PWS_DIABETES_EDUCATION.pdf

PERFORMANCE WORK STATEMENT

DIABETES EDUCATION PROFESSIONAL CONSULTANT

SECTION 1. GENERAL INFORMATION

1.1 Through the Special Diabetes Program for Indians (SDPI), the Indian Health

Service/California Area Office (IHS/CAO) is authorized to contract for a Diabetes Education Professional Consultant.

1.2 The Diabetes Education Professional Consultant is a person with current knowledge and considerable experience that is acceptable by medical standards of practice. This Consultant is to be a reliable resource to other medical providers and health educators working in California tribal or urban healthcare centers. The Indian Health Service (IHS) provides the SDPI grant funds to thirty-seven (37) tribal and urban healthcare centers. To continue to be eligible to receive the SDPI grant funds, these healthcare centers must:

1.2.1 Create and maintain a current diabetes registry of their patients with a Diabetes diagnosis

1.2.2 Perform and submit an Annual Diabetes Care and Outcomes Audit to continue their eligibility for the SDPI grant

1.2.3 Concentrate effort on at least one of the twenty IHS Diabetes Best Practices

1.2.4 Follow the IHS Standards of Diabetes Care

1.2.5 Receive continuous training and technical assistance to provide optimized diabetes care

1.3 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 CAO-ADC California Area Office Area Diabetes Consultant CDE Certified Diabetes Educator CQI Continuous Quality Improvement CRS Clinical Reporting System DDTP Division of Diabetes Treatment and Prevention DM Diabetes Mellitus

DP Diabetes Prevention Initiative GPRA Government Performance and Results Act HbA1c Hemoglobin A1c HH Healthy Heart Initiative IHS Indian Health Service IPC Improving Patient Care IT Information Technology PA Physician Assistant PCMH Patient Centered Medical Home QI Quality Improvement Q-Man Query Utility Manager RPMS Resource and Patient Management System SDPI Special Diabetes Program for Indians TA Technical Assistance 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 the 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 used for these outputs, and the performance requirements of the listed outputs.

2.12 Pre-Diabetes

The metabolic condition that exists prior to diabetes

2.13 Project Officer

A government representative appointed by the IHS/CAO 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 virtual technical assistance to each of the 37 California Indian Health clinic sites during the period of performance. On-site visits will be provided to the programs requiring increased assistance as determined by the Contractor and CAO-ADC. The goal of the IHS/CAO is to improve diabetes outcomes, prevent diabetes, improve efficiency, coordination of services and increasing resource utilization via promotion of the Improving Patient Care (IPC) IHS initiative and Patient Centered Medical Home models.

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

Urban Programs

5.2.1 American Indian Health and Services Corp. (Santa Barbara)

5.2.2 Bakersfield American Indian Health Project (Bakersfield)

5.2.3 Fresno American Indian Health Project (Fresno)

5.2.4 Native American Health Center (Oakland)

5.2.5 San Diego American Indian Health Center (San Diego)

5.2.6 United American Indian Involvement, Inc. (Los Angeles)

5.2.7 Indian Health Center of Santa Clara Valley (San Jose)

5.2.8 Sacramento Native American Health Center (Sacramento)

Tribal Programs:

5.2.9 Central Valley Indian Health Center

5.2.10 Chapa-De Indian Health Program, Inc.

5.2.11 Colusa Indian Community Council

5.2.12 Consolidated Tribal Health Project, Inc.

5.2.13 Feather River Tribal Health, Inc.

5.2.14 Greenville Rancheria

5.2.15 Hoopa Valley Tribe (Kima:w)

5.2.16 Indian Health Council, Inc.

5.2.17 Karuk Tribe of California

5.2.18 Lake County Tribal Health Consortium

5.2.19 M. A. C. T. Health Board (CRIHB)

5.2.20 Northern Valley Indian Health

5.2.21 Pit River Health Services, Inc.

5.2.22 Quartz Valley Indian Reservation

5.2.23 Redding Rancheria

5.2.24 Riverside-San Bernardino County Indian Health Inc.

5.2.25 Round Valley Indian Health Center

5.2.26 Santa Ynez Tribal Health

5.2.27 Shingle Springs Tribal Health

5.2.28 Sonoma County Indian Health Project, Inc. (CRIHB)

5.2.29 Southern Indian Health, Inc.

5.2.30 Strong Family Health Center (Modoc Indian Health)

5.2.31 Susanville Indian Rancheria Health Center (Lassen Indian Health Center)

5.2.32 Table Mountain Rancheria

5.2.33 Toiyabe Indian Health Project

5.2.34 Tule River Indian Health Center, Inc.

5.2.35 Tuolumne Me-Wuk Indian Health Center

5.2.36 United Indian Health Services, Inc. (CRIHB)

5.2.37 Warner Mountain (CRIHB)

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

5.4 The Contractor will be responsible to provide technical assistance through web conferences, in person, and by phone to the above listed sites.

• This includes Diabetes Case Management

• Diabetes program management

• Healthcare systems improvement and Quality Improvement

• Program evaluation using the Diabetes Audit and GPRA reports as Quality

Assurance benchmarks

• Provide an assessment tool to evaluate effectiveness of TA

5.5 IHS utilizes the Resource and Patient Management System (RPMS) solely as its patient data base system. The Contractor must be able to provide TA to the diabetes program coordinator and/or designee in the following tasks using the RPMS User Guide:

• Reports using the Clinical Reporting System (CRS)

• Navigate the Diabetes Management System (DMS) Package

• Create all reports in the DMS package

• Generate IHS “Annual Diabetes Care & Outcomes Audit” via the Web Audit

• Ability to correct errors in data entry

• Provide an assessment tool to evaluate effectiveness of TA

• The Contractor is NOTexpected to have expert knowledge on other soft ware

Electronic Medical Record Systems

5.6 The Contractor will develop an assessment tool to evaluate the understanding of the individuals he/she is providing in-depth training to during a site visit on these topics:

• Diabetes case management, quality improvement, and program management

• RPMS – DMS data entry and report generation

• Diabetes audit

5.7 Assist the Diabetes Program Coordinators in promoting positive health outcomes for their population of patients with diabetes. Sourcing Diabetes Case Management and performing evaluation by using the cumulative California Area Diabetes Audit data.

5.7.1 Demonstrate and monitor the percentage of California Area diabetes patients with improved results in at least 6 indicators by the end of the 2014 Diabetes Audit.

Audit items targeted with 2013 audit results noted are the “ABCs” of Diabetes:

HbA1c at goal, Blood Pressure at goal, LDL Cholesterol at goal; as well as Eye Exams, Foot Exams, and Depression Screening at goals. Improvement targets are in the following Table:

Targeted Diabetes Audit Measures

Current (2013) percentage

Goal for Improvement

Projected Goal for 2013 Diabetes

Audit HbA1c at goal 39% 0% Maintain 39% Blood Pressure at goal 36% 0% Maintain 36% LDL Cholesterol at goal

48% 0% Maintain 48%

Foot Exams 69% 1% 70% Eye Exams 54% 1% 55% Depression Screening 84% 1% 85%

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

5.8.1 On-site visits to at least 20 out of 37 tribal/urban programs and subsequent written reports within 45 days of the visit. Site visits to include: evaluation of the existing diabetes program, clinic capacity, diabetes education, Diabetes Audit and GPRA results with a focus on the above Targeted Diabetes Audit Measures, and over-all quality improvement process measures when applicable.

5.8.2 At least Quarterly 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.

5.8.3 Provide oversight of the Web Audit submission of the Annual Diabetes Care and

Outcomes Audit by all 37 Tribal/Urban health care programs for the 2015 audit year (calendar year 2014 January thru December).

5.8.4 Create a year-by-year cumulative Diabetes Audit report for all of the California

Area using aggregated data based on the final audit data submitted into Web Audit.

5.9 The Contractor shall provide the following processes:

5.9.1 Participate in a multi-disciplinary team in the California Area Office. Fill the role as “Recorder” to write the meeting minutes and goals/plans pertaining to the Area-wide approaches discussed in the following meetings.

5.9.1.1 One meeting will be held at the IHS CAO located at 650 Capitol

Mall, Suite 7-100, Sacramento, CA 95814. The contractor is expected to attend this meeting. All travel costs shall be included in the contractor total price.

5.9.1.2 One meeting will be held via webconference.

5.9.2 Promote and teach concepts of Diabetes Case Management to all tribal/urban health programs with basic evaluation of the Diabetes Program Coordinator’s capacity to be reported to the CAO-ADC in the monthly reports.

5.9.3 Participate via teleconference on training sessions provided from the CAO to the

Health Programs and email reminders to the California programs of the DDTP Required Training webinars.

5.9.4 Participate in the development and writing of the California Area Office SDPI grant application providing the Best Practice: Systems of Care.

5.10 The contractor shall provide a minimum of four hours collaborative work per month with the Grants Specialist Contractor and ADC

5.11 The contractor shall meet the following qualifications:

5.11.1 The contractor shall be a licensed Registered Nurse, Registered Dietitian, Physician Assistant, or Physician.

5.11.2 The contractor shall satisfactorily demonstrate knowledge of working with Diabetes programs.

5.11.3 The contractor shall satisfactorily demonstrate knowledge of working with AI/AN programs.

5.11.4 The contractor shall satisfactorily demonstrate knowledge of the IHS Quality Improvement initiative: Improving Patient Care (IPC).

5.11.5 The contractor shall satisfactorily demonstrate advanced working knowledge of

RPMS.

5.11.5.1 The contractor is not required to have knowledge of other software programs used by health care programs if they are not using

RPMS.

5.11.6 The contractor shall have advanced working knowledge of:

5.11.6.1 The IHS Diabetes Standards of Care

5.11.6.2 The IHS Diabetes Best Practices

5.11.6.3 The diabetes education curriculum “Balancing Your Life and

Diabetes”

SECTION 6 APPLICABLE PUBLICATIONS

6.1 AADE Guidelines for the Practice of Diabetes Self-Management Education and Training

(DSME/T) at:

http://www.diabeteseducator.org/DiabetesEducation/position/Practice_Guidelines.html

6.2 AADE7 System Self-Care

http://www.diabeteseducator.org/ProfessionalResources/AADE7/A7S.html

6.3 IHS Diabetes Best Practices:

http://www.ihs.gov/MedicalPrograms/Diabetes/index.cfm?module=toolsBestPractices

6.4 IHS Balancing Your Life and Diabetes, available on the IHS.gov website at:

http://www.ihs.gov/MedicalPrograms/Diabetes/RESOURCES/Catalog/index.cfm?modul e=productList&productNameApprox=Balancing%20Your%20Life%20and%20Diabetes

6.5 Standards of Care and Clinical Practice Recommendations: Type 2 Diabetes/ Diagnosis of Type 2 Diabetes and Prediabetes:

http://www.ihs.gov/MedicalPrograms/Diabetes/index.cfm?module=SOCDiagnosisDM http://www.diabeteseducator.org/DiabetesEducation/position/Practice_Guidelines.html http://www.diabeteseducator.org/ProfessionalResources/AADE7/A7S.html http://www.ihs.gov/MedicalPrograms/Diabetes/index.cfm?module=toolsBestPractices http://www.ihs.gov/MedicalPrograms/Diabetes/RESOURCES/Catalog/index.cfm?module=productList&productNameApprox=Balancing%20Your%20Life%20and%20Diabetes http://www.ihs.gov/MedicalPrograms/Diabetes/RESOURCES/Catalog/index.cfm?module=productList&productNameApprox=Balancing%20Your%20Life%20and%20Diabetes http://www.ihs.gov/MedicalPrograms/Diabetes/index.cfm?module=SOCDiagnosisDM

SECTION 7 ATTACHMENT/TECHNICAL EXHIBIT LISTING

7.1 Performance Requirements Summary

7.2 Reports, Data and Other Deliverables

7.3 Directory of Health Programs