PWS_Diabetes_Education_2018-2019.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 the diabetes health educators and other medical providers working in California tribal or urban healthcare centers. To be qualified to fill the consultant position a current health occupations license or registration (such as Registered Nurse, Physician Assistant, and Registered Dietitian) is required, along with experience in diabetes care and education, knowledge of federally funded tribal and urban Indian healthcare clinics and considerable proficiency in providing diabetes care management and evaluation of the diabetes programs. As well as a demonstrated ability to teach these skills to others to support improving diabetes outcomes, prevent diabetes, improve efficiency, coordination of services and increasing resource utilization.

The contract involves close coordination with the IHS/CAO, IHS/ DGM and DDTP and has responsibility for monitoring the programmatic aspects diabetes education and diabetes clinical care among California Tribal and urban Indian healthcare centers. In coordination with the IHS/CAO and DDTP exercises responsibility for evaluation of the healthcare centers diabetes programs capacities and in sustaining compliance with the terms and conditions by the grant program. 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 CAO and its contractors will be able to provide individualized assistance to the tribal and urban Indian healthcare programs during the application process. The Contractor will evaluate capacity of grantees and provide program feedback that can assist in strengthening submission of their continuation application. To continue to be eligible to receive the SDPI grant funds, these healthcare centers must:

1.2.1 Successfully apply annually via the Federal GrantSolutions System to IHS for their Continuation SDPI Community Directed grant or Grants.gov if the process becomes competitive Perform and submit an Annual Diabetes Care and Outcomes Audit to continue their eligibility for the SