PBWS.pdf

Indian Health Service

PERFORMANCE BASED WORK STATEMENT

DIABETES CASE MANAGER/GPRA CONSULTANT

1.0 BACKGROUND

The Overall Project Goal is to improve the health status of American Indian/ Alaska Native (AI/AN) people with diabetes and prevent diabetes in the population at risk.

The SDPI grant has been appropriated by Congress to assist AI/AN communities with the epidemic of Diabetes Mellitus and programs must approach this problem using Indian Health Service (IHS) Best Practices.

Through the Government Performance and Results Act (GPRA) the Office of Management and Budget (OMB) sets standards of healthcare as benchmarks for IHS/Tribal/Urban(I/T/U) programs to evaluate the quality of care provided by their organization. Quarterly and Annual reports are provided to all I/T/U sites nationally.

There are 37 Tribal and Urban clinics in the California Area that receive a Special Diabetes Program for Indians (SDPI) Community Directed grant. This contract will focus on 14 of those programs:

Urban Programs:

1. Sacramento Native American Health Center, Sacramento

2. Indian Health Center of Santa Clara Valley, San Jose

Tribal Programs:

3. Indian Health Council, Pauma Valley

4. Karuk Tribe of California, Happy Camp

5. Round Valley Indian Health Center, Covelo

6. Pit River Health Services, Burney

7. Lassen Indian Health Center, Susanville

8. Shingle Springs Tribal Health, Shingle Springs

9. Sonoma County Indian Health Project, Inc., Santa Rosa

10. Consolidated Tribal Health Project, Inc., Redwood Valley

11. Feather River Tribal Health, Oroville

12. Greenville Rancheria Tribal Health Program, Red Bluff & Greenville

13. Strong Family Health Center, Alturas

14. Quartz Valley, Fort Jones

2.0 ABBREVIATIONS AND DEFINITIONS

ADC Area Diabetes Consultant AI/AN American Indian/Alaska Native CAC Clinical Applications Coordinator

CAN-DO California Area Native American Diabetes Organization CAO California Area Office CDE Certified Diabetes Educator CQI Continuous Quality Improvement CRS Clinical Reporting System DM Diabetes Mellitus DPP Diabetes Prevention Project GPRA Government Performance and Results Act HbA1c Hemoglobin A1c IHS Indian Health Service IPC Improving Patient Care IT Information Technology PA-C Physician Assistant-Certified RPMS Resource and Patient Management System SDPI Special Diabetes Program for Indians SOW Statement of Work Web Audit Diabetes Audit submitted via the internet to IHS

Annual Diabetes Outcomes Audit – Data entered during calendar year for diabetes care Best Practices – Indian Health Services approach to Quality Diabetes Care Diabetes Registry – A registry of patients served by the program and maintained through RPMS Pre-Diabetes – The condition that exists prior to diabetes Standards of Care – IHS evidence based standards of Quality Diabetes Care

3.0 OBJECTIVE

This Performance Based Work Statement (PBWS) is to provide 2 visits to the 14 California Indian Health clinic sites over the next 12 months, to optimize the health and wellness of California Area AI/AN people by improving diabetes outcomes, preventing diabetes, improving efficiency, coordination of services and increasing resource utilization via promotion of the Improving Patient Care (IPC) IHS initiative.

4.0 SCOPE

This PBWS describes the general requirements of the contractor under this agreement. The contractor will coordinate site visits with the Tribal/Urban Indian Health clinic site staff, specifically the Diabetes Coordinator, GPRA Coordinator, Executive Director and/or Medical Director when possible.

The Contractor will be responsible to provide technical assistance virtually, in person, and by phone to the above listed sites. This includes Case Management guidelines, healthcare systems improvement via IPC, SDPI grant development and compliance as well as program evaluation using the Diabetes Audit and GPRA reports as benchmarks/long-term goals.

Indian Health Service (IHS) utilizes the Resource and Patient Management System (RPMS) solely as its patient data base system. The Contractor will assist the Tribal/Urban Indian Health program sites using RPMS to provide the Annual Diabetes Outcomes Audit through the IHS Web Audit and produce Government Performance and Results Act (GPRA) reports using the Clinical Reporting System (CRS).

