Vital Access Provider Assurance Program (VAPAP)

Financial Sustainability Transformation Plan Summary

Contents:

  1. VAPAP CONTACT INFORMATION
  2. CURRENT STATE OVERVIEW
  3. ROOT CAUSE ANALYSIS
  4. DSRIP ALIGNMENT
  5. TRANFORMATION INITIATIVES
  6. PLAN FOR PROGRAM GOVERNANCE
  7. MOU & ATTESTATION

Transformation Plan Summary (DRAFT)

A. VAPAP CONTACT INFORMATION

Please enter the information requested below in the adjacent boxes:

VAPAP Facility
Operating Certificate No. #
(if applicable):		  
Legal Entity Name of Facility (as it
appears on the Operating Certificate):		  
Mailing Address:
 
Authorized Officer Contact Name:  
Contact Title:  
Contact Phone:  
Contact Email:  

Please complete the following for each PPS that should be noted as a stakeholder in the facility´s Transformation Plan:

PPS Lead – Primary PPS
Operating Certificate No. #
(if applicable):		  
Legal Entity Name of Facility (as it
appears on the Operating Certificate):		  
Mailing Address:
 
Authorized Officer Contact Name:  
Contact Title:  
Phone:  
Email:  

PPS Lead – Secondary PPS (if applicable)
Operating Certificate No. #
(if applicable):		  
Legal Entity Name of Facility (as it
appears on the Operating Certificate):		  
Mailing Address:
 
Authorized Officer Contact Name:  
Contact Title:  
Phone:  
Email:  

B. CURRENT STATE OVERVIEW:

Provide an overview of the current financial distress situation that your facility is facing and that is causing the need for State VAPAP subsidy payments (please limit your response to three (3) pages of text in 12 point font):

C. ROOT CAUSE ANALYSIS:

The root cause analysis is intended for facilities to identify the root cause of its financial distress and the need for VAPAP payments. In subsequent sections please define the initiatives to address them. Please select the categories below that best relate to the root cause of your facility´s financial distress by entering an "X" in the subsequent box. In addition, please estimate what percentage of the financial distress is attributed to that cause - intended for purpose of relevance; all percentages should add up to 100%. For those selected categories where an "X" was entered, please provide a summary of the cause that includes all of the following: a description, explanation as to why that issue exists, and an explanation of the impact.

Please note, each proposed transformation initiative in Section E should be linked to the categories selected below.

Category Enter "X"
if Applicable		 Impact
as a %		 Root Cause Summary:
       
       
       
       
       
Structure (governance/ownership)    
Revenue    
Total impact: 100%

D. DSRIP ALIGNMENT:

Please note, responses to the questions in this section should relate to those PPSs included in Section A above.

  1. Overall, what impact does DSRIP have on the facility?
  1. Is your facility participating in DSRIP? If yes, what DSRIP projects is your facility participating in?
  1. What are your facility´s commitments and targets with these projects?
  1. What funds flow arrangements have been outlined between your facility and the PPS to participate in the PPS Funds Flow plan? Please briefly describe the plan or approach for each of the PPS´s budget categories from which your facility may receive DSRIP related funds.
  1. Have any specific plans been made or discussed with your PPS regarding participation in their DSRIP Financial Sustainability Plan (Section 9 of their approved Organizational Application)? Yes / No. If "Yes", please describe briefly if your PPS has identified your facility as being financially fragile and the plan or approach with the PPS to improve your facility´s financial status.
  1. How will the PPS network support your facility through the implementation of the VAPAP transformation plan?
  1. How will your facility communicate and coordinate with the PPS during the implementation of the transformation plan and of DSRIP projects?

E. TRANSFORMATION INITIATIVES:

Please provide answers to the questions below to define transformation initiatives that will address those items noted in the Root Cause Analysis for each initiative proposed in your VAPAP transformation plan. Each facility is required to include between 1 – 5 initiatives. Initiatives should tie to those listed in the "Initiatives" tab of the accompanying VAPAP Transformation Template spreadsheets

Initiative 1 Title:

Related Root Cause:
  1. Please provide an explanation of initiative and implementation plan for it.
  1. Please indicate the following:
    Start Date –
    Complete Date –
    Total Duration –
  1. What are the total savings and/or revenue projected from the start to end of the program?
  1. What (if any) resources will be required to implement the initiative?
    1. Capital and operating expenses:
    2. Resources:
  1. How will the initiative support or impact your facility in meeting DSRIP commitments and targets? Please indicate if the impact is positive or negative to the facility and why.
  1. Explanation of alignment with Community Needs Assessment (CNA):
    1. Does this initiative impact essential services to your community?

      If yes, please answer b–e. As applicable, descriptions should be consistent with the PPS´s CNA description of the population served by the facility:

    2. If this initiative is expected to add additional services provided by the facility, please describe briefly how this aligns with the CNA.

