Performance Work Statement.pdf

Performance Work Statement Diabetes Case Manager/GPRA Consultant (14 Sites)

Table of Contents

Page

1. General 2

2. Definitions 2

3. Government Furnished Information and Property 4

4. Contractor Furnished Property 4

5. Specific Requirements 5

6. Applicable Publications 7

7. Attachment/Technical Exhibit Listing 7

PERFORMANCE WORK STATEMENT

DIABETES CASE MANAGER/GPRA CONSULTANT

SECTION 1 GENERAL INFORMATION

1.1 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.

1.2 There are 37 Tribal and Urban clinics in the California Area that receive a Special

Diabetes Program for Indians (SDPI) Community Directed grant.

1.3 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.

1.4 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.

1.5 Period of Performance: One year from time of award.

SECTION 2 DEFINITIONS

The language in this section is suggested for use only as appropriate and necessary.

2.1 Acronyms

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 Web Audit Diabetes Audit submitted via the internet to IHS

2.2 Area

A defined geographical region for Indian Health Service administrative purposes.

2.3 Annual Diabetes Outcomes Audit

Data entered during calendar year for diabetes care.

2.4 Best Practices

Indian Health Services approach to Quality Diabetes Care

2.5 Contracting Officer (CO)

A government employee authorized and warranted to issue contracts, and to make subsequent modification(s). The CO has full authority to make determinations on all changes and disputes regarding the contract.

2.6 Contractor

The individual awarded a legal binding contract to provide supplies and/or services.

2.7 Diabetes Registry

A registry of patients served by the program and maintained through RPMS

2.8 Defective Service

A service output that does not meet the standard of performance requirement specified in the contract for that service.

2.9 Inspector

A government employee authorized to provide verbal and written performance direction to the Contractor that the Contractor must follow without exception.

2.10 Performance Requirement

The point that divides acceptable and unacceptable performance of a task according to the PRS and the Inspection of Services Clause.

2.11 Performance Requirements Summary

A listing of the service outputs under the contract that are to be evaluated by the project officer on a regular basis, the surveillance methods to be sued for these outputs, and the performance requirements of the listed outputs.

2.12 Pre-Diabetes

The condition that exists prior to diabetes

2.13 Project Officer

A government representative appointed by the CAIHS to assist in the management of the contract. The project officer will work cooperatively under the direction of the contracting officer.

2.14 Quality Assurance

A planned and systematic pattern of all government actions necessary to provide confidence that adequate technical requirements are established; products and services conform to established technical requirements; and satisfactory performance is achieved. Quality assurance refers to actions by the government assurance functions for a contracted service.

2.15 Quality Control

Those actions taken by a contractor to control the production of outputs to ensure that they conform to the contract requirements.

2.16 Standards of Care

IHS evidence based standards of Quality Diabetes Care

SECITON 3 GOVERNMENT FURNISHED INFORMATION AND

PROPERTY

None

SECTION 4 CONTRACTOR FURNISHED PROPERTY

The contractor shall provide all equipment, material, and supplies necessary to provide Diabetes Management services described herein.

SECTION 5 SPECIFIC REQUIREMENTS

5.1 This Performance Work Statement (PWS) is to provide at least one visit to each of the 14

California Indian Health clinic sites during the period of performance, more if necessary based on the program needs, 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.

5.2. The contractor will provide services to the following programs:

Urban Programs

5.2.1 Sacramento Native American Health Center

5.2.2 Indian Health Center of Santa Clara Valley

Tribal Programs:

5.2.3 Indian Health Council

5.2.4 Karuk Tribe of California

5.2.5 Round Valley Indian Health Center

5.2.6 Pit River Health Services

5.2.7 Susanville Indian Rancheria Health Center

5.2.8 Shingle Springs Tribal Health Program

5.2.9 Sonoma County Indian Health

5.2.10 Consolidated Tribal Health Project

5.2.11 Feather River Tribal Health

5.2.12 Greenville Rancheria

5.2.13 Strong Family Health Center (formerly Modoc Indian Health)

5.2.14 Quartz Valley Indian Reservation

5.3 The contractor will coordinate site visits with the Tribal/Urban Indian Health clinic site staff, specifically the Diabetes Coordinator, GPRA Coordinator (if applicable), Executive Director and/or Medical Director when possible.

5.4 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.

5.5 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).

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

5.6.1 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 2011 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 (2011) percentage

Goal for Improvement

Projected Goal for 2012

Diabetes Audit HbA1c at goal 42% 2% 44% Blood Pressure at goal 38% 1% 39% Eye Exams 59% 3% 62% Foot Exams 74% 2% 76% LDL Cholesterol 48% 1% 49% Depression Screening 74% 1% 75%

5.7 Continue to provide diabetes support to California tribal health care programs to improve patient care and outcomes. This task will include the following measures:

5.7.1 On-site visits to 14 tribal/urban programs and subsequent written reports by the end of the period of performance. Site visits to include: evaluation of existing diabetes program, clinic capacity, diabetes education, Diabetes Audit and GPRA results, Continuous Quality Improvement (CQI)/data improvement efforts.

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

5.7.3 Submission of annual Diabetes Audit data by the 14 Tribal health care programs in this contract for the 2013 audit year (calendar year 2012 January thru December).

5.8 The contract shall provide the following clinical processes:

5.8.1 Participate in a multi-disciplinary team in the California Area Office. Retain minutes and goals/plans pertaining to the Area-wide approaches discussed in the bi-annual meetings.

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

5.8.3 Participate in training sessions provided from the CAO to the Health Programs.

5.9 The contractor shall provide community partnering, by developing a survey to collect data on diabetes prevention programs at tribal clinics and in tribal communities.

5.10 The contractor shall meet the following qualifications: The contractor shall be a licensed

Registered Nurse, Physician Assistant, Physician or Registered Dietitian. The contractor shall have a minimum of 5 years of 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. The contractor is not required to have knowledge of other software programs used by health care programs if they are not using RPMS.

SECTION 6 APPLICABLE PUBLICATIONS

IHS Guidelines for Care of Adults with Pre-diabetes and/or the Metabolic Syndrome in Clinical Settings (provided as technical exhibit #4)

SECTION 7 ATTACHMENT/TECHNICAL EXHIBIT LISTING

7.1 Performance Requirements Summary

7.2 Reports, Data and Other Deliverables

7.3 Directory of Health Programs

7.4 IHS Guidelines for Care of Adults with Pre-diabetes and/or the Metabolic Syndrome in

Clinical Settings