Form 1 FORM - PFO Workplan Timeline Template.xlsx

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Overview

Workplan Timeline
Outcome Payment Timeline

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Sheet 1: Workplan Timeline

OMB No. 0906-XXXX, Expires XX/XX/20XX INSTRUCTIONS: Using the template below, provide a detailed workplan timeline for implementation of Pay for Outcomes initiative, and identifies responsible staff and timelines for completion. The PFO Workplan Timeline must extend across the entire length of the proposed PFO project period and include start and completion dates for activities. The proposed PFO project period for the PFO initiative should be clearly articulated, and should reflect the appropriate amount of time to observe/achieve the outcome measure(s), complete the PFO evaluation, and ensure that funds are obligated within the PFO statutory period of availability. Submit this Workplan Timeline as Attachment A to your Pay for Outcomes SIR Response.

Pay for Outcomes Workplan Timeline Template - DRAFT

Year of PFO Project Period

Phase

Activity

Staff Person Responsible

Start Date

Completion Date

1

2

3

4

5

6

7

8

9

10

Planning

Identify and secure third-party funding (if applicable)

Identify and secure third-party evaluator

Select LIAs/Providers

Complete/update contracts (including evaluation contract)

Draft and execute data-sharing agreements (if applicable)

Finalize legal structure, select fiscal agent and set up special purpose vehicle (if applicable)

Transfer third-party funding to LIAs/Providers (if applicable)

Implementation

COHORT 1

Drawdown of total funding for Cohort 1 services

Amount of MIECHV funding (indicate amount in relevant project year)

Amount of third-party funding (indicate amount in relevant project year) (if applicable)

Enroll Cohort 1

Service delivery, monitoring and oversight

Data collection

Evaluation report

Make outcome payments

COHORT 2

Drawdown of total funding for Cohort 2 services

Amount of MIECHV funding (indicate amount in relevant project year)

Amount of third-party funding (indicate amount in relevant project year) (if applicable)

Enroll Cohort 2

Service delivery, monitoring and oversight

Data collection

Evaluation report

Make outcome payments

Stakeholder Engagement

Identify stakeholders

Form stakeholder engagement committees (if applicable)

Determine meeting schedule

Hold meetings

Reporting

Draft PFO Annual Report

Submit PFO Annual Report

Public Burden Statement: HRSA is requesting approval to collect information in response to a Supplemental Information Request (SIR), which will include eligible entities' plans for implementation and evaluation of Pay for Outcomes (PFO) initiatives to be applied for through the MIECHV Program. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906 -XXXX and it is valid until XX/XX/202X. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 92 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

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Sheet 2: Outcome Payment Timeline

INSTRUCTIONS: Complete an Outcome Payment Timeline for each cohort served by the Pay for Outcomes initiative, and for each outcome measure per cohort.
Outcome Payment Timeline
	Year of PFO Project Period
Outcomes and Activities	1	2	3	4	5	6	7	8	9	10	Total Accumulated Payments Expected
OUTCOME MEASURE 1:
Enrollment Period
Services Performed
When Outcome is Expected (Date Range)
Data Received to Measure Success
Evaluation Results Available
Outcome Payments Made
Amount of Payment per Instance
Total Payments Expected											0
OUTCOME MEASURE 2 (If applicable):
Enrollment Period
Services Performed
When Outcome is Expected (Date Range)
Data Received to Measure Success
Evaluation Results Available
Outcome Payments Made
Amount of Payment per Instance
Total Payments Expected											0