    3. Describe current and predicted future demand for this initiative at your facility, with direct references to the CNA for your region.

    4. How will the implementation of DSRIP projects affect both the supply and demand for this service in your region?

    5. How do you project these marketplace dynamics will impact the financial contribution of this service over the coming years?

    6. Explain how your proposed initiative aligns with this environment.
  1. What are the internal and/or external risks associated with successful implementation of the initiative?
  1. How will the initiative be sustainable after VAPAP funds are discontinued?
Ensure that the financial projections and milestones that will be used to assess progress and successful
implementation of this initiative are outlined in Section D of the attached spreadsheet.

Initiative 2 Title:

Related Root Cause:
  1. Please provide an explanation of initiative and implementation plan for it.
  1. Please indicate the following:
    Start Date –
    Complete Date –
    Total Duration –
  1. What are the total savings and/or revenue projected from the start to end of the program?
  1. What (if any) resources will be required to implement the initiative?
    1. Capital and operating expenses:
    2. Resources:
  1. How will the initiative support or impact your facility in meeting DSRIP commitments and targets? Please indicate if the impact is positive or negative to the facility and why.
  1. Explanation of alignment with Community Needs Assessment (CNA):
    1. Does this initiative impact essential services to your community?

      If yes, please answer b–e. As applicable, descriptions should be consistent with the PPS´s CNA description of the population served by the facility:

    2. If this initiative is expected to add additional services provided by the facility, please describe briefly how this aligns with the CNA.

    3. Describe current and predicted future demand for this initiative at your facility, with direct references to the CNA for your region.

    4. How will the implementation of DSRIP projects affect both the supply and demand for this service in your region?

    5. How do you project these marketplace dynamics will impact the financial contribution of this service over the coming years?

    6. Explain how your proposed initiative aligns with this environment.
  1. What are the internal and/or external risks associated with successful implementation of the initiative?
  1. How will the initiative be sustainable after VAPAP funds are discontinued?
Ensure that the financial projections and milestones that will be used to assess progress and successful
implementation of this initiative are outlined in Section D of the attached spreadsheet.

Initiative 3 Title:

Related Root Cause:
  1. Please provide an explanation of initiative and implementation plan for it.
  1. Please indicate the following:
    Start Date –
    Complete Date –
    Total Duration –
  1. What are the total savings and/or revenue projected from the start to end of the program?
  1. What (if any) resources will be required to implement the initiative?
    1. Capital and operating expenses:
    2. Resources:
  1. How will the initiative support or impact your facility in meeting DSRIP commitments and targets? Please indicate if the impact is positive or negative to the facility and why.
  1. Explanation of alignment with Community Needs Assessment (CNA):
    1. Does this initiative impact essential services to your community?

      If yes, please answer b–e. As applicable, descriptions should be consistent with the PPS´s CNA description of the population served by the facility:

    2. If this initiative is expected to add additional services provided by the facility, please describe briefly how this aligns with the CNA.

    3. Describe current and predicted future demand for this initiative at your facility, with direct references to the CNA for your region.

    4. How will the implementation of DSRIP projects affect both the supply and demand for this service in your region?

    5. How do you project these marketplace dynamics will impact the financial contribution of this service over the coming years?

    6. Explain how your proposed initiative aligns with this environment.
  1. What are the internal and/or external risks associated with successful implementation of the initiative?
  1. How will the initiative be sustainable after VAPAP funds are discontinued?
Ensure that the financial projections and milestones that will be used to assess progress and successful
implementation of this initiative are outlined in Section D of the attached spreadsheet.

Initiative 4 Title:

Related Root Cause:
  1. Please provide an explanation of initiative and implementation plan for it.
  1. Please indicate the following:
    Start Date –
    Complete Date –
    Total Duration –
  1. What are the total savings and/or revenue projected from the start to end of the program?
  1. What (if any) resources will be required to implement the initiative?
    1. Capital and operating expenses:
    2. Resources:
  1. How will the initiative support or impact your facility in meeting DSRIP commitments and targets? Please indicate if the impact is positive or negative to the facility and why.
  1. Explanation of alignment with Community Needs Assessment (CNA):
    1. Does this initiative impact essential services to your community?

      If yes, please answer b–e. As applicable, descriptions should be consistent with the PPS´s CNA description of the population served by the facility:

    2. If this initiative is expected to add additional services provided by the facility, please describe briefly how this aligns with the CNA.

    3. Describe current and predicted future demand for this initiative at your facility, with direct references to the CNA for your region.

    4. How will the implementation of DSRIP projects affect both the supply and demand for this service in your region?

    5. How do you project these marketplace dynamics will impact the financial contribution of this service over the coming years?

