SAMPLE FORM Ryan White Part A Implementation Plan Grantee Name: Big City EMA Fiscal Year: 2013 Page 7 of 15 Pages Medical Transportation Services Service Priority Name: Total Priority Allocation: $35,000 9 Part A Core Medical Part A Support MAI Core Medical MAI Support Service Priority Number: ☐ ☒ ☐ ☐ Improve health outcomes by ensuring transportation is available to any Reference Current Comprehensive Plan: Service Goal: client needing assistance with transportation to access medical services. Section G. p. 25 3. Quantity 4. Time Frame: 2. Service 5. Funds: Indicate the estimated Unit Provide the 3b) Total 1. Objectives: duration of activity Definition: approximate amount 3a) Number Number of List quantifiable time-limited objectives related to the relating to the Define the of funds to be used of people to service service priorities listed above objective listed service unit to to provide this be served units to be be provided service. provided Start Date End Date By March 1, 2014, 100% of RW funded medical a: $280 case management service providers will have bus 1-day pass 50 70 $3,520 passes available for distribution to clients requiring 7-day pass 240 440 3/1/2013 2/28/2014 $16,200 30-day pass 150 600 assistance with transportation to medical Total: $20,000 appointments May 1, 2014, 100% of medical case b:By management service providers will have taxi vouchers available for distribution to clients requiring One-way trip 75 600 5/1/2013 2/28/2014 $15,000 assistance with transportation to medical appointments 6. Select a minimum of two objectives and list planned client level outcomes to be tracked: Decrease in the percentage of clients who identify transportation as a barrier to accessing medical care from 70% to 30%.
SAMPLE FORM Ryan White Part A Implementation Plan Grantee Name: Big City EMA Fiscal Year: 2013 Page 7 of 15 Pages Service Priority Name: Medical Transportation Services Total Priority Allocation: $35,000 Service Priority Number: 9 Part A Core Medical ☐ Part A Support ☒ MAI Core Medical ☐ MAI Support ☐ Service Goal: Improve health outcomes by ensuring transportation is available to any client needing assistance with transportation to access medical services. Reference Current Comprehensive Plan: Section G. p. 25 1. Objectives: List quantifiable time-limited objectives related to the service priorities listed above 2. Service Unit Definition: Define the service unit to be provided 3. Quantity 4. Time Frame: Indicate the estimated duration of activity relating to the objective listed 5. Funds: Provide the approximate amount of funds to be used to provide this service. 3a) Number of people to be served 3b) Total Number of service units to be provided Start Date End Date a: By March 1, 2014, 100% of RW funded medical case management service providers will have bus passes available for distribution to clients requiring assistance with transportation to medical appointments 1-day pass 7-day pass 30-day pass 50 240 150 70 440 600 3/1/2013 2/28/2014 $280 $3,520 $16,200 Total: $20,000 b:By May 1, 2014, 100% of medical case management service providers will have taxi vouchers available for distribution to clients requiring assistance with transportation to medical appointments One-way trip 75 600 5/1/2013 2/28/2014 $15,000 6. Select a minimum of two objectives and list planned client level outcomes to be tracked: Decrease in the percentage of clients who identify transportation as a barrier to accessing medical care from 70% to 30%.
FY%202017%20Part%20A%20Implementation%20Plan%20Form%20and%20Sample%20Attachment%20D.docx