FIRST TEETH FIRST - WESLEY HEALTH CENTERS MOU.PDF

MEMORANDUM OF UNDERSTANDING
Between
MARICOPA COUNTY
By and through the
DEPARTMENT OF PUBLIC HEALTH
4041 N. Central Avenue, #1400, Phoenix, Arizona 85012
And
Wesley Community and Health Centers
Background C-86-22-
Poor oral health can have a detrimental impact on children’s quality of life, their performance at
school, and their success in life. In fact, more than 51 million school hours are lost each year in
Arizona due to dental-related illness.
The Maricopa County Department of Public Health-Office of Oral Health (MCDPH-OOH)
requests that Wesley Community and Health Centers (WCHC) join MCDPH-OOH in partnership
to prevent tooth decay and improve the health of their clients.
This partnership will bring the First Teeth First Program to Wesley Community and Health Centers
(various locations) and will provide dental screenings and fluoride varnish applications to children
0-5 years and dental screenings for expectant mothers at no cost to participants.
The First Teeth First Program has been in existence since 2011 and is funded by First Things First.
During the 2019-2020 grant period more than 12,000 children were screened throughout Maricopa
County and over 1,200 expectant mothers received dental screenings.
Dental screenings and fluoride varnish applications are non-invasive and pain free. Fluoride
varnish applications are evidence based and have proven safe and effective in the reduction of
tooth decay. We also know that preventive oral health care is linked to improvements in overall
health and well-being. With an integrated Medical-Dental delivery system we can expand access
to care as well as improve patient outcomes.

This MEMORANDUM OF UNDERSTANDING (MOU) is hereby made and entered into by and between
the Maricopa County Department of Public Health, hereinafter referred to as MCDPH and the Wesley
Community and Health Centers, hereinafter referred to as WCHC.
A. PURPOSE
The purpose of this MOU is to develop a framework of cooperation and partnership between MCDPH, and
WCHC to provide The First Teeth First Program to eligible clients for the prevention of tooth decay.
B. STATEMENT OF MUTUAL BENEFIT AND INTERESTS
The mutual benefit for both parties is the prevention of tooth decay for clients and referral and navigation
services to a dental home.
C. MCDPH SHALL
• Provide registered dental hygienists and bilingual site assistants to conduct basic dental screenings
to children birth through age 5 and fluoride varnish applications.
• Provide basic dental screenings to expectant mothers.
• Prior to allowing a provider to serve patients, MCDPH ensures the provider is licensed,
credentialed, and privileged to perform services within their scope of practice.
• Require all staff to have a current fingerprint clearance card on file with the program.
• Provide adequate staffing for shifts assigned to health centers.
• Communicate with clinic manager when services will not be provided at clinic.
• Bring all necessary dental supplies needed to conduct the dental screening activities while on site.
• Provide referral and navigation services to clients in need of a dental home.
• Provide oral health education materials to staff and clients.
• Provide summary reports for each clinic, which will include number of children screened,
varnished, expectant mothers screened, and clients with urgent dental needs. These reports will be
provided on a quarterly basis.
• Maintain all client information according to confidentiality requirements.
• Submit fluoride varnish application claims for children two through five years of age on AHCCCS
that receive fluoride varnish applications by First Teeth First staff.
• Agree to abide by respective retention, record access and confidentiality regulations
required by state and federal regulatory agencies.
D. WESLEY COMMUNITY AND HEALTH CENTERS SHALL
• Promote participation in the dental screenings to clients of the clinic.
• Provide adequate physical space at each clinic for dental screenings to be delivered to clients of
WCHC. The space at each clinic will include at a minimum:
1. Space for FTF staff to complete paperwork and data entry.
2. Provide storage for dental supplies to be stored on site.
3. Accessible electrical outlet.
• Communicate with FTF staff when an WCHC patient is eligible and interested in FTF services.
• WCHC shall encourage patients that are having a well child visit to see FTF for their EPSDT oral
health screening.
• Communicate if child is there for a well child visit.
• Provide Wi-Fi access to FTF staff for data entry purposes.
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E. IT IS MUTUALLY UNDERSTOOD AND AGREED BY AND BETWEEN THE PARTIES
THAT:
1. This instrument is neither a fiscal nor a funds obligation document. Any endeavor or transfer
of anything of value involving reimbursement or contribution of funds between the parties to
this instrument will be handled in accordance with applicable laws, regulations, and
procedures including those for Government procurement and printing. Such endeavors will
be outlined in separate agreements that shall be made in writing by representatives of the
parties and shall be independently authorized by appropriate statutory authority. This
instrument does not provide such authority. Specifically, this instrument does not establish
authority for noncompetitive award to the cooperator of any contract or other agreement.
2. MONITORING CONTRACT PERFORMANCE
Both parties agree to operate in accordance with stipulations agreed upon within this
respective contract and addendum. Annually, each party shall review language and
responsibilities outlined within the respective contract and addendum to ensure performance
of both parties meets expectations outlined herein. Should either party violate or not meet the
expectations outlined herein, either party may pursue action outlined in the term and
termination clause of this contract.
3. EFFECTIVE DATE
This agreement will begin retro-actively as of 08:30 A.M. on June 17, 2021.
4. EXPIRATION DATE
This agreement will end as of 11:59 P.M. on June 30, 2023 but may be terminated by either
party.
5. MODIFICATION OR AMENDMENT
Modifications within the scope of the instrument shall be made by mutual consent of the
parties, by the issuance of a written modification or amendment, signed and dated by all
parties, prior to any changes being enacted.
6. TERMINATION
Any of the parties, in writing, may terminate the instrument in whole, or in part, at any time
before the date of expiration. A 30-day notice of termination of services will be required by
both parties.
7. CLIENT CONFIDENTIALITY
Both parties understand and concur that this agreement is subject to all State and Federal laws
protecting client confidentiality. Client/patient confidentiality will be maintained equally for
all individuals presenting for services whether being provided by WCHC or MCDPH. The
use or disclosure by either party of any information concerning an eligible individual served
under this agreement is directly limited to the fulfillment of this agreement.
8. LAWS, RULES AND REGULATIONS
Both parties understand and concur that this agreement is subject to all State and Federal
laws, rules and regulations that pertain hereto.
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9. PARTICIPATION IN SIMILAR ACTIVITIES
This agreement in no way restricts MCDPH or WCHC from participating in similar activities
with other public or private agencies, organizations, and individuals.
10. NON-LIABILITY
Neither MCDPH, WCHC, nor their respective officers and employees shall be liable for any
act or omission by the other party or other party’s subcontractor, employee, officer, agent, or
representative occurring in the fulfillment of this agreement.
11. INDEMNITY
MCDPH agrees to indemnify, hold harmless, and defend WCHC, its officers and
employees from and against any and all claims, damages, suits and proceedings,
regardless of the merits, from liability, punitive damages, costs or expense of every
type, all or any part thereof arising out of or in connection with or by reason of any
negligent act or omission of MCDPH or any subcontractors or anyone directly or
indirectly employed by either MCDPH or any subcontractors in the performance of
this MOU. MCDPH and its subcontractors shall reimburse WCHC for its costs,
including attorney’s fees for defense of any litigation arising from such claim.
MCDPH shall include a clause to this effect in all subcontracts inuring to the benefit
of WCHC.
Similarly, WCHC agrees to indemnify, hold harmless, and defend MCDPH, its
officers and employees from and against any and all claims, damages, suits and
proceedings, regardless of the merits, from liability, punitive damages, costs or
expense of every type, all or any part thereof arising out of or in connection with or
by reason of any negligent act or omission of WCHC or any subcontractors or anyone
directly or indirectly employed by either WCHC or any subcontractors in the
performance of this MOU. WCHC and its subcontractors shall reimburse MCDPH
for its costs, including attorney’s fees for defense of any litigation arising from such
claim. WCHC shall include a clause to this effect in all subcontracts inuring to the
benefit of MCDPH and Maricopa County.
12. COMMUNICATION
Each party agrees to notify the other, in writing, of changes in policy which may affect this
agreement. Notification is to be made to the attention of the principal contacts identified in
Section 12 below.