    6. Explain how your proposed initiative aligns with this environment.
  1. What are the internal and/or external risks associated with successful implementation of the initiative?
  1. How will the initiative be sustainable after VAPAP funds are discontinued?
Ensure that the financial projections and milestones that will be used to assess progress and successful
implementation of this initiative are outlined in Section D of the attached spreadsheet.

Initiative 5 Title:

Related Root Cause:
  1. Please provide an explanation of initiative and implementation plan for it.
  1. Please indicate the following:
    Start Date –
    Complete Date –
    Total Duration –
  1. What are the total savings and/or revenue projected from the start to end of the program?
  1. What (if any) resources will be required to implement the initiative?
    1. Capital and operating expenses:
    2. Resources:
  1. How will the initiative support or impact your facility in meeting DSRIP commitments and targets? Please indicate if the impact is positive or negative to the facility and why.
  1. Explanation of alignment with Community Needs Assessment (CNA):
    1. Does this initiative impact essential services to your community?

      If yes, please answer b–e. As applicable, descriptions should be consistent with the PPS´s CNA description of the population served by the facility:

    2. If this initiative is expected to add additional services provided by the facility, please describe briefly how this aligns with the CNA.

    3. Describe current and predicted future demand for this initiative at your facility, with direct references to the CNA for your region.

    4. How will the implementation of DSRIP projects affect both the supply and demand for this service in your region?

    5. How do you project these marketplace dynamics will impact the financial contribution of this service over the coming years?

    6. Explain how your proposed initiative aligns with this environment.
  1. What are the internal and/or external risks associated with successful implementation of the initiative?
  1. How will the initiative be sustainable after VAPAP funds are discontinued?
Ensure that the financial projections and milestones that will be used to assess progress and successful
implementation of this initiative are outlined in Section D of the attached spreadsheet.

F. PLAN FOR PROGRAM GOVERNANCE:

Please provide a summary of the plan for governance that has been determined for your VAPAP transformation program:
  1. Please describe the facility´s plan for project oversight during the creating/submission of the transformation plan, as well as during the periods of time associated with implementing the transformation initiatives.


  2. Please describe the facility´s plan for monitoring progress throughout the implementation period.


  3. Please describe the role of the PPS in the facility´s transformation plan.


G. MOU and ATTESTATIONS:

Instructions:

The facility´s Operator Signatory (e.g., CEO or CFO) must sign and date the Certification Statement provided on the following page as certification of the assertions included as part of the multi–year transformation plan. In addition, the related PPS Lead´s Operator Signatory (e.g., CEO, CFO, Executive Director) must also sign and date the Certification Statements.

  1. Insert Signatory´s Name and Title below.
  2. Print the Certification Statement (print specs are pre–set) to obtain a hard copy of the pre–filled Certification Statement document.
  3. The authorized Operator Signatory must sign and date the hard copy Certification Statement document.
  4. Make a PDF of the signed and dated hard copy Certification Statement document.
  5. Submit the Certification Statement as a PDF to the Department along with the electronic filing of the plan.

AUTHORIZATION FOR SUBMISSION OF THE
VITAL ACCESS PROVIDER ASSURANCE PROGRAM (VAPAP)
MULTI–YEAR TRANSFORMATION PLAN

VAPAP Facility:
VAPAP Facility Operating Certificate# ______________________________

CERTIFICATION STATEMENT

I hereby certify that I have read and examined the facility´s VAPAP multi–year transformation plan, and that to the best of my knowledge and belief, the information fairly and accurately represents an appropriate initial direction for the transformation plan, meets the needs of the local community, and aligns with facility´s DSRIP goals.

VAPAP Facility Officer Certification

Sign Date:
Authorized Signature:
Print Signatory Name:
Print Signatory Title:

VAPAP Facility Governing Board Certification

Sign Date:
Authorized Signature:
Print Signatory Name:
Print Signatory Title:


AUTHORIZATION FOR SUBMISSION OF THE
VITAL ACCESS PROVIDER ASSURANCE PROGRAM (VAPAP)
MULTI–YEAR TRANSFORMATION PLAN

VAPAP Facility:
VAPAP Facility Operating Certificate# ______________________________

CERTIFICATION STATEMENT

I hereby certify that I have read and examined the facility´s VAPAP multi–year transformation plan, and that to the best of my knowledge and belief, the information fairly and accurately represents an appropriate initial direction for the transformation plan, meets the needs of the local community, and aligns with facility´s DSRIP goals.

PPS Lead – Officer Certification

Sign Date:
Authorized Signature:
Print Signatory Name:
Print Signatory Title:

Secondary PPS – Officer Certification

Sign Date:
Authorized Signature:
Print Signatory Name:
Print Signatory Title: