work to fill identified service gaps. • Provide documentation of ODH approval of provider and services to ensure they are in line with essential services outlined in RFP. • Provide document of executed Agreements for new providers that include, if appropriate, how providers will be reimbursed for services that are not billable through Medicaid or other insurance provider.

Objective C: Documentation of an established system for accepting, distributing, and tracking referrals which will include the following:

• A description of your referral system. o Obtain patient contact information and tobacco treatment history (consistent with what is required by the state evaluation). o What kind of service where they referred (group, personal, quit line). o The provider to which they were referred. o Confirmation that referral is received by provider. o Ability to document follow-up activities. • Ability to accept telephone, email, or fax referrals. • Method for processing referrals. Under what criteria will you send a referral to a specific provider. • Describe data security and retention policies. • How will you will exchange information between provider making referral and service provider. • NOTE: You should have the structure of your referral system identified by Month 4 to train providers on referrals in Month 4 to begin taking referrals in Month 5. Objective D: An established system for health insurance billing for cessation services which will include the following:

• Documentation that the provider is approved to bill Medicaid for cessation service. • Documentation of payment for cessation services billed. • If applicant is providing services they must be able to provide this documentation. • NOTE: ODH will not reimburse for funded entity to build or implement a new system. However, services associated with partnering to use an existing system (e.g. training) can be included in the grant proposal.

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Appendix C1 Deliverable - Objective 3: By the end of Month 5 execute a plan to increase the identification of tobacco users and the number of tobacco users that are referred for treatment through County’s CCI project. Objective A: Demonstrate that XX (to be filled in by funded entity) healthcare providers or service delivery organizations have been trained on the referral process to CCI which will include the following:

• Provide a list of all physicians, hospitals, health clinics and FQHCs in the service area that need to be trained. • Timeline of training to reach all providers on list. (Include how you will reach providers unable to be reached with in-person training (conference calls, webinar, provider materials). • Provide documentation of approval of training and promotional materials by ODH. • Schedule and conduct trainings – provide sign in sheets from trainings provided.

Objective B: Demonstrate that XX (to be filled in by funded entity) community partnerships to support and promote CCI and tobacco cessation services in the community have been established that includes the following:

• Provide a list of all community organizations in the service area that need to be informed of the CCI referral service. • Timeline of training to reach all organizations on list. • Provide sign-in sheets for trainings.

Objective C: Demonstrate that XX (to be filled in by funded entity) promotional activities (e.g. media releases, community events, social media) have been implemented to support and promote CCI and tobacco cessation services in the community which includes the following:

• Provide list of target audiences to reach with promotional activities with a justification of why activities should reach proposed audience. • Provide meeting notes and sign in from meeting with ODH Tobacco Public Information Specialist. • Documentation of ODH preapproval of promotional activities or materials. • Timeline for any promotional activities not completed by Month 5.

Deliverable - Objective 4: Begin delivering cessation services no later than the end of Month 5 and continue through Month 12. Services shall include the following: • Submit expense reports for cessation services to ODH on a monthly or quarterly basis, depending on the billing/reporting cycle selected by the funded entity, and will reflect actual utilization rates times the Medicaid payment rates. • Expense reports shall delineate the number of people served, types of service, dates of service, and should be billed at the established Medicaid payment rates. • Demonstrate that uninsured individuals have been connected with services that will assist them in gaining insurance coverage. Identify which staff person will attend required training on this issue. • Provide evidence of denied claims when billing for individuals with private insurance. o Documentation must include the name of the carrier and other information as requested by ODH.

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Appendix C1 NOTE: ODH will not reimburse for Medicaid services or telephonic counseling in lieu of the Quit Line unless approved prior to offering as a component of a special outreach program for a disparate population.

Deliverable Objective 5 Beginning no later in Month 7 and continuing through Month 12, the lead agency will have completed and documented follow up contact has been attempted with all individuals who received any service through the CCI. Objective A: Provide a protocol for consistent and long term follow up with those referred to cessation treatment which will include the following: • Describe what system you have in place that identifies when and how often each participant should be contacted for follow up to assess patient success or refer to additional services. (NOTE See table below for minimum requirements). • Provide scripts or protocols for each routine follow-up contacts that provide direction for possible treatment outcomes (e.g. support or reentry due to relapse). • Provide documentation that the follow up protocols have been approved by ODH. • Provide documentation that staff who are going to conduct follow up contacts have been trained. For trainings after month 7, provide a timeline for ongoing training and oversight.

Days/months Local Health Evaluation Team post-referral Department/ Treatment Provider/Applicant 30/1 Treatment Provider/LHD 60/2 Treatment Provider/LHD 90/3 Phone: Script includes language about status and options for support (can refer back to funded entity if relapsed) 120/4 Treatment Provider/LHD 150/5 Treatment Provider/LHD 180/6 Phone: Script includes language about status and options for support (can refer back to funded entity if relapsed) 210/7 240/8 270/9 Treatment Provider/LHD 300/10 330/11 365/12 Treatment Provider/LHD Phone (can refer back to funded entity if relapsed) 18 months Treatment Provider/LHD 24 months Treatment Provider/LHD

Objective B: Implement the protocol for long term follow up of CCI participants: C1-5

Appendix C1 • Provide a monthly report (by 10th of each month starting in month 8) to external evaluator which includes each contact, date, and results using a pre-agreed upon participant identification number. • Develop protocol, assuring all strategies align with essential services outlined in RFP. • For patients requiring reconnection with services demonstrate that referrals to providers have been made and accepted. Or received?

Deliverable - Objective 6: By the end of Month 12, participate in quality assurance reviews, one process evaluation and one outcome evaluation to determine the sustainability of CCI. Objective A: By Month 6 provide documentation that quality assurance protocols are in place. • Attendance at monthly state evaluation planning team meetings to jointly develop measures for quality assurance which will focus on the following: o Referral system is functioning as intended. o Service providers are providing services that are consistent with ODH Guidelines. o Fidelity of referral follow up protocols. o Partnership engagement and are they doing the things we need them to do. o Are partnerships and promotional activities bringing in participants as appropriate? Objective B: Participate in a state evaluation which will include the following. • Participate in no fewer than 75% of all Evaluation Planning Team meetings. Meeting frequency will be biweekly two hour meetings. • Gaining consent from participants to collect data and providing data to external evaluator including establishment of agreements with partners who may be providing services outside the CCI process. • Participating and facilitating participation in site visits and other data collection methods for a state process evaluation. • Assisting in establishing program evaluation indicators and providing evaluation data from LHD and service providers as determined by the Evaluation Planning Team.

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Appendix C2

Appendix C2 Form# OFA-012 Name of Subgrant Program: Tobacco Use Prevention and Cessation Program-Community Cessation Initiative Budget Period: 11/1/17 - 10/31/18 # of Deliverables: 6 Use Budget Justification Scenario #: 3 (provide one for each county if regional application) ____ Base Only ____ Base and Deliverables __X__ Deliverables Only Base Deliverable - Deliverable - Deliverable - Deliverable - Deliverable - Deliverable - Total Name of Sub- Objective 1 Objective 2 Objective 3 Objective 4 Objective 5 Objective 6 recipient or By the end of By the end of By the end of Begin Beginning no By the end of County or Region Month 3 a series Month 5 develop Month 5 execute delivering later in Month 7 Month 12, of planning and launch a a plan to cessation and continuing participate in documents to community increase the services no through Month quality establish cessation provider identification of later than the 12, the lead assurance necessary network with tobacco users end of Month agency will have reviews, one infrastructure to mechanisms for and the number 5 and continue completed and process execute CCI service delivery, a of tobacco users through documented evaluation and program documented that are referred Month 12. follow up one outcome activities will be referral for treatment contact has evaluation to submitted to process/system, through County’s been attempted determine the ODH. These and provider CCI project. with all sustainability of documents will billing. individuals who CCI. be added to the received any funded entity’s service through overall project the CCI. plan. 0 *To be provided *To be provided *To be provided *To be *To be provided *To be provided by applicant by applicant by applicant provided by by applicant by applicant applicant Total

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Appendix D Appendix D: County Specific Tobacco Need Score

Ohio County Points Awards by county tobacco ranking for cessation intervention need and county type The priority ranking table for cessation intervention need is developed using county-level measures of socioeconomic status, percent of the population covered by Medicaid, adult tobacco behavior, health outcomes, and market and retail metrics. A composite score is calculated and the counties are ranked from 1-88. A higher number represents a greater need for cessation interventions. The counties are divided into typology: urban; suburban; rural, non- Appalachian, and Appalachian. Within each typology category, the counties are divided into 5 quintiles. Points are awarded based on need, with the highest number of priority points being assigned to counties in the first quintile (Q1) across county typology.

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Appendix E Appendix E: Community Cessation Initiative Grantee Application Weighting

Section Weight Executive Summary 3 Community Inventory Tool 15 Description of Agency 5 Problem/Need/Program 28 Methodology 37 Work Plan (2 points each Objective) 12 Budget 0 Subtotal: Points based on applicant’s response Maximum: 100 Need-based Priority Points (assigned by ODH) 15 Consortium-based Priority Points (assigned by ODH) 5 TOTAL Maximum: 120

Executive Summary Weight Appropriate Identification of disparate populations 1 Services and programs identified and partners described appropriately 1 Description of existing billing system or what will be needed to develop/modify a billing system 1 Community Inventory Weight All questions are addressed and answered 5 Detailed information is provided to ensure the applicant agency has thoroughly identified existing policies 5 and capacity to address tobacco Availability of services and areas in need of support are identified and relate to overall proposed workplan 5 Description of Applicant Agency Weight Agency structure and eligibility described 1 Capacity of agency to communicate effectively to diverse audiences described 1 Adequate number and experience of personnel who will work on grant objectives 1 Staffing levels and funding request appropriate for initiatives 1 Personnel or equipment deficiencies and how they will be addressed. 1 Problem/Need/Program Weight Local health status and social determinants of health concerns described 4 How concerns will be addressed (mix of program and stakeholders) 20 Measurable indicators 4

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Appendix E Methodology Weight How tobacco disparities and health inequities will be addressed as they relate to applicant’s county. 5 Diverse and comprehensive coalition described and Letters of Commitment submitted to show 7 commitment PCMH practices identified and/or engaged 3 Local CHA/CHIP or CHNA that have identified tobacco cessation as a priority described 3 Local hospital participation in bundled payment programs described 3 Participation in CliniSync/Health Bridge described 2 Infant Mortality grantees identified 2 (Core Services) Disparate population strategy plans evidence-based 2 (Core Services) Individual counseling provided as part of plans 2 (Core Services) Group counseling provided as part of plans 2 (Core Services) Ohio Tobacco Quitline promoted as part of plans 2 (Core Services) Pharmacotherapy promoted as part of plans 2 LHD experience with referrals described and TA identified 1 LHD experience with billing described and TA identified 1 CCI Work Plan Weight Objective 1 – Planning documents submitted to ODH 2 Objective 2 – Develop and launch a community cessation provider network, referral system, and billing 2 capability Objective 3 – Increase identification of tobacco users and number referred for treatment 2 Objective 4 – Deliver cessation services 2 Objective 5 – Follow up contact initiated and documented 2 Objective 6 – Participate in quality assurance and evaluation activities 2 Budget* Weight Does not exceed the maximum award for county 0 Primary reason and justification is satisfactory and relates expenditures to the work plan 0 Adequately discusses the reasonableness of proposed costs 0 All cost components are included in the Deliverables identified 0 Budget is reasonable and adequate to meet the goals and objectives of the project 0 *Budget shortcomings can be addressed via “special condition”

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Appendix F

Reviewer: ______

Date: ______

Community Cessation Initiative Grant Reviewer Evaluation Form

Applicant Agency: ______Total Requested Budget: ______

County Served: ______

Scoring Instructions Does not Meet Weak Weak to Meets Meets Meets to Strong Strong

0 1 2 3 4 5

Does Not Meet (0): Response does not comply substantially with requirements or is not provided Weak (1): Response was poor related to meeting the objectives Weak to Meets (2): Response indicates the objectives will not be completely met or Section Points* at a level that will be below average Executive Summary Maximum: 3 Meets (3): Response generally meets the objectives (or expectations) Community Inventory Maximum: 15 Meets to Strong (4): Response indicates the objectives will be exceeded Description of Agency Maximum: 5 Strong (5): Response significantly exceeds objectives or expectations Problem/Need/Program Maximum: 28 Methodology Maximum: 37 Recommend Work Plan Maximum: 12 Not recommended Budget Priority Points ODH to assign Comments: (maximum 15) Consortium Points ODH to assign Special Conditions: (maximum 5) Total

(use back as necessary)

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Appendix F

*ODH will use the score assigned by each evaluator to convert to points based on the allocations in the Grantee Application Weighting form (Appendix D). For example, the Executive Summary is worth three points – one point for each line item to be evaluated. Below is an explanation of how the evaluators score would be converted to points by ODH: An evaluator gives the applicant a score of 5 (Strong) for Appropriate identification of disparate populations, a 3 (Meets) for Services and programs identified and partners described appropriately, and a 0 (Does not meet) for Description of existing billing system or what will be needed to develop/modify system. This represents 53% (8/15) of the maximum possible score. With a total of 3 weighted points this is converted to 1.6 points for the Executive Summary.

Executive Summary (Max: 3 points) Score Comments Appropriate Identification of disparate populations Services and programs identified and partners described appropriately Description of existing billing system or what will be needed to develop/modify system. Community Inventory (Max: 15 points) Score Comments All questions are addressed and answered 5 Detailed information is provided to ensure the applicant agency 5 has thoroughly identified existing policies and capacity to address tobacco Availability of services and areas in need of support are 5 identified and relate to overall proposed workplan Description of Applicant Agency (Max: 5 points) Score Comments Agency structure and eligibility described Capacity of agency to communicate effectively to diverse audiences described Adequate number and experience of personnel who will work on grant objectives Staffing levels and funding request appropriate for initiatives Personnel or equipment deficiencies and how they will be addressed. F-2

Appendix F Problem/Need/Program (Max: 28 points) Score Comments Local health status and social determinants of health concerns described How concerns will be addressed Measurable indicators Methodology (Max: 37 points) Score Comments How tobacco disparities and health inequities will be addressed as they relate to applicant’s county. Diverse and comprehensive coalition described and Letters of Commitment submitted to show commitment PCMH practices identified and/or engaged Local CHA/CHIP or CHNA that have identified tobacco cessation as a priority described Local hospital participation in bundled payment programs described Participation in CliniSync/Health Bridge described Infant Mortality grantees identified (Core Services) Disparate population strategy plans evidence- based (Core Services) Individual counseling provided as part of plans (Core Services) Group counseling provided as part of plans (Core Services) Ohio Tobacco Quitline promoted as part of plans (Core Services) Pharmacotherapy promoted as part of plans LHD experience with referrals described and TA identified LHD experience with billing described and TA identified CCI Work Plan (Max: 2 points each Objective) Score Comments Objective 1 – Planning documents submitted to ODH Objective 2 – Develop and launch a community cessation provider network, referral system, and billing capability Objective 3 – Increase identification of tobacco users and number referred for treatment Objective 4 – Deliver cessation services Objective 5 – Follow up contact initiated and documented Objective 6 – Participate in quality assurance and evaluation activities Budget* Score Comments F-3

Appendix F Does not exceed the maximum award for county Primary reason and justification is satisfactory and relates expenditures to the work plan Adequately discusses the reasonableness of proposed costs Personnel, Other Direct Costs, Equipment, and Contracts are identified and appropriate to program scope of work Budget is reasonable and adequate to meet the goals and objectives of the project *Budget shortcomings can be addressed via “special conditions”

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Appendix G Appendix G: CCI Evaluation

CCI pilot study entities (agencies) and their partners will undergo extensive evaluation to determine if the CCI model is effective, and to provide evidence for determining whether the model can be included as a cessation Evidence-Base Practice (EBP). Agencies receiving funding will be required to participate in rigorous process and outcome evaluations. Consequently, agencies who submit a proposal agree to fully participate in the program evaluation and provide all required data in a timely manner. Additionally, contracted agencies will be responsible for assigning a person to represent their agency and all partnering agencies by becoming a member of the State Evaluation Team (SET). The SET will meet regularly in Columbus throughout the year. The contracting agency should consider staffing and other resource expenses for this in its deliverables-based budget. Each partnering agency, within a jurisdiction, that provides cessation services under a Partnership Agreement will be reimbursed $1,000 per year to cover their expenses in providing evaluation data.

The program evaluation will include the following activities:

A. Quarterly performance reports will consist of providing specific information about tasks (Performance Measures) as well as qualitative descriptions of barriers and successes. Actual performance measures will be provided to the agency and will include information such as:

i. The number of Partnership Agreements; ii. Number and types of cessation programs available; iii. Sub-populations targeted for cessation programs; iv. Number, type of partners and how each partner supports the effort of cessation services; v. Number and type of referral sources; vi. The degree to which cessation programs are evidence-based (meet the standardized guidelines provided); vii. Entering information gathered from interviews with referred individuals into a web portal provided by ODH; a) Information may include previous quit attempts, current tobacco use, attitudes and knowledge regarding tobacco and second-hand smoke, contact information, referral information, and status. b) Number and result of each follow-up contact by the community health worker or individual providing long-term follow up activities; viii. Program barriers, challenges, and successes; ix. And, number of rejected insurance claims for cessation services provided. B. Participate in process evaluations, which will consist of site visits, interviews, surveys, program fidelity checks and document checks of the contracted agencies and partners. C. Obtain signed consent from referred individuals to participate in the evaluation and provide referral data (data entered into the referral portal) and contact information to the SET to conduct follow-up interviews. Follow-up interviews administered to cessation participants will be conducted at 3, 6, and 12 months following referral. These interviews are in addition to contact made by CCI representative (e.g. community G-1

Appendix G health worker) at 4, 5, 9, 12, 18 and 24 months’ post referral if the patient has not returned to treatment. These short interviews will consist of items regarding their experiences and interactions with cessation programs and personnel, cessation attempts, and results. The external evaluator will report back to the local program regarding the results of these follow-up surveys for their referrals. D. A cost-benefit analysis that estimates past expenditures prior to the grant and current expenditures, along with health care costs and other social benefits of providing cessation services. E. As part of the Partnership Agreement, the partnering agencies should agree to provide participant information to the external evaluator. Additionally, the partnering agencies agree (see suggested items for Partnership Agreement, Appendix N) to provide information regarding current and future rendered cessation services such as: i. Description of services; ii. Number and characteristics of participants; including a) Type of cessation service; b) Number of times participated (dosage); c) Dates of participation; d) Participant status (completion/termination); iii. Success rate (if available); iv. And, funding allocations for services rendered. v. This information will also be collected from funded agencies who currently have, or intend to provide, cessation services

F. Proposed Evaluation Timeline* Program Year Tasks Timeline Participants Program Year 1 (2017-2018) Evaluation team Beginning with contract • External Evaluators. meetings award and monthly thereafter • ODH Program Staff. (at least for the initial grant • Medicaid Program Staff. implementation). • Representative from CCI Staff.** Benchmark cessation Within one month of contract • SET will finalize data elements cost data (expenses award or Partnership required. and receipts) of Agreement award for partners. • External Evaluator will coordinate current services. and assist in collecting data. Standardized reports. Quarterly. • Submitted through GMIS by local CCI Staff Submit referral Monthly • Submitted by CCI Staff. survey data and consent forms. Site visit and Approximately 9-12 months • External Evaluator will visit funded interviews of after contract award. agency site and interview

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Appendix G Program Year Tasks Timeline Participants program staff. coordinator and relapse management team. • External Evaluators will interview funded agency partners (Partnership Agreement). Participant evaluation Conducted at 3, 6, and 12 • Conducted by External Evaluators. follow-up. months following first • Results will be provided to CCI referral. Staff. Year 1 Evaluation August 2017 • External Evaluators. Report. Program Year 2 (2018-2019) Evaluation Team Meet quarterly or sooner as • External Evaluators. Meetings. needed. Discuss on-going • ODH Program Staff. evaluation and findings from • Medicaid Program Staff. previous evaluation efforts. • Representative from CCI Staff. Cessation cost data Quarterly for funded agency • Evaluation Team will finalize data (expenses and services and Partnership elements required. receipts) of current Agreement partner services. • External Evaluators will coordinate services. and assist in collecting data. Standardized reports. Quarterly. • Submitted through GMIS by CCI Staff. Submit referral Monthly. • Submitted by CCI Staff. survey data and consent forms. Web survey. Winter 2018. • Funded agency and partner administrative and counseling staff. Participant evaluation Conducted at 3, 6, and 12 • Conducted by External Evaluator. follow-up. months following first • Results will be provided to CCI referral. Staff. Year 2 Evaluation August 2018. • External Evaluators. Report. Program Year 3 (2019-2020) Evaluation Team Meet quarterly or sooner as • External Evaluators. Meetings. needed. Discuss on-going • ODH Program Staff. evaluation and findings from • Medicaid Program Staff. previous evaluation efforts. • Representatives from CCI Staff.

Cessation cost data Quarterly for funded agency • External Evaluators will coordinate (expenses and services and Partnership and assist in collecting data. receipts) of current Agreement partner services. services. Standardized reports. Quarterly. • Submitted through GMIS by CCI Staff. Submit referral Monthly. • Submitted by CCI staff. survey data and G-3

Appendix G Program Year Tasks Timeline Participants consent forms. Web survey. Spring 2019. • Funded agency and partner administrative and counseling staff. Participant evaluation Conducted at 3, 6, and 12 • Conducted by External Evaluator. follow-up. months following first • Results will be provided to CCI referral. Staff. Year 3 Evaluation August 2019. • External Evaluator. Report.

*Please note that the SET will guide the CCI evaluation and the above-mentioned performance measures; other evaluation activities may change following SET discussions. ** CCI staff refers to the local funded agency CCI program staff.

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Appendix H Appendix H: Work Plan Template

CCI 2017 Local Health Department Grant Work Plan Agency: ______County(ies) Served: ______

NOTE: Applicants(s) may add additional activities to the submitted work plan but must at least include all activities noted below.

Deliverable - Objective 1 First Year Objective: By the end of Month 3 a series of planning documents to establish necessary infrastructure to execute CCI program activities will be submitted to ODH. These documents will be added to the funded entity’s overall project plan. Person Dates for Each Activity Activity Description Responsible Start End Objective A: Submit a Strategic Planning Document (20-page limit excluding position descriptions). 1. Summarize the results of the Community Inventory analysis. 2. Identify the gaps in cessation services. 3. List staff and stakeholders identified and included in workgroups. 4. Develop staffing infrastructure/plan. Objective B: Submit a Project Implementation Plan. 1. For the prioritized service gaps and disparate populations identified in Strategic Planning Document develop a plan and timeline for implementation of cessation services. 2. Identify partners specific to each priority area and

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Appendix H describe how those partnerships will be established and maintained and the responsibilities of each partner. 3. Identify what specific methods will be used to service targeted disparate populations. 4. Identify resources required and how they will be obtained. 5. Identify Technical Assistance needs and attend meetings or other vehicles for receiving and sharing information related to TA. 6. Attend training offered by ODH on Health Equity and Tobacco Control.

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Appendix H Deliverable - Objective 2 First Year Objective: By the end of Month 5 develop and launch a community cessation provider network with mechanisms for service delivery, a documented referral process/system, and provider billing.

Person Dates for Each Activity Activity Description Responsible Start End Objective A: Establish of a community network system of existing service providers in place to offer essential cessation services to residents of county(ies). 1. Assemble a list of approved existing service providers that are able to offer essential cessation services to residents of your jurisdiction. 2. Submit information about provider to ODH for approval to ensure services provided are in line with essential services outlined in RFP. 3. Execute Agreements for existing qualified/ODH- approved providers that include, if appropriate, how providers will be reimbursed for services that are not billable through Medicaid or other insurance provider. Objective B: XX (to be filled in by Applicant) new providers are in place offering cessation services. (NOTE: This deliverable should only be chosen if existing providers are not adequate to meet the needs of the service area) 1. Summarize types of services (e.g. group, individual, referral for telephonic) to be provided and how new

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Appendix H providers (applicant, LHD or community provider) work to fill identified service gaps. 2. Submit information about provider(s) to ODH for approval to ensure services provided are in line with essential services outlined in RFP. 3. Develop and execute Agreements for new providers that include, if appropriate, how providers will be reimbursed for services that are not billable through Medicaid or other insurance provider. Objective C: Documentation of an established system for accepting, distributing, and tracking referrals. 1. Develop and document your referral system. 2. Ensure ability to accept telephone, email, or fax referrals. 3. Identify under what criteria you will send a referral to a specific provider. 4. Develop and document data security and retention policies. 5. Determine how you will exchange information between provider making referral and service provider. Objective D: An established system for health insurance billing for cessation services.

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Appendix H 1. Document that the provider is approved to bill Medicaid for cessation service. 2. Document payment for cessation services billed.

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Appendix H Deliverable - Objective 3 First Year Objective: By the end of Month 5 execute a plan to increase the identification of tobacco users and the number of tobacco users that are referred for treatment through County’s CCI project. Person Dates for Each Activity Activity Description Responsible Start End Objective A: Demonstrate that XX (to be filled in by funded entity) healthcare providers or service delivery organizations have been trained on the referral process to CCI. 1. Identify all physicians, hospitals, health clinics and FQHCs in the service area that need to be trained. 2. Develop timeline of training to reach all providers on list. 3. Submit training and promotional material to ODH for approval. 4. Schedule and conduct trainings. Objective B: Demonstrate that XX (to be filled in by funded entity) community partnerships to support and promote CCI and tobacco cessation services in the community have been established. 1. Identify all community organizations in the service area that need to be trained. 2. Develop timeline of training to reach all organizations on list. Objective C: Demonstrate that XX (to be filled in by funded entity) promotional activities (e.g. media releases, community events, social media) have been implemented to support and promote CCI and tobacco cessation services in the community. • Develop list of target audiences to reach with promotional activities

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Appendix H with a justification of why activities should reach proposed audience. • Develop meeting note and sign-in protocols to ensure ability to submit documentation to ODH. • Submit promotional activities and materials to ODH for advance approval. • Develop timeline, including for services not completed by Month 5.

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Appendix H Deliverable - Objective 4

First Year Objective: Begin delivering cessation services no later than the end of Month 5 and continue through Month 12. Person Dates for Each Activity Activity Description Responsible Start End • Develop expense reports to submit to ODH that reflect actual utilization times Medicaid payment rates and all other detailed outlines in Appendix C1 Scope of Work. • Determine how to connect uninsured individuals with services that will assist them in gaining insurance coverage. • Develop mechanism for tracking and documenting evidence of denied claims for any bill submitted on behalf of an individual with private insurance.

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Appendix H Deliverable - Objective 5 First Year Objective: Beginning no later in Month 7 and continuing through Month 12, the lead agency will have completed and documented follow up contact has been attempted with all individuals who received any service through the CCI. Person Dates for Each Activity Activity Description Responsible Start End Objective A: Provide a protocol for consistent and long term follow up with those referred to cessation treatment. 1. Implement a system that identifies when and how often each participant should be contacted for follow up to assess patient success or refer to additional services. 2. Write scripts or protocols for each routine follow-up contacts that provide direction for possible treatment outcomes (e.g. support or reentry due to relapse). 3. Submit protocols to ODH for approval. 4. Train staff and develop timeline for ongoing training and oversight. Objective B: Implement the protocol for long term follow up of CCI participants. 1. Develop a monthly report to provide external evaluator which includes each contact, date, and results using a pre-agreed upon participant identification number. H-9

Appendix H 2. Develop protocol, assuring all strategies align with essential services outlined in RFP. 3. For patients requiring reconnection with services develop mechanisms to demonstrate that referrals to providers have been made and accepted. Or received?

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Appendix H

Deliverable - Objective 6 First Year Objective: By the end of Month 12, participate in quality assurance reviews, one process evaluation and one outcome evaluation to determine the sustainability of CCI. Person Dates for Each Activity Activity Description Responsible Start End Objective A: By Month 6 provide documentation that quality assurance protocols are in place. 1. Attend monthly state evaluation planning team meetings to jointly develop measures for quality assurance. Objective B: Participate in a state evaluation. 1. Participate in no fewer than 75% of all Evaluation Planning Team meetings. 2. Gain consent from participants to collect data and provide data to external evaluator including establishment of agreements with partners who may be providing services outside the CCI process. 3. Participate in site visits and other data collection methods for a state process evaluation. 4. Assist in establishing program evaluation indicators and providing

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Appendix H evaluation data from LHD and service providers as determined by the Evaluation Planning Team.

*Evaluation Reports to include: • Reimbursable services- why they need reimbursed by the grant • Where the referrals came from • Denials from commercial or Medicaid – why • Report completion of group and individual counseling by program site

*Provider Reports to include: • Report back to referring health care providers about their patients’ status • Report completion of group and individual counseling by program site

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Appendix I

Appendix I – Applicant Funding Table Instructions: Locate the county(ies) your bid represents to determine the maximum amount of funding you may request for Year One of the CCI program. If a consortium of applicants wishes to bid, the consortium must pick a lead entity. The location of the lead will determine OMAS county type. A consortium may request up to the combined total for the counties represented.

The Work Plan (Appendix H) and Budget Justification (Appendix K) must support the funding being requested. However, certain assumptions and categories of funding were considered in developing the maximum funding amounts. We provide those considerations below as potential guidance for you in developing your own budget. These are not required assumptions. Those areas with assumptions that are required for inclusion in your budgets include:

• The funding equivalent of at least 0.1 FTE to support evaluation. This applies to individual county applicants as well as consortiums.

• The use of Ohio Medicaid reimbursement levels for service delivery payment (Appendix J)

The major categories considered in developing the maximum funding amounts are as follows:

• Personnel: This can include funding for a dedicated CCI Staff, an entity to work with community partnerships on data collection, or other necessary partial staff roles. It MUST include the equivalent of at least 0.1 FTE to support evaluation. This also includes other associated expenses for the FTE(s), including office supplies, travel, etc.

• Programs for Disparate Populations: A central feature of the CCI program is development of initiatives to support disparate populations that typically have higher tobacco use rates. Individual county data will help identify the most appropriate target populations but it might include different socioeconomic categories, different ethnicities, LGBTQ populations, targeted age groups, lower educational achievement groups as described on page 7 (Incorporation of Strategies to Eliminate Health Inequities). Funding assumes using evidence-based Core Services as outlined in Appendix R but might also require different staffing, different outreach methodologies, different follow up protocols, different service delivery locations etc.

• ODH used a placeholder value of $10,000 for each disparate program developed. You will need to develop a more detailed justification of the costs you anticipate for your program development and implementation.

• External Partner Data Collection: CCI does not assume the applicant will provide all cessation services itself; it explicitly factors in the need to reach out to community partners to identify tobacco cessation services already provided or to support development of new programs and to refer tobacco users to those programs as appropriate.

• Because the CCI evaluation team will require data from all community partners, $1,000 is included for the entity to provide to each community partner once an Agreement has been signed to support data collection and dissemination. I-1

Appendix I

• Cessation Services: ODH developed a model to estimate the number of individual and group counseling sessions that will be provided in each county as a result of CCI. Reimbursement rates will be the same as prevailing Medicaid reimbursement rates (see Appendix J). In your budget, please determine utilization estimates based on the services the applicant will be offering. Over the course of three years, CCI assumes a 10% increase in users that attempt to quit, and an increase from 10% of participants using counseling to help them quit in year 1 to 12% in year 2 to 15% in year 3. As a deliverable based budget, the activities of providing services will be billed on an ongoing basis using actual utilization x Medicaid rates. More details will be provided at the Bidder’s Conference.

• Media: ODH will develop most of the media material for this initiative. However, the applicant may wish to supplement with unique local options and will be responsible for developing plans and strategies to promote the program.

• Media funding should not exceed ten percent of the total funding being requested.

Table One: Maximum Amount Permitted Under CCI Grant for Year One

County Maximum Funding Permitted Appalachian Adams $191,657 Ashtabula $218,185 Athens $180,553 Belmont $184,446 Brown $218,541 Carroll $193,506 Clermont $218,541 Columbiana $211,467 Coshocton $183,799 Gallia $184,708 Guernsey $183,799 Harrison $184,446 Highland $188,704 Hocking $180,553 Holmes $189,110 Jackson $184,708 Jefferson $211,467 Lawrence $191,657 Meigs $184,708 I-2

Appendix I Monroe $184,446 Morgan $183,799 Muskingum $183,799 Noble $183,799 Perry $183,799 Pike $188,704 Ross $188,704 Scioto $191,657 Trumbull $293,953 Tuscawaras $193,506 Vinton $180,553 Washington $194,034 Non-Appalachian Rural Ashland $190,995 Champaign $185,387 Clinton $207,459 Crawford $192,380 Darke $190,208 Defiance $184,972 Erie $191,117 Fayette $188,704 Hancock $179,303 Hardin $187,820 Henry $184,972 Huron $190,995 Knox $209,505 Logan $185,387 Marion $192,380 Mercer $175,350 Morrow $186,687 Ottawa $191,117 Paulding $175,350 Preble $190,208 Putnam $179,303 Sandusky $181,966 Seneca $181,966 Shelby $190,208 I-3

Appendix I Van Wert $175,350 Warren $207,459

Wayne $189,110

Williams $184,972

Wyandot $181,966

Suburban

Auglaize $187,820 Clark $214,406 Delaware $186,687 Fairfield $207,046 Fulton $184,972 Geauga $189,804 Greene $214,406 Lake $245,548 Licking $209,505 Madison $214,406 Medina $206,844 Miami $190,208 Pickaway $188,704 Portage $239,442 Union $192,380 Wood $201,806 Urban Allen $187,820 Butler $292,715 Cuyahoga $575,305 Franklin $523,534 Hamilton $446,960 Lorain $301,947

Lucas $320,951

Mahoning $268,589

Montgomery $349,402

Richland $212,300

Stark $324,811 Summit $358,984

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Appendix J Appendix J: Medicaid Billing for Tobacco Cessation Treatment

In 2012, the Ohio Medicaid smoking rate was 48.8%.1 This is more than double the overall adult smoking rate in Ohio of 23.1%.2 As a provider, you can make an impact on reducing tobacco use by asking your patients if they smoke and providing even brief counseling, pharmacotherapy and referral to cessation resources. Ohio Medicaid covers tobacco cessation treatment for patients enrolled in Medicaid fee-for-service or a Medicaid Managed Care Plan. The Ohio Department of Health created the following chart to assist providers:

Medicaid Managed Care Plan (MCP) Medicaid Fee-for-Service (Providers are encouraged to check with each MCP with questions about billing instructions or coverage policies.)

Modifier Reimbursed Buckeye Community Molina Healthcare Paramount United Healthcare Service (code) CareSource Required Amount Health Plan of Ohio Advantage Community Plan 99406 Individual Tobacco Requires Counseling (greater Modifier $9.43 Yes Yes Yes Yes Yes than 3 and up to 10 25* minutes) 99407 Requires Individual Tobacco Modifier $19.00 Yes Yes Yes Yes Yes Counseling (greater 25* than 10 minutes) S9453 Smoking Cessation classes, non- $14.52 Yes Yes Yes Yes Yes physician provider, per session Medications FDA Approved FDA Approved Quit Line Services Unlimited access to Ohio Unlimited access to Unlimited access to Unlimited access to Unlimited access to Unlimited access to Tobacco Quit Line by Ohio Tobacco Quit Ohio Tobacco Quit Ohio Tobacco Quit Ohio Tobacco Quit Ohio Tobacco Quit calling 1-800-Quit Now Line by calling Line by calling Line by calling Line by calling Line by calling 1-800-Quit Now 1-800-Quit Now 1-800-Quit Now 1-800-Quit Now 1-800-Quit Now Pharmacotherapy No restrictions No restrictions Chantix – no prior Step therapy Chantix- 2 times a Chantix – limited to 6 restrictions authorization for 6 required for Chantix, year limit for months/year, months/year; step Prior Authorization smoking cessation Nicotrol requires therapy for Nicotrol required for Nicotrol trials that have to be prior authorization – both oral inhaler inhaler and spray 6 months apart and nasal inhaler Provider Services 1-800-686-1516 1-866-296-8731 1-800-488-0134 1-855-322-4079 1-800-891-2542 1-800-600-9007 *Only required if an office visit is performed on the same day as tobacco cessation service.

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Appendix J

Value-Based Purchasing (VBP) Ohio’s models for VBP (episodes of care and patient-centered medical homes) include tobacco use as a significant risk factor. Payment is risk-adjusted for this variable. Subsequently, it is in the clinician’s best interest to use an ICD-10 code (i.e. Z72.0) to document the tobacco use status of all patients seen. Additionally, identification of this code on a claim will allow for feedback to clinicians and hospital systems as it relates to tobacco use. General Medicaid Fee-for-Service Considerations • All codes must be billed through a Medicaid provider. • Medicaid fee for service allows the following provider types to receive reimbursement for tobacco cessation counseling: Advanced practice nurses, clinics, freestanding birth clinics, outpatient hospital clinics, physicians, physician assistants and psychologists. Independently licensed social workers, clinical counselors, and marriage and family therapists can also receive reimbursement for tobacco cessation counseling. Non- Independently licensed clinical counselors and social workers, and nurses may provide these services incident to a physician service or under physician supervision. Codes MUST include modifier 25 to be identified as a separately identifiable service. Codes not accompanied by modifier 25 will be considered incidental to patient visit and may be rejected.

Medicaid Managed Care Plans Ohio Department of Medicaid (ODM) contracts with five Medicaid managed care plans (MCPs). ODM requires all MCPs to offer coverage comparable to Medicaid Fee-for-Service (often referred to as “traditional” Medicaid). Each Ohio Medicaid MCP is required to cover tobacco cessation medications. Limits and prior authorization requirements may vary by health plan. Providers can contact the MCP’s Provider Services Department at the number identified on page 1 of this document with questions or concerns.

Medications Ohio Medicaid covers all seven of the FDA approved medications for tobacco cessation – five forms of nicotine replacement therapy (patches, gum, lozenges, inhalers and sprays), antidepressants, and nicotinic receptor agonists. Prescriptions are required for all medications, including over-the-counter medications.3 The cessation medication coverage does not have significant lifetime limits, annual limits, or limits of duration of treatment.

Ohio Tobacco Quit Line The telephonic delivery of counseling services is an evidenced-based strategy for tobacco cessation. The Ohio Tobacco Quit Line, through the Ohio Department of Health, offers tobacco cessation counseling services for Ohioans. Those seeking assistance with quitting tobacco products can be referred to 1-800-QUIT- NOW. Participants enrolled in the program are offered a five-call proactive counseling series and access to nicotine replacement therapy, if eligible. Please email [email protected] with any questions or concerns. ______Ohio Medicaid Assessment Survey 2012: An Examination of Substance Use Among Adults in Ohio May 2013, Amy K. Ferketich and Ling Wang, The Ohio State University College of Public Health 2 Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 2012. Prevalence and Trends Data: http://apps.nccd.cdc.gov/brfss/ 3 Ohio Medicaid Pharmacy Program, http://pharmacy.medicaid.ohio.gov/ J-2

Appendix K

Appendix K: CCI BUDGET JUSTIFICATION EXAMPLE (Deliverable Funding Only)

NOTES:

1. Budget justification line items MUST be in the same order as in the GMIS budget.

Instructions: Please use Appendix I Applicant Funding Table to locate the county(ies) the applicant represents to determine the maximum amount of funding you may request for Year One of the CCI program. Appendix I also provides further information regarding some of the budget categories considered by ODH in setting the overall budget ranges for this solicitation.

The Work Plan (Appendix H for template and Attachment 3 for applicant submission) and Budget Justification must support the funding being requested.

OTHER DIRECT COSTS

Deliverable – Objectives (Note: Budget leverage cannot be used to move funding into or out of any Deliverables – Objective line item. Also, indirect cannot be charged against this line item.)

Please provide very brief written description of how applicant will accomplish meeting the Objectives. Detail in the table below need only go down to the Activity level. A detailed breakout of the deliverable budget is not required and should not be included in the budget justification. In the Budget Request column, the $ value of each Objective A, B, C, etc. should reflect the roll-up of all Activities associated with the Deliverable. You may add additional activities but may not eliminate any of the activities below. Any activities added must also be reflected in your work plan.

K-1

Appendix K Deliverable - Objective 1: By the end of Month 3 a series of planning documents to establish necessary infrastructure to execute CCI program activities will be submitted to ODH. These documents will be added to the funded entity’s overall project plan.

Brief Narrative:

Budget Request Deliverable - Objective 1: By the end of Month 3 a series of planning documents to establish necessary infrastructure to execute CCI program activities will be submitted to ODH. These documents will be added to the funded entity’s overall project plan. Objective A: Submit Strategic Planning Document (20-page limit excluding position descriptions). $ Objective B: Submit Project Implementation Plan. $

Deliverable – Objective 2: By the end of Month 5 develop a community cessation provider network with mechanisms for service delivery, a documented referral process/system, and provider billing

Brief Narrative:

Deliverable – Objective 2: By the end of Month 5 develop and launch a community cessation provider network with mechanisms for service delivery, a documented referral process/system, and provider billing Objective A: Establish of a community network system of existing service providers in place to offer $ essential cessation services to residents of county(ies). Objective B: XX (to be filled in by applicant) new providers are in place offering cessation services. $ (NOTE: This deliverable should only be chosen if existing services are not adequate to meet the needs of the service area.) Objective C: Documentation of an established system for accepting, distributing, and tracking referrals. Objective D: An established system for health insurance billing for cessation services. $

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Appendix K

Brief Narrative:

Deliverable - Objective 3: By the end of Month 5, execute a plan to increase the identification of tobacco users and the number of tobacco users that are referred for treatment through County’s CCI project Objective A: Demonstrate that XX (to be filled in by funded entity) healthcare providers or service $ delivery organizations have been trained on the referral process to CCI. Objective B: Demonstrate that XX (to be filled in by funded entity) community partnerships to support $ and promote CCI and tobacco cessation services in the community have been established. Objective C: Demonstrate that XX (to be filled in by funded entity) promotional activities (e.g. media $ releases, community events, social media) have been implemented to support and promote CCI and tobacco cessation services in the community.

Deliverable - Objective 4: Begin delivering cessation services no later than the end of Month 5 and continue through Month 12.

Brief Narrative:

Deliverable - Objective 4: Begin delivering cessation services no later than the end of Month 5 and continue through Month 12. Objective A: Using agreed upon tracking mechanisms, demonstrate that services are being delivered $

Deliverable - Objective 5: Beginning no later in Month 7 and continuing through Month 12, the lead agency will have completed and documented follow up contact has been attempted with all individuals who received any service through the CCI. K-3

Appendix K

Brief Narrative:

Deliverable - 5: Beginning no later in Month 7 and continuing through Month 12, the lead agency will have completed and documented follow up contact has been attempted with all individuals who received any service through the CCI. Objective A: Provide a protocol for consistent and long term follow up with those referred to cessation $ treatment Objective B: Implement the protocol for long term follow up of CCI participants $

Objective 6: By the end of Month 12, participate in quality assurance reviews, one process evaluation and one outcome evaluation to determine the sustainability of CCI

Brief Narrative:

Total Other Direct Costs $ Total

Notes:

1. The budget justification must be signed by the agency head listed in GMIS. 2. Budget revisions that do not include a signed budget justification by the agency head listed in GMIS will be disapproved. 3. Authorized representative certification language must also be included with agency head signature.

K-4

Appendix K Subrecipient’s authorized representative certifies the foregoing:

• Subrecipient understands and agrees that it must follow the federal cost principle that applies to its type of organization (2 CFR, Part 225; 2 CFR, Part 220; or, 2 CFR, Part 230). • Sub-recipient’s budgeted costs are reasonable, allowable and allocable under OGAPP and federal rules and regulations. • The OGAPP and the rules and regulations have been read and are understood. • Subrecipient understands and agrees that costs may be disallowed if deemed unallowable or in violation of OGAPP and federal rules and regulations. • The appropriate programmatic and administrative personnel involved in this application are aware of agency policy in regard to subawards and are prepared to establish the necessary inter-institutional agreements consistent with those policies. • Subrecipient agrees and understands that costs incurred in the fulfillment of the Deliverables must be allowable under OGAPP and federal rules and regulations to qualify for reimbursement.

[Signature]

[Print Name & Title]

[Date]

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Appendix L

Appendix L – Sample Community Inventory (hard copy)

Thank you for your interest in participating in the Community Cessation Initiative. Completion of this inventory is a requirement of the Request for Proposal (RFP) and it must be submitted as part of a complete grant application packet.

The inventory must be completed in an online form that can be accessed at www.websrg.com/cci_inv. You can enter your responses directly into the web form and print a copy to be included with your application submittal and for your records. Directions are available on the online form.

To access the web form, use the above link and enter the first 4 letters of your county as the password. For example, if your county is Franklin, use “fran” (no quotes) as the password.

If you are part of a group submittal (more than one county) please complete the survey for each county separately.

Once gathered, this data should be used to inform decisions about areas for which your organization to focus goals and objectives in response to this grant opportunity.

Should you have any question about the items on this tool, feel free to contact Amy Gorenflo, Cessation Services Program Administrator, at 614-466-1717 or [email protected] .

If you have any problems accessing the on-line form or questions about how to report on the form, feel free to contact Dr. Kathleen Carr the State Evaluator at 614-220-8860 or [email protected] .

A. Geographic area and population

A1. County Name L-1

Appendix L

A2. Agency Name

B. Tobacco related indicators

Please answer the following questions as they relate to your county. Please use county-level data available here (link to PDF copy of Appendix L) or you may use the printed copy in the RFP Appendix L.

B1. Population, Total (Count) B2. Population, Adult 18+ (Count) B3. Population, Youth 0-17 (Count) B4. Percent in poverty -- All Ages B5. Percent in poverty -- Under Age 18 B6. County Type (Metro, Suburban, Rural, Appalachian) B7. RWJF County Health Rankings -- Social & Economic Factors Sub Ranks B8. Proportion of population receiving Medicaid (Age 19+) B9. Proportion of population that is uninsured (Age 19+) B10. Medically Underserved Areas/Populations in county (yes/no) B11. RWJF County Health Rankings -- Clinical Care Sub Rank B12. Current Adult (18+) Smoking Prevalence, County Health Ranking (RWJF) rates B13. Youth smoking prevalence B14. Heart disease prevalence B15. Heart disease mortality B16. COPD prevalence B17. COPD mortality B18. Trend in Current Adult Smoking, Annualized rate of change (%) 1996-2012 B19. Trend in Daily Adult Smoking, Annualized rate of change (%) 1996-2012 B20. Percent of live births to mothers that smoked in the 3 months before pregnancy B21. Percent of live births to mothers that smoked any time during pregnancy B22. RWJF County Health Rankings -- Health Behaviors Sub Rank B23. Lung and bronchus cancer (invasive) age-adjusted incidence rates (per 100,000) B24. Percent of live births that are LBW (<2500g), 10-Year average B25. RWJF County Health Rankings -- Health Outcomes rank B26. Number of Licensed Tobacco Retailers B27. Tobacco retailer density (number stores per 1,000 total population) B28. Number of tobacco retailers within distance of school and park B29. Medical care cost savings (Rate) from community-wide smoke free/clean air policies (10-yr cumulative $/per 100K residents) B30. Medical care cost savings (Total) from community-wide smoke free/clean air policies (10-yr cumulative $/per County Total Population)

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Appendix L

C. Healthcare landscape and LHD infrastructure to address tobacco

Before completing this section, please catalog the community’s tobacco cessation services. A database has been created and is available on ODH’s website at www.odh.ohio.gov/tobacco. This database may be used to inform answer choices, but should not be used as a substitute for gathering additional information. These questions should be thoughtfully considered and all answers provided must be based on information available to the local health district completing this assessment.

Using the questions below as a guide, provide information about health systems/practices in the county. This includes public health services as well as private practitioners and facilities. ANSWER CHOICES:

• Not Available: Item of reference is not available anywhere in the priority community.

• Limited Availability: Item of reference is available, but is not sufficient enough to meet the identified needs of the service area. Capacity in the community is not fully developed.

• Widely Available: Item of reference is available and there is sufficient enough to meet the identified needs of the service area. Capacity in the community is fully developed.

C1. Describe the level of availability of cessation treatment available in the community. a. Individual counseling b. Group counseling c. Telephonic counseling (do not include referrals to Ohio Tobacco Quit Line)

C2. Programs in the county offer some form of nicotine replacement therapy (NRT) to participants?

C3. Drug dependency treatment programs in the community.

C4. Community support services aimed at helping to prevent relapse to smoking once someone has successfully quit.

C5. Professional development for healthcare providers for counseling and intervention techniques for use with tobacco-using patients.

C6. Directory of tobacco cessation services.

C7. Culturally appropriate tobacco cessation materials are available to tobacco-using patients.

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Appendix L C8. Healthcare provider office tracking system used for identifying and intervening with tobacco-using patients.

C9. Healthcare providers assess patient’s willingness to quit and refer to treatment.

C10. Healthcare providers advocate for free or low cost pharmacological quitting aids with insurance companies and/or community resources.

C11. Healthcare providers utilize secondhand smoke (ETS) education for tobacco using patients who are pregnant or have families.

C12. Tailored tobacco cessation interventions designed to reach the following populations known to be disproportionately affected by tobacco use, or that are of special concern due to tobacco-related health impacts?

a. Pregnant women b. Women of childbearing age c. Persons with a behavioral health diagnosis d. Lesbian, gay, bisexual or transgender individuals e. Low income individuals f. Persons with low educational attainment g. Persons with disabilities h. Persons living with HIV

C13. Provide information regarding how your health district is situated to work with other community organizations. You may include additional documentation of past collaborations, particularly relating to efforts to address chronic disease, should be included as part of your application packet.

D. Existing community partnerships

D1. Are there any agreements in place between public health and major hospital systems and/or community health centers to work together to screen patients for tobacco use and/or offer treatment? a. Yes –please specify b. No

D2. Describe how the nonprofit hospital system(s) serving the population are satisfying their mandated community benefit offering. Is tobacco addressed in the community benefit?

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Appendix L E. Baseline measures of tobacco-related attitudes and practices in different sectors

E1. Please describe your opinion of the social norms relating to tobacco. Provide evidence of the way community opinion leaders view tobacco prevention and policy change.

E2. Provide information about policies (local, community, organizational) in place to protect non-smokers, especially children, from secondhand smoke.

E3. Please describe your policies/programs for creating tobacco free environments in the community such as parks, cultural arts centers, multi-family homes, faith-based programs, etc.

E4. Describe the mechanism in place for community enforcement of the law which prohibits the sale of tobacco products to minors? This would include a maintained system for tobacco compliance checks. E5. Describe the methods LHDs or other public health entities use to communicate important public health messages, particularly with regard to tobacco dependence, to local providers. Include information about successes and challenges experienced.

E6. Has your community ever conducted a health assessment for your county/jurisdiction? a. Yes-continue b. No and Don’t Know skip to E8

E7. Provide details about the last community health assessment conducted for the county/jurisdiction.

a. Specifically address the following: i. Date fielded ii. Date published iii. Lead agency iv. Partners

b. Describe the process used for collecting primary and secondary data, and briefly review the tools and resources used. For any surveys conducted (i.e., primary data collection efforts), please describe the survey sample, number of respondents, and response rate.

c. Outline the process used for analyzing data, and discuss the method used to set priorities.

d. What questions were asked about tobacco use? Provide specific wording and answer choices.

e. How was the process conducted? L-5

Appendix L

i. Were there any special activities conducted to assess disparate populations? (e.g., additional information collection, oversampling, or statistical analyses)

f. What was the overall response rate?

g. Was a Community Health Improvement Plan (CHIP) developed using results from the assessment?

h. If a CHIP was developed, was tobacco or tobacco related illness prioritized?

**Please provide a copy or a link to assessment and also provide the community health improvement plan if one was completed.

E8. Does your local health jurisdiction conduct their own enforcement of the Smoke Free Workplace Law?

F. Additional information needed to address gaps in providing tobacco cessation services

F1. Define and describe any barriers to addressing tobacco dependence in your community/jurisdiction.

F2. What other types of organizational support would be needed to increase service capacity and expand reach?

Once you have completed this form on www.websrg.com/cci_inv print a copy for your files and submit a copy for each county with your grant application packet.

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Appendix M Appendix M. Ohio Data on Tobacco-Related Disparities and County Characteristics

Tobacco use and health data highlight the need for ongoing efforts to address tobacco-related disparities in Ohio. Tobacco surveillance data show that the populations at the highest risk for smoking in Ohio include residents that are socioeconomically disadvantaged, those with disabilities and/or mental health challenges, African American Ohioans, and those that identify as LGBT. Pregnant women are also a population of special concern due to tobacco-related health impacts. Data presented in this Appendix focus on tobacco use, tobacco-related morbidity and mortality, and vulnerability to adverse tobacco-related health impacts. However, tobacco-related disparities and priority populations can also be defined and identified in additional ways, such as inequity related to differences in health systems and access to cessation services, or differences in community policy, infrastructure, tobacco market environment, or secondhand smoke exposure.

• Prevalence is the rate of tobacco use, and describes how much tobacco a group uses. In Ohio, people with low socioeconomic status and educational attainment, people with disabilities, people with mental health and/or substance abuse disorders, and people that identify as lesbian, gay, bisexual, or transgender (LGBT) use tobacco at much higher rates than the general population. • Morbidity and mortality describe illness and death from tobacco use. In addition to being affected by the type and amount of tobacco use, morbidity and mortality are influenced by factors such as access to health care, quality of care, and population-specific risk factors. In Ohio, African American men have disproportionately high rates of mortality compared to white men for several tobacco-related conditions, including cancer, heart disease, and stroke. • Populations with increased vulnerability to tobacco are often particularly impacted by smoking. In Ohio, pregnant women and infants have increased vulnerability because of linkages between maternal smoking and preterm delivery, stillbirth, fetal growth restriction, spontaneous abortion, and sudden infant death syndrome (SIDS). The Ohio Department of Health (ODH) uses many different data sources to understand and respond to tobacco disparity issues. State-level data on Ohio disparities in current smoking prevalence from the 2015 Behavioral Risk Factor Surveillance System (BRFSS) are presented in Tables 1 and 2. Tables 3 through 11 present county and regional data on additional tobacco-related outcomes and risk factors, as well as basic demographic data, for each of Ohio’s 88 counties. Finally, an example of tobacco market research data from Nielsen is provided in Table 12. Market research data provides tobacco use and expenditure information at lower levels of geography such as census tracts and census block groups, which may also aid in targeting local-level program interventions where they are needed the most.

Socioeconomic Status. Ohio tobacco surveillance data from the 2015 Behavioral Risk Factor Surveillance System (BRFSS) clearly show a strong inverse relationship between tobacco use and socioeconomic status (Table 1). The percentage of current cigarette smokers among Ohioans with an annual household income of <$15K is almost triple that seen among those with incomes of $50K or more (38.6% and 13.0%, respectively). Current cigarette smoking prevalence among those who did not graduate from high school (42.7%) is significantly higher than all other educational levels, and more than five times higher than the smoking prevalence among college graduates (7.6%).1 Related to income and education, substantial disparities in smoking prevalence have also been observed among certain industry and occupational groups such as construction, mining, food preparation and serving, and transportation.2 The roles of poverty and education are also evident when looking at geographic patterns of tobacco use in Ohio (Table 2). Regional estimates of smoking prevalence show that many of the highest smoking rates in Ohio are in the state’s Appalachian region (e.g., Regions 11 and 14 in M-1

Appendix M Table 2), which is characterized by high poverty and unemployment.3 The high burden of smoking among women with low socioeconomic status is of particular concern in Ohio due to linkages between maternal smoking and adverse health outcomes for the fetus and infant – including causal associations between perinatal smoking and preterm delivery, stillbirth, fetal growth restriction, spontaneous abortion, and sudden infant death syndrome (SIDS).4 At 6.8 per 1,000 live births in 2014, Ohio’s infant mortality rate is among the worst in the nation; there are also significant disparities in infant mortality in Ohio, with the highest rates in the state occurring among African American babies (14.3 per 1,000 live births) and Ohio’s metropolitan and Appalachian counties.5 In 2015, 15.2 percent of women in Ohio reported smoking at some point during pregnancy.6 Similar to the overall poverty-related patterns in smoking, perinatal smoking rates are higher in Ohio’s Appalachian region and other economically distressed areas (Table 6).

Race/Ethnicity. The 2015 BRFSS shows a significant difference between the rates of smoking in white and black Ohioans. This is the first year since 2012 where a significant difference between the two groups has been identified. The smoking rates among white, black, and Hispanic Ohioans are 20.4, 28.2, and 29.2%, respectively (Table 1). African Americans are of special concern because they suffer disproportionately from health impacts associated with smoking. For example, African American men are at increased risk for lung cancer mortality compared to white men, and black Ohioans had a 13 percent higher age-adjusted heart disease death rate in 2012 compared with whites (209.0 per 100,000 and 184.7 per 100,000, respectively).4,7,8 Those who identify as multiracial may also have higher rates of tobacco use (39.2%) (Table 1), although more data are needed to develop reliable estimates for racial minority groups with smaller populations. There may also be product-specific differences in tobacco use associated with race, such as higher use of smokeless tobacco among white as compared to African Americans.9

Disability, Sexual Orientation, and Mental Health. Some of the most pronounced disparities in adult smoking in Ohio are among people with disabilities, mental health challenges, and those who identify as lesbian, gay, bisexual, or transgender (LGBT) (Table 1). Current cigarette smoking prevalence among Ohioans with a disabilityi (28.1%) is significantly higher than those without a disability (19.7%) and about 3 out of every 5 Ohioans with a disability have been a smoker at some point in their lives (59.4%). The smoking prevalence rates among Ohioans with mental health issuesii (36.6%) and LGBT adults (35.1%) are both almost double the smoking rate seen in the general population (21.6%) (Table 1). People with disabilities, mental illnesses, and those that identify as LGBT are distinct communities of individuals who share unique cultures and collective lived experiences that cut across the boundaries of race, ethnicity, age, gender and income-level. Thus, people who find themselves at the intersection of identifying with one or more of the above factors may amplify the risk of smoking even further.

Priorities for Reducing Tobacco-Related Disparities in Ohio. Although no single characteristic fully explains an individual’s risk for tobacco use or related health impacts, tobacco surveillance data show that the populations in Ohio at highest risk for smoking include residents that are socioeconomically disadvantaged, those with disabilities or mental health challenges, and those that identify as LGBT. African American residents and pregnant women are also populations of special interest for intervention efforts in Ohio due to tobacco-related health consequences. These groups represent current priority populations for tobacco-related prevention and cessation interventions in i Disability defined as being limited in any way in any activity because of a physical, mental, or emotional problem. ii Mental health issues defined as frequent poor mental health (14 or more days per month), where self-reported mental health was "not good" in terms of stress, depression, or problems with emotions.

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Appendix M Ohio.

Possible factors that contribute to the tobacco-related disparities observed in these populations include: stress from stigma and discrimination related to economic determinants, education, race, homophobia, or disability; the tobacco industry's targeted product marketing to certain groups; and lower-quality health care in some populations due to inadequate access, lack of culturally appropriate tobacco treatment programs, and provider ignorance/bias. Perceived discrimination has been shown to play a role in unhealthy behaviors such cigarette smoking, substance use, improper nutrition, and refusal to seek medical services. In addition, perceived discrimination and stigma may place individuals at an increased risk for mental health disorders, which also contributes to higher rates of externalizing behaviors, such as alcohol, tobacco, and poly-substance use.10

M-3

Appendix M Table 1. Current Cigarette Smoking Prevalence among Ohio Adults (18+ years), by Demographic Characteristic, 2015 Smoking Frequency Weighted Prevalence 95% Confidence (n) Frequency (%) Limits All Ohio Adults 1,929 1,877,143 21.6 20.2 22.9 Male 855 969,227 23.1 21.0 25.2 Female 1,074 907,916 20.2 18.3 22.0 Age 18 to 24 79 245,286 22.2 16.9 27.5 Age 25 to 34 210 373,946 26.8 22.6 31.1 Age 35 to 44 267 354,399 26.7 22.7 30.7 Age 45 to 54 415 398,888 26.4 23.2 29.6 Age 55 to 64 505 324,164 21.0 18.4 23.5 Age 65 or older 453 180,459 9.9 8.5 11.3 White - Non-Hispanic 1,634 1,435,533 20.4 18.9 21.8 Black - Non-Hispanic 151 277,670 28.2 22.9 33.4 Hispanic 37 71,718 29.2 18.7 39.7 Other race only, Non-Hispanic 40 21,259 12.1 5.1 19.0 Multiracial, Non-Hispanic 46 48,466 39.2 25.7 52.8 Less than $15,000 346 275,739 38.6 32.6 44.6 $15,000 to less than $25,000 447 457,445 35.3 31.0 39.5 $25,000 to less than $35,000 189 173,739 21.5 16.9 26.1 $35,000 to less than $50,000 243 252,062 22.5 18.7 26.4 $50,000 or more 419 432,941 13.0 11.3 14.7 Did not graduate High School 283 431,733 42.7 36.8 48.5 Graduated High School 825 716,923 24.2 21.9 26.5 Attended College or Technical School 548 571,337 21.3 18.9 23.8 Graduated College or Technical School 270 155,212 7.6 6.3 9.0 Physical, mental, or emotional disabilityiii 738 555,718 28.1 25.1 31.0 No disability 1,183 1,318,857 19.7 18.1 21.2 Frequent poor mental healthiv 422 378,093 36.6 32.0 41.1 Not frequent poor mental health 1,466 1,451,233 19.3 17.8 20.7 Lesbian, Gay, Bisexual, Transgender (LGBT) 68 97,243 35.1 25.2 45.0 Not LGBT 1,616 1,470,368 21.0 19.5 22.5

Source: Ohio Behavioral Risk Factor Surveillance System (BRFSS), 2015

* Interpret smoking prevalence rates for Hispanic, multiracial, and other races with caution; rates may be unstable due to small sample sizes.

iii Disability defined as being limited in any way in any activity because of a physical, mental, or emotional problem. iv Frequent poor mental health defined as having 14+ days of self-reported mental health as "not good" during the past 30 days, including stress, depression, and problems with emotions.

M-4

Appendix M Table 2. Current Regional Cigarette Smoking Prevalence among Ohio Adults (18+ years), 2015

Frequency Weighted Smoking 95% Confidence Region (n) Frequency Prevalence (%) Limits Region 1: Defiance, Fulton, Henry, Lucas, 121 95,775 17.7 13.8 21.7 Paulding, Williams, Wood Region 2: Allen, Auglaize, Hancock, Hardin, 86 40,877 15.2 10.9 19.4 Mercer, Putnam, Van Wert Region 3: Crawford, Erie, Huron, Ottawa, 125 70,098 19.3 15.0 23.5 Richland, Sandusky, Seneca, Wyandot Region 4: Cuyahoga, Geauga, Lake, Lorain 152 318,710 22.6 18.3 26.9 Region 5: Ashland, Holmes, Medina, Stark, 145 230,764 23.4 18.5 28.3 Summit, Wayne Region 6: Ashtabula, Columbiana, 139 138,356 22.3 17.5 27.0 Mahoning, Portage, Trumbull Region 7: Delaware, Knox, Marion, Morrow, 98 56,714 19.1 13.3 24.8 Union Region 8: Fairfield, Franklin, Licking, 181 288,628 23.3 19.6 27.1 Madison, Pickaway Region 9: Champaign, Clark, Darke, Greene, 129 168,566 19.1 15.1 23.1 Logan, Miami, Montgomery, Preble, Shelby Region 10: Butler, Clermont, Clinton, 139 265,341 21.7 17.5 25.9 Hamilton, Warren Region 11: Adams, Brown, Fayette, 162 63,704 26.2 20.9 31.6 Highland, Pike, Ross, Scioto Region 12: Coshocton, Guernsey, Morgan, 132 46,856 19.4 15.3 23.4 Muskingum, Noble, Perry, Tuscarawas Region 13: Belmont, Carroll, Harrison, 153 47,034 23.9 19.3 28.4 Jefferson, Monroe, Washington Region 14: Athens, Gallia, Hocking, 167 45,720 23.8 19.4 28.1 Jackson, Lawrence, Meigs, Vinton

Source: Ohio Behavioral Risk Factor Surveillance System (BRFSS), 2015; Regions are assigned based on CDC’s imputed county identifiers.

M-5

Appendix M Table 3: Population Counts and County Type for Counties in Ohio Total Pop Adult 18+ Youth <18 Total Pop Adult 18+ Youth <18 County County Type14 County County Type14 (Count)11 (Count)12 (Count)13 (Count)11 (Count)12 (Count)13 Adams 28,129 21,225 6,904 Appalachian Logan 45,507 34,570 10,937 Rural, non-Appalachian Allen 105,040 80,533 24,507 Metropolitan Lorain 304,216 234,927 69,289 Metropolitan Ashland 53,035 40,751 12,284 Rural, non-Appalachian Lucas 435,286 334,199 101,087 Metropolitan Ashtabula 99,175 76,800 22,375 Appalachian Madison 43,918 34,585 9,333 Suburban Athens 64,713 54,629 10,084 Appalachian Mahoning 233,204 185,469 47,735 Metropolitan Auglaize 45,841 34,715 11,126 Suburban Marion 65,720 51,801 13,919 Rural, non-Appalachian Belmont 69,461 56,193 13,268 Appalachian Medina 176,029 134,623 41,406 Suburban Brown 44,116 33,769 10,347 Appalachian Meigs 23,331 18,273 5,058 Appalachian Butler 374,158 283,279 90,879 Metropolitan Mercer 40,831 30,472 10,359 Rural, non-Appalachian Carroll 28,187 22,120 6,067 Appalachian Miami 103,900 79,822 24,078 Suburban Champaign 39,128 29,987 9,141 Rural, non-Appalachian Monroe 14,465 11,435 3,030 Appalachian Clark 136,554 105,376 31,178 Suburban Montgomery 533,116 413,284 119,832 Metropolitan Clermont 201,560 152,779 48,781 Appalachian Morgan 14,843 11,608 3,235 Appalachian Clinton 41,835 31,794 10,041 Rural, non-Appalachian Morrow 35,152 26,646 8,506 Rural, non-Appalachian Columbiana 105,686 83,645 22,041 Appalachian Muskingum 85,818 65,843 19,975 Appalachian Coshocton 36,516 27,947 8,569 Appalachian Noble 14,363 11,751 2,612 Appalachian Crawford 42,480 33,130 9,350 Rural, non-Appalachian Ottawa 41,154 33,106 8,048 Rural, non-Appalachian Cuyahoga 1,259,828 988,748 271,080 Metropolitan Paulding 18,989 14,443 4,546 Rural, non-Appalachian Darke 52,196 39,579 12,617 Rural, non-Appalachian Perry 35,812 27,145 8,667 Appalachian Defiance 38,510 29,463 9,047 Rural, non-Appalachian Pickaway 56,876 44,315 12,561 Suburban Delaware 189,113 136,940 52,173 Suburban Pike 28,256 21,509 6,747 Appalachian Erie 75,828 59,934 15,894 Rural, non-Appalachian Portage 161,882 130,679 31,203 Suburban Fairfield 150,381 113,586 36,795 Suburban Preble 41,586 31,859 9,727 Rural, non-Appalachian Fayette 28,800 21,875 6,925 Rural, non-Appalachian Putnam 34,171 25,405 8,766 Rural, non-Appalachian Franklin 1,231,393 939,871 291,522 Metropolitan Richland 121,942 95,344 26,598 Metropolitan Fulton 42,580 32,281 10,299 Suburban Ross 77,159 60,423 16,736 Appalachian Gallia 30,397 23,407 6,990 Appalachian Sandusky 60,179 46,158 14,021 Rural, non-Appalachian Geauga 94,295 71,535 22,760 Suburban Scioto 77,258 60,256 17,002 Appalachian Greene 163,820 129,881 33,939 Suburban Seneca 55,669 43,242 12,427 Rural, non-Appalachian Guernsey 39,590 30,553 9,037 Appalachian Shelby 48,951 36,233 12,718 Rural, non-Appalachian Hamilton 806,631 618,901 187,730 Metropolitan Stark 375,736 293,334 82,402 Metropolitan Hancock 75,337 58,259 17,078 Rural, non-Appalachian Summit 541,943 424,281 117,662 Metropolitan Hardin 31,796 24,388 7,408 Rural, non-Appalachian Trumbull 205,175 162,161 43,014 Appalachian Harrison 15,543 12,273 3,270 Appalachian Tuscarawas 92,788 71,512 21,276 Appalachian Henry 27,937 21,266 6,671 Rural, non-Appalachian Union 53,776 40,109 13,667 Suburban Highland 43,045 32,638 10,407 Appalachian Van Wert 28,462 21,778 6,684 Rural, non-Appalachian Hocking 28,725 22,070 6,655 Appalachian Vinton 13,234 10,152 3,082 Appalachian Holmes 43,898 29,317 14,581 Appalachian Warren 221,659 164,303 57,356 Rural, non-Appalachian Huron 58,714 44,213 14,501 Rural, non-Appalachian Washington 61,213 48,907 12,306 Appalachian Jackson 32,748 24,862 7,886 Appalachian Wayne 115,537 87,100 28,437 Rural, non-Appalachian Jefferson 67,694 54,461 13,233 Appalachian Williams 37,291 28,690 8,601 Rural, non-Appalachian Knox 61,167 46,915 14,252 Rural, non-Appalachian Wood 129,590 102,762 26,828 Suburban Lake 229,230 181,236 47,994 Suburban Wyandot 22,353 17,114 5,239 Rural, non-Appalachian Lawrence 61,623 47,802 13,821 Appalachian Licking 169,390 129,305 40,085 Suburban M-6

Appendix M Table 4: Socioeconomic Measures for Counties in Ohio County All Ages in Under Age 18 in County Health Rankings: Social County All Ages in Under Age 18 in County Health Rankings: Social Poverty (%)15 Poverty (%)16 & Economic Factors Rank17 Poverty (%)15 Poverty (%)16 & Economic Factors Rank17 Adams 24.8 33.3 87 Logan 17.0 27.2 45 Allen 18.0 24.9 53 Lorain 14.7 21.7 52 Ashland 14.6 21.0 25 Lucas 20.7 29.4 86 Ashtabula 21.5 32.1 76 Madison 12.6 17.1 35 Athens 29.9 31.4 65 Mahoning 18.9 28.7 72 Auglaize 8.3 12.1 4 Marion 21.3 27.3 80 Belmont 16.1 24.5 50 Medina 7.0 9.6 7 Brown 15.0 23.8 71 Meigs 22.6 32.7 82 Butler 14.4 20.3 42 Mercer 8.9 11.7 5 Carroll 13.5 21.4 34 Miami 10.6 15.7 16 Champaign 11.3 17.7 27 Monroe 15.7 23.0 74 Clark 18.2 27.6 66 Montgomery 19.7 30.3 73 Clermont 11.2 15.4 24 Morgan 18.1 27.6 78 Clinton 13.7 20.4 60 Morrow 12.1 21.1 37 Columbiana 15.9 23.5 58 Muskingum 19.1 27.2 67 Coshocton 18.1 27.4 64 Noble 16.3 20.0 57 Crawford 15.4 24.7 47 Ottawa 10.1 15.6 32 Cuyahoga 19.6 30.0 79 Paulding 12.3 18.1 26 Darke 12.2 17.0 23 Perry 17.8 25.1 59 Defiance 11.7 18.1 18 Pickaway 13.2 19.0 36 Delaware 4.8 5.1 1 Pike 21.9 32.7 88 Erie 13.9 22.3 46 Portage 14.2 18.2 29 Fairfield 9.6 13.9 14 Preble 13.0 19.9 40 Fayette 15.8 25.3 49 Putnam 7.8 9.6 2 Franklin 17.3 24.6 62 Richland 15.9 23.4 56 Fulton 10.5 14.8 15 Ross 19.2 27.2 69 Gallia 26.1 37.9 83 Sandusky 14.5 21.2 39 Geauga 7.8 11.5 10 Scioto 27.2 36.1 85 Greene 13.2 18.1 17 Seneca 17.5 25.6 38 Guernsey 17.2 26.4 61 Shelby 10.7 16.0 21 Hamilton 17.6 24.4 63 Stark 14.9 21.6 43 Hancock 12.7 18.2 12 Summit 13.4 20.3 48 Hardin 19.0 24.8 44 Trumbull 17.2 28.3 75 Harrison 16.9 25.6 51 Tuscarawas 13.4 18.3 31 Henry 10.2 15.0 19 Union 7.7 9.2 6 Highland 19.3 27.6 77 Van Wert 10.1 14.8 11 Hocking 17.5 26.1 54 Vinton 23.7 36.3 84 Holmes 12.4 18.5 13 Warren 5.8 7.5 3 Huron 13.4 19.9 55 Washington 15.7 21.2 41 Jackson 20.0 30.2 81 Wayne 13.9 20.4 20 Jefferson 20.0 31.1 70 Williams 14.2 21.6 28 Knox 15.1 21.4 30 Wood 13.5 12.3 9 Lake 8.9 13.4 22 Wyandot 10.0 13.8 8 Lawrence 17.5 27.4 68 Licking 13.5 20.6 33 M-7

Appendix M Table 5: Insurance and Health Care Access Measures for Counties in Ohio

Medicaid Uninsured Medically County Health Rankings: Medicaid Uninsured Medically County Health Rankings: County County Recipients (%)18 (%)19 Underserved20 Clinical Care Rank21 Recipients (%)18 (%)19 Underserved20 Clinical Care Rank21 Adams 26.78 13.8 Yes 86 Licking 17.39 5.7 No 24 Allen 18.70 5.7 Yes 28 Logan 21.42 9.9 Yes 38 Ashland 16.36 8.1 No 19 Lorain 17.03 7.0 Yes 29 Ashtabula 20.87 8.6 Yes 80 Lucas 24.29 8.6 Yes 51 Athens 21.69 8.4 Yes 40 Madison 18.77 4.7 Yes 36 Auglaize 11.27 4.6 No 21 Mahoning 22.07 6.1 Yes 13 Belmont 19.55 5.5 Yes 69 Marion 23.26 4.5 Yes 59 Brown 15.17 NA Yes 65 Medina 8.66 5.9 Yes 6 Butler 16.38 6.9 Yes 44 Meigs 27.00 9.4 Yes 77 Carroll 19.29 5.1 Yes 58 Mercer 11.31 3.7 No 53 Champaign 20.80 NA No 46 Miami 12.48 7.3 Yes 34 Clark 22.00 8.6 Yes 63 Monroe 19.97 4.7 Yes 81 Clermont 14.10 8.9 Yes 23 Montgomery 22.08 7.0 Yes 17 Clinton 16.43 7.8 Yes 35 Morgan 21.17 8.6 Yes 79 Columbiana 18.63 9.5 Yes 66 Morrow 14.23 6.1 Yes 74 Coshocton 23.26 10.0 Yes 85 Muskingum 25.68 7.4 Yes 45 Crawford 16.51 11.4 No 55 Noble 15.35 13.9 Yes 84 Cuyahoga 23.85 6.1 Yes 5 Ottawa 11.29 NA Yes 49 Darke 10.74 9.8 Yes 33 Paulding 24.13 NA Yes 64 Defiance 10.64 6.7 Yes 41 Perry 29.13 11.2 Yes 67 Delaware 9.25 7.3 No 1 Pickaway 19.21 NA Yes 61 Erie 16.69 4.4 Yes 15 Pike 18.74 NA Yes 76 Fairfield 16.24 6.8 Yes 11 Portage 15.81 7.9 Yes 39 Fayette 25.19 NA Yes 52 Preble 17.61 10.2 No 57 Franklin 18.39 8.8 Yes 18 Putnam 13.69 NA Yes 4 Fulton 15.18 NA No 14 Richland 20.83 8.3 Yes 47 Gallia 24.15 7.7 No 37 Ross 23.26 5.0 Yes 30 Geauga 10.20 5.8 No 12 Sandusky 14.98 6.3 Yes 48 Greene 14.39 5.0 Yes 9 Scioto 23.91 10.4 Yes 70 Guernsey 24.15 4.8 Yes 68 Seneca 15.65 NA No 42 Hamilton 20.09 6.6 Yes 3 Shelby 14.00 5.0 No 27 Hancock 13.86 7.1 No 7 Stark 18.63 6.9 Yes 10 Hardin 18.77 9.4 Yes 73 Summit 18.77 6.7 Yes 22 Harrison 30.35 NA Yes 87 Trumbull 18.66 6.5 Yes 56 Henry 10.57 NA No 8 Tuscarawas 17.74 5.7 Yes 71 Highland 25.02 9.3 Yes 82 Union 13.59 NA Yes 25 Hocking 24.51 6.4 Yes 62 Van Wert 16.12 3.9 Yes 60 Holmes 10.35 14.3 Yes 88 Vinton 20.52 11.8 Yes 83 Huron 13.78 4.9 No 54 Warren 9.39 6.6 Yes 2 Jackson 19.59 5.8 Yes 75 Washington 17.82 5.9 Yes 43 Jefferson 27.57 4.9 Yes 72 Wayne 12.18 7.1 No 31 Knox 15.14 6.8 Yes 50 Williams 7.90 1.9 No 20 Lake 11.87 7.6 Yes 16 Wood 13.06 6.3 Yes 26 Lawrence 24.96 8.1 Yes 78 Wyandot 19.39 NA No 32 M-8

Appendix M Table 6: Smoking Prevalence and Health Risk Behavior Measures for Counties in Ohio County Current Adult Smokers (%) (County Current Youth Smokers (%) 12-17 Years Births to Mothers that Smoked County Health Rankings: Health Health Rankings, Modeled County Est.)22 (NSDUH Modeled Regional Est.)23 During Pregnancy (%)24 Behaviors Sub Rank25 Adams 23.0 11.3 25.1 65 Allen 21.2 9.8 23.0 75 Ashland 20.1 9.1 17.8 26 Ashtabula 22.1 9.5 27.5 68 Athens 22.9 12.1 22.7 72 Auglaize 19.5 9.8 16.0 38 Belmont 20.6 10.6 26.2 66 Brown 20.9 9.3 24.8 76 Butler 19.5 10.0 15.2 30 Carroll 20.2 10.6 21.3 49 Champaign 19.6 9.8 18.4 46 Clark 19.9 12.6 23.8 48 Clermont 18.6 9.3 17.0 16 Clinton 20.4 9.3 22.4 69 Columbiana 20.9 10.6 23.8 56 Coshocton 20.8 12.1 23.3 63 Crawford 18.1 9.1 29.0 13 Cuyahoga 18.3 9.3 9.0 39 Darke 18.8 9.8 18.0 29 Defiance 19.1 8.7 20.1 42 Delaware 14.0 9.1 6.7 1 Erie 20.0 8.9 21.6 43 Fairfield 17.5 9.9 15.2 9 Fayette 20.7 11.3 29.8 58 Franklin 18.7 7.6 11.0 37 Fulton 18.2 8.7 15.5 17 Gallia 22.9 11.3 26.6 80 Geauga 16.1 11.8 9.4 2 Greene 18.3 12.6 11.7 14 Guernsey 21.0 12.1 26.9 81 Hamilton 19.6 6.7 11.4 59 Hancock 19.0 8.7 12.9 22 Hardin 20.7 9.8 25.7 62 Harrison 20.1 10.6 24.8 27 Henry 18.5 8.7 13.8 18 Highland 22.0 11.3 26.4 74 Hocking 21.4 12.1 25.2 70 Holmes 20.2 9.1 6.4 23 Huron 18.3 9.1 21.3 35 Jackson 22.3 11.3 22.4 85 Jefferson 21.1 10.6 27.4 71 Knox 20.0 9.9 16.1 50 Lake 17.6 11.8 11.9 6 Lawrence 20.9 11.3 19.0 78 M-9

Appendix M Table 6: Smoking Prevalence and Health Risk Behavior Measures for Counties in Ohio County Current Adult Smokers (%) (County Current Youth Smokers (%) 12-17 Years Births to Mothers that Smoked County Health Rankings: Health Health Rankings, Modeled County Est.)22 (NSDUH Modeled Regional Est.)23 During Pregnancy (%)24 Behaviors Sub Rank25 Licking 18.2 9.9 18.3 19 Logan 20.1 9.8 22.9 47 Lorain 18.2 9.3 18.6 20 Lucas 20.2 8.1 15.2 73 Madison 19.0 12.6 19.3 25 Mahoning 20.3 9.5 21.9 52 Marion 21.6 9.1 32.0 87 Medina 15.9 9.1 12.4 5 Meigs 22.6 11.3 30.4 86 Mercer 15.9 8.7 11.7 3 Miami 18.9 9.8 17.2 24 Monroe 18.1 10.6 15.2 28 Montgomery 20.6 7.5 13.2 55 Morgan 21.2 12.1 27.1 64 Morrow 19.5 9.1 20.6 53 Muskingum 22.2 12.1 21.9 83 Noble 20.2 12.1 21.5 67 Ottawa 17.4 8.9 16.6 8 Paulding 19.0 8.7 20.7 21 Perry 21.3 12.1 23.0 82 Pickaway 19.1 11.3 25.4 57 Pike 23.5 11.3 30.5 77 Portage 19.9 11.8 15.9 15 Preble 19.4 9.8 20.4 33 Putnam 16.5 8.7 9.3 10 Richland 19.8 9.1 20.6 61 Ross 21.7 11.3 26.5 79 Sandusky 19.5 8.9 20.8 45 Scioto 25.0 11.3 27.1 88 Seneca 19.3 8.9 25.0 34 Shelby 19.2 9.8 19.0 44 Stark 19.4 9.5 19.0 36 Summit 20.1 9.3 13.5 40 Trumbull 20.4 9.5 24.2 54 Tuscarawas 17.7 10.6 15.1 31 Union 18.4 9.1 11.3 12 Van Wert 19.0 8.7 24.0 41 Vinton 22.8 12.1 31.8 84 Warren 16.1 9.3 8.6 4 Washington 20.7 10.6 20.3 51 Wayne 18.6 9.1 14.0 7 Williams 20.2 8.7 19.6 60 Wood 18.0 8.9 10.1 11 Wyandot 17.1 8.9 17.2 32 M-10

Appendix M Table 7: Age-Adjusted Death Rates (per 100,000 Population) for Selected Tobacco-Associated Chronic Diseases, by County, Ohio County Cancer Death Heart Disease Stroke Death COPD/CLRD County Cancer Death Heart Disease Stroke Death COPD/CLRD Rate26 Death Rate27 Rate28 Death Rate29 Rate26 Death Rate27 Rate28 Death Rate29 Adams 209.5 193.9 52.4 52.9 Licking 184.9 181.1 42.6 69.2 Allen 193.9 198.3 43.8 55.2 Logan 191.3 173.9 51.6 50.6 Ashland 192.2 201.0 46.9 51.7 Lorain 179.3 168.5 32.3 59.9 Ashtabula 221.7 202.5 36.6 54.5 Lucas 187.4 231.5 44.4 54.3 Athens 189.5 221.6 41.8 68.1 Madison 207.7 212.6 43.8 58.7 Auglaize 157.8 193.1 42.8 46.2 Mahoning 193.1 213.8 41.8 37.0 Belmont 187.9 273.2 36.5 52.1 Marion 187.0 183.6 33.8 65.8 Brown 217.3 183.6 44.8 59.3 Medina 182.7 153.5 32.4 48.8 Butler 189.2 152.3 36.5 55.7 Meigs 225.0 182.8 54.6 89.4 Carroll 228.8 218.2 35.2 59.4 Mercer 178.2 242.9 47.8 33.1 Champaign 184.4 154.2 47.1 73.1 Miami 177.6 179.1 38.9 58.6 Clark 200.8 198.9 53.8 65.7 Monroe 169.2 259.1 35.9 36.8 Clermont 191.1 166.5 57.7 42.6 Montgomery 190.7 173.6 41.1 51.1 Clinton 238.6 226.0 66.1 70.3 Morgan 185.9 194.9 76.1 47.2 Columbiana 194.2 207.7 45.7 52.7 Morrow 201.2 169.9 38.3 40.8 Coshocton 191.8 230.4 23.2 48.0 Muskingum 211.1 174.0 59.5 63.5 Crawford 185.3 171.8 38.8 59.2 Noble 113.6 174.0 25.3 37.1 Cuyahoga 186.6 198.5 35.4 39.0 Ottawa 166.8 230.1 56.3 50.3 Darke 169.4 188.6 35.7 43.5 Paulding 235.8 192.3 71.9 52.2 Defiance 206.0 167.3 47.6 63.8 Perry 257.5 250.5 41.1 84.6 Delaware 150.2 126.5 34.9 36.7 Pickaway 174.7 204.7 36.4 69.5 Erie 201.6 160.7 29.8 60.2 Pike 203.3 214.2 56.1 78.2 Fairfield 167.8 155.3 52.8 46.7 Portage 189.1 196.9 33.6 57.1 Fayette 173.4 312.1 51.4 47.2 Preble 204.7 220.1 37.2 45.8 Franklin 179.2 174.7 44.2 50.6 Putnam 146.7 164.4 41.7 57.2 Fulton 181.7 145.8 32.7 45.2 Richland 176.9 203.5 33.7 49.0 Gallia 196.3 205.4 42.8 87.0 Ross 203.3 226.9 48.3 63.8 Geauga 168.1 136.4 18.9 34.8 Sandusky 196.5 159.7 31.8 39.1 Greene 153.4 178.8 30.9 40.4 Scioto 187.8 275.7 46.9 91.4 Guernsey 210.2 180.6 40.8 46.4 Seneca 180.4 239.6 40.2 69.1 Hamilton 190.6 169.2 49.9 46.2 Shelby 163.8 196.4 46.0 37.5 Hancock 193.5 143.8 49.9 37.2 Stark 176.6 177.0 41.1 50.2 Hardin 154.2 272.8 64.7 46.9 Summit 184.1 174.7 37.8 49.7 Harrison 170.3 205.2 29.0 36.3 Trumbull 196.7 213.5 37.6 50.1 Henry 197.6 205.6 42.3 40.6 Tuscarawas 156.7 180.7 34.7 51.4 Highland 245.7 182.6 43.5 93.9 Union 148.9 139.4 54.1 59.2 Hocking 216.8 190.6 39.7 58.1 Van Wert 167.3 205.4 37.7 51.1 Holmes 123.8 181.9 35.6 38.2 Vinton 199.3 253.1 44.2 96.7 Huron 198.2 163.7 44.8 80.3 Warren 161.6 167.3 40.6 50.4 Jackson 209.2 251.7 33.1 88.0 Washington 200.3 182.6 49.2 60.7 Jefferson 194.7 281.7 38.9 75.8 Wayne 161.2 171.9 47.8 70.3 Knox 170.9 224.2 43.7 53.9 Williams 162.2 175.7 33.2 56.8 Lake 175.9 180.5 35.5 46.5 Wood 170.3 189.9 42.2 39.2 Lawrence 207.3 211.7 57.7 83.3 Wyandot 174.3 156.7 31.0 37.3 M-11

Appendix M Table 8: Incidence and Regional Prevalence Rates for Selected Tobacco-Associated Chronic Diseases for Counties in Ohio County Lung Cancer Incidence Cancer Prevalence Heart Disease Prevalence Stroke Prevalence COPD/CLRD Prevalence County Health Rankings: (Cases per 100,000)30 (Regional %) 31 (Regional %)32 (Regional %)33 (Regional %)34 Health Outcomes Sub Rank35 Adams 93.3 6.9 12.0 3.8 12.3 87 Allen 69.8 5.2 10.3 3.2 8.5 36 Ashland 62.3 7.0 7.9 3.6 7.4 21 Ashtabula 80.4 6.6 7.5 3.7 8.0 62 Athens 83.7 7.4 12.4 4.8 13.3 68 Auglaize 69.5 5.2 10.3 3.2 8.5 11 Belmont 66.3 11.2 12.0 3.6 12.4 51 Brown 112.0 6.9 12.0 3.8 12.3 69 Butler 72.9 4.8 7.7 3.0 8.7 44 Carroll 72.9 11.2 12.0 3.6 12.4 42 Champaign 60.3 6.0 8.7 3.9 8.6 35 Clark 77.5 6.0 8.7 3.9 8.6 67 Clermont 87.4 4.8 7.7 3.0 8.7 31 Clinton 85.3 4.8 7.7 3.0 8.7 70 Columbiana 72.4 6.6 7.5 3.7 8.0 57 Coshocton 78.8 7.5 10.2 3.6 13.1 55 Crawford 69.1 7.1 6.5 NA 7.1 43 Cuyahoga 70.2 5.8 6.6 3.9 8.9 64 Darke 63.4 6.0 8.7 3.9 8.6 28 Defiance 71.3 7.3 10.1 4.5 10.2 18 Delaware 62.6 6.8 7.4 2.4 4.2 1 Erie 62.1 7.1 6.5 NA 7.1 56 Fairfield 75.9 7.4 6.5 3.4 6.6 14 Fayette 91.9 6.9 12.0 3.8 12.3 76 Franklin 71.6 7.4 6.5 3.4 6.6 58 Fulton 54.1 7.3 10.1 4.5 10.2 26 Gallia 90.2 7.4 12.4 4.8 13.3 86 Geauga 55.0 5.8 6.6 3.9 8.9 2 Greene 61.6 6.0 8.7 3.9 8.6 17 Guernsey 80.1 7.5 10.2 3.6 13.1 66 Hamilton 74.9 4.8 7.7 3.0 8.7 61 Hancock 58.8 5.2 10.3 3.2 8.5 13 Hardin 67.7 5.2 10.3 3.2 8.5 72 Harrison 69.1 11.2 12.0 3.6 12.4 59 Henry 56.1 7.3 10.1 4.5 10.2 10 Highland 84.2 6.9 12.0 3.8 12.3 78 Hocking 72.5 7.4 12.4 4.8 13.3 63 Holmes 37.5 7.0 7.9 3.6 7.4 8 Huron 75.0 7.1 6.5 NA 7.1 34 Jackson 88.3 7.4 12.4 4.8 13.3 84 Jefferson 78.0 11.2 12.0 3.6 12.4 81 Knox 68.5 6.8 7.4 2.4 4.2 39 Lake 76.8 5.8 6.6 3.9 8.9 15 Lawrence 82.8 7.4 12.4 4.8 13.3 82 M-12

Appendix M Table 8: Incidence and Regional Prevalence Rates for Selected Tobacco-Associated Chronic Diseases for Counties in Ohio County Lung Cancer Incidence Cancer Prevalence Heart Disease Prevalence Stroke Prevalence COPD/CLRD Prevalence County Health Rankings: (Cases per 100,000)30 (Regional %) 31 (Regional %)32 (Regional %)33 (Regional %)34 Health Outcomes Sub Rank35 Licking 82.6 7.4 6.5 3.4 6.6 23 Logan 75.4 6.0 8.7 3.9 8.6 49 Lorain 72.2 5.8 6.6 3.9 8.9 30 Lucas 62.0 7.3 10.1 4.5 10.2 73 Madison 79.4 7.4 6.5 3.4 6.6 33 Mahoning 70.5 6.6 7.5 3.7 8.0 75 Marion 88.6 6.8 7.4 2.4 4.2 60 Medina 63.7 7.0 7.9 3.6 7.4 5 Meigs 70.8 7.4 12.4 4.8 13.3 79 Mercer 47.0 5.2 10.3 3.2 8.5 7 Miami 74.1 6.0 8.7 3.9 8.6 24 Monroe 67.0 11.2 12.0 3.6 12.4 50 Montgomery 77.9 6.0 8.7 3.9 8.6 80 Morgan 81.8 7.5 10.2 3.6 13.1 77 Morrow 79.3 6.8 7.4 2.4 4.2 37 Muskingum 80.3 7.5 10.2 3.6 13.1 71 Noble 56.2 7.5 10.2 3.6 13.1 41 Ottawa 68.0 7.1 6.5 NA 7.1 27 Paulding 91.0 7.3 10.1 4.5 10.2 29 Perry 79.5 7.5 10.2 3.6 13.1 54 Pickaway 78.4 7.4 6.5 3.4 6.6 48 Pike 90.8 6.9 12.0 3.8 12.3 88 Portage 72.5 6.6 7.5 3.7 8.0 22 Preble 73.0 6.0 8.7 3.9 8.6 46 Putnam 48.7 5.2 10.3 3.2 8.5 3 Richland 70.1 7.1 6.5 NA 7.1 53 Ross 83.3 6.9 12.0 3.8 12.3 74 Sandusky 65.5 7.1 6.5 NA 7.1 38 Scioto 102.4 6.9 12.0 3.8 12.3 83 Seneca 66.5 7.1 6.5 NA 7.1 47 Shelby 55.3 6.0 8.7 3.9 8.6 25 Stark 67.9 7.0 7.9 3.6 7.4 45 Summit 68.4 7.0 7.9 3.6 7.4 52 Trumbull 82.9 6.6 7.5 3.7 8.0 65 Tuscarawas 64.2 7.5 10.2 3.6 13.1 32 Union 66.9 6.8 7.4 2.4 4.2 4 Van Wert 57.9 5.2 10.3 3.2 8.5 19 Vinton 114.2 7.4 12.4 4.8 13.3 85 Warren 66.8 4.8 7.7 3.0 8.7 6 Washington 73.5 11.2 12.0 3.6 12.4 40 Wayne 57.8 7.0 7.9 3.6 7.4 16 Williams 65.6 7.3 10.1 4.5 10.2 20 Wood 52.3 7.3 10.1 4.5 10.2 9 Wyandot 72.0 7.1 6.5 NA 7.1 12 M-13

Appendix M Table 9: Tobacco Retail Environment Measures for Counties in Ohio County Total Number of Number of Tobacco Retailers within Number of Tobacco Retailers within Tobacco Retailer Density (No. Tobacco Retailer Density Tobacco Retailers35 Walking Distance of a School36 Walking Distance of a Public Park37 per 1,000 Residents)38 (No. per 10 Sq. Miles)39 Adams 34 14 0 1.21 0.6 Allen 113 68 0 1.08 2.8 Ashland 56 29 0 1.06 1.3 Ashtabula 125 36 0 1.25 1.8 Athens 66 23 0 1.02 1.3 Auglaize 48 32 0 1.05 1.2 Belmont 82 49 0 1.17 1.5 Brown 54 14 0 1.22 1.1 Butler 250 123 222 0.67 5.4 Carroll 25 11 0 0.89 0.6 Champaign 44 16 0 1.12 1.0 Clark 145 88 0 1.06 3.6 Clermont 164 76 152 0.81 3.6 Clinton 15 2 0 0.36 0.4 Columbian 121 56 0 1.14 2.3 Coshocton 40 27 0 1.10 0.7 Crawford 50 36 0 1.18 1.2 Cuyahoga 1324 1065 772 1.09 29.0 Darke 59 16 0 1.13 1.0 Defiance 39 4 0 1.01 0.9 Delaware 105 54 12 0.56 2.4 Erie 102 57 0 1.35 4.1 Fairfield 90 52 5 0.60 1.8 Fayette 40 18 0 1.42 1.0 Franklin 1118 845 720 0.90 21.0 Fulton 48 18 0 1.13 1.2 Gallia 22 7 0 0.69 0.5 Geauga 76 20 20 0.81 1.9 Greene 68 37 0 0.42 1.6 Guernsey 66 20 0 1.64 1.3 Hamilton 802 606 798 0.99 19.8 Hancock 71 45 0 0.94 1.3 Hardin 31 22 0 0.97 0.7 Harrison 23 11 0 1.48 0.6 Henry 25 13 0 0.89 0.6 Highland 40 12 0 0.93 0.7 Hocking 30 9 0 1.04 0.7 Holmes 31 17 0 0.73 0.7 Huron 61 26 0 1.04 1.2 Jackson 44 13 0 1.31 1.0 Jefferson 80 41 0 1.18 2.0 Knox 60 38 0 0.98 1.1 Lake 214 126 3 0.93 9.4 Lawrence 66 36 0 1.09 1.5 M-14

Appendix M Table 9: Tobacco Retail Environment Measures for Counties in Ohio County Total Number of Number of Tobacco Retailers within Number of Tobacco Retailers within Tobacco Retailer Density (No. Tobacco Retailer Density Tobacco Retailers35 Walking Distance of a School36 Walking Distance of a Public Park37 per 1,000 Residents)38 (No. per 10 Sq. Miles)39 Licking 120 54 0 0.71 1.8 Logan 42 17 0 0.92 0.9 Lorain 278 145 2 0.91 5.7 Lucas 494 341 0 1.13 14.5 Madison 13 6 0 0.30 0.3 Mahoning 256 134 0 1.10 6.2 Marion 68 43 0 1.03 1.7 Medina 125 59 0 0.71 3.0 Meigs 31 4 0 1.29 0.7 Mercer 65 30 0 1.59 1.4 Miami 94 53 0 0.90 2.3 Monroe 19 11 0 1.31 0.4 Montgome 539 363 0 1.01 11.7 Morgan 16 1 0 1.08 0.4 Morrow 35 12 0 1.00 0.9 Muskingum 113 51 0 1.32 1.7 Noble 21 6 0 1.46 0.5 Ottawa 137 37 0 3.33 5.4 Paulding 26 9 0 1.37 0.6 Perry 47 25 0 1.31 1.2 Pickaway 52 21 0 0.91 1.0 Pike 49 13 0 1.73 1.1 Portage 138 73 0 0.83 2.8 Preble 52 19 1 1.25 1.2 Putnam 34 25 0 0.99 0.7 Richland 145 88 0 1.19 2.9 Ross 78 29 0 1.01 1.1 Sandusky 74 37 0 1.23 1.8 Scioto 68 21 0 0.80 1.1 Seneca 60 35 0 1.08 1.1 Shelby 59 32 0 1.21 1.4 Stark 334 180 0 0.89 5.8 Summit 465 306 0 0.86 11.3 Trumbull 279 126 0 1.36 4.5 Tuscarawas 102 63 0 1.09 1.8 Union 38 18 0 0.71 0.9 Van Wert 25 6 0 0.88 0.6 Vinton 12 5 0 0.91 0.3 Warren 143 53 128 0.65 3.6 Washingto 68 34 0 1.11 1.1 Wayne 95 58 0 0.82 1.7 Williams 54 23 0 1.39 1.3 Wood 108 54 0 0.83 1.7 Wyandot 36 13 0 1.61 0.9 M-15

Appendix M Table 10: Tobacco Policy Environment Measures for Counties in Ohio County Tobacco Policy Score, Avg. No. of Youth in Public No. of low SES Youth in Number of 2- and 4-year Number of Occupied Adults with Smoke Free Home of all School Districts40 School (preK-12)41 Public School (PreK-12)42 Colleges & Universities43 Multi-housing Units44 Rules (%, Regional Est.)45 Adams 60.00 4,857 3,315 . 718 62.5 Allen 80.10 15,495 8,339 4 9,262 77.8 Ashland 80.00 6,138 2,237 1 4,008 74.9 Ashtabula 68.13 13,653 8,313 1 7,482 75.6 Athens 86.00 7,296 4,213 2 7,176 69.1 Auglaize 64.50 7,759 2,435 . 2,932 77.8 Belmont 81.25 8,756 2,960 2 5,235 69.1 Brown 63.17 7,158 3,633 1 1,823 62.5 Butler 75.45 56,334 25,005 3 37,050 75.2 Carroll 98.50 2,779 587 . 826 69.1 Champaign 77.20 6,905 2,397 1 2,301 73.8 Clark 82.25 20,181 12,223 2 13,666 73.8 Clermont 72.10 26,739 9,814 1 19,232 75.2 Clinton 57.50 7,774 3,505 1 3,458 75.2 Columbiana 78.00 13,862 7,058 4 7,435 75.6 Coshocton 71.25 4,767 3,271 . 1,837 70.5 Crawford 72.50 6,419 3,542 . 3,483 75.4 Cuyahoga 79.85 145,197 76,680 24 250,994 73.6 Darke 63.00 7,844 2,824 . 3,445 73.8 Defiance 70.80 6,213 2,415 1 2,409 76.2 Delaware 80.20 30,694 4,148 2 13,838 71.8 Erie 73.00 11,355 4,546 2 8,802 75.4 Fairfield 75.25 24,585 9,023 2 11,586 76.4 Fayette 85.00 4,787 2,704 . 2,421 62.5 Franklin 77.59 171,475 89,374 23 239,316 76.4 Fulton 86.14 7,657 2,475 . 2,243 76.2 Gallia 62.00 4,330 3,278 2 1,157 69.1 Geauga 71.29 10,331 1,890 1 3,968 73.6 Greene 75.00 21,306 6,359 8 17,947 73.8 Guernsey 76.67 4,560 2,441 . 1,829 70.5 Hamilton 71.35 100,721 36,942 25 157,770 75.2 Hancock 77.75 11,859 3,745 3 7,981 77.8 Hardin 76.17 4,143 1,865 1 2,121 77.8 Harrison 66.00 1,944 959 . 572 69.1 Henry 77.20 4,282 1,570 1 1,527 76.2 Highland 78.20 7,352 4,075 1 1,824 62.5 Hocking 100.00 3,821 1,930 . 1,310 69.1 Holmes 77.50 3,902 1,459 . 1,289 74.9 Huron 70.71 9,857 4,203 . 4,984 75.4 Jackson 68.33 5,109 3,237 1 1,574 69.1 Jefferson 72.17 8,866 4,866 2 5,083 69.1 Knox 77.50 7,670 2,835 2 3,960 71.8 Lake 74.20 31,501 11,929 5 25,106 73.6 Lawrence 51.88 9,322 7,755 2 2,988 69.1 M-16

Appendix M Table 10: Tobacco Policy Environment Measures for Counties in Ohio County Tobacco Policy Score, Avg. No. of Youth in Public No. of low SES Youth in Number of 2- and 4-year Number of Occupied Adults with Smoke Free Home of all School Districts40 School (preK-12)41 Public School (PreK-12)42 Colleges & Universities43 Multi-housing Units44 Rules (%, Regional Est.)45 Licking 84.82 26,375 9,274 3 13,468 76.4 Logan 75.00 6,448 2,667 . 3,084 73.8 Lorain 67.07 40,917 16,776 3 29,365 73.6 Lucas 76.88 51,293 22,359 9 59,713 76.2 Madison 76.60 6,547 2,428 1 2,779 76.4 Mahoning 67.13 28,998 13,762 2 25,360 75.6 Marion 86.50 9,042 6,042 2 4,935 71.8 Medina 83.13 27,590 5,738 . 14,581 74.9 Meigs 76.00 3,343 2,557 . 668 69.1 Mercer 74.50 7,917 1,937 1 2,253 77.8 Miami 72.50 15,775 3,741 2 8,811 73.8 Monroe 97.00 2,222 1,271 . 408 69.1 Montgomer 87.35 67,771 36,686 11 80,729 73.8 Morgan 68.00 1,952 1,111 . 469 70.5 Morrow 68.50 5,294 1,765 . 997 71.8 Muskingum 72.00 14,175 8,324 3 7,308 70.5 Noble 73.00 1,670 743 . 337 70.5 Ottawa 60.20 5,229 1,926 . 4,242 75.4 Paulding 73.67 3,107 1,296 . 928 76.2 Perry 72.25 5,762 4,227 . 1,389 70.5 Pickaway 88.00 9,321 4,304 1 2,591 76.4 Pike 70.60 4,780 3,257 . 1,145 62.5 Portage 78.17 20,690 7,451 4 18,485 75.6 Preble 68.67 6,221 2,758 . 1,978 73.8 Putnam 73.22 5,951 1,435 . 1,275 77.8 Richland 70.90 16,720 8,483 2 12,093 75.4 Ross 75.75 10,821 7,229 2 4,325 62.5 Sandusky 74.83 9,279 4,709 1 4,239 75.4 Scioto 56.27 11,498 7,057 2 4,684 62.5 Seneca 74.71 6,381 3,088 2 3,917 75.4 Shelby 67.38 7,841 2,676 . 4,061 73.8 Stark 79.56 57,070 29,857 8 38,717 74.9 Summit 79.89 70,595 33,918 9 70,083 74.9 Trumbull 74.38 26,940 15,097 4 18,843 75.6 Tuscarawas 71.22 13,687 5,076 1 6,435 70.5 Union 92.67 7,716 1,972 . 3,150 71.8 Van Wert 86.25 3,691 1,591 . 1,254 77.8 Vinton 90.00 2,138 1,861 . 290 69.1 Warren 75.11 36,611 6,054 1 18,160 75.2 Washington 73.86 7,798 3,136 2 4,241 69.1 Wayne 74.00 15,214 5,887 3 9,926 74.9 Williams 72.14 5,534 2,383 , 2,560 76.2 Wood 74.00 16,519 4,852 2 15,063 76.2 Wyandot 70.00 3,399 1,163 , 1,617 75.4 M-17

Appendix M Table 11: Estimated Potential Impacts of Smoke-Free Policy Interventions for Counties in Ohio County Medical care cost savings, Community-wide Smoke Free/clean air policies Medical care cost savings (Total) from community-wide Smoke Free/clean air (10-yr cumulative rate, $/per 100K residents)46 policies (10-yr cumulative $/per County Total Population)47 Adams -5,293,040 -1,311,721 Allen -5,676,642 -5,205,537 Ashland -5,041,506 -2,302,052 Ashtabula -6,114,711 -5,345,786 Athens -3,473,317 -2,049,952 Auglaize -3,874,847 -1,522,117 Belmont -6,053,333 -3,613,719 Brown -5,356,324 -2,094,323 Butler -5,271,259 -17,163,061 Carroll -5,505,791 -1,367,969 Champaign -5,239,972 -1,837,396 Clark -5,317,329 -6,298,536 Clermont -5,415,270 -9,483,654 Clinton -4,605,337 -1,694,948 Columbiana -6,040,319 -5,590,134 Coshocton -5,298,753 -1,674,406 Crawford -5,896,896 -2,186,569 Cuyahoga -4,546,373 -49,927,041 Darke -5,335,258 -2,399,959 Defiance -4,296,281 -1,448,577 Delaware -3,165,014 -4,956,000 Erie -5,849,898 -3,853,503 Fairfield -3,413,903 -4,416,123 Fayette -5,290,937 -1,323,634 Franklin -3,644,627 -37,876,604 Fulton -5,217,180 -1,935,522 Gallia -5,426,609 -1,445,703 Geauga -3,599,973 -2,922,854 Greene -3,143,867 -4,457,029 Guernsey -5,307,132 -1,830,058 Hamilton -3,948,293 -27,563,349 Hancock -5,203,404 -3,375,552 Hardin -4,520,194 -1,268,683 Harrison -5,636,784 -758,598 Henry -5,223,244 -1,261,152 Highland -5,220,982 -1,963,402 Hocking -4,887,278 -1,251,779 Holmes -3,765,380 -1,385,020 Huron -5,519,867 -2,868,951 Jackson -5,198,259 -1,505,520 Jefferson -6,187,040 -3,648,992 Knox -3,675,124 -1,940,906 Lake -3,833,321 -7,602,894 Lawrence -5,545,361 -2,995,049 M-18

Appendix M Table 11: Estimated Potential Impacts of Smoke-Free Policy Interventions for Counties in Ohio County Medical care cost savings, Community-wide Smoke Free/clean air policies Medical care cost savings (Total) from community-wide Smoke Free/clean air (10-yr cumulative rate, $/per 100K residents)46 policies (10-yr cumulative $/per County Total Population)47 Licking -3,868,659 -5,663,949 Logan -5,265,397 -2,091,679 Lorain -5,664,247 -14,857,150 Lucas -4,321,429 -16,655,133 Madison -4,827,939 -1,859,384 Mahoning -5,939,526 -11,950,445 Marion -4,801,322 -2,783,038 Medina -3,558,104 -5,411,271 Meigs -5,424,976 -1,117,003 Mercer -3,228,228 -1,121,874 Miami -5,502,080 -4,878,144 Monroe -5,677,850 -702,464 Montgomery -4,382,699 -20,197,493 Morgan -5,345,305 -684,146 Morrow -4,786,924 -1,465,182 Muskingum -5,819,456 -4,318,909 Noble -5,886,109 -723,344 Ottawa -5,780,208 -2,038,737 Paulding -5,253,589 -891,849 Perry -5,852,264 -1,857,392 Pickaway -3,633,937 -1,791,495 Pike -5,245,783 -1,304,207 Portage -5,048,752 -7,241,576 Preble -5,343,693 -1,955,738 Putnam -5,140,620 -1,520,030 Richland -5,747,288 -6,119,885 Ross -5,407,513 -3,715,340 Sandusky -3,345,621 -1,754,109 Scioto -5,656,442 -3,874,946 Seneca -5,311,629 -2,596,802 Shelby -4,602,035 -1,987,389 Stark -5,715,072 -18,378,414 Summit -5,232,707 -24,566,304 Trumbull -5,926,464 -10,603,926 Tuscarawas -4,083,912 -3,224,249 Union -4,675,863 -2,202,893 Van Wert -5,275,012 -1,290,110 Vinton -4,809,354 -567,359 Warren -3,475,514 -6,596,282 Washington -4,687,174 -2,476,890 Wayne -3,787,334 -3,748,968 Williams -5,235,016 -1,693,004 Wood -2,870,916 -3,194,928 Wyandot -5,357,129 -1,030,872 M-19

Appendix M Table 12. Example Nielsen Market Research Data on Tobacco-Related Products and Behaviors The Ohio Department of Health uses many different data sources to understand and respond to tobacco use issues. One of those data sources is market research data from Nielsen. Market research data provide tobacco use and expenditure information at lower levels of geography such as census tracts and census block groups. The use of market research data in conjunction with demographic data can greatly facilitate the identification of communities and groups who experience tobacco related disparities, which helps to target program interventions where they are needed the most. Applicants may use this data to help justify the geographic scope of interventions proposed and who is targeted.

Estimated/Projected Smoking Product Expenditures and Index Score5* Source: Nielsen Market

Potential/PRIZM® 2016

Nielsen Market Research Profiles on expenditures, use habits, and the propensity of households to purchase and/or use tobacco products and other relevant products (e.g., smoking cessation aids) are available down to the census tract level upon request to the Ohio Department Health Tobacco Program. Examples of the types of data available include the following. • Smoking product expenditures (consumers concentration reports) and estimated users (cigarettes, menthol cigarettes, cigars, pipes, smokeless tobacco) • Propensity indexes for use of smoking products (relative estimated/expected likelihood a household or adult will use a product or service) • Smoking levels (number of packs in past week, heavy smokers (7+ packs/week)) • Smoking cessation behaviors (use of smoking cessation aids, nicotine patch, or cold turkey method to stop smoking in past year) Data Sources 1 Ohio Behavioral Risk Factor Surveillance System (BRFSS), 2015. Ohio Department of Health. 2 Current cigarette smoking prevalence among working adults--United States, 2004-2010. MMWR Morb Mortal Wkly Rep. 2011 Sep 30; 60(38):1305-9.

5 Index score in this table is the likelihood (relative to a national average of 100) that the households/adults in the area are expected to use a smoking product; for example, an index score of 120 for a particular area can be interpreted to mean that households in the area are 20% more likely to use tobacco than the average household/adult. M-20

Appendix M 3 The Ohio Poverty Report. Ohio Development Services Agency, February 2016. https://www.development.ohio.gov/files/research/P7005.pdf 4 The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General, 2014. http://www.surgeongeneral.gov/library/reports/50-years-of-progress/ 5 2014 Ohio Infant Mortality Data: General Findings. Ohio Department of Health, Maternal and Child Health, http://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/cfhs/Infant%20Mortality/2014%20Ohio%20Infant%20Mortality% 20Report%20Final.pdf. 6 2015 Final Birth Files. Ohio Department of Health, Bureau of Vital Statistics. Percentage of mothers that smoked, among births with known maternal smoking status. 7 African Americans and Tobacco. American Lung Association. http://www.lung.org/stop-smoking/about-smoking/facts- figures/african-americans-and-tobacco.html; Cancer Facts & Figures for African Americans, 2013–2014, American Cancer Society. 8 The Impact of Chronic Disease in Ohio: 2015. Ohio Department of Health, Bureau of Health Promotion. http://www.healthy.ohio.gov/~/media/HealthyOhio/ASSETS/Files/Chronic%20Disease%20Plan/CD%20Burden%20Final_ Webv2.pdf 9 Tobacco Product Use Among Adults — United States, 2013–2014. Hu SS, Neff L, Agaku IT, et al. MMWR Morb Mortal Wkly Rep 2016;65:685-691. http://www.cdc.gov/mmwr/volumes/65/wr/mm6527a1.htm 10 Fact Sheet: Health Disparities and Stress. American Psychological Association. http://www.apa.org/topics/health- disparities/stress.pdf 11 National Center for Health Statistics (NCHS) Vintage 2014 Bridged-Race Postcensal Population Estimates. ODH Public Health Data Warehouse, http://publicapps.odh.ohio.gov/EDW/DataCatalog 12 NCHS, 2014. 13 NCHS, 2014. 14 2015 Ohio Medicaid Assessment Survey (OMAS), Addendum to the Methodology Report. The Ohio State University (OSU) Government Resource Center. http://grc.osu.edu/omas/datadownloads/index.cfm 15 Small Area Income & Poverty Estimates (SAIPE), 2014. U.S. Census Bureau. https://www.census.gov/did/www/saipe/ 16 SAIPE, 2014. 17 County Health Rankings 2016: Social & Economic Factors Sub Ranks for Ohio. Robert Wood Johnson Foundation (RWJF). http://www.countyhealthrankings.org/rankings/data/OH; Social & Economic Factors Sub Rank includes data on education, employment, income, family/social support, and community safety (higher rank indicates lower socioeconomic status). 18 Ohio Medicaid Assessment Survey (OMAS), 2015; Data accessed via the OSU Government Resource Center, OMAS Adult Dashboard. http://grcapps.osu.edu/dashboards/OMAS/adult/ 19 OMAS, 2015. 20 Medically Underserved Areas/Populations (MUA/P), by County, 2016. Health Resources Services Administration (HRSA). Health Data Warehouse. https://datawarehouse.hrsa.gov/topics/shortageareas.aspx 21 County Health Rankings 2016: Clinical Care Sub Ranks for Ohio. Robert Wood Johnson Foundation (RWJF). http://www.countyhealthrankings.org/rankings/data/OH; Clinical Care Sub Rank includes data on access to primary care, dentists, and mental health providers, as well as quality of care (higher rank indicates poorer care quality and access).

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Appendix M 22 County Health Rankings 2016: Modeled County-Level Smoking Prevalence, 2014. Robert Wood Johnson Foundation (RWJF). http://www.countyhealthrankings.org/rankings/data/OH; county-level prevalence estimates were calculated using single-year 2014 BRFSS data and a multilevel modeling approach based on respondent answers and their age, sex, and race/ethnicity. 23 National Survey on Drug Use and Health (NSDUH), 2010-2012 Small Area Estimates for Youth Smoking (ages 12-17). Substance Abuse and Mental Health Services Administration (SAMHSA). http://www.samhsa.gov/data/population-data- nsduh/reports 24 2015 Final Birth Files. Ohio Department of Health, Bureau of Vital Statistics. Percentage of mothers that smoked, among births with known maternal smoking status. 25 County Health Rankings 2016: Health Behaviors Sub Ranks for Ohio. Robert Wood Johnson Foundation (RWJF). http://www.countyhealthrankings.org/rankings/data/OH. Health behaviors rank includes data on tobacco use, obesity, diet and exercise, alcohol and drug use, and sexual activity (higher rank indicates riskier health behavior). 26 Bureau of Vital Statistics 2011 Death Certificate Files. Ohio Department of Health. Cause of death cancer-related; death rates are age-adjusted rates per 100,000 population. 27 Bureau of Vital Statistics, 2012 Death Certificate Files. Ohio Department of Health. Cause of death heart disease; death rates are age-adjusted rates per 100,000 population. 28 Bureau of Vital Statistics, 2012 Death Certificate Files. Ohio Department of Health. Stroke-related cause of death; death rates are age-adjusted rates per 100,000 population. 29 Bureau of Vital Statistics, 2012 Death Certificate Files. Ohio Department of Health. COPD (Chronic Obstructive Pulmonary Disease) or CLRD (Chronic lower respiratory disease) as cause of death; death rates are age-adjusted rates per 100,000 population. 30 Lung & Bronchus Cancer in Ohio, 2008-2012. Ohio Department of Health (February 2016). http://www.healthy.ohio.gov/~/media/HealthyOhio/ASSETS/Files/OCISS/LungBronchProfile_Final.pdf. Data from the Ohio Cancer Incidence Surveillance System, 2008-2012, age-adjusted incidence rates (average annual number of lung and bronchus cancer cases per 100,000 population). 31 Ohio Behavioral Risk Factor Surveillance System (BRFSS), 2014. Ohio Department of Health (ODH). Regional prevalence rate is assigned to all counties within an assigned region. Regions are assigned based on CDC’s imputed county identifiers. 32 Ohio BRFSS, 2014. Ohio Department of Health (ODH). Regional prevalence rate is assigned to all counties within an assigned region. Regions are assigned based on CDC’s imputed county identifiers. Interpret counties in regions 5, 7, and 8 with caution; rates may be unstable due to small sample sizes. 32 Ohio BRFSS, 2014. Ohio Department of Health (ODH). Interpret stroke prevalence rates with caution; rates may be unstable due to small sample sizes. Regional prevalence rate is assigned to all counties within an assigned region. Regions are assigned based on CDC’s imputed county identifiers. 33 Ohio BRFSS, 2014. Ohio Department of Health (ODH). Regional prevalence rate is assigned to all counties within an assigned region. Regions are assigned based on CDC’s imputed county identifiers. 34 County Health Rankings 2016: Health Outcomes Sub Rank. Robert Wood Johnson Foundation (RWJF). http://www.countyhealthrankings.org/rankings/data/OH. Health outcomes rank includes data on length of life and quality of life (as measures of physical and mental health and low birth weight). 35 Ohio Tobacco Retailer Licenses (through March 2016). Data collected from County Auditors in 88 Ohio Counties and compiled by the Ohio Department of Health Tobacco Program, June 2016.

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Appendix M 36 Counter Tools Tobacco Store Mapper for Ohio. https://mapping.countertools.org/ohio/. Walking distance defined as ½ mile or less; data on tobacco retailers current through March 2016. 37 Counter Tools, 2016. 38 Counter Tools, 2016. 39 Counter Tools, 2016. 40 Tobacco Free K-12 Schools Policy Tracking Database, Updated June 9, 2016. Ohio Department of Health, Tobacco Program. Tobacco Policy score is based on ODH's policy evaluation rubric. 41 Ohio Department of Education (ODE), FY 2016 Fall Enrollment for Public Schools (October 2015 Headcounts). http://education.ohio.gov/Topics/Data/Frequently-Requested-Data/Enrollment-Data 42 ODE, FY 2016. 43 Integrated Postsecondary Education Data System (IPEDS), 2014. National Center for Educational Statistics. Two- and Four-year degree-granting colleges and universities. https://nces.ed.gov/ipeds/datacenter/ 44 2010-2014 American Community Survey 5-Year Estimates. U.S. Census Bureau. The estimated number of multi-family units was calculated by addition of the number of occupied units classified as 1-unit attached, 2-unit, 3 or 4 units, 5 to 9 units, 10 to 19 units, and 20 or more units in a single structure. 45 Ohio Behavioral Risk Factor Surveillance System (BRFSS), 2012-2014, 3-year regional averages. Ohio Department of Health. Percent of Ohio adults that live in a home with smoke-free rules where smoking is not allowed anytime or anywhere. (Regional rate assigned to all counties within an assigned region). 46 Community Health Advisor: Estimated 10-year medical care cost savings per 100,000 population as a result of enacting community-wide clean air policies. Robert Wood Johnson Foundation (RWJF). http://www.communityhealthadvisor.org/. Estimated cost-savings from a public-sector (community-wide, state and local) ordinance. Public-sector ordinances establish smoke-free standards for all, or for designated, indoor workplaces, indoor spaces, and outdoor public places. Private-sector smoke-free policies, such as those that ban tobacco use on private property or restrict smoking to designated outdoor locations, are not included in the CHA Tool estimates.

47 Community Health Advisor: Estimated 10-year medical care cost savings for total county population as a result of enacting community-wide clean air policies. Robert Wood Johnson Foundation (RWJF). http://www.communityhealthadvisor.org

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Appendix N

Appendix N: Suggested Items for Partner Agreement

Agency Responsibilities 1. Work with PARTNER to provide cessation services that meet ODH guidelines. 2. Assist in setting up paying relationships for being reimbursed for cessation services at the amount set by Medicaid for referred individuals who do not have any additional means of reimbursement. 3. Agrees to refer eligible individuals to PARTNER for cessation services. 4. Provide follow-up services to assist unsuccessful participants. 5. Represent PARTNER on the State Evaluation Team.

Partner Responsibilities 1. Coordinating the delivery of services to provide the following cessation services to individuals referred by the AGENCY who fit PARTNER eligibility criteria. 2. Describe services to be administered. 3. Work with the AGENCY and ODH to provide cessation services that meet ODH standardized guidelines. 4. Gain ODH approval that it has met said guidelines prior to providing services covered in this PA. 5. Enter tracking information regarding referred participant’s participation into a web portal on a monthly basis. 6. Agree to participate in the state evaluation conducted by ODH and the State Evaluation Team that will include participating in site visits, interviews and other evaluative activities. 7. Agree to be monitored for program guideline fidelity. 8. Provide financial information and success rates for current cessation services and approved cessation services to the State Evaluation Team for a cost-benefit analysis 9. Enter information about each participant into a web portal provided by ODH. Information will include: a. Type of cessation service received b. Number of times participated (dosage) c. Dates of participation d. Topics covered e. Status

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Appendix O Appendix O: PCMH Background Information

ODH has worked with primary care practices that operate as Patient Centered Medical Homes (PCMH) for many years. A PCMH is a medical office or clinic that offers coordinated, comprehensive primary care that is personal and focused on making sure the patient’s health care needs are met. The Patient Centered Medical Home model of care is one that facilitates partnerships between individual patients and their personal healthcare providers and, when appropriate, the patient’s family. Care is managed using modern tools such as registries, information technology, health information exchange and other means to assure that patients get the appropriate care when and where they need and want it in a culturally appropriate manner.

Ohio’s four largest commercial insurers and the private plans that manage most Medicaid patients will pay more to primary care doctors practicing preventive care under the state of Ohio’s Comprehensive Primary Care Program. They helped design the plan alongside Medicaid officials and the Medicaid managed care plans. Starting January 1, qualified practices get monthly per-patient payment for reducing medical claims by keeping patients well. Quality requirements include tobacco use screening and cessation intervention.

The goal for PCMH as laid out in Ohio’s State Health Care Innovation Plan (October 30, 2013) is for medical homes to provide part of the foundation for total cost management and quality accountability. By engaging patients, they significantly improve the quality of health and reduce health care costs by managing chronic disease more effectively and preventing more expensive events (such as emergency department visits). The accountability they introduce helps shift the mindset of providers, payers and patients. For example, integration between primary care and public health will connect clinicians with community services, build community health teams to empower patients to successfully manage illness and maximize resources, improve the use of clinical data to assess and monitor population health, and create greater capacity to reach into more neighborhoods and improve health outcomes in whole populations.

Providers in patient centered medical homes will have to shift their practice patterns and build capabilities to succeed in a payment model that tracks total cost of care and rewards value rather than volume. The goal is to reach at least 50 percent of the population in selected markets within three years and 80-90 percent of Ohio’s population with some value-based payment model within five years.

According to the State Innovation Models Round 2 Model Test: Ohio Operational Plan, on December 14, 2015, the Office of Health Transformation (OHT) and the Ohio Department of Medicaid (ODM) made a decision to accelerate the timeframe originally proposed for the PCMH Model Test implementation and instead of a three year regional rollout, implement the PCMH model statewide in 2016. Given the diverse provider environment and the goal to include as many practices as possible, Ohio is considering the best way to provide targeted capability-building support (“practice transformation”) to some providers for a limited time to serve as temporary support for the initial investments required to begin the path to becoming a PCMH.

PCMH primary care practice sites are located across the state of Ohio. For example, most Federally Qualified Health Centers are PCMHs. Several organizations have lists of practices including NCQA, AAHC and Joint Commission certified practices and those working with Ohio Medicaid and the Office of Health Transformation.

ODH has compiled the list based on all available information and included it here.

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Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Community Health Care - 5147 Manchester Road, Adams Manchester X Akron OH 44319 PCMH, NCQA 218 Stern Dr., Seaman OH Adams HealthSource - Seaman X 45679 PCMH, NCQA SOMC Medical Care Foundation, Inc. - SOMC 126 North Cross Street, Adams West Union Family Practice X West Union, OH 45693 PCMH, NCQA 610 E. Kiracofe Ave, Elida Allen James T. Bowlus MD Inc. X OH 45807 PCMH Health Partners of Western 441 E. 8th Street, Lima OH PCMH, NCQA, Allen Ohio X X 45804 HB198 Health Partners of Western Ohio - Dr. Gene Wright 441 E. 8th Street, Lima OH Allen Community Health Center X X 45804 PCMH, NCQA LMPC - Cridersville Medical 306 Reichelderfer Road, Allen Center X Cridersville OH 45806 PCMH, NCQA 1003 Bellefontaine Ave, Allen Lima Family Care X Suite 150, Lima OH 45804 PCMH, NCQA LMPC - Lima Group Family 1003 Bellefontaine Ave, Allen Physicians X Suite 125, Lima OH 45804 PCMH, NCQA LMPC - Northland Family 240 W. Northern Ave, Allen Practice X Lima OH 45801 PCMH, NCQA LMPC - LMPC Family 525 N. Eastown Road, Allen Healthcare X Lima OH 45807 PCMH, NCQA St. Rita's Professional Services - Family Medicine - 2745 Ft. Amanda Road, Allen Shawnee X Lima OH 45805 PCMH, NCQA St. Rita's Professional Services - Family Medicine - 3224 Jarvis Drive, Lima OH Allen UNOH X 45807 PCMH, NCQA St. Rita's Professional Services - Delphos Medical 1800 E. 5th Street, Allen Associates X Delphos OH 45833 PCMH, NCQA St. Rita's Professional Services - Family Medicine 582 N. Cable Road, Lima Allen Associates X OH 45805 PCMH, NCQA St. Rita's Professional Services - Martz and Martin 825 W. Market Street, Allen Family Practice X Suite 205, Lima OH 45801 PCMH, NCQA St. Rita's Professional Services - Primary Care 967 Bellefontaine Ave, Allen Associates X Suite 201, Lima OH 45804 PCMH, NCQA St. Rita's Professional Services - Spencerville 107 N. Canal Street, Allen Family Practice X Spencerville OH 45887 PCMH, NCQA O-2

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification 88 North Plains Road Suite Athens Family Healthcare, Inc. X 1, The Plains, OH 45780 PCMH, HB198 88 North Plains Road, Family Healthcare, Inc. - The Suite 1, the Plains OH Athens Plains X 45780 PCMH, NCQA Hopewell Health Centers - 25716 Wilson Street, Athens Coolville X X Coolville OH 45723 PCMH, NCQA LMPC - Lincoln Family 1251 Lincoln Ave, Auglaize Practice X Wapakoneta OH 45895 PCMH, NCQA GLPP - Grand Lake Primary Care at St. Marys - PCSM St 1040 Hager Street, St Auglaize Marys Practice X Marys, OH 45885 PCMH, NCQA GLPP - Grand Lake Primary 1165 S. Knoxville Ave, Care at St. Marys - PCW Suite 105, St. Marys, OH Auglaize Wheatland Practice X 45885 PCMH, NCQA GLPP - Miami and Erie Family Practice and Pediatrics - MEFP Minster 04463 St. Rt. 66, Minster, Auglaize Practice X OH 45865 PCMH, NCQA GLPP - Wapakoneta Primary 812 Redskin Trail Suite A, Auglaize Care Practice X Wapakoneta OH 45895 PCMH, NCQA Integrated Medicine Professional Corportation 51342 National Road, (Neurobehavioral Medicine Suite K, St. Clairsville, OH Belmont Consultants) X 43950 PCMH, HB198 HealthSource - Georgetown 5160 State Route 125, Brown Pediatrics X Georgetown OH 45121 PCMH, NCQA 150 Health Partners Circle, Brown HealthSource - Mt. Orab X Mt. Orab OH 45154 PCMH, NCQA 14 North Second St, Ripley Brown HealthSource - Ripley X OH 45167 PCMH, NCQA Mercy Health Physicians - 7109 Bachman Road, Brown Sardinia Family Medicine X Sardinia OH 45171 PCMH, NCQA Mercy Health Physicians 2 - Georgetown Family 4881 State Route 125, Brown Medicine X Georgetown OH 45121 PCMH, NCQA Mercy Health Physicians Mt. 621 West Main Street, Mt. Brown Orab Family Medicine X Orab OH 45154 PCMH, NCQA Mercy Health Physicians 7109 Bachman Road, Brown Sardinia Family Medicine X Sardinia OH 45171 PCMH, NCQA 210 S. Second Street, 2nd Butler Primary Health Solutions X Floor, Hamilton OH 45011 NCQA

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Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Butler Count Community Health Consortium - Primary 210 S. Second Street, 1st Butler Health Solutions BEVER X X Floor, Hamilton OH 45011 PCMH, NCQA Butler Count Community 903 N. W. Washington Health Consortium - Primary Blvd, Suite A, Hamilton OH Butler Health Solutions WEST X X 45013 PCMH, NCQA Mercy Health Physicians 2 - 5150 Sandy Lane, Fairfield Butler Fairfield Internal Medicine X OH 45014 PCMH, NCQA 7589 Tylers Place Blvd, Butler TCHMA-Wetherington X West Chester OH 45069 PCMH, NCQA TriHealth Physician Practices 7665 Monarch Court, Suite LLC - West Chester Medical 101, West Chester OH Butler Group X 45069 PCMH, NCQA, CPCI UC Health Primary Care (2) - 7690 Discovery Dr, Suite Family Medicine at 1400, West Chester OH Butler University Pointe X 45069 PCMH, NCQA UC Health Primary Care (2) - Internal Medicine and 7690 Discovery Dr, Suite Pediatrics at University 2700, West Chester OH Butler Pointe X 45069 PCMH, NCQA UC Health Primary Care (2) - 5900 West Chester Road, Butler Union Centre X West Chester OH 45069 PCMH, NCQA Cincinatti Childrens Hospital Medical Center - Fairfield 3050 Mack Road, MLC Butler Primary Care Clinic X 6007, Fairfield OH 45014 PCMH, NCQA Mercy Health Physicians 2 - 741-A Wessel Drive, Butler Fairfield Family Medicine X Fairfield OH 45014 PCMH, NCQA Mercy Health Physicians 2 - 2960 Mack Road, Suite Butler Mack Road Family Medicine X 107, Fairfield OH 45014 PCMH, NCQA Mercy Health Physicians 2 - 6770 Cincinnati-Dayton Springdale Family Medicine Road, Suite 105, Liberty Butler at Liberty Falls X Township OH 45044 PCMH, NCQA Family Practice Associates of 74 N. Breiel Blvd, Butler Southwest Ohio X Middletown OH 45042 PCMH, NCQA, CPCI 3145 Hamilton Mason Kettering Physician Network Road, 2nd Floor, Hamilton Butler - Heritage Internal Medicine X OH 45011 PCMH, NCQA Kettering Physician Network 945 Deis Drive, Fairfield Butler - Village Green Primary Care X OH 45014 PCMH, NCQA 7777 University Drive, Mid-City Pediatrics - West Suite D, West Chester OH Butler Chester X 45069 PCMH, NCQA

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Appendix O ODH FQHC Type of County Name of Practice List List Address Certification 3035 Hamilton Mason Queen City Physicians - Road, Suite 200, Hamilton Butler Butler County Pediatrics X 45011 PCMH, NCQA UC Health Primary Care 841 West State Street, Butler Trenton X Trenton OH 45037 PCMH, NCQA 1010 Summit Drive, Butler Summit Family Physicians X Middletown OH 45042 PCMH, NCQA, CPCI Generations Family 1042 Summit Drive, Butler Medicine: Avera Lead MD X Middletown OH 45042 CPCI Mercy Health Physicians 2 - South Urbana Family 1300 South US 68, Urbana Champaign Medicine X OH 43078 PCMH, NCQA 432 N. Main Street, New Clark New Carlisle Family Practice X Carlisle OH 45344 PCMH, HB198 Rocking Horse Children's 651 South Limestone St, Clark Health X X Springfield OH 45387 PCMH, HB198 Mercy Health Physicians 2 - 2057 South Limestone South Springfield Family Street, Springfield OH Clark Medicine X 45504 PCMH, NCQA Health Partners of Western Ohio - New Carlisle 106 N. Main Street, New Clark Community Health Center X X Carlisle OH 45344 PCMH, NCQA Springfield Center - Family 3250 Middle Urbana Road, Clark Medicine: Peter Muir J MD X Springfield OH 45502 CPCI Springfield Health Care 30 Warder Street, Suite Clark Center X 100 Springfield OH 45504 CPCI Rocking Horse Community 1 E Pleasant Street, Clark Health Center X Springfield OH 45506 PCMH 105 Sycamore Street Clark Medway Medical Clinic X Medway, OH 45341 CPCI 5400 DuPont Circle, Suite Clermont Healthsource of Ohio X A, Millford OH 45150 NCQA HealthSource - Batavia 2055 Hospital Drive, Suite Clermont Family Practice and OB/Gyn X X #130, Batavia OH 45103 PCMH, NCQA 1507 S.R. 28, Loveland OH Clermont HealthSource - Goshen X 45140 PCMH, NCQA TriHealth Physician Practices LLC - Bethesda Group 5861 Cinema Drive, Clermont Practice, Milford X Milford OH 45140 PCMH, NCQA, CPCI HealthSource - New 1050 Old US 52, New Clermont Richmond Family Practice X Richmond OH 45157 PCMH, NCQA Mercy Health Physicians 2 - 6746 Dick Flynn Blvd, Clermont Goshen Internal Medicine X Goshen OH 45122 PCMH, NCQA

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Appendix O ODH FQHC Type of County Name of Practice List List Address Certification ESD - Pediatric Group - 905 Main Street, Milford Clermont Milford X OH 45140 PCMH, NCQA 2055 Hospital Drive, Suite Clermont Clermont Internists X 300, Batavia, OH 45103 PCMH, NCQA Mercy Health Physicians 201 Old Bank Road, Suite Clermont Milford Family Medicine X 103, Milford OH 45140 PCMH, NCQA 140 West Main Clinton HealthSource - Wilmington X Wilmington OH 45177 PCMH, NCQA Butler Count Community Health Consortium - Primary 1036 South Verity Health Solutions Parkway, Middletown OH Clinton MIDDLETOWN X X 45044 PCMH, NCQA 38722 Saltwell Road, Columbiana CAA Of Columbiana County X Lisbon OH 44432 NCQA CAA Health Center - Lisbon 7880 Linole Place, Lisbon Columbiana Community Health Center X OH 44432 PCMH, NCQA CAA Health Center - East Liverpool Community Health 16687 St. Clair Ave, East Columbiana Center X Liverpool OH 43920 PCMH, NCQA CAA Health Center - Salineville Community 103 West Main Street, Columbiana Health Center X Salineville OH 43945 PCMH, NCQA 270 Portland Way South, Crawford John T. Hanna, MD, FAAFP X Galion OH 44833 PCMH, HB198 MMP-Family Physicians New 202 W. Mansfield, New Crawford Washington X Washington OH 44854 PCMH, NCQA Drs. Weinberger and Vizy 3690 Orange Place, Cuyahoga LLC X Beachwood OH 44122 PCMH, NCQA MetroHealth - Lee-Harvard 4071 Lee Road, Suite 260, Cuyahoga Health Center X Cleveland OH 44128 PCMH, NCQA 15322 St. Clair Ave, Cuyahoga Collinwood Health Center X Cleveland OH 44110 PCMH, NCQA East Cleveland Health 15201 Euclid Ave, Cuyahoga Center X Cleveland OH 44112 PCMH, NCQA 8300 Hough Ave, Cuyahoga Hough Health Center X X Cleveland OH 44103 PCMH, NCQA 1468 E 55th Street, Cuyahoga Norwood Health Center X Cleveland OH 44103 PCMH, NCQA 13301 Miles Ave, Cuyahoga Southeast Health Center X Cleveland OH 44105 PCMH, NCQA 12100 Superior Ave, Cuyahoga Superior Health Center X Cleveland OH 44103 PCMH, NCQA Unity Health Network - 3033 State Road, Suite 202 Cuyahoga Cuyahoga Falls X Cuyahoga Falls OH 44223 PCMH, NCQA O-6

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Lake Health Thomas Family 26151 Euclid Ave, Suite Cuyahoga Practice Euclid X 201, Euclid OH 44132 PCMH, NCQA MetroHealth System - Asia 2999 Payne Ave, Suite Cuyahoga Town Health Center X 216, Cleveland OH 44114 PCMH, NCQA MetroHealth System - 6835 Broadway Ave, Cuyahoga Broadway Health Center X Cleveland OH 44105 PCMH, NCQA MetryoHealth System - 5208 Memphis Ave, Cuyahoga Brooklyn Health Center X Cleveland OH 44144 PCMH, NCQA MetroHealth System - 2816 East 116th Street, Cuyahoga Buckeye Health Center X Cleveland OH 44120 PCMH, NCQA MetroHealth System - J. 11100 St. Clair Ave, Cuyahoga Glen Smith Health Center X Cleveland OH 44108 PCMH, NCQA MetroHealth System - MetroHealth Medical Center, Main Campus Family 2500 MetroHealth Dr, Cuyahoga Medicine Dept. X Cleveland OH 44109 PCMH, NCQA MetroHealth System - MetroHealth Medical Center, Main Campus 2500 MetroHealth Dr, Cuyahoga Internal Medicine Dept X Cleveland OH 44109 PCMH, NCQA MetroHealth System - Middleburg Heights Health 16000 Pearl Road, Cuyahoga Center X Strongsville OH 44136 PCMH, NCQA MetroHealth System - West 3838 West 105th Street, Cuyahoga Park Health Center X Cleveland OH 44111 PCMH, NCQA 3609 Park East Dr, North MetroHealth System - Building, 3rd Floor, Cuyahoga Beachwood Health Center X Beachwood OH 44122 PCMH, NCQA 24700 Center Ridge Road, King James Building 1, MetroHealth System - Suite 220, Westlake OH Cuyahoga Westlake Health Center X 44146 PCMH, NCQA St Vincent Medical Group 2475 East 22nd Street, Medical Arts Physician Suite 120, Cleveland OH Cuyahoga Center X 44115 PCMH, NCQA 2054 South Green Road, Cuyahoga Senders Pediatrics X South Euclid OH 44121 PCMH, NCQA 16110 Detroit Ave, Cuyahoga North Coast Health X Lakewood OH 44107 PCMH, NCQA 1530 St. Clair Ave, Cuyahoga Care Alliance Health Center X X Cleveland OH 44114 PCMH, NCQA Neighborhood Family 3569 Ridge Road, Cuyahoga Practice X Cleveland OH 44102 NCQA

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Appendix O ODH FQHC Type of County Name of Practice List List Address Certification 6300 Wilson Mills Road, Suite W31 Mayfield Cuyahoga 6300 Wilson Mills Road X Village, OH 44143 AAAHC 300 N. Commons Dr, Mayfield Village, OH Cuyahoga 300 N Commons Drive X 44143 AAAHC 2112 Euclid Ave, Cuyahoga 2112 Euclid Ave X Cleveland, OH 44115 AAAHC 16500 Chagrin Blvd. Suite Family Medicine 202, Shaker Heights, OH Cuyahoga Occupational Health Center X 44120 PCMH, HB198 The Free Medical Clinic of 12201 Euclid Ave, PCMH, NCQA, Cuyahoga Greater Cleveland X X Cleveland OH 44106 HB198 The MetroHealth Old Brooklyn Senior Health and 4229 Pearl Road Room N- Cuyahoga Wellness Center X 204, Cleveland, OH 44109 PCMH, HB198 HealthSpan, Bedford 19999 Rockside Road, Cuyahoga Medical Office X Bedford OH 44146 PCMH, NCQA 10 Severence Circle, HealthSpan, Cleveland Cleveland Heights, OH Cuyahoga Heights Medical Center X 44118 PCMH, NCQA HealthSpan, Parma Medical 12301 Snow Road, Parma Cuyahoga Center X OH 44130 PCMH, NCQA 20575 Center Ridge Road, HealthSpan, Rocky River Suite 500, Rocky River OH Cuyahoga Medical Office X 44116 PCMH, NCQA HealthSpan, Strongsville 17406 Royalton Road, Cuyahoga Medical Office X Strongsville OH 44136 PCMH, NCQA MetroHealth System - 2500 MetroHealth Dr, Cuyahoga Comprehensive Care X Cleveland OH 44109 PCMH, NCQA MetroHealth System - Senior Health Outpatient 2500 MetroHealth Dr, Cuyahoga Program X Cleveland OH 44109 PCMH, NCQA Neighborhood Family 6412 Franklin Blvd, Cuyahoga Practice Detroit Shoreway X Cleveland OH 44102 PCMH, NCQA 265 W. Portage Trail, Suite Summa Physician Inc.- 200, Cuyahoga Falls, OH Cuyahoga Millpond Family Physicians X 44223 PCMH, NCQA Family Health Services of 5735 Meeker Rd, Darke Darke County, Inc. X Greenville, OH 45331 AAAHC, HB198 702 N. Main St, Arcanum, Darke 702 N. Main Street X OH 45304 AAAHC 10484 Kley Rd, Versailles, Darke 10484 Kley Road X OH 45380 AAAHC

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Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Family Health Services of 5735 Meeker Rd, Darke Darke County, Inc. X X Greenville, OH 45331 PCMH 1250 Ralston Ave, Defiance Rosemary Karen Reiter MD X Defiance OH 43512 PCMH, HB198 ProMedica Physician Group - 1250 Ralston Ave, Suite Defiance Defiance Family Physicians X 104 Defiance, OH 43512 PCMH, NCQA ProMedica Physician Group - 1250 Ralston Ave, Suite Defiance Defiance Internal Medicine X 202, Defiance OH 43512 PCMH, NCQA ProMedica Physician Group - 1250 Ralston Ave, Suite Defiance Rosemary Karen Reiter, MD X 204, Defiance OH 43512 PCMH, NCQA Mercy Defiance Clinic Family 1400 E 2nd Street, Defiance Practice X Defiance OH 43512 PCMH, NCQA Mercy Defiance Clinic 1400 E 2nd Street, Defiance Internal Medicine X Defiance OH 43512 PCMH, NCQA 1400 E 2nd Street, Defiance Mercy Defiance Clinic Peds X Defiance OH 43512 PCMH, NCQA COPC - Dublin Internal 570 Polaris Parkway Suite Delaware Medicine X 250, Westerville OH 43082 PCMH, NCQA 6515 Pullman Drive, Suite OSU Family Practice - Lewis 220, Lewis Center OH Delaware Center X 43035 PCMH, NCQA Pediatric Associates, Inc. - 7420 Gooding Blvd Suite Delaware Lewis Center X 100, Delaware OH 43015 PCMH, NCQA Erie County Health 420 Superior Street, Erie Department X Sandusky OH 44870 PCMH, HB198 Family Health Services of 1912 Hayes Ave, Sandusky PCMH, NCQA, Erie Erie County X X OH 44870 HB198 NOMS - Baxter Family 1326 E. Perkins Ave, Erie Practice X Sandusky OH 44870 PCMH, NCQA 808 S Main Street, Huron Erie NOMS - Huron X OH 44839 PCMH, NCQA NOMS - Strub Family 2500 W Strub Road Suite Erie Practice X 230, Sandusky OH 44870 PCMH, NCQA NOMS - Strub Internal 2500 W Strub Road Suite Erie Medicine X 230, Sandusky OH 44870 PCMH, NCQA 1012 East Perkins Ave, Erie Family Medicine Sandusky X Sandusky OH 44870 PCMH, NCQA FPG - Family Medicine 101 South Washington Erie Castalia X Street, Castalia OH 44870 PCMH, NCQA Fairfield Community Health 1155 E Main Street, Fairfield Center X Lancaster OH 43130 NCQA 641 Hill Road, Suite A, Fairfield MCMG - Pickerington X Pickerington OH 43147 PCMH, NCQA

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Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Pediatric Associates of 1550 Sheridan Drive, Suite PCMH, NCQA, Fairfield Lancaster, Inc X 102, Lancaster, OH 43130 HB198 Fairfield Community Health 216 Trace Drive, Lancaster Fairfield Center - Hunter Trace X X OH 43130 PCMH, NCQA Fairfield Community Health 1155 East Main Street, Fairfield Center - Main Street X X Lancaster OH 43130 PCMH, NCQA 1550 Sheridan Drive Suite Farfield Colonnade Medical Group X 202, Lancaster OH 43130 PCMH 1055 W. Market Street, Fairfield Community Health Suite H, Baltimore OH Farfield Center - Baltimore X X 43105 PCMH, NCQA 1510 Columbus Ave #230, FCMH Medical and Surgical Washington Court House, Fayette Associates X OH 43160 PCMH, HB198 1450 Columbus Ave, Suite HealthSource - Washington 203, Washington CH, OH Fayette Court House Family Practice X 43160 PCMH, NCQA 308 Highland Ave, Suite c, Washington Court House Fayette Adena Medical Group - WCH X OH 43160 PCMH, NCQA Kettering Physician Network 903 N.W. Washington - Heritage Primary Care - Boulevard, Suite B, Fayette Washington Blvd X Hamilton OH 45013 PCMH, NCQA Fayette County Memorial 1510 Columbus Ave, Suite Hospital Medical Surgical 230, Washington Court Fayette Associates X House, OH 43160 PCMH, NCQA Lower Lights Christian 1160 W Broad St, Franklin Health Center X Columbus OH 43222 NCQA 1800 Watermark Dr., Suite Franklin PrimaryOne Health X 420, Columbus OH 43215 NCQA 3823 Trueman Court, Franklin American Health Network X Hilliard OH 43026 PCMH, NCQA 2350 Briggs Road, Franklin Briggs Road Medical Center X Columbus OH 43223 PCMH, NCQA COPC - Amico, Stock and 3382 Paris Blvd, Franklin Associates X Westerville OH 43081 PCMH, NCQA 770 Jasonway Ave, Suite 1- Franklin COPC - Amy R. Kelly, MD X A, Columbus OH 43214 PCMH, NCQA COPC - Arlington Mill Run 3535 Fishinger Blvd. Suite Franklin Internal Medicine X 285, Hilliard OH 43026 PCMH, NCQA 801 Eastwind Drive, Franklin COPC - Associated Pediatrics X Westerville OH 43081 PCMH, NCQA COPC - Building Blocks 6503 E. Broad St, Suite Franklin Pediatrics X 100, Columbus OH 43213 PCMH, NCQA O-10

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification COPC - Capital City medical 2489 Stelzer Road, Suite Franklin Associates X 101, Columbus OH 43219 PCMH, NCQA COPC - Central Ohio 4030 West Henderson Franklin Medicine X Road, Columbus OH 43220 PCMH, NCQA 4895 Olentangy River COPC - Columbus Internal Road, Suite 200 Columbus Franklin Medicine X OH 43214 PCMH, NCQA 4845 Knightsbridge COPC - COPC Chen and Boulevard, Suite 210, Franklin Associates X Columbus OH 43214 PCMH, NCQA 631 Copeland Mill Road, COPC - COPC Internal Suite A, Westerville OH Franklin Medicine Group X 43081 PCMH, NCQA 291 West Schrock Road, Suite A, Westerville OH Franklin COPC - COPC Westerville X 43081 PCMH, NCQA 760 Lakeview Plaza Blvd, COPC - Crosswoods Suite 500, Worthington, Franklin Pediatrics X OH 43085 PCMH, NCQA COPC - Fairway Family 1171 Fairway Blvd, Franklin Physicans X Columbus OH 43213 PCMH, NCQA 6096 E. Main Street, Suite Franklin COPC - Faith Family Health X 102, Columbus OH 43213 PCMH, NCQA COPC - Family Medicine and Pediatrics at Winchester 6201 Gender Road, Canal Franklin Square X Winchester OH 43110 PCMH, NCQA COPC - Family Medicine 1930 Crown Park Court, Franklin North X Columbus OH 43235 PCMH, NCQA 535 Officecenter Place, COPC - Family Physicians of Suite A, Gahanna OH Franklin Gahanna X 43230 PCMH, NCQA 190 South State Street, COPC - Family Practice Suite A, Westerville OH Franklin Center of Westerville X 43081 PCMH, NCQA 4885 Olentangy River Road, Suite 110, Columbus Franklin COPC - J. William Wulf, MD X OH 43214 PCMH, NCQA COPC - Jasonway Internal 770 Jasonway Ave, Suite Franklin Medicine X G2, Columbus OH 43214 PCMH, NCQA 555 West Schrock Road, COPC - Northside Internal Suite 110, Westerville OH Franklin medicine X 43081 PCMH, NCQA COPC - Ohio Center for 5040 Bradenton Ave, Franklin Pediatrics X Dublin OH 43017 PCMH, NCQA

O-11

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification COPC - Parsons Avenue 1439 Parsons Avenue, Franklin Medical Clinic X Columbus OH 43207 PCMH, NCQA 1085 Beecher Crossing COPC - Pediatric and North, Gahanna, OH Franklin Adolscent Practitioners X 43230 PCMH, NCQA COPC - Professional 5510 Nike Drive, Hilliard Franklin Pediatrics of Hilliard X OH 43026 PCMH, NCQA COPC - Provider Physicians 6421 E. Main Street, Franklin East X Reynoldsburg, OH 43068 PCMH, NCQA 4885 Olentangy River COPC - Provider Physicians Road, Suite 2-50, Franklin North X Columbus OH 43214 PCMH, NCQA COPC - Scioto View Family 3440 Riverside Drive, Franklin Practice X Upper Arlington OH 4321 PCMH, NCQA COPC - Small World 5175 Morse Road, Franklin Pediatrics X Gahanna OH 43230 PCMH, NCQA 507 Executive Campu COPC - Step by Step Drive, Suite 160, Franklin Pediatrics X Westerville OH 43082 PCMH, NCQA 6488 East Main Street, COPC - Stonegate Family Suite C, Reyoldsburg, OH Franklin Health X 43068 PCMH, NCQA 6465 East Broad Street COPC - Suburban Internal Suite D, Columbus OH Franklin Medicine X 43213 PCMH, NCQA 11925 Lithopolis Road, COPC - Tri County Family NW Canal Winchester OH Franklin Physicians X 43110 PCMH, NCQA 484 County Line Road, W COPC - Westerville Internal Suite 200 Westerville, OH Franklin Medicine X 43082 PCMH, NCQA COPC - Westerville Medical 285 West Schrock Road, Franklin Associates X Westerville OH 43081 PCMH, NCQA COPC - Worthington Internal 55 Caren Ave, Suite 170, Franklin Medicine X Worthington OH 43085 PCMH, NCQA COPC - LaHue, Gramman, 4825 Knightsbridge Blvd, Franklin Boezi and Coss X Columbus OH 43214 PCMH, NCQA 933 High Street, Suite 116, Franklin Kristin L. Oaks D.O. Inc X Worthington OH 43085 PCMH, NCQA Lower Lights Christian 1251 West Broad Street, Franklin Health Center X X Columbus OH 43222 PCMH, NCQA MCMG - Health Stations 946 Parsons Ave, Franklin Church for All People X Columbus OH 43206 PCMH, NCQA MCMG - Health Stations 3480 Refugee Road, Franklin First Church of God X Columbus OH 43232 PCMH, NCQA O-12

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification MCMG - Health Stations 6699 East Livingston Ave, Franklin Reynoldsburg High School X Reynoldsburg, OH 43068 PCMH, NCQA 150 Taylor Station Road, Suite 140, Columbus OH Franklin MCMG - Taylor Station X 43213 PCMH, NCQA 2150 Marble Cliff Drive, Suite B, Columbus OH Franklin MCMG - TriVillage X 43215 PCMH, NCQA 2150 Marble Cliff Drive Park, Suite 250, Columbus Franklin MCMG - Upper Arlington X OH 43215 PCMH, NCQA 495 Cooper Road, Suite Franklin MCMG - Westerville X 311 Westerville OH 43081 PCMH, NCQA 81 E. Wilson Bridge Road, Franklin MCMG - Worthington X Worthington OH 43085 PCMH, NCQA Ohio Health-Grant Family 4850 E. Main Street, Suite Franklin Medicine X 110, Columbus OH 43147 PCMH, NCQA 2030 Stringtown Road, Suite 300, Grove City OH Franklin OhioHealth- Doctors X 43123 PCMH, NCQA 1727 Bethel Road, Franklin OSU Family Practice - Bethel X Columbus OH 43220 PCMH, NCQA 543 Taylor ave, Second Franklin OSU Family Practice - East X flood, Columbus OH 43203 PCMH, NCQA 920 N Hamilton Road, OSU Family Practice - Suite 300, Gahanna OH Franklin Gahanna X 43230 PCMH, NCQA OSU Family Practice - New 240A Market Street, New Franklin Albany X Albany OH 43054 PCMH, NCQA 2231 North High Street, Franklin OSU Family Practice - Rardin X Columbus OH 43201 PCMH, NCQA OSU Family Practice - Total 1492 E. Broad Street, Suite Franklin Health and Wellness X 1203 Columbus OH 43205 PCMH, NCQA OSU Family Practice - Upper 1615 Fishinger Road, Franklin Arlington X Columbus OH 43221 PCMH, NCQA 445 East Dublin-Granville OSU Family Practice - Road, Worthington OH Franklin Worthington X 43085 PCMH, NCQA OSU General Internal 1609 Northwest Blvd, Franklin Medicine - Grandview X Columbus OH 43212 PCMH, NCQA OSU General Internal 3900 Stoneridge Lane, Franklin Medicine - Stoneridge X Suite B, Dublin OH 43017 PCMH, NCQA OSUWMC General Internal 543 Taylor ave, Suite 3176, Franklin Medicine - CarePoint East X Columbus OH 43203 PCMH, NCQA

O-13

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification 2050 Kenny Road, Martha OSUWMC General Internal Morehouse Pav, Suite Franklin Medicine - Morehouse X 2335, Columbus OH 43221 PCMH, NCQA Richard C. Brandes MD 1299 Olentangy River Inc/dba Villiage Family Road, Suite B, Columbus Franklin Medicine X OH 43212 PCMH, NCQA Columbus Neighborhood Health Center, Inc. - East 1180 East Main Street, Franklin Central Health Center, Inc X Columbus OH 43205 PCMH, NCQA Columbus Neighborhood Health Center, Inc. - Great 3781 South High Street, Franklin Southern X Columbus OH 43207 PCMH, NCQA Columbus Neighborhood Health Center, Inc. - John 1905 Parsons Ave, Franklin Maloney X Columbus OH 43207 PCMH, NCQA Columbus Neighborhood Health Center, Inc. - 3433 Agler Road, Suite Franklin Northeast Health Center Inc. X 2800, Columbus OH 43219 PCMH, NCQA Columbus Neighborhood Health Center, Inc. - St. 1500 East 17th Ave, Franklin Stephen's Health Center Inc X Columbus OH 43219 PCMH, NCQA Columbus Neighborhood Health Center, Inc. - 2300 West Broad Street, Franklin Westside Health Center Inc X Columbus OH 43204 PCMH, NCQA Nationwide Children's Hospital - Near East Primary 1125 East Main Street, Franklin Care Center X Columbus OH 43205 PCMH, NCQA 2030 Stringtown Road, OhioHealth - Grant Family Suite 200, Grove City OH Franklin Practice Southwest X 43123 PCMH, NCQA Nationwide Children's Hospital - Eastland Primary 4434 Crossroads Center, Franklin Care Center X Columbus OH 43232 PCMH, NCQA Nationwide Children's Hospital - Linden Primary 1390 Cleveland Ave, Franklin Care Center X Columbus OH 43211 PCMH, NCQA Nationwide Children's Hospital - Main Campus 555 S. 18th Street, Franklin Primary Care Red X Columbus OH 43205 PCMH, NCQA Nationwide Children's Hospital - Main Campus 555 S. 18th Street, Franklin Primary Care Yellow X Columbus OH 43205 PCMH, NCQA

O-14

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Nationwide Children's Hospital - Northland Primary 4560 Morse Centre Road, Franklin Care Center X Columbus OH 43229 PCMH, NCQA Nationwide Children's Hospital - Olentangy Primary 1275 Olentangy River Franklin Care Center X Road, Columbus OH 43212 PCMH, NCQA Nationwide Children's Hospital - South High 1405 South High Street, Franklin Primary Care Center X Columbus OH 43207 PCMH, NCQA Nationwide Children's Hospital - Westside Primary 441 Industrial Mile Road, Franklin Care Center X Columbus OH 43228 PCMH, NCQA Nationwide Children's Hospital - Whitehall Primary 561 South Yearling Road, Franklin Care Center X Whitehall OH 43213 PCMH, NCQA Pediatric Associates, Inc. - 4595 Trueman Blvd, Franklin Hilliard X Hilliard OH 43026 PCMH, NCQA 1021 Country Club Road, Pediatric Associates, Inc. - Suite A, Columbus OH Franklin Whitehall X 43214 PCMH, NCQA Ohio Health - Riverside 697 Thomas Lane, Franklin Family Practice Center X Columbus OH 43214 PCMH, NCQA OSU General Internal 3691 Ridge Mill Drive, Franklin Medicine - Hilliard X Hilliard OH 43026 PCMH, NCQA 55 North High Street, New Franklin MCMG - New Albany (2) X Albany OH 43054 PCMH, NCQA 815 West Broad Street, Mount Carmel GME - Suite 200, Columbus OH Franklin MetroWest X 43222 PCMH, NCQA Mount Carmel GME - MCSA 477 Cooper Road, Suite Franklin FMA X 300, Westerville OH 43081 PCMH, NCQA MMP-Primary Care and 1 Turtle Creek Circle, Fulton Associates Swanton X Swanton OH 43558 PCMH, NCQA ProMedica Physician Group - 1990 County Road, Fulton Metamora Family Practice X Metamora OH 43540 PCMH, NCQA Lake Health Chardon 510 Fifth Ave, Chardon OH Geauga Pediatrics X 44024 PCMH, NCQA Lake Health Newbury Family 10780 Kinsman Road, Geauga Practice X Newbury OH 44065 PCMH, NCQA 4172 Indian Ripple Road, Greene Integrated Medical Group X Beavercreek, OH 45440 PCMH, HB198 PriMed Physicians - 6520 Acro Court, Greene Centerville Family Practice X Centerville OH 45459 PCMH, NCQA

O-15

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification PriMed Physicians 2322 Lakeview Drive, Greene Beavercreek Family Practice X Beavercreek OH 45431 PCMH, NCQA, CPCI Providence Medical Group - 1516 Yankee Park Place, Greene Contemporary Pediatrics X Centerville OH 45458 PCMH, NCQA Mercy Health Physicians 2 - SRMG Xenia Family 1768 West Park Square, Greene Medicine X Xenia OH 45385 PCMH, NCQA 4172 Indian Ripple Road, Suite A, Beavercreek OH Greene Integrated Medical Group X 45440 PCMH, NCQA, CPCI 725 University Blvd, 2nd Greene Wright State Physicians X floor, Fairborn OH 45324 PCMH, NCQA PriMed Physicians - 2332 Lakeview Drive, Greene Beavercreek Pediatrics X Beavercreek OH 45431 PCMH, NCQA Providence Medical Group - 4120 W. Franklin Street, Greene Henderson and Associates X Bellbrook OH 45305 PCMH, NCQA Providence Medical Group - 2510 Commons Blvd, Suite Beavercreek Commons 110, Beavercreek OH Greene Family Practice X 45431 PCMH, NCQA, CPCI Providence Medical Group - 4403 St Rt 72, Suite D, Greene Sugarcreek Family Medicine X Bellbrook OH 45385 PCMH, NCQA 2825 Burnet Avenue, Hamilton Cincinatti Health Network X Cincinnati OH 45219 NCQA City of Cincinnati Primary 3101 Burnet Ave, Hamilton Care X Cincinatti OH 45229 NCQA 1401 Steffen Ave, Hamilton The Healthcare Connection X Cincinnati OH 45215 NCQA Winton Hills Medical and 5275 Winneste Ave, Hamilton Health Center X Cincinnati OH 45232 NCQA Group Health Associates - 55 Progress Place, Hamilton Springdale X Cincinatti OH 45246 PCMH, NCQA, CPCI HealthSource - Eastgate 559 Old S.R. 74, Cincinatti Hamilton Pediatrics X OH 45244 PCMH, NCQA Mercy Health Physicians - Anderson Hills Internal 8000 Five Mile Road, Suite Hamilton Medicine X 305 Cincinnati OH 45230 PCMH, NCQA Mercy Health Physicians - 8000 Five Mile Road, Suite Hamilton Anderson Primary Care X 250 Cincinnati OH 45230 PCMH, NCQA Mercy Health Physicians - 2135 Dana Ave, Suite 400, Hamilton Avondale Internal Medicine X Cincinnati OH 45207 PCMH, NCQA Mercy Health Physicians - 5314 Delhi Ave, Cincinnati Hamilton Delhi Family Medicine X OH 45238 PCMH, NCQA

O-16

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Mercy Health Physicians - State Road Internal 7495 State Road Suite 200, Hamilton Medicine X Cincinnati OH 45255 PCMH, NCQA Mercy Health Physicians 2 - 7502 State Road, Suite Hamilton Anderson Family Medicine X 3310, Cincinnati OH 45255 PCMH, NCQA Mercy Health Physicians 2 - 4600 McAuley Place, Suite Hamilton Blue Ash Primary Care X 115, Cincinnati OH 45242 PCMH, NCQA Mercy Health Physicians 2 - 8094 Beechmont Ave, Hamilton Forest Hills Family Medicine X Cincinnatti OH 45255 PCMH, NCQA Mercy Health Physicians 2 - 2450 Kipling Ave, Suite Hamilton Mt. Airy Primary Care X 108, Cincinnati OH 45239 PCMH, NCQA Mercy Health Physicians 2 - 5525 Marie Avenue, Hamilton Westside Internal Medicine X Cincinnati OH 45248 PCMH, NCQA 4750 East Galbraith Road, Mercy Health Physicians- Suite 210, Cincinnati OH Hamilton Kenwood Family Medicine X 45236 PCMH, NCQA Queen City Physicians - Hyde Park Internal Medicine- TriHealth 2753 Erie Ave, Cincinnati Hamilton Physician Partner X OH 45208 PCMH, NCQA, CPCI Queen City Physicians- 7825 Laurel Ave, Hamilton Madeira X Cincinnati OH 45243 PCMH, NCQA, CPCI Queen City Physicians- Western Hills Internal 6350 Glenway Ave, #400, Hamilton Medicine X Cincinnati OH 45211 PCMH, NCQA, CPCI Queen City Physicians- Western Ridge Internal 6949 Good Samaritan Medicine - TriHealth Drive, Suite 210, Cincinnati Hamilton Physician Partners X OH 45247 PCMH, NCQA, CPCI 7539 Beechmont Ave, TCHMA-Anderson Family Suite C, Cincinnati OH Hamilton Medicine X 45255 PCMH, NCQA 7539 Beechmont Ave, TCHMA-Anderson Internal Suite K, Cincinnati OH Hamilton Medicine X 45255 PCMH, NCQA 7809 Laural Ave, Suite 11, Hamilton TCHMA-Madeira X Cincinnati OH 45243 PCMH, NCQA, CPCI TCHMA-Mt. Auburn Family 2123 Auburn Ave, Suite Hamilton Medicine X 235, Cincinnati OH 45219 PCMH, NCQA The Healthcare Connection - 1401 Steffen Ave, Hamilton Lincoln Heights X Cincinnati OH 45215 PCMH, NCQA The Healthcare Connection - 8146 Hamilton Ave, Hamilton Mt. Healthy Family Practice X Cincinatti, OH 45231 PCMH, NCQA The Healthcare Connection - 1501 Madison Ave, 3rd Hamilton GCB X Floor, Cincinnati OH 45206 PCMH, NCQA O-17

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification TriHealth Physician Partners 463 Ohio Pike #300, Hamilton - Queen City Medical Group X Cincinnati OH 45244 PCMH, NCQA TriHealth Physician Partners - Rudemiller Family 6350 Glenway Ave, #205, Hamilton Medicine X Cincinnati OH 45211 PCMH, NCQA 4422 Carver Woods Drive, TriHealth Physician Partners, Suite 100, Cincinnati OH Hamilton Blue Ash Family Physicians X 45242 PCMH, NCQA TriHealth Physician Partners, 3425 North Bend Road, Hamilton Western Family Physicians X Cincinnati OH 45239 PCMH, NCQA, CPCI TriHealth Physician Practices LLC - Madeira Family 7829 Laural Ave, Hamilton Practice X Cincinnati OH 45243 PCMH, NCQA TriHealth Physician Practices LLC - Physician Association 1253 Kemper Meadow of Good Samaritan Hospital, Drive, Suite 250, Forest Hamilton Northwest X Park OH 45240 PCMH, NCQA TriHealth Physican Practices LLC - White Oak Family 7631 Cheviot Road, Hamilton Practice X Cincinnati OH 45247 PCMH, NCQA, CPCI TriHealth Physician Practices LLC - Physician Association of Good Samaritan Hospital, 425 Farrel Court, Hamilton Delhi X Cincinnati OH 45233 PCMH, NCQA TriHealth Physician Practices, LLC - Pavilion 6200 Pfeiffer Road, Suite Hamilton Medical Associates X 330, Cincinnati OH 45242 PCMH, NCQA TriHealth Physician Practices, LLC dba The 6331 Glenway Ave, Hamilton Family Medical Group X Cincinnati OH 45211 PCMH, NCQA UC Health Primary Care (2) - 222 Piedmont Ave, Suite Hamilton Piedmont X 6000 Cincinnati OH 45219 PCMH, NCQA UC Health Primary Care (2) - 11340 Montgomery Road, Hamilton Harper's Point X Cincinnati OH 45249 PCMH, NCQA UC Health Primary Care (2) - Internal Medicine Resident 234 Goodman Street, Hamilton Clinic X Cincinnati OH 45219 PCMH, NCQA UC Health Primary Care (2) - 9275 Montgomery Road, Hamilton Montgomery X Cincinnati OH 45242 PCMH, NCQA 4460 Red Bank UC Health Primary Care (2) - Expressway Suite 100, Hamilton Women's Health Redbank X Cincinnati OH 45227 PCMH, NCQA UC Health Primary Care (2) 305 Cresent Ave, Hamilton Whyoming X Wyoming OH 45215 PCMH, NCQA

O-18

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification UC Health University 234 Goodman Street, Hamilton Internal Medicine/Pediatrics X Cincinnati OH 45219 PCMH, NCQA 7810 Five Mile Road, Hamilton Group Health - Anderson X Cincinnati OH 45230 PCMH, NCQA 8245 Northcreek Dr, Hamilton Group Health - Kenwood X Cincinnati OH 45236 PCMH, NCQA, CPCI 2001 Anderson Ferry Rd, Hamilton Group Health - Western Hills X Cincinnati OH 45238 PCMH, NCQA 379 Dixmyth Ave, Hamilton Group Health - Clifton X Cincinnati OH 45220 PCMH, NCQA, CPCI 9070 Winton Rd, Hamilton Group Health - Finneytown X Cincinnati OH 45231 PCMH, NCQA, CPCI 1740 Langdon Farm Road, Hamilton WinMed @ CAA X Cincinnati OH 45237 PCMH, NCQA 1202 Linn Street Suite 101, Hamilton WinMed at City West X Cincinnati OH 45203 PCMH, NCQA TriHealth Physician Practices LLC - Loveland Family 411 W. Loveland Ave, Hamilton Medicine X #102, Loveland OH 45140 PCMH, NCQA TriHealth Physician Practices LLC - Glenwood Family 10196 Springfield Pike, Hamilton Practice X Cincinnati OH 45215 PCMH, NCQA Cincinatti Childrens Hospital Medical Center - Hopple Street Neighborhood Health 2750 Beekmand Ave, MLC Hamilton Center X 6001 Cincinnati OH 45225 PCMH, NCQA Cincinnati Childrens Hospital Medical Center - The Pediatric Primary Care 3430 Burnet Ave, MLC Hamilton Center (PPCC) X 5026 Cincinnati OH 45229 PCMH, NCQA TriHealth Physician Practices LLC (2) - Montgomery Family 11029 Montgomery Road, Hamilton Medicine, Kenwood X Cincinnati OH 45249 PCMH, NCQA Trihealth Physician Practices 4260 Glendale Milford LLC (2) - Blue Ash Internal Road, Suite 101 Blue Ash Hamilton Medicine X OH 45242 PCMH, NCQA Trihealth Physician Practices LLC (2) - Moreira and Robles 10495 Montgomery Road, Internal Medicine Suite 15, Cincinnati OH Hamilton Associates, IMA X 45242 PCMH, NCQA, CPCI Mercy Health Physicians - 6350 Cheviot Road, Hamilton White Oak Primary Care X Cincinnati OH 45247 PCMH, NCQA Mercy Health Physicians (2) 16 East Main Street Suite Hamilton - Addyston Family Medicine X 100, Addyston OH 45001 PCMH, NCQA O-19

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Mercy Health Physicians 2 - 9403 Kenwood Road Suite Hamilton Blue Ash Internal Medicine X D203, Cincinnati OH 45242 PCMH, NCQA Mercy Health Physicians 2 - 1380 Compton Road, Mt. Hamilton Midwest Primary Care X Healthy OH 45231 PCMH, NCQA Mercy Health Physycians 2 - 4631 Ridge Ave, Suite B, Hamilton Oakley Primary Care X Cincinnati OH 45209 PCMH, NCQA Mercy Health Physicians 2 - 4101 Edwards road, Rookwood Internal Second Floor, Cininnati OH Hamilton Medicine and Pediatrics X 45209 PCMH, NCQA Mercy Health Physicians 2 - 4130 Dry Ridge Road, Hamilton Dry Ridge Family Medicine X Cincinnati OH 45252 PCMH, NCQA Mercy Health Physicians 2 - 10450 New Haven Road, Hamilton Harrison Primary Care X Harrison OH 45030 PCMH, NCQA Mercy Health Physicians 2 - 3301 Mercy Health Blvd, Monfort Heights Family Suite 340, Cincinnati OH Hamilton Medicine X 45211 PCMH, NCQA Mercy Health Physicians 2 - 6045 Bridgetown Road, Hamilton Oak Hills Internal Medicine X Cincinnati OH 45248 PCMH, NCQA Mercy Health Physicians 2 - 212 West Sharon Road, Hamilton Springdale Family Medicine X Cincinnati OH 45246 PCMH, NCQA 7685 Beechmont Ave, Hamilton TCHMA - Bullard Cincinnati OH 45255 796 Old State Route 74, Suite 100, Cincinnati OH Hamilton TCHMA - Eastgate X 45245 PCMH, NCQA City of Cincinnati Primary 2136 West Eighth Street, Hamilton Care - Price Hill X X Cincinnati OH 45204 PCMH, NCQA City of Cincinnati Primary 1525 Elm Street, Hamilton Care - Elm Street X X Cincinnati OH 45202 PCMH, NCQA City of Cincinnati Primary 5818 Madison Road, Hamilton Care - Cann X X Cincinnati OH 45227 PCMH, NCQA City of Cincinnati Primary 2750 Beekmand Ave, Hamilton Care - Millvale at Hopple X X Cincinnati OH 45225 PCMH, NCQA City of Cincinnati Primary 3917 Spring Grove Ave, Hamilton Care - Northside X X Cincinnati OH 45223 PCMH, NCQA Pediatric Association of Mt 4671 Ferguson Dr, Hamilton Carmel - Eastgate X Cincinnati OH 45245 PCMH, NCQA 8250 Kenwood Crossing Mid-City Pediatrics - Way, Suite 205, Cincinnati Hamilton Kenwood X OH 45236 PCMH, NCQA 2475 W. Balbraith Road, Queen City Physicians - Suite A, Cincinnati Oh Hamilton Groesbeck Pediatrics X 45239 PCMH, NCQA

O-20

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification UC Health Primary Care 3120 Burnet Ave, Suite Hamilton Burnet X 406, Cincinnati OH 45229 PCMH, NCQA UC Health Primary Care General Medicine Faculty 3130 Highland Ave, Hamilton Practice X Cincinnati OH 45216 PCMH, NCQA US Health primary Care Internal Medicine and 3130 Highland Ave, Hamilton Pediatrics X Cincinnati OH 45216 PCMH, NCQA 11590 Century Boulevard, UC Health Primary Care Tri- Suite 102, Cincinnati OH Hamilton County X 45246 PCMH, NCQA McMicken Integrated Care 40 East McMicken Ave, Hamilton and Mobile Medical Van X Cincinnati OH 45202 PCMH, NCQA Mercy Health Physicians - Dent Crossing Family 6507 Harrison Ave, Suite Hamilton Medicine X N, Cincinnati OH 45247 PCMH, NCQA Mercy Health Physicians - 4421 Eastgate Blvd, Suite Hamilton Eastgate Family Medicine X 300, Cincinnati OH 45245 PCMH, NCQA Mercy Health Physicians - 10541 Harrison Ave, Hamilton Harrison Internal Medicine X Harrison OH 45030 PCMH, NCQA Mercy Health Physicians - 4700 East Galbraith Road, Hamilton Blue Ash Family Medicine X Cincinnati OH 45236 PCMH, NCQA 4750 East Galbraith Road, Mercy Health Physicians - Suite 210, Cincinnati OH Hamilton Kenwood Family Medicine X 45236 PCMH, NCQA Mercy Health Physicians 4750 East Galbraith Road, Kenwood Internal Medicine Suite 210, Cincinnati OH Hamilton 210 X 45236 PCMH, NCQA Mercy Health Physicians Red 4760 Red Bank Road, Suite Hamilton Bank Family Medicine X 104, Cincinnati OH 45227 PCMH, NCQA Mercy Health Physicians 175 West Galbraith Road, Hamilton Wyoming Primary Care X Cincinnati OH 45216 PCMH, NCQA Mercy Health Physicians 3301 Mercy Health Blvd, West Internal Medicine and Suite 340, Cincinnati OH Hamilton Pediatrics X 45211 PCMH, NCQA TriHealth Physician Practices LLC (2) - Health First 10675A Loveland Madeira Hamilton Loveland X Road, Loveland OH 45140 PCMH, NCQA, CPCI The Christ Hospital Medical 2123 Auburn Ave, Suite Hamilton Office Building X 334, Cincinnati OH 45219 CPCI 6825 Wooster Pike, Hamilton Health First Physicians X Cincinnati OH 45227 CPCI

O-21

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification The Christ Hospital Physicians - Dr. Amador S. 5885 Harrison Ave, Suite Hamilton Delamerced MD X 2700 Cincinnati OH 45248 CPCI The Christ Hospital Obstetrics and Gynecology - 2567 Erie Ave, Cincinnati Hamilton Dr. Eric M Niemeyer MD X OH 45208 CPCI The Christ Hospital Obstretrics and Gynecology 312 Walnut Street, Suite Hamilton - Dr. Marshall McHenry MD X 1160 Cincinnati, OH 45202 CPCI 4900 Babson Place Suite TCH Health and Aging 400 Cincinnati, OH 45227- Hamilton Center X 2693 CPCI 7545 Beechmont Ave, TCHMA Anderson Family Suite A, Cincinnati OH Hamilton Medicine X 45255 CPCI Compton Family Care Inc - Internal Medicine, Family 24 Compton Road, Suite Hamilton Practitioners X 205, Cincinnati OH 45216 CPCI Jeremy E Bruce, MD - 2123 Auburn Ave, Suite Hamilton Internal Medicine X 440, Cincinnati OH 45219 CPCI 4411 Montgomery Road, The Christ Hospital - Frank Suite 201, Cincinnati OH Hamilton D. Perrino MD Inc. X 45212 CPCI The Christ Hospital Physicians - Internal 3805 Edwards Road, Suite Hamilton Medicine X 300, Cincinnati OH 45209 CPCI The Christ Hospital Obstetrics and Gynecology - 5680 Bridgetown Road, Hamilton Dr. Steven C. Cooley MD X Cincinnati OH 45248 CPCI Christ Hospital Physicians - 2727 Madison Road, Suite Hamilton Internal Medicine X 208, Cincinnati OH 45209 CPCI Christ Hosptial Physicians - 5535 Montgomery Road, Hamilton Norwood Internal Medicine X Cincinnati OH 45212 CPCI Lawrence P Wang MD - 614 Wooster Pike, Suite 7, Hamilton Internal Medicine X Terrace Park, OH 45174 CPCI 506 Van Buren Street, Hancock Graystone Family Practice X Fostoria OH 44830 PCMH, NCQA 455 West Fourth Street, ProMedica Physician Group - Suite 100, Fostoria OH Hancock Badik and Badik X 44830 PCMH, NCQA 501 Van Buren Street, ProMedica Physician Group - Suite 206, Fostoria OH Hancock Fostoria Family Medicine X 44830 PCMH, NCQA

O-22

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification 1800 North Blanchard Street, Suite 121, Findlay Hancock Caughman Health Center X OH 45840 PCMH, NCQA 520 W. Lincold Ave, Suite Hardin Ada Life Medical Center X A, Ada OH 45810 PCMH, NCQA Health Partners of Western Ohio - Kenton Community 111 W. Espy Street, Hardin Health Center X X Kenton OH 43326 PCMH, NCQA 1600 E Riverview Ave, Henry County Family Suite 101, Napoleon OH Henry Physicians, Inc. X 43545 PCMH, HB198 Mercy Defiance - Napoleon 1426 Scott Street, Henry Clininc X Napoleon, OH 43545 PCMH, NCQA 1108 NorthView Drive, HealthSource - Hillsboro Suite 1, Hillsboro OH Highland Health Center X 45133 PCMH, NCQA 1075 North Washington Adena Medical Group - Street, Greenfield OH Highland Greenfield X 45123 PCMH, NCQA Family Healthcare, Inc. - 1383 West Hunter Street, Hocking Logan X Logan OH 43138 PCMH, NCQA MMP-Family Physicians 65 W. Main Street, Huron Greenwich X Greenwich OH 44837 PCMH, NCQA MMP-Family Physicians 18 Plymouth Street, Huron Plymouth X Plymouth OH 44865 PCMH, NCQA 100 Neal Zick Road, Huron MMP-Primary Care Willard X Willard OH 44890 PCMH, NCQA 521 N Sandusky St, Huron NOMS - Hemeyer Bellevue X Bellevue OH 44811 PCMH, NCQA 813 Northwest St., Huron NOMS - Bellevue X Bellevue OH 44811 PCMH, NCQA Adena Oak Hill Family 315 Washington Street, Jackson Practice X Oak Hill OH 45656 PCMH, HB198 Adena Medical Group - 1000 Veterans Drive, Jackson Jackson X Jackson OH 45640 PCMH, NCQA Adena Medical Group - Oak 315 Washington Street, Jackson Hill X Oak Hill OH 45656 PCMH, NCQA CAC - Valley View Health 14590 State Route 93, Jackson Center - Jackson X X Jackson OH 45640 PCMH, NCQA 9500 Mentor Ave, Suite Lake Lake County Family Practice X 100, Mentor OH 44060 PCMH, NCQA 510 5th Ave Chardon Lake Health Chardon Family Campus, Chardon OH Lake Practice X 44024 PCMH, NCQA

O-23

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification 6270 N/ Ridge Road, Lake Health Madison Family Madison Campus, Lake Practice X Madison OH 44057 PCMH, NCQA Lake Health Mentor Family 6990 Lindsay Dr, Suite 3, Lake Practice X Mentor OH 44060 PCMH, NCQA Lake Health Mentor Internal 9485 Mentor Ave, Suite Lake Medicine X 210, Mentor OH 44060 PCMH, NCQA Lake Health North Coast 7580 Auburn Road, Suite Lake Family Practice X 202, Concord OH 44077 PCMH, NCQA Lake Health Painesville 1223 Mentor Ave, Lake Internal Medicine X Painesville, OH 44077 PCMH, NCQA Lake Health West Internal 36100 Euclid Ave, Suite Lake Medicine X 210, Willoughby OH 44094 PCMH, NCQA 2747 SOM Center Road, Lake Health Willoughby Hills Willoughby Hills, OH Lake Internal Medicine X 44094 PCMH, NCQA 36100 Euclid Ave, Lake Lake Health Willoughby West medical Building, Lake Internal Medicince X Willoughby OH 44094 PCMH, NCQA Lake Health Willowick 29804 Lakeshore Blvd, Lake Internal Medicine X Willowick OH 44095 PCMH, NCQA Lake Health Willowick 29804 lakeshore Blvd, Lake Internal Medicine X Willowick OH 44095 PCMH, NCQA 6270 North Ridge Road, Lake Health Madison Chardon Campus, Madison Lake Pediatrics X OH 44060 PCMH, NCQA Lake Health Thomas Family 8316 Yellowbrick Road, Lake Practice Mentor X Mentor OH 44060 PCMH, NCQA Lake Health Willoughby 36100 Euclid Ave, Suite Lake Pediatrics X 300, Willoughby OH 44094 PCMH, NCQA 8007 Auburn Road, Suite Lake Tina M Joyce DO, LLC X 3, Concord OH 44077 PCMH, NCQA 36001 Euclid Ave, Suite Lake Marinella L Turc, MD X B11, Willoughby OH 44094 PCMH, NCQA 38429 Lakeshore Blvd, Lake Erieside Medical Group X Willoughby OH 44064 PCMH, NCQA 36001 Euclid Ave, Suite Lake M.H. Phillip Chiang MD, Inc X B4, Willoughby OH 44094 PCMH, NCQA 305 N 5th Street, Ironton Lawrence CAO Family Medical Centers X OH 45638 NCQA 1005 E Ring Road, Suite 2, Lawrence OLBH - Ironton Primary Care X Ironton OH 45638 PCMH, NCQA Chesapeake Family Medical 717 3rd Ave, Chesapeake Lawrence Center X OH 45619 PCMH, NCQA O-24

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Ironton Family Medican 304 North 2nd Street, Lawrence Center X Ironton OH 45638 PCMH, NCQA Community Health & Wellness Partners of Logan 4879 US Highway 68 S, Logan County X West Liberty OH 43357 NCQA Mary Rutan Hospital 118 Dowell Ave, Logan Pediatrics X Bellefontaine OH 43311 PCMH, NCQA 4879 US Highway 68 S, Logan Oakhill Medical Associates X West Liberty OH 43357 PCMH, NCQA Mary Rutan Hospital 2231 Timber Trail, Logan Internal Medicine X Bellefontaine OH 43311 PCMH, NCQA Lorain County Health & 3745 Grove Ave, Lorain, Lorain Dentistry X OH 44055 NCQA Community Health Partners Physicians, Inc d/b/a Mercy Medical Partners - Amherst 578 N. Leavitt Road, Lorain East (Adult) X X Amherst, OH 44001 PCMH, NCQA Community Health Partners Physicians, Inc d/b/a Mercy Medical Partners - Avon 37460 Harvest Drive, Avon Lorain (Peds) X X OH 44011 PCMH, NCQA Community Health Partners Physicians, Inc d/b/a Mercy Medical Partners - Lagrange 105 Opportunity Way, Lorain (adult) X X Lagrange OH 44050 PCMH, NCQA Community Health Partners Physicians, Inc d/b/a Mercy Medical Partners - Lorain 3600 Kolbe Road, Suite Lorain (Adult) X X 227, Lorain OH 44053 PCMH, NCQA Community Health Partners Physicians, Inc d/b/a Mercy Medical Partners - Lorain 3600 Kolbe Road, Suite Lorain (Peds) X X 205, Lorain OH 44053 PCMH, NCQA Community Health Partners Physicians, Inc d/b/a Mercy Medical Partners - Oberlin 224 West Lorain St, Suite Lorain (Peds) X X E, Oberlin OH 44074 PCMH, NCQA Community Health Partners Physicians, Inc d/b/a Mercy Medical Partners - Oberlin 224 West Lorain St, Suite Lorain IM (Adult) X X F, Oberlin OH 44074 PCMH, NCQA

O-25

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Community Health Partners Physicians, Inc d/b/a Mercy Medical Partners - Vermilion 1607 State Rt 60, Suite 6, Lorain (Adult) X X Vermilion OH 44089 PCMH, NCQA Community Health Partners Physicians, Inc d/b/a Mercy Medical Partners - 508 Dickson Street, Suite Lorain Wellington (Adult) X X 2, Wellington OH 44090 PCMH, NCQA HealthSpan, Avon Medical 36711 American Way, Lorain Office X Avon OH 44011 PCMH, NCQA Lorain County Health and 1205 Broadway Ave, Lorain Dentistry - Broadway X X Lorain OH 44052 PCMH, NCQA Lorain County Health and 412 E. River Road, Elyria Lorain Dentistry - Eriver X X OH 44035 PCMH, NCQA Lorain County Health and 3745 Grove Ave, Lorain, Lorain Dentistry - Grove Ave X X OH 44055 PCMH, NCQA Tri-City Medical Services, LLC d/b/a/ Mercy Tri-City 1480 Center Road, Suite A, Lorain Medicine - Avon X Avon OH 44011 PCMH, NCQA Tri-City Medical Services, LLC d/b/a/ Mercy Tri-City 1120 E. Broad Street, Lorain Medicine - Elyria X Elyria OH 44035 PCMH, NCQA Tri-City Medical Services, LLC d/b/a/ Mercy Tri-City 6115 Emerald Street, Lorain Medicine - N. Ridgeville X North Ridgeville OH 44039 PCMH, NCQA Mercy Health Physicians Lorain LLC - Avon Primary 1480 Center Road, Suite A, Lorain Care X Avon OH 44011 PCMH, NCQA Mercy Health Physicians Lorain LLC - Elyria Primary 1120 E. Broad Street, Lorain Care X Elyria OH 44035 PCMH, NCQA Mercy Health Physicians 3600 Kolbe Road, Suite Lorain Lorain LLC - Lorain Pediatrics X 205, Lorain OH 44053 PCMH, NCQA Mercy Health Physicians Lorain LLC - Lorain Primary 3600 Kolbe Road, Suite Lorain Care X 227, Lorain OH 44053 PCMH, NCQA Mercy Health Physicians Lorain LLC - North Ridgeville 6115 Emerald Street, Lorain Primary Care X North Ridgeville OH 44039 PCMH, NCQA Mercy Health Physicians Lorain LLC - Amherst Family 101 Cooper Foster Road, Lorain Medicine X Amherst OH 44001 PCMH, NCQA

O-26

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Mercy Health Physicians Lorain LLC - Oberlin Primary 319 West Lorain Street, Lorain Care X Oberlin OH 44074 PCMH, NCQA Neighborhood Health 313 Jefferson Ave, Toledo Lucas Association X OH 43604 NCQA Mercy Internal Medicine 2213 Franklin Ave, Toledo Lucas Associates X OH 43620 PCMH, HB198 MMP-Bay Meadows Family 2815 Dustin Road, Oregon Lucas Practice X OH 43616 PCMH, NCQA MMP-Comprehensive Care 4126 Holland-Sylvania Family Physicians-Sylvania Road, Suite 220, Toledo Lucas Pod X OH 43623 PCMH, NCQA MMP-Family Physicians Issac 10501 Isaac Streets Dr, Lucas Streets Dr. X #106, Oregon OH 43616 PCMH, NCQA MMP-Family Physicians and 1657 Holland Road, Suite Lucas Specialists Holland Road X A, Maumee OH 43537 PCMH, NCQA MMP-Family Physicians 2200 Jefferson Ave, Lucas Mercy Campus X Toledo OH 43604 PCMH, NCQA MMP-Family Physicians 723 Phillips Ave, #201-A, Lucas Phillips Ave. X Toledo OH 43612 PCMH, NCQA MMP-Family Physicians 2755 Shoreland Ave, Lucas Point Shoreland X Toledo OH 43611 PCMH, NCQA MMP-Family Physicians St. 2702 Navarre Ave, Oregon Lucas Charles X OH 43616 PCMH, NCQA MMP-Internal Medicine Physicians Family Care Center A Dept. of 2213 Franklin Ave, Toledo Lucas Mercy St. Vincent X OH 43620 PCMH, NCQA MMP-Mercy Family 4041 Sylvania Ave, Suite Lucas Physicians West Park X 100, Toledo OH 43623 PCMH, NCQA MMP-Pediatric Associates Family Care Center A Dept. 2213 Franklin Ave, Toledo Lucas 0f Mercy St. Vincent X OH 43620 PCMH, NCQA 3841 Navarre Avenue, Lucas Oregon Clinic X Oregon OH 43616 PCMH, NCQA ProMedica Physician Group - 3909 Woodley Road, Suite Lucas Alexis Medical Center X 100, Toledo OH 43606 PCMH, NCQA ProMedica Physician Group - 660 Beaver Creek Circle, Arrowhead Family Suite 110 Maumee OH Lucas Physicians X 43537 PCMH, NCQA ProMedica Physician Group - 5308 Harroun Road, Suite Lucas Arun D. Mathur, MD X 170 Sylvania OH 43560 PCMH, NCQA ProMedica Physician Group - 2751 Bay Park Dr, Suite Lucas Bay Park Family Practice X 303, Oregon OH 43616 PCMH, NCQA O-27

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification ProMedica Physician Group - 2865 Reynolds Road, Suite Lucas Cantor and Freeman X 260, Toledo Oh 43615 PCMH, NCQA ProMedica Physician Group - 3740 W Sylvania Ave, Suite Lucas Family Practice of Toledo X 100, Toledo OH 43623 PCMH, NCQA ProMedica Physician Group - 7140 Port Sylvania Drive, Port Sylvania Family Suite 300, Toledo OH Lucas Physicians X 43617 PCMH, NCQA ProMedica Physician Group - ProMedica Physicians Adult 2150 W. Central Ave, Lucas Medicine Clinic X Toledo OH 43606 PCMH, NCQA ProMedica Physician Group - 1601 Brigham Dr, Suite Lucas River Road Family Physicians X 250 Perrysburg OH 43551 PCMH, NCQA ProMedica Physician Group - Sylvania Adult and Pediatric 5308 Harroun Road, Suite Lucas Medicine X 155, Sylvania OH 43560 PCMH, NCQA ProMedica Physician Group - 3909 Woodley Road, Suite Lucas West Central Medical Group X 600, Toledo OH 43606 PCMH, NCQA ProMedica Physician Group (2) - Fallen Timbers Family 5705 Monclova Road, Lucas Physicians X Maumee OH 43537 PCMH, NCQA 5757 Monclova Road, ProMedica Physician Group Suite 11, Maumee OH Lucas (2) - Shalini Singh, DO X 43537 PCMH, NCQA 5757 Monclova Road, ProMedica Physician Group Suite 15, Maumee OH Lucas (2) - Timothy Mattison, MD X 43537 PCMH, NCQA 3909 Woodley Rd, Promedica Health Center, Suite 500, Toledo OH Lucas Westgate Medical Group X 43606 PCMH, NCQA 3909 Woodley Rd, Promedica Health Center, Woodley Park Internal Suite 300, Toledo OH Lucas Medicine X 43606 PCMH, NCQA Cordelia Martin Health 430 Nebraska Ave, Toledo Lucas Center X OH 43604 PCMH, NCQA South Side Community 732 South Ave, Toledo OH Lucas Health Center X 43609 PCMH, NCQA 726 Wick Ave, Mahoning ONE Health Ohio X Youngstown OH 44505 NCQA Austintown Family Health 5533 Mahoning Ave, Suite Mahoning Center X D, Austintown OH 44515 PCMH, NCQA HMHP-Boardman Complete 7000 South Ave, Suite 2, Mahoning Family Health X Boardman OH 44512 PCMH, NCQA

O-28

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification HMHP-Church Hill Family 4694 Belmont Ave, Mahoning Health Center X Youngstown OH 44505 PCMH, NCQA 1053 Belmont Ave, Mahoning HMHP-Family Health Center X Youngstown OH 44501 PCMH, NCQA HMHP-Internal Medicine 1001 Covington Street, Mahoning Clinic X Youngstown OH 44510 PCMH, NCQA Center Street Community 205 W Center Street Suite Marion Health Center X X 200, Marion OH 43302 PCMH, NCQA Family Practice Center of 251 Leatherman Road, Medina Wadsorth, Inc. X Wadsworth OH 44281 PCMH, HB198 HealthSpan, Medina Medical 3443 Medina Road, Suite Medina Office X 108, Medina, OH 44256 PCMH, NCQA 185 Wadsworth Road, Suite F, Wadsworth OH Medina Michael A Bianco MD X 44281 PCMH, NCQA Summa Physician Inc.- 1 Park Center Dr, #304, Medina Wadsworth Family Practice X Wadsworth, OH 44281 PCMH, NCQA Summa Physicians Inc.- Family Medicine Associate 3780 Medina Road, Suite Medina of Medina X 310, Medina OH 44256 PCMH, NCQA Summa Physicans Inc. - 267 Center Street, Seville Medina Seville Family Practice X OH 44273 PCMH, NCQA 185 Wadsworth Road, Community Health Care - Suite D, Wadsworth OH Medina Wadsworth X 44281 PCMH, NCQA Family Healthcare, Inc. - 41865 Pomeroy Pike, Meigs Pomeroy X Pomeroy OH 45769 PCMH, NCQA GLPP - Grand Lake Family Practice and Pediatrics 801 Pro Drive Suite D1, Mercer Celina Practice X Celina OH 45822 PCMH, NCQA 909 E Wayne Street, Suite Mercer Mercer Medical Group X 124, Celina OH 45822 PCMH, NCQA 9159 N. County Road, 25A, Miami Piqua Family Practice Piqua OH 45356 PCMH, HB198 Upper Valley Family Care - 200 Kienle Dr, Piqua OH Miami Pique X 45356 PCMH, NCQA, CPCI Upper Valley Family Care - 700 S. Stanfield Road, Troy Miami Troy X OH 45373 PCMH, NCQA, CPCI Community Health Center of 2132 E 3rd St, Dayton OH Montgomery Greater Dayton X 45403 NCQA Dayton Primary Care 301 West First Street Suite Montgomery (Providence Medical Group) X 100, Dayton OH 45402 PCMH, HB198 Five Rivers Health Centers 2345 Philadelphia Drive, PCMH, NCQA, Montgomery Family Health Center X X Dayton OH 45406 HB198

O-29

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification 5 S. Alexandersville Rd, Montgomery Alex Central Health Center X Miamisburg, OH 45432 PCMH, NCQA 1323 West Third Street, Montgomery Charles Drew Health Center X Dayton OH 45402 PCMH, NCQA 2351 Stanley Avenue, Montgomery Corwin Nixon Health Center X Dayton OH 45404 PCMH, NCQA 2132 East Third Street, Montgomery East Dayton Health Center X Dayton OH 45409 PCMH, NCQA PriMed Physicians - 7211 North Main Street, Montgomery Woodbury Family Practice X Suite 1, Dayton OH 45415 PCMH, NCQA, CPCI Primed Physicians - Wright 1152 West Third Street, Montgomery Dunbar Family Practice X Dayton OH 45402 PCMH, NCQA 540 Lincoln Park PriMed Physicians Lincoln Boulevard, Suite 200, Montgomery Park Internal Medicine X Kettering OH 45429 PCMH, NCQA, CPCI PriMed Physicians Patterson 948 Patterson Road, Montgomery Woods Family Practice X Dayton OH 45419 PCMH, NCQA, CPCI PriMed Physicians Vandalia 1 East National Road, Montgomery Family Practice X Vandalia OH 45377 PCMH, NCQA, CPCI Providence Medical Group - 1870 Dayton Pike, Montgomery Fedrizzi Practice X Germantown OH 45327 PCMH, NCQA Providence Medical Group - Germantown Medical 1265 W. Market Street, Montgomery Associates X Germantown OH 45327 PCMH, NCQA, CPCI 25 Thorpe Ave, Dayton OH Montgomery Southview Health Center X 45420 PCMH, NCQA Victor Cassano Health 165 South Edwin C Moses Montgomery Center X Blvd, Dayton OH 45402 PCMH, NCQA 921 S Edwin C. Moses Montgomery Samaritan Homeless Clinic X Blvd, Dayton OH 45417 PCMH, NCQA 500 Lincoln Park Kettering Physician Network Boulevard, Suite 110, Montgomery - South Dayton Internists X Kettering OH 45429 PCMH, NCQA, CPCI Kettering Physician Network - Miamisburg Family 415 Byers Road, Suite 300, Montgomery Practice - Byers X Miamisburg OH 45342 PCMH, NCQA PriMed Physicians - 6520 Acro Court, Montgomery Centerville Pediatrics X Centerville OH 45459 PCMH, NCQA PriMed Physicians - Huber 8638 Old Troy Pike, Huber Montgomery Heights Pediatrics X Heights, OH 45424 PCMH, NCQA PriMed Physicians - 5250 Far Hills Ave, Montgomery Kettering Pediatrics X Kettering, OH 45429 PCMH, NCQA PriMed Physicians - 120 W. Wenger Road, Montgomery Northwest Dayton Pediatrics X Englewood OH 45322 PCMH, NCQA O-30

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification PriMed Physicians - Wright 1152 West Third Street, Montgomery Dunbar Pediatrics X Dayton OH 45402 PCMH, NCQA 7740 Washington Village Providence Medical Group - Drive, Suite 120, Montgomery Cornerstone Family Practice X Centerville OH 45459 PCMH, NCQA Providence Medical Group - 505 Corporate Center Montgomery Crossroads Medical Center X Drive, Vandalia OH 45377 PCMH, NCQA Providence Medical Group - 301 W. First Street, Suite Montgomery Dayton Primary Care X 100, Dayton OH 45402 PCMH, NCQA 8701 Old Troy Pike, Suite Providence Medical Group - 20, Huber Heights OH Montgomery Buckeye Family Practice X 45424 PCMH, NCQA Providence Medical Group - 1217 West Market Street, Montgomery Noel J. Watson M.D. X Germantown OH 45327 PCMH, NCQA 8701 Old Troy Pike, Suite Providence Medical Group - 10, Huber Heights OH Montgomery PMG - The Heights X 45424 PCMH, NCQA Providence Medical Group - 49 E Center Street, Montgomery Farmsville Medical Center X Farmersville OH 45325 PCMH, NCQA, CPCI Providence Medical Group - Germantown Family 1870 Dayton Pike, Montgomery Medicine X Germantown OH 45327 PCMH, NCQA Providence Medical Group - 6255 Chambersburg Road, Montgomery Northeast Family Practice X Huber Heights OH 45424 PCMH, NCQA Providence Medical Group - 8701 Old Troy Pike, Suite Suburban Family Practice - 50, Huber Heights OH Montgomery Koren X 45424 PCMH, NCQA, CPCI 7720 Paragon Road, Suite Montgomery Cornerstone Family Practice X B, Centerville OH 45459 CPCI Muskingum Valley Health 716 Adair Ave, Zanesville Muskingum Centers X X OH 43701 NCQA Medical Home Primary Care 3620 Court Drive Suite K, Muskingum Center X Zanesville, OH 43701 PCMH, HB198 611 Fulton St, Suite A, Port Ottawa NOMS - Port Clinton X Clinton OH PCMH, NCQA Family Healthcare, Inc. - 409 Lincoln Park Drive, Perry New Lexington X New Lexington OH 43764 PCMH, NCQA Pickaway Health Services - 27 Walnut Street, Ashville Pickaway Family Practice Ashville X OH 43103 PCMH, NCQA Pickaway Health Services - 210 Sharon Road, Suite D, Pickaway Internal Medicine X Circleville OH 43113 PCMH, NCQA Pickaway Health Services - 600 N. Pickaway St, Suite Pickaway MOB Peds X 301,Circleville OH 43113 PCMH, NCQA