The Contractor will be responsible to report to the Area Diabetes Consultant (ADC), Helen Maldonado, PA-C, CDE and collaborate with other key personnel at the California Area Office

(CAO):

Chief Medical Officer; David Sprenger, MD GPRA Coordinator; Elaine Brinn IT Specialist/RPMS Training Coordinator; Toni Johnson Clinical Applications Coordinator (CAC); Steve Viramontes Contract Specialist; Michael Hodahkwen Tribal & Urban Project Officers; Various

Assist clinics in identifying patients with a diagnosis of pre-diabetes and establishing Pre- Diabetes Registers by 3/31/2012. Measures:

A. Number of clinics with a Pre-Diabetes Register by 3/31/2012.

B. Number of patients in Pre-Diabetes Registers 3/31/2012.

C. Number of clinics instituting evidence-based prevention programs (such as DPP) by

3/31/2012.

D. Number of programs adopting a clinical protocol for the management of Pre-Diabetes by the end of the grant period. Recommend the IHS Guidelines for Care of Adults with Pre-diabetes and/or the Metabolic Syndrome in Clinical Settings (April 2006).

Promote positive health outcomes for patients with diabetes by annual evaluation of the cumulative California Area Diabetes Audit data. Measure:

The percentage of California Area diabetes patients with improved results in at least 6 indicators by the end of the 2012 Diabetes Audit. Audit items targeted with 2010 audit results noted are:

HbA1c at goal, Blood Pressure at goal, Eye Exams, Diet Education, Exercise Education, and Depression Screening. Improvement targets are in the following Table:

Targeted Diabetes Audit Measures

Current (2010) percentage

Goal for Improvement Final Goal for 2012 Diabetes

Audit HbA1c at goal 42% 1% 43% Blood Pressure at goal 37% 1% 38% Eye Exams 56% 2% 58% Diet Education 69% 2% 71% Exercise Education 64% 2% 66% Depression Screening 69% 2% 71%

Continue to provide diabetes support to California tribal health care programs to improve patient care and outcomes. Measures:

A. On-site visits to 14 or tribal/urban programs and subsequent written reports by 3/31/2012.

Site visits to include: evaluation of existing diabetes program, clinic capacity, diabetes education, Diabetes Audit and GPRA results, CQI/data improvement efforts.

B. Bi-monthly CAN-DO (California Area Native American Diabetes Organization) conference calls to provide support and education on current diabetes topics and standards; facilitate sharing between tribal programs.

C. Submission of annual Diabetes Audit data by 35 or more Tribal health care programs for the 2012 audit year (calendar year 2011 January thru December).

Clinical Processes

1. Participate in a multi-disciplinary team, establish roles and responsibilities, set meeting schedule. Retain minutes and goals/plans on Area intra-net for all Team members to access.

2. Diabetes Contractor will conduct site visits to 14 California tribal/urban health care programs. Written reports will be retained on the CAO intra-net for easy access by CAO staff.

3. Develop plan for assisting clinics/programs in identification of pre-diabetes patients and establishing RPMS or other data system registers for these patients.

4. Develop questionnaire for clinic reporting of Pre-Diabetes Register data (# of patients included).

5. Develop plan to promote the IHS Guidelines for Care of Adults with Pre-diabetes and/or the Metabolic Syndrome in Clinical Settings.

6. Develop tool to evaluate clinic readiness to implement Diabetes Case Management activities.

7. Discuss CAO SDPI goals/objectives with Diabetes Coordinators on CAN-DO call and coordinate with their own SDPI goals.

8. Coordinate submission of 2012 Diabetes Audits to the WebAudit by 35 or more California clinics, review raw data for errors, work with clinics on corrections, create and distribute one-page, multi-year audit data comparison tables.

9. Provide technical support to tribal programs to maintain accurate Diabetes Registers.

10. Continue to promote and teach concepts of Diabetes Case Management to all tribal/urban health programs.

Community Partnering

1. Develop survey to collect data on diabetes prevention programs at tribal clinics and in tribal communities.

5.0 CONTRACTOR QUALIFICATIONS

The contractor performing this assistance to the programs shall be a licensed Registered Nurse, Physician Assistant, Physician or Registered Dietitian. The contractor shall have a minimum of

5 years experience working with Diabetes programs and a minimum of 3 years of experience with AI/AN programs. The Contractor shall have a working knowledge of the IHS initiative:

Improving Patient Care (IPC). The Contractor shall have advanced working knowledge of RPMS, this is essential. The Contractor is NOT required to have knowledge of other software programs used by health care programs if they are not using RPMS.

6.0 PERIOD OF PERFORMANCE

The period of performance for this agreement is one (1) year from time of award.

7.0 REPORTS, DATA, AND OTHER DELIVERABLES

7.1 Letter Report

The letter report will be a brief 1-2 page summary of a site visit or other task, based on an individual task item.