13. PRINCIPAL CONTACTS
The principal contacts for this agreement are:
Maricopa County, Department of Public Health Wesley Community and Health Centers
First Teeth First Program Coordinator Chief Operating Officer
Phone: 602-372-4650 Phone: 602-368-9603
E-mail: Berenise.Bauer@maricopa.gov Email: JRentscheler@wccphx.net
Grant/Contract Administrator
Phone: 602-372-0674
FAX: 602-506-6885
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C-86-22
IN WITNESS WHEREOF, the parties agree to the changes indicated herein:
FOR AND ON BEHALF OF FOR AND ON BEHALF OF
MARICOPA COUNTY WESLEY COMMUNITY AND HEALTH
CENTERS
By ___________________________ By ____________________________
Jack Sellers, Blaine Bandi,
Chairman, Board of Supervisors Chief Executive Officer
_______________________________ ________________________________
Date Date
ATTEST:
________________________________
Clerk of the Board
________________________________
Date
APPROVED AS TO FORM APPROVED AS TO FORM
________________________________ _____________________________
Attorney for Maricopa County
DATE: __________________________ DATE: _________________________
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HRSA COMPLIANCE ADDENDUM
Services referenced in this agreement are provided by an entity other than WCHC, with which
the health center has a formal written referral arrangement. The actual service is provided and
paid/billed for by the referral provider.
In compliance with requirements set forth by the Health Resources Services Administration
(HRSA) for Federally Qualified Health Centers (FQHC) engaged in a Column III formal written
referral arrangement, WCHC ensures this agreement contains stipulations that describe at
minimum:
• The manner by which the referral will be made and managed, and the process for tracking
and referring patients back to WCHC for appropriate follow-up care;
• How the referred service is made available equally to all WCHC patients, regardless of
ability to pay.
REFERRAL PROCESS
WCHC shall document the patient’s request for referral in the Electronic Health Record (EHR).
WCHC shall act as facilitator of the referral process, assisting the patient in scheduling an
appointment with the referral provider at a time that is convenient to all parties involved.
Following confirmation of appointment, WCHC shall send pertinent information to the referral
provider (i.e., patient contact information, reason for referral, service outcomes and related lab
and imaging results, medications list, etc.) prior to the scheduled appointment for review by the
referral provider. Patients requesting or requiring assistance with transportation to/from their
scheduled referral appointment will be aided relative to procedures set forth in WCHC’s board-
approved, non-emergent patient transportation policy.
Following the patient’s appointment, referral provider shall send pertinent information relating to
the patient’s appointment (i.e., service outcomes and related lab and imaging results, medications
list, etc.) back to WCHC. WCHC is responsible for migrating these notes into the patient’s EHR,
notifying the patient’s assigned primary care provider. The patient’s assigned primary care
provider shall review notes and, in their professional judgement, determine if a follow-up
appointment is necessary. If a follow-up appointment is necessary, the provider will determine
the method of encounter (by telephone or in-person). Details of the follow-up appointment shall
be documented in the patient’s EHR and, once input, the referral process will be formally closed.
REGARDLESS OF ABILITY TO PAY
Services outlined within this agreement are provided and paid/billed for by the referral provider.
The referral provider ensures services are made available equally to all WCHC patients,
regardless of ability to pay. WCHC ensures that fees for such services are either discounted in a
manner such that:
• Individuals and families with incomes above 100 percent of the current FPG and at or
below 200 percent of the FPG receive an equal or greater discount for these services
than if WCHC’s Sliding Fee Discount Schedule were applied to the referral provider’s
fee schedule; and
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• Individuals and families at or below 100 percent of the FPG receive a full discount or a
nominal charge for these services.
A copy of WCHC’s most recent Sliding Fee Discount Schedule shall be provided in attachment
to this addendum, should the referral provider adopt WCHC’s schedule. Should new Federal
Poverty Guidelines be announced prior to the termination of this agreement, WCHC shall replace
the existing attached schedules with an updated version, immediately following Board approval
of the revised schedules. Should the referral provider offer a discount to patients at or below 200
percent of Federal Poverty Guidelines equal or greater than a discount if WCHC’s Sliding Fee
Discount Schedule was applied, the referral provider will attach a copy of their discount program
or charity care policy to this addendum.
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