PWS_Grant_Consultant_2016-2017.pdf

PERFORMANCE WORK STATEMENT

DIABETES SDPI GRANT 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 SDPI Grant Consultant.

1.2 The Diabetes SDPI Grant 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 the diabetes program staff working in California tribal or urban healthcare centers. A person with a health occupations license (Registered Nurse, Licensed Vocational Nurse, Physician Assistant, Registered Dietitian) or nutrition education and training in this professional occupation would be qualified to fill the position. A person with working experience will bring the unique perspective of clinical experience to this position. In addition, this person should have considerable experience in successful grant writing and grant management as well as a strong ability to teach these skills to others. The work involves close coordination with the IHS/CAO, IHS/ DGM and DDTP and has responsibility for monitoring the programmatic aspects of the SDPI California grantee programs. In coordination with the DGM and DDTP exercises responsibility for assuring compliance with the terms and conditions by the grantee programs. The work also involves provision of technical programmatic expertise regarding diabetes prevention, education, and treatment to California SDPI grantee programs. The IHS provides the SDPI grant funds to potentially thirty-seven (37) California tribal and urban healthcare centers. The FY 2017 SDPI Application process is NOT Competitive and CAO and its contractors will be able to provide individualized assistance to the programs during the application process. This Contractor is allowed to , evaluate all California grant applications and provide each program feedback prior to submission of their continuation application. To continue to be eligible to receive the SDPI grant funds, these healthcare centers must:

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

1.2.2 Apply annually via the Federal GrantSolutions System to IHS for their

Continuation SDPI Community Directed grant or Grants.gov if the process becomes competitive;

1.2.3 Provide mid-year and annual reports via GrantSolutions, including Narrative and Federal Financial Statement - SF 425 and comply with all grant regulations;

1.2.4 Receive continuous training and technical assistance to provide optimized diabetes care;

1.2.5 Must manage grant funds within IHS grant guidelines and comply with the IHS Diabetes Best Practice templates.

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 DGM Division of Grants Management DM Diabetes Mellitus DP Diabetes Prevention Initiative GPRA Government Performance and Results Act HbA1c Hemoglobin A1c HH Healthy Heart Initiative IHS Indian Health Service IHS/CAO Indian Health Service/California Area Office IPC Improving Patient Care IT Information Technology ORC Objective Review Committee 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 Web Audit Diabetes Audit submitted via the internet to IHS

2.2 Area

A defined geographical region for Indian Health Service administrative purposes. There are 12 Areas in the IHS System. We are the California Area.

2.3 Annual Diabetes Outcomes Audit

Data entered during the previous 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 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 that are SDPI grantees during the period of performance. One on-site visit to at least 22 of the 37 sites will be provided to the programs during the period of performance. The goal of the IHS/CAO is to improve diabetes outcomes, prevent diabetes, and improve efficiency, coordination of services and increasing resource utilization via promotion of the Improving Patient Care (IPC) IHS Quality Improvement initiative and Patient Centered Medical Home models. The contractor will work collaboratively with the SPDI grantees and the IHS. The contractor is also responsible for the full range of programmatic technical assistance and grants management duties for the California Area region.

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 Hopland Band of Pomo Indians

5.2.16 Hoopa Valley Tribe (Kima:w)

5.2.17 Indian Health Council, Inc.

5.2.18 Karuk Tribe of California

5.2.19 Lake County Tribal Health Consortium

5.2.20 M. A. C. T. Health Board

5.2.21 Northern Valley Indian Health

5.2.22 Pit River Health Services, Inc.

5.2.23 Quartz Valley (Anav)

5.2.24 Redding Rancheria

5.2.25 Riverside-San Bernardino County Indian Health Inc.

5.2.26 Round Valley Indian Health Center

5.2.27 Santa Ynez 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 Toiyabe Indian Health Project

5.2.33 Tule River Indian Health Center, Inc.

5.2.34 Tuolumne Me-Wuk Indian Health Center

5.2.35 United Indian Health Services, Inc. (CRIHB)

5.2.36 Warner Mountain (CRIHB)

5.2.37 Wilton Tribe

5.3 Following a successful Continuation application and the Tribal/Urban program continues to be a grantee, the contractor will coordinate site visits with the Tribal and Urban Indian Health clinic staff; specifically, the Diabetes Coordinator, Grant Writer (if applicable) and/or Executive Director. The site visits may be coordinated with the Diabetes Education Consultant Contractor and report all activity to the ADC. During the site visit the Contractor will address current issues with the program’s SDPI grant; planning for the future, evaluating the current goals and objectives.

5.3.1 The Contractor will keep the grantees aware of their application deadlines, mid-year report deadlines and final report deadlines.

5.3.2 The Contractor will keep the grantees aware of their required trainings through

IHS/DDTP and the trainings offered by CAO.

5.3.3 The Contractor will keep the grantee’s SDPI focus on their choice of Best

Practice and target group.

5.3.4 The Contractor will maintain each grantee’s Required Key Measure (RKM) reports and provide assistance to the grantee if necessary.

5.3.5 The Contractor will provide assistance to the grantees with their Target Group, and use of the SDPI Outcomes System (SOS) to enter, check, and download their RKM data for their Target Group for their selected Diabetes Best Practice.

See Section 6.5 for the SDPI Community Directed Grant Program Hub

5.4 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. This tool will be submitted to the ADC prior to the Contractor’s first Site Visit for evaluation on these topics:

5.4.1 SMART format for grant objectives

5.4.2 Use of the Annual Diabetes Care and Outcomes Audit report to set goals

5.4.3 Use of the Required Key Measure for the Best Practice used in the program’s

SDPI application

5.5 The Contractor will coordinate with the IHS Division of Grants Management (DGM) regarding grant issues for tribal or urban diabetes programs.

5.5.1 Coordinates and monitors all aspects of the diabetes grant requirements within the

Tribal, and Urban Indian health programs and other diabetes related activities.

5.5.2 Provides technical assistance to program staff and grantees in the interpretation and application of grant regulations, policies and procedures.

5.5.3 Reviews all appropriate data to determine the adequacy and acceptability of applicants that have had no prior experience with federal grants.

5.5.4 Once the applicant is a successful grantee, the Contractor will conduct a cost analysis of the grantee budget request and justification to ensure that all costs are allowable, allocable, necessary, and reasonable.

5.5.5 Appraises the grantee of these requirements during the life of the grant and in the proper use of public funds.

5.5.6 Formulates the approach to satisfy program requirements.

5.6 Advises and assists the ADC in the development of program announcements and program guidance, etc.

5.6.1 This includes attending grant application review panel meetings and objective reviews in an advisory capacity or serving on an Objective Review Committee during a competitive grant application process.

5.6.2 Develops appropriate materials and participates in seminars, workshops, conferences, meetings, etc. for IHS grant applicants and/or grantees

5.7 Participates in grantee program site visits for the CAO. It is anticipated that at least two weeks per month will be spent on site/technical assistance visits.

5.7.1 Monitors the grants process and maintains close coordination with program officials to ensure that all required actions are executed by grantees in a timely manner after award.

5.7.2 In coordination with the Division of grants management, exercises responsibility for assuring compliance with terms of grants, negotiating with grantees to resolve problems of grant obligations and determining action(s) to be taken to ensure compliance with grant terms and obligations.

5.7.3 Reviews all progress, financial status, closeout, and other reports required by the terms and conditions of the grant and exercises responsibility for ensuring that such reports are properly processed.

5.7.4 Will provide appropriate training or referral to the appropriate resource to the grantee for grant applications via Grants.gov and Continuation grant applicationas and reports via the GrantSolutions System

5.7.5 Will provide the ADC with a site visit report following each one within 30 days

5.7.6 Will provide the ADC with a monthly report of work provided virtually, including hour spent on each program, meeting or training.

5.8 Coordination with the ADC and Diabetes Education Contractor is necessary to provide training on the Annual Diabetes Care and Outcomes Audit performed via Web Audit.

Every SDPI grantee is required to include their Annual Diabetes Audit to show improvements or declines in their SDPI Best Practice required key measure.

5.9 The CAO has 6 targeted activities as goals for the entire region and the contractor will assist in all, they are:

5.9.1 Update individual program Diabetes Audit multi-year tables

5.9.2 Continue CAN-DO conference calls at least quarterly

5.9.3 Diabetes contractors to continue on-site technical assistance

5.9.4 Coordinate the Annual Diabetes Day conference for California programs in May

5.9.5 Continue to provide information to programs on the new individualized goals for glycemic control and blood pressure

5.9.6 Continue focus on diabetes care management and assisting California programs in identifying at-risk clients (HbA1c>=9, Uncontrolled BP > 150/90, LDL > 100) and implementing patient-centered care plans

5.10 Bi-monthly (every other month) 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.

5.11 The contract shall provide the following processes:

5.11.1 Participate in at least 2 multi-disciplinary team meetings in the California Area Office. Fill the role as “Time Keeper or Recorder” during the following meetings:

5.11.1.1 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.

5.11.1.2 One meeting will be held via web conference

5.11.1.3 At least one four hours per month collaborating via phone or email with ADC and Diabetes Education Consultant

5.11.1.4 Participate in the CAO targeted activity goals

5.12 The contractor shall meet the following qualifications:

5.12.1 The contractor shall be a Licensed Vocational Nurse, Registered Nurse, Certified Diabetes Educator, Registered Dietitian, or Nutritionist.

5.12.2. Mastery of knowledge of theories, principles, practices and procedures in relation to health care delivery and consultation in American Indian tribal communities and Alaska native villages

5.12.3 Knowledge of grants management processes and procedures

5.12.4 Knowledge of state of the art methods/techniques/treatment modalities employed to prevent, manage and treat Type 2 diabetes and its complications in AI/AN patients.

5.12.5 Knowledge of social, cultural and economic factors of individuals, families, tribal communities and organizations as they apply to public health care in diabetes

5.12.6 Thorough knowledge of community resources in clinical and public health diabetes activities in relation to health care delivery in American Indian and Alaskan Native communities

5.12.7 Knowledge of materials, conferences, seminars and methods of updating diabetes knowledge and skills for diabetes and related chronic conditions of health professionals, paraprofessionals and community health workers

5.12.8 Knowledge of principles of consultation and skill in collaborative approaches working with multiple geopolitical groups and organizations

5.12.9 Ability to function as part of a multi-functional team that includes but is not limited to CAO professional staff, Area diabetes consultant, and other IHS departmental professionals on various projects and the ability to develop creative ideas and approaches and integrate these into programmatic developments

5.12.10 Ability to lead workgroups, committees and other task oriented groups with minimal guidance

5.13 The contractor shall demonstrate working knowledge of RPMS to be able to utilize the Diabetes Management System, iCare, and/or CRS which are sub-programs of the IHS software.

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

5.14 The contractor shall have working knowledge of:

5.14.1 GrantSolutions System and Grants.Gov

5.14.2 The IHS Diabetes Standards of Care

5.14.3 The IHS Diabetes Best Practices

5.14.4 Microsoft Power Point, Word, and Excel

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 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

6.5 SDPI Community Directed Grant Program Hub

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

SECTION 7 ATTACHMENT/TECHNICAL EXHIBIT LISTING

7.1 Performance Requirements Summary

7.2 Reports, Data and Other Deliverables

7.3 Directory of Health Programs

Technical Exhibit #1

7.1 Performance Requirements Summary

Performance-based Task Indicator Standard Quality Assurance

The Contractor shall conduct at least 22/37 site visits and provide continuous virtual technical assistance on SDPI grant development and management, deadlines and required trainings.

Section 5.1 – 5.4.4, 5.7-5.7.7 of PWS

Delivery of site visit report and monthly report

Submission of reminders and recorded attendance

Site visit report will be delivered within 45 days following the visit and/or end of month’s work

Assessment Tool will demonstrate an increase in knowledge

Attendance records submitted immediately following trainings

100% Inspection of the monthly reports

100% Inspection of site visit reports

100% Inspection of Assessment Tool

Random monitoring of site visit reviews by the Project Officer

Provide training to all SDPI Grantees on SMART objectives, use of DM Audit measures, and Required Key Measures of Best Practices

Section 5.4 – 5.4.3 of PWS

SDPI Grantee goals/objectives must be in SMART format

Use of DM Audit measures

Required Key Measure (RKM)

SMART format used

Assessment tool will show increase of knowledge and be submitted with site visit report within 45 days

100% Inspection of the SDPI Grant application

100% Inspection of the Assessment Tool

Coordination with ADC and Diabetes Education Consultant on CAO diabetes measures and quality improvement

Section 5.8, 5.9-5.9.6, 5.10.

5.11-5.11.4

Accessible and available to ADC and/or DM Ed.

Consultant within 8 hours max.

Participates in planning, coordination of CAO’s healthcare indicators, CAN-DO calls, and meetings

100% Attendance at all scheduled meetings with ADC and DM Education Consultant

Create an Assessment Tool

Section 5.4

Assessment of effectiveness of training

Assessment tool will be submitted to the ADC prior to first site visit

100% Inspection of the Assessment Tool results for each site visit

SDPI GRANT CONSULTANT 2016-2017

Technical Exhibit #2 Reports, Data, and Other Deliverables

Letter Report, which includes a brief 1-2 page summary of a site visit or other task, based on an individual task item.

Site Visit Report, which will include the following:

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

This section must state:

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

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

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

4. 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.

G. SDPI Required Key Measure This section must state:

1. The Required Key Measure

2. How the program is measuring their progress

3. Recommendations made to the program for improvement

4. Progress from previous year goals and objectives

H. Assessment tool This section must state:

1. Assess the increased knowledge provided during visit

2. Assess the program staff’s ability to plan, develop, and execute SMART format goals and objectives

3. Evaluate strengths and weaknesses in accomplishing their goals

I. Clinical Care Data Review This section must state:

1. Status of the Government Performance and Results Act (GPRA) for previous year

(July 1 – June 30)

2. Summary of discussion of the results with appropriate staff as it relates to SDPI grant program and healthcare improvement

3. Diabetes Outcomes Audit results (Audit year Jan. 1 – Dec. 31)

4. Summary of discussion of the results with appropriate staff and how it relates to their Required Key Measure

J. RPMS Usage

This section must state:

1. Status of all Diabetes Patients:

-Total number on Diabetes Registry -Active (AI/AN & primary care at clinic) -Transient (primary medical care elsewhere) -Inactive (not seen in past 2 years) -Lost to Follow-up (status unknown) -Non IHS (non AI/AN) -Un-reviewed (require review & status designation) -Deceased

2. Pre-Diabetes Registry (if applicable)

3. Reports ran at time of visit

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

This section must state:

1. SDPI Best Practice focus

2. Use of data to measure goals and objective

3. Readiness or interest in the quality improvement as it relates to their diabetes program