7.2 Site Visit Report

The site visit report must include:

A. Health program name, location, date B. Staff names and titles participating in site visit C. Purpose of Visit D. Organizational Overview E. Diabetes Program description and staffing list F. Diabetes Education

1. This section must state:

a. How group and/or individual education occurs on site,

b. The Name of the Diabetes Curriculum utilized,

c. All Activities included in the programs approach to education.

d. Diabetes prevention education efforts in their community

G. Diabetes Case Management

1. This section must state:

a. How the management of the patients identified with diabetes and/or pre-diabetes is handled in the program,

b. Description of the use of the programs diabetes audit data

c. Description of the Case Manager’s team meetings

d. Outreach efforts and coordination with medical staff and other departments within the organization.

H. Description of Clinical/Data Committees within organization I. Clinical Care Data Review

1.This section must state:

a. Status of the Government Performance and Results Act (GPRA) for previous year (July 1 – June 30) b Summary of discussion of the results with appropriate staff

c. Diabetes Outcomes Audit results d Summary of discussion of the results with appropriate staff

J. RPMS Usage

1. This section must state:

a. Status of all Diabetes Patients:

1) Total number on Diabetes Registry

2) Active (AI/AN & primary care at clinic)

3) Transient (primary medical care elsewhere)

4) Inactive (not seen in past 2 years)

5) Lost to Follow-up (status unknown)

6) Non IHS (non AI/AN)

7) Un-reviewed (require review & status designation)

8) Deceased

b. Pre-Diabetes Registry (if applicable)

c. Reports ran at time of visit

K. Status of the Health Programs SDPI grant/ Best Practice goals and objectives.

1. This section must state:

a. The Best Practice(s) selected for SDPI grant application

b. Following the format of the semi-annual report, status of objectives and activities for each Best Practice

c. Data used for programs self-evaluation of progress of goals, objectives and activities

d. During CAO Diabetes Contractor site visits to California tribal clinics and health programs, identify Diabetes Team members, frequency of meetings, and data improvement goals. Note these details in site visit reports sent to the ADC and clinic staff.

L. Summary of the visit M. Recommendations to the program

1. This section must state:

a. SDPI Best Practice focus

b. Use of data to measure goals and objective

8.0 ANTICIPATED WORK SITES

Please see attachment for a list of the health programs.

LAST UPDATED: 1/12/2011

American Indian Health & Services Scott Black, Director 4141 State Street, Ste. B-11 Santa Barbara, CA 93110-2829 Voice: (805) 681-7356 Fax: (805) 681-7358

Cabazon Band of Mission Indians Veronica Abell, Tribal Coordinator 84-245 Indio Springs Parkway Indio, CA 92203-3499 Voice: (760) 342-2593 Fax: (760) 347-7880

California Rural Indian Health Board, Inc.

James Crouch, Director (CRIHB) 4400 Auburn Blvd., 2nd floor Sacramento, CA 95841-4145 Voice: (916) 929-9761 Fax: (916) 929-7246

Central Valley Indian Health, Inc (CVIH) Chuck Fowler, Director 20 North Dewit Avenue Clovis, CA 93612-0311 Voice: (559) 299-2578 Fax: (559) 299-0245

Chapa-De Indian Health Program, Inc Lisa Davis, Director 11670 Atwood Road Auburn, CA 95603-9522 Voice: (530) 887-2800 Fax: (530) 887-2819

Bakersfield American Indian Health Project David Rambeau, Director/ Dan Tatum, Prog. Director

1617 30th Street Bakersfield, CA 93301-1907 Voice: (661) 327-4030 Fax: (661) 327-0145

Cold Springs Rancheria Charlene Cross, Tribal Administrator 32861 Sycamore Road, Ste. 100, POB 209

Tollhouse, CA 93667-9513 Voice: (559) 855-2451 Fax: (559) 855-8359

Colusa Indian Community Council Debbie Adamiak, Director 3710 Hwy 45, Ste. A Colusa, CA 95932-4026 Voice: (530) 458-5501 Fax: (530) 458-8660

Consolidated Tribal Health Project Inc.

Fredrick Rundlet, Director P.O. Box 387 Calpella, CA 95418-0387 Voice: (707) 485-5115 Fax (707) 485-7837

Coyote Valley Tribal Council Brad McDonald, Tribal Admin.

7751 North State Street, P.O. Box 39 Redwood Valley, CA 95470 -9663 Voice: (707) 485-8723 Fax: (707) 485-1247

Feather River Tribal Health Inc.

Maria Hunzeker, Director 2145 5th Ave Oroville, CA 95965-5870 Voice: (530) 534-5394 Fax: (530) 534-3820

Fresno American Indian Health Project, UAII David Rambeau, Director, Dan Tatum, Program Dir.

