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.