O-31

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Adena Medical Group - 798 North Court Street, Pickaway Circleville X Circleville OH 43113 PCMH, NCQA Adena Family and Internal 12340 St. Rt. 104, Waverly Pike Med Waverly X OH 45690 PCMH, HB198 Piketon Family Health 7777 US Highway 23, Pike Center X Piketon OH 45661 PCMH, NCQA Adena Medical Group - 100 Indian Ridge Drive, Pike Piketon X Piketon OH 45661 PCMH, NCQA CAC - Valley View Health 227 Valley View Drive, Pike Centers - Waverly X X Waverly OH 45690 PCMH, NCQA HealthSpan, Kent Medical 2500 State Route 59, Suite Portage Office X 28, Kent OH 44240 PCMH, NCQA 307 West Main Street, Portage Unity Health Network - Kent X Suite B, Kent OH 44240 PCMH, NCQA 9150 Market Swuare Unity Health Network - Drive, Suite 201, Portage Streetsboro X Streetsboro OH 44241 PCMH, NCQA 1993 St. Rt 59, Kent OH Portage AxessPointe - Kent X X 44240 PCMH, NCQA LMPC - Putnam County 102 Ash Street, Putnam Family Care at Continental X Continental OH 45831 PCMH, NCQA LMPC - Putnam County 102 Putnam parkway, Putnam Family Care at Ottawa X Ottawa OH 45875 PCMH, NCQA 100 Progressive Drive, St. Rita's Professional Columbus Grove OH Putnam Services - Columbus Grove X 45830 PCMH, NCQA St. Rita's Professional Services - Klass Family 601 US 224, Glandorf OH Putnam Medicine X 45848 PCMH, NCQA Third Street Family Health 600 W Third St, Mansfield Richland Services X OH 44906 NCQA 1625 Airport Road, New Richland Perry County Family Practice X Lexington OH 43764 PCMH, HB198 2541 Panther Dr NE, New Richland Hopewell Health Centers X Lexington OH 43764 NCQA MMP-Family Physicians 21 W. Main Street, Shiloh Richland Shiloh X OH 44878 PCMH, NCQA Third Street Community 600 West Third Street, Richland Clinic, Inc X Mansfield OH 44906 PCMH, NCQA 311 Caldwell St, Ross 311 Caldwell St X Chollicothe, OH 45601 AAAHC Hopewell Health Centers, 1049 Western Ave, Ross Inc. - Chillicothe X X Chillicothe, OH 45601 PCMH, NCQA

O-32

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification 60 Capitol Drive, Ross Adena Medical Group - CFP X Chillicothe OH 45601 PCMH, NCQA 4437 State Route 159, Adena Medical Group - Suite 115, Chilicothe OH Ross Internal Medicine X 45601 PCMH, NCQA 100 North Walnut Street, Ross Adena Medical Group - PRFP X Chillicothe OH 45601 PCMH, NCQA Adena Medical Group - 626 Central Center, Ross Chillicothe X Chillicothe OH 45601 PCMH, NCQA NOMS - Fremont Family 1479 N River Road, Sandusky Practice X Fremont OH 43410 PCMH, HB198 1479 N River Road, Sandusky NOMS - Fremont X Fremont OH 43410 PCMH, NCQA SOMC Family Medicine 1835 Oakland Avenue, Scioto Residency Center X Portsmouth OH 45662 PCMH, HB198 West Portsmouth Family 23030 St Rt 73, West Scioto Health Center X Portsmouth OH 45663 PCMH, NCQA CAC - Valley View Health 621 Broadway, Scioto Center - Broadway X X Portsmouth OH 45662 PCMH, NCQA SOMC Medical Care Foundation, Inc. - SOMC 1835 Oakland Ave, First Family Medicine Residency Floor, Portsmouth OH Scioto Center X 45662 PCMH, NCQA SOMC Medical Care Foundation, Inc. - SOMC 10 Thomas Hollow Road, Scioto Lucasville Family Practice X Lucasville OH 45648 PCMH, NCQA SOMC Medical Care Foundation, Inc. - SOMC 8792 State Route 335, Scioto Minford Family Practice X Minford OH 45653 PCMH, NCQA SOMC Medical Care 1711 27th Street, Braunlin Foundation, Inc. - SOMC Building, Suite 403, Scioto Portsmouth Family Practice X Portsmouth OH 45662 PCMH, NCQA SOMC Medical Care Foundation, Inc. - SOMC 5611 Gallia Street, Scioto Sciotoville Family Practice X Sciotoville OH 45662 PCMH, NCQA SOMC Medical Care Foundation, Inc. - SOMC Wheelersburg Family 613 Center Street, Scioto Practice X Wheelersburg OH 45694 PCMH, NCQA 1611 27th Street, Fulton Building, Suite 101, Scioto SOMC Pediatric Associates X Portsmouth OH 45662 PCMH, NCQA MMP-Pediatric Associates 433 W. Market Street, Seneca Tiffin X Tiffin OH 44883 PCMH, NCQA

O-33

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification 2815 S State Route 100, Seneca NOMS - Tiffin X Tiffin OH 44883 PCMH, NCQA 1587 Boettler Road, Suite 104, Uniontown, OH Stark Green Primary Care X 44685 PCMH, HB198 211 15th St NW, Canton, Stark Little Flower Family Practice X OH 44703 PCMH, HB198 Lifecare Family Health & 2725 Lincoln Street E, Stark Dental Center X Canton OH 44707 NCQA Community Health Care - 4761 Higbee Ave NW, Stark Beldon X Canton OH 44718 PCMH, NCQA Community Health Care - 944 E. Cherry Street, Canal Stark Canal Fulton X Fulton OH 44614 PCMH, NCQA Community Health Care - 855 W. Maple Street, Suite Stark Hartville X 110, Hartville OH 44632 PCMH, NCQA Community Health Care - 1302 W. Main Street, Suite Stark Louisville X A, Louisville OH 44641 PCMH, NCQA Community Health Care - 6724 Wales Ave, Massillon Stark Massillon X OH 44646 PCMH, NCQA Community Health Care - 6722 Wales Ave, Massillon Stark Pediatrics X OH 44646 PCMH, NCQA 4860 Frank Ave NW, North Stark Family Physicians, Inc. X Canton OH 44710 PCMH, NCQA HealthSpan, North Canton 4914 Portage Street, NW, Stark Medical Office X Canton OH 44720 PCMH, NCQA Summa Physicians Inc.- 1700 Boettler Road, Suite Stark Green Family Medicine X 200, Uniontown OH 44685 PCMH, NCQA Richard D Watkins Canton 2725 Lincoln Street E, Stark Community Clinic, Inc X Canton OH 44707 PCMH, NCQA 2600 Seventh St SW Stark Aultman Family Medicine X Canton, OH 44710 PCMH, NCQA ONE Health Ohio - Good Samaritan Community 1390 Arch Street, Alliance Stark Health Center X X OH 44601 PCMH, NCQA 6525 Market Ave, North Suite 101, North Canton Stark Family Medicine, Inc. X OH 44721 PCMH, NCQA Internal Medicine Practice at 2600 7th Street, SW Stark Aultman X Canton OH 44710 PCMH, NCQA Pioneer Physicians Network, Inc. - Louisville Medical 1917 Williamsburg Way, Stark Center Physicians X Louisville OH 44641 PCMH, NCQA

O-34

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Pioneer Physicians Network, Inc - Great Trail Family 1028 E. Lincolnway, Stark Practice X Minerva OH 44657 PCMH, NCQA Pioneed Physicians Network, Inc - Hearthstone Family 4444 S. Arlington Road, Stark Practice X Uniontown OH 44685 PCMH, NCQA AxessPointe Community 1400 S Arlington St. Unit Summit Health Centers X 38, Akron OH 44306 NCQA 400 Wabash Ave, Akron General Medical Center, Summit Center for Family Medicine X Akron, OH 44307 PCMH, HB198 Family Medicine Center of 55 Arch St. Suite 3A, Akron Summit Akron X OH 44304 PCMH, HB198 676 South Broadway Street Suite 105, Akron OH Summit Canal Physician Group X 44311 PCMH, HB198 The Nursing Center for 209 Carroll Street, Akron Summit Community Health X OH 44325 PCMH, HB198 Community Health Care - 290 9th Street, Barberton Summit Barberton X OH 44203 PCMH, NCQA Community Health Care - 1700 Boettler Road, Suite Summit Green X 100, Uniontown OH 44685 PCMH, NCQA HealthSpan, Chapel Hill 1260 Independce Ave, Summit Medical Office X Akron OH 44310 PCMH, NCQA 4055 Embassy Parkway HealthSpan, Fairlawn Suite 110, Fairlawn OH Summit Medical Office X 44333 PCMH, NCQA HealthSpan, Twinsburg 8920 Canyon Falls Blvd, Summit Medical Office X Twinsburg OH 44087 PCMH, NCQA Pioneer Physicians Network, 3593 South Arlington Inc. - Internal Medicine of Road, Suite D, Akron OH Summit Green X 44312 PCMH, NCQA Pioneer Physicians Network, Inc. - South Main St. Medical 4880 South Main St, Suite Summit Center X 4, Akron OH 44319 PCMH, NCQA Summa Physician Inc.-AES 388 S. Main St, Suite 201, Summit Family Medicine X Akron OH 44311 PCMH, NCQA Summa Physician Inc.- 155 Fifth Street NE, Summit Barberton Family Practice X Barberton, OH 44203 PCMH, NCQA Summa Physicians Inc.- 87 Conservatory Dr, Suite Summit Diamond Family Practice X B, Barberton OH 44203 PCMH, NCQA Summa Physicians Inc.- 1069 Kenmore Boulevard, Summit Kenmore Family Medicine X Akron OH 44314 PCMH, NCQA

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Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Summa Physicians Inc- 182 East Ave, Tallmadge, Summit Bachtel and Associates X OH 44278 PCMH, NCQA Summa Physicians, Inc - White Pong Internal 789 White Pond Drive, Summit Medicine X Suite A, Akron OH 44320 PCMH, NCQA Unity Health Network - 5655 Hudson Drive, Suite Summit Hudson X 130, Hudson OH 44236 PCMH, NCQA Unity Health Network - 7689 Sagamore Hills Blvd, Summit Nordonia Hills X Sagamore Hills OH 44067 PCMH, NCQA 4465 Darrow Road, Stow Summit Unity Health Network - Stow X OH 44224 PCMH, NCQA Unity Health Network - 1900 23rd Street, Summit SWRH Internal Medicine X Cuyahoga Falls OH 44223 PCMH, NCQA Unity Health Network - 116 East Ave, Suite 3, Summit Tallmadge X Tallmadge OH 44278 PCMH, NCQA 8054 Darrow Road, Unity Health Network - Building D, Suite 1, Summit Twinsburg X Twinsburg OH 44087 PCMH, NCQA 1400 S Arlington St., Akron Summit AxessPointe - Akron X X OH 44306 PCMH, NCQA 390 E. Robinson Ave, Summit AxessPointe - Barberton X X Barberton OH 44203 PCMH, NCQA Akron General Partners 676 South Broadway Physician Group - Center for Street, Suite 105, Akron Summit Family Medicine X OH 44311 PCMH, NCQA Akron General Partners Physician Group Green 1946 Town Park Blvd, Summit Primary Care X Suite 200, Akron OH 44685 PCMH, NCQA 300 Locust Street, Suite Summit Locust Pediatric Care Group X 390, Akron OH 44308 PCMH, NCQA 3009 Smith Road, Suite Summit Ohio Family Practice Centers X 200, Fairlawn OH 44333 PCMH, NCQA Pioneer Physicians Network, Inc - Columbia Woods 3300 Greenwich Road, Summit Medical Group X Suite 8, Norton OH 44203 PCMH, NCQA Pioneer Physicians Network, Inc - Internal Medicine of 3593 S. Arlington Road, Summit Green X Suite D, Akron OH 44312 PCMH, NCQA Pioneer Physicians Network, Inc - Northampton Primary 3239 State Road, Summit Care X Cuyahoga Falls OH 44223 PCMH, NCQA Pioneer Physicians Network, Inc - Northeast Family 65 Community Road Suite Summit Health Center X C, Tallmadge OH 44278 PCMH, NCQA O-36

Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Pioneer Physicians Network, Inc - South Main Street 4880 South Main Street, Summit Medical Center X Suite 4, Akron OH 44319 PCMH, NCQA Community Health Care - 2971 Graham Road, Stow Summit Stow X OH 44224 PCMH, NCQA Community Health Care - 1193 Norton Ave, Suite A, Summit Norton X Norton OH 44203 PCMH, NCQA HMHP-Community Care 1296 Tod Place, Warren Trumbull Center X OH 44484 PCMH, NCQA HMHP-Cortland Family 421 S. High Street, Trumbull Health Center X Cortland OH 44410 PCMH, NCQA ONE Health Ohio - Lloyd 1977 Niles Road, SE Trumbull McCoy Health Center X X Warren OH 44484 PCMH, NCQA ONE Health Ohio - Warren West Community Health 716 Tod Ave, Warren OH Trumbull Center X X 44485 PCMH, NCQA ONE Health Ohio - Market Street Pediatrics, DBA Kidz 1821 East Market Street, Trumbull 1st Pediatrics X X Warren OH 44483 PCMH, NCQA 14210 Scottslawn Road, Union 14210 Scottslawn Road X Marysville, OH 43040 AAAHC COPC - Marysville Primary 1044 Columbus Ave, Union Care X Marysville OH 43040 PCMH, NCQA COPC - McConnell Family 118 Morey Drive, Union Practice X Marysville OH 43040 PCMH, NCQA Family Healthcare, Inc. - 31891 St Rt 93 North, Vinton McArthur X McArthur OH 45651 PCMH, NCQA 67 Nunner Road, Warren Maineville Family Physicians X Maineville OH 45039 PCMH, NCQA, CPCI Mercy Health Physicians 2 - Mason Area Medical 770 Reading Road, Suite A, Warren Associates X Mason OH 45040 PCMH, NCQA 9313 Mason-Montgomery Mercy Health Physicians 2 - Road, Suite 250 Mason OH Warren Mason Family Medicine X 45040 PCMH, NCQA PriMed Physicians - 243 West Central Ave, Warren Springboro Family X Springboro OH 45066 PCMH, NCQA, CPCI Providence Medical Group - Companions in Holistic 78 Remick Blvd, Warren Health Care X Springboro OH 45066 PCMH, NCQA TriHealth Physician Practices 100 Arrow Springs Blvd, LLC - Bethesda Group Suite 2700 Lebanon OH Warren Practice, Arrow Spring X 45036 PCMH, NCQA, CPCI

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Appendix O ODH FQHC Type of County Name of Practice List List Address Certification 6010 Mason-Montgomery Warren Group Health - Mason X Rd, Mason OH 45040 PCMH, NCQA Trihealth Physican Practices 100 Arrow Springs Blvd, LLC (2) - Deerfield Family Suite 2800 Lebanon OH Warren Practice X 45036 PCMH, NCQA, CPCI Kettering Physician Network 52 Remick Boulevard, Warren - Springboro Primary Care X Springboro OH 45066 PCMH, NCQA PriMed Physicians - 243 West Central Ave, Warren Springboro Pediatrics X Springboro OH 45066 PCMH, NCQA Providence Medical Group - 70 Remick Blvd, Warren Family Health Center X Springboro OH 45066 PCMH, NCQA 7423 S. Mason Montgomery Road, Mason Warren Health First Mason X OH 45040 CPCI 7451 S. Mason Mason Family Medicine - Dr. Montgomery Road, Suite Warren Albert Weisbrot, MD X C, Mason OH 45040 CPCI 4353 East St. Rt. 73, Warren Waynesville Health Care X Waynesville OH 45068 CPCI MHCPI Department of Internal Medicine/Pediatrics 807 Farson Street, Suite Washington - Belpre Dr. Cook X 203, Belpre OH 45714 PCMH, NCQA MHCPI Department of Primary Care - Belpre Dr. 809 Farson Street, Suite Washington Avery X 101, Belpre OH 45714 PCMH, NCQA MHCPI Department of Primary Care - Belpre Dr. 805 Farson Street, Suite Washington Maijub X 116, Belpre OH 45714 PCMH, NCQA MHCPI Department of Primary Care - Wayne Street 802 Wayne Street, Suite Washington Dr. Barnes X 200, Marietta OH 45750 PCMH, NCQA MHCPI Department of Pediatrics - Belpre Dr. 807 Farson Street, Suite Washington Caslow X 203, Belpre OH 45714 PCMH, NCQA 830 South Main Street, Wayne Dunlop Family Physicians X Orrville, OH 44667 PCMH, HB198 Summa Physicians Inc.- 223 North Main Street, Wayne Medical Center of Rittman X Rittman OH 44270 PCMH, NCQA Summa Physicians Inc. - 25 S Main Street, Rittman Wayne Rittman Family Practice X OH 44270 PCMH, NCQA Dunlap Family Physicians - 49 Maple Street, Box 510, Wayne Apple Creek Location X Apple Creek OH 44606 PCMH, NCQA Dunlap Family Physicians - 129 North Wenger Road, Wayne Dalton Location X Dalton OH 44618 PCMH, NCQA

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Appendix O ODH FQHC Type of County Name of Practice List List Address Certification Dunlap Family Physicians - 830 South Main Street, Wayne Orrville Location X Orrville, OH 44667 PCMH, NCQA Mercy Family Physicians 1103 Village Square Suite Wood Perrysburg - CHP X 202, Perrysburg, OH 43554 PCMH, HB198 MMP-Family Physicians 1103 Village Square Suite Wood Perrysburg X 202, Perrysburg, OH 43554 PCMH, NCQA

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Appendix P Appendix P: State Health Assessment/Community Health Assessment Background Information

State Health Assessment/Community Health Assessments As described by the 2016 State Health Assessment (preliminary draft 6/24/2016), the federal State Innovation Model (SIM) began with a December 2014 four year $75 million grant for implementation of episode-based payments and rollout of a statewide patient centered medical home model over a four year period. The Governor’s Office of Health Transformation leads this initiative.

As part of the SIM project, Ohio must develop a population health plan. In September 2015, the Ohio Department of Medicaid and Ohio Department of Health contracted with the Health Policy Institute of Ohio (HPIO) to facilitate stakeholder engagement and provide guidance on improving population health planning. The Governor’s Office of Health Transformation released the resulting report in January 2016, Improving Population Health Planning in Ohio. The report offered guidance that can help improve the state health assessment (SHA) and state health improvement plan (SHIP).

The SHA is a comprehensive and actionable picture of health and wellbeing in Ohio. The purpose of the SHA is to: • Inform identification of priorities for the SHIP • Provide a template for state agencies and local partners (uniform set of categories and metrics)

The SHIP is an actionable plan to improve health and control healthcare costs. The purpose of the SHIP is to: • Provide state agency leaders, local health departments, hospitals and other state and local partners with a strategic menu of priorities, objectives and evidence-based strategies • Signal opportunities for partnership with sectors beyond health

Local health departments are going through a parallel process in which they conduct community health assessments (CHAs) and develop community health improvement plans (CHIPs) as prerequisites for PHAB accreditation by July 1, 2018. Many local health departments in Ohio have already conducted CHAs and CHIPs.

Community Health Needs Assessment Similarly, to be recognized as tax exempt under Section 501(c)(3) of the Internal Revenue Code, hospitals are required to conduct a community health needs assessment (CHNA) and adopt an implementation strategy every three years.

The following is a list of hospitals that identified tobacco cessation as a priority in their CHNA:

Hospital County Region Children's Hospital Medical Center of Akron/Akron Children's Hospital Summit NE Ashtabula County Medical Center Ashtabula NE Akron General Medical Center Summit NE Akron City Hospital/Summa Health System/Summa Akron City and St. Thomas Hospital Summit NE Wooster Community Hospital Wayne NE Summa Health System Medina NE University Hospitals Rainbow Babies and Children's Hospital Cuyahoga NE

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Appendix P Hospital County Region University Hospitals Case Medical Center Cuyahoga NE University Hospitals Geneva Medical Center Ashtabula NE University Hospitals Geauga Medical Center Geauga NE University Hospitals Conneaut Medical Center Ashtabula NE Trinity Medical Center West Jefferson NE Trinity Medical Center East Jefferson NE Trinity Hospital Twin City Tuscarawas NE Summa Health System Summit NE University Hospitals Parma Medical Center Cuyahoga NE Lodi Community Hospital Medina NE University Hospitals Elyria Medical Center Lorain NE Mercy Regional Medical Center Lorain NE Promedica Toledo Hospital Lucas NW ProMedica Wildwood Orthopedic and Spine Hospital Lucas NW OhioHealth Marion General Hospital Marion Central Licking Memorial Hospital Licking Central Knox Community Hospital Knox Central Promedica Bay Park Community Hospital Lucas NW Adena Greefield Medical Center Highland SW Mercy Health - Clermont Hospital Clermont SW Southern Ohio Medical Center Scioto SE Selby General Hospital Washington SE Adena Pike Medical Center Pike SE Marietta Memorial Hospital Washington SE Genesis Hospital Muskingum SE Coshocton County Memorial Hospital Coshocton SE Bucyrus Community Hospital Crawford NW Adena Regional Medical Center Ross SE Bluffton Hospital Allen NW OhioHealth Hardin Memorial Hospital Hardin NW Magruder Hospital Ottawa NW Galion Community Hospital (part of Avita Health System) Crawford NW

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Appendix Q Appendix Q: Hospital Bundled Payment Background Information

The goal for episode-based payment as laid out in Ohio’s State Health Care Innovation Plan (October 30, 2013) is to establish clear accountability for both outcomes and cost of care, rewarding providers for delivering high quality, guideline concordant care. The foundation of the model is provider accountability – each episode of care will have a clearly defined Principal Accountable Provider, who has the most influence over end-to-end care. Because the model is designed to work within the existing provider delivery system and market structure (it is retrospective by design, encouraging coordination and accountability but not requiring ownership or formal governance changes among providers), providers of all sizes and administrative capabilities are able to participate. The clearly demonstrable opportunities for improvement (e.g., reduce unnecessary admissions, increase guideline concordant care) and the fact that episodes can be implemented regardless of market structure and capabilities means it can provide material impact near term.

According to the State Innovation Models Round 2 Model Test: Ohio Operational Plan, the episode-based payment model encourages high quality, patient-centered, cost-effective care by holding a single provider or entity accountable (Principle Accountable Provider, or PAP) for care across all services in a specific episode. It aligns provider incentives to reinforce this behavior and discourage under-utilization. By creating a common view of the patient journey, it encourages providers to coordinate patient care throughout an episode of care rather than simply focusing on specific visits or procedures. For SIM, Ohio’s multi-payer coalition created an Episode-Based Payment Charter outlining desired levels of payer alignment across four elements of the Ohio episode model: (1) accountability (PAP, cost normalization), (2) payment model (retrospective design, payment incentives, quality measures), (3) performance management (gain sharing, risk adjustment, exclusions), and (4) timing (reporting period, synchronizing performance periods). From October 2013 to May 2014, the multi- payer coalition, with extensive provider input, completed six episode definitions on which the state began reporting in March of 2015. Calendar year 2016 marks the first performance period for the first six episodes meaning that episodes ending during that timeframe will be used to determine whether or not a provider receives a positive or negative incentive. This past year, Ohio designed seven additional episodes. Reporting for this second set of episodes will begin in early 2016. In 2016, Ohio will design a new wave of episodes that will include both behavioral and physical health journeys.

Medicare is also introducing bundled payments. Modern Healthcare reported in July 2016 that three new episodes of care will be included in bundled payments, potentially compelling hundreds of additional hospitals into becoming financially accountable for what happens to Medicare patients long after they leave the hospital.

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Appendix R Appendix R: Core Community Cessation Services

Funded entities participating in the CCI will ensure that evidence-based tobacco cessation interventions required to be covered by insurers according to the Affordable Care Act are available and accessible within the county. These include the guidelines listed below which were developed using the publication Treating Tobacco Use and Dependence: Clinical Practice Guideline (2008 update) sponsored by U.S. Public Health Service, U.S. Department of Health and Human Services. Additional recommendations were also added to meet the needs of the project.

All cessation services supported by the CCI are required to be approved by the Ohio Department of Health’s Tobacco Program. Information about the certification process and specific requirements will be shared with funded communities.

The guidelines listed below were developed using the publication Treating Tobacco Use and Dependence: Clinical Practice Guideline (2008 update) sponsored by U.S. Public Health Service, U.S. Department of Health and Human Services. Additional recommendations were also added to meet the needs of the project.

Assessment/ • All tobacco users should be assessed to determine willingness to make a quit Intake attempt. This may or may not happen prior to the individual making contact with CCI (e.g. patient may self-refer). • Complete of Fagerstrom instrument to determine level of dependence • Sign release to share information with healthcare provider. • Discuss treatment options, including what type of counseling is preferred • Begin to discuss replacement therapy and/or prescription medication options Referral to • Discuss tobacco user’s preferences regarding individual, group or phone services counseling • Screen for inclusion in disparate population • Assess insurance status for pharmacotherapy access Individual • Each session is a minimum of 10 minutes counseling • A minimum of four sessions must be offered • Motivational interviewing is an essential treatment component • Services should include practical counseling, problem solving and social support • No more than a 72 hour wait to schedule a session Group • Each session is a minimum of 30 minutes counseling • A minimum of four sessions must be offered to all groups • A minimum of four participants per group • Groups must be offered a minimum of six times in a 12-month period • Motivational interviewing is an essential treatment component • Services should include practical counseling, problem solving and social support Telephone • Use alone or as a supplement to group and/or individual treatment counseling • Use of Ohio Tobacco Quit Line (1-800-Quit Now) is encouraged • A minimum of four sessions must be offered • Services should include practical counseling, problem solving and social support R-1

Appendix R • Web-based cessation programming should be encouraged to use in concert with telephone counseling Medication • Every tobacco user should be offered FDA approved medications (unless use is contraindicated) • Non-FDA approved methods (e.g. electronic nicotine delivery systems) must not be recommended • Connect patients to medication: o Insured patients: assist with procuring prescription (including over-the- counter) from a prescriber o Uninsured/underinsured patients: assist with obtaining free NRT (Quit Line, community program, etc.) • Key concepts to be communicated: o Medications increase success and reduce withdrawal symptoms o Certain combinations of cessation medications are effective o Combining counseling and medication increases abstinence rates Follow Up • Set expectations regarding follow up, from both treatment provider and independent evaluator, at each patient contact, especially when patient is being discharged from treatment (no further appointments scheduled) • Patient must be contacted by CCI staff or treatment provider at one month and two months post-treatment • Patient will be contacted by independent evaluator as part of ongoing evaluation at four, five, nine, 12, 18 and 24 months if the patient has not returned to treatment. Interviewing protocol will include questions that would screen for signs of relapse. If patient reports relapse, evaluator will refer back to treatment provider, either through passive referral (provide contact information for treatment provider) or active referral (have treatment provider contact patient directly). Patient consent to be referred will be obtained by evaluator. • Additional contact may be made if requested and appropriate • Ensure mechanisms are in place to guarantee follow up will take place • Encourage collection of multiple forms of contact (email, cell) • All patients will be provided contact information for treatment provider • If relapse occurs, start over with assessment and referral Disparate • Tailored services to meet the needs of all populations Populations • Conduct groups of similar persons (such as pregnant woman) • Services and referral networks must be available for all populations identified as having the largest tobacco-use disparity in the target area Clinical Staff • Multiple types of clinicians are effective and should be used • Medical/health care clinician deliver a strong message to quit and information about health risks and benefits, and recommend and prescribe medications • Nonmedical clinicians could then deliver additional counseling interventions Documentation • Every patient contact should be documented as part of an individual file, either through secure electronic medical record or secured paper file • Patient records should be retained a minimum of five years • All personally identifiable health information should be kept secure and confidential Accessibility • Both individual and group counseling options availability within a ten-mile Standards radius of any residence in the geographic region suggested R-2

Appendix R • Access to a telephone line (in private location) must be offered to patients lacking the means to engage in telephone counseling. For example, a private office in the physical location of the agency would be offered. • In-person services must be regularly offered before and after normal business hours

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