1535 E. Shaw Avenue, Suite 105 Fresno, CA 93710-8012 Voice: (559) 320-0490 Fax:

(559) 320-0494

Friendship House Assoc. of Amer. Inds.

Helen Waukazoo, Director 56 Julian Avenue San Francisco, CA 94103-3547 Voice: (415) 865-0964 Fax: (415) 865- 5428

Greenville Rancheria Margaret Alspaugh, Director 410 Main Street, P.O. Box 279 Greenville, CA 95947-0279 Voice: (530) 284-7990 Fax: (530) 284-6612

Guidiville Indian Rancheria Walter Gray III, Tribal Admin.

P.O. Box 339 Talmage, CA 95481-0339 Voice: (707) 462-3682 Fax: (707) 462-9183

Hoopa Valley Tribe (Kima:w) Mihail Soare, Acting Director 1200 Airport Road, P.O. Box 1288 Hoopa, CA 95546-1288 Voice: (530) 625-4261 Fax: (530) 625-4842

Hopland Band of Pomo Indians Gayle Zepeda, Director 3000 Shanel Road Hopland, CA 95449-9809 Voice: (707) 472-2100 Fax: (707) 472-2104

Indian Health Center of Santa Clara Valley Elizabeth Hunt, Director 1333 Meridian Avenue San Jose, CA 95125-5212 Voice: (408) 445-3400 Fax: (408) 448-1727

Indian Health Council, Inc.

Romelle Majel-McCauley, Director

P.O. Box 406 Pauma Valley, CA 92061-0406 Voice: (760) 749-1410 Fax: (760) 749-1564

Karuk Tribe of California Lessie Aubrey, Director 64236 2nd Avenue, P.O. Box 1016 Happy Camp, CA 96039-1016 Voice: (530) 493-1600 Fax: (530) 493-1660

Lake County Tribal Health Consortium Ashley Tuomi, Exec. Director 925 Bevins Court, P.O. Box 1950 Lakeport, CA 95453-1950 Voice: (707) 263-8382 Fax: (707) 263-0329

Lytton Rancheria Marisa Snow, Tribal Administrator 437 Aviation Blvd.

Santa Rosa, CA 95403-1069 Voice: (707) 575-5917 Fax: (707) 575-6974

M.A.C.T. Health Board, Inc. (CRIHB) Richard Chaffey, Director 52 South Main St., PO Box 939 Angels Camp, CA 95222 -0939 Voice: (209) 754-6262 Fax: (209) 736-1813

Strong Family Health Cntr (Modoc Indian Health)

Dave Boissineau, Director 1203 Oak Street Alturas, CA 96101-3225 Voice: (530) 233-4591 Fax: (530) 233-3055

Native American Health Center Martin Waukazoo, Director 1151 Harbor Bay Parkway, Suite 203 Alameda, CA 94502 -6533 Voice: (510) 747-3030 Fax: (510) 748-0116

Native Directions Inc.

Ramona Valadez, Director 13505 Union Road Manteca, CA 95336-9258 Voice: (209) 858-2421 Fax: (209) 858-4692

Northern Valley Indian Health Inder Wadhwa, Director 207 N. Butte Street Willows, CA 95988-2803 Voice: (530) 934-4641 Fax: (530) 934-2204

American Indian &Alaska Native Healthcare in

Hawaii Ke Alo Mamo Lisa Kaanoi, IH Coordinator 1505 Dillingham Blvd., Ste 205 Honolulu, HI 96817-4822 Voice: (808) 848-8000 Fax: (808) 848-

Pinoleville Band of Pomo Indians Lenora Steele, Tribal Admin.

500 Pinoleville Dr., Ste. B Ukiah, CA 95482-7121 Voice: (707) 463-1454 Fax: (707) 463-6601

Pit River Health Services, Inc.

Laura Kirk, Interim Director 36977 Park Avenue Burney, CA 96013-4067 Voice: (530) 335-5090 Fax: (530) 335-5241

LAST UPDATED: 1/12/2011

Quartz Valley Indian Reservation Arvada Nelson, Director 9024 Sniktaw Lane Fort Jones, CA 96032-9408 Voice: (530) 468-4470 Fax: (530) 468-4478

Redding Rancheria Indian Health Clinic Glen Hayward, Director 3184 Churn Creek Road Redding, CA 96002-2122 Voice: (530) 224-2700 Fax: (530) 224-2738

Riverside/San Bernardino County IHC Lin Killam, Director 11555 1/2 Potrero Road Banning, CA 92220 -6946 Voice: (951) 849-4761 Fax: (951) 849-5612

Round Valley Indian Health Center, Inc.

James Russ, Director Corner of Hwy 162 & Bigger Lane, PO Box 247

Covelo, CA 95428-0247 Voice: (707) 983-6404 Fax: (707) 983-6184

Sacramento Native American Health Center

Britta Guerrero, Director 2020 J Street Sacramento, CA 95814-3120 Voice: (916) 341-0575 Fax: (916) 341-

San Diego American Indian Health Cntr.

Joseph Bulfer, Chief Exec. Officer 2602 First Avenue, Suite 105 San Diego, CA 92103-6599 Voice:

(619) 234-0572 Fax:

(619) 234-0505

Santa Rosa Rancheria Chuck Fowler, Director 16835 Alkali Drive, Bldg M, PO Box 8 Lemoore, CA 93245-9463 Voice: (559) 924-1541 Fax: (559) 924-2197

Santa Ynez Band of Mission Indians Jesse Montoya, Director 90 Via Juana Lane Santa Ynez, CA 93460-9679 Voice: (805) 688-7070 Fax: (805) 686-2060

Scotts Valley Band of Pomo Indians Bennet Wright, Tribal Admin. 301 Industrial Avenue Lakeport, CA 95453 -5643 Voice:

(707) 263-4220 Fax: (707) 263-4345

Sherwood Valley Band of Pomo Indians Carmon Ochoa, Interim Tribal Admin.

190 Sherwood Hill Drive Willits, CA 95490-4666 Voice: (707) 459-9690 Fax: (707) 459- 6936

Shingle Springs Tribal Health Programs Beth Bodi, Director (CRIHB) 4140 Mother Lode Dr., Ste. 112, PO Box 1340 Shingle Springs, CA. 95682-1340 Voice: (530) 672-8059 Fax:

(530) 672-2111

Sierra Tribal Consortium Michael Roth, Director 610 West McKinley Ave.

Fresno, CA 93728-1425 Voice: (559) 445-2691 Fax: (559) 445-3125

Sonoma County Indian Health (CRIHB) Molin Malicay, CEO 144 Stony Point Road Santa Rosa, CA 95401-4122 Voice: (707) 521-4545 Fax: (707) 526-1016

Southern Indian Health Council, Inc.

Donna James, Director 4058 Willows Road Alpine, CA 91901-1668 Voice: (619) 445-1188 Fax: (619) 659-3144

Susanville Indian Rancheria Health Center Barbara Pierson, Director 795 Joaquin Street Susanville, CA 96130 -3628 Voice: (530) 257-2542 Fax: (530) 251-5208

Sycuan Band of Mission Indians Sal Falco, Admin. Director/Controller 5442 Sycuan Road El Cajon, CA 92019-1816 Voice: (619) 445-0707 Fax: (619) 445-9764

Table Mountain Rancheria Marilyn Benck, Director 23638 Sky Harbor Road Friant, CA 93626-9733 Voice: (559) 822-2587 Fax: (559) 822-2693

Toiyabe Indian Health Project David Lent, Interim Director 52 Tu Su Lane Bishop, CA 93514-8058 Voice: (760) 873-8464 Fax: (760) 873-3935

Tule River Indian Health Center, Inc.

Zahid Sheikh, Director 380 N. Res. Rd., P.O. Box 768 Porterville, CA 93258-0768 Voice: (559) 784-2316 Fax: (559) 791-2585

Tule River Tribal Council Ryan Garfield, Tribal Chairperson 340 N. Res Rd., P.O. Box 589 Porterville, CA 93258-0589 Voice: (559) 781-4271 Fax: (559) 781-4610

Tuolumne Me-Wuk Indian Health Center Frank Kearns, Director 18880 Cherry Valley Blvd Tuolumne, CA 95379-9506 Voice: (209) 928-5400 Fax: (209) 928-5412

United American Indian Involvement, Inc David Rambeau, Director 1125 West 6th Street, Suite 103 Los Angeles, CA 90017-1879 Voice: (213) 202-3970 Fax: (213) 202-3977

United Indian Health Services, Inc. (CRIHB) Jerome Simone, Director 1600 Weeot Way Arcata, CA 95521-4734 Voice: (707) 825-5000 Fax: (707) 825-6747

Warner Mountain Indian Health Project Lucinda Lame Bull, Acting Director (CRIHB) 132 Mee Thee-Uh Rd, P.O. Box 247 Fort Bidwell, CA 96112 -0247 Voice: (530) 279-6194 Fax: (530) 279-6288

Rolling Hills Clinic Michael Schaub, Executive Director Paskenta Band of Nomlaki Indians P.O.

Box 398 Orland, CA 95963-0398 Voice: (530) 865-2010 Fax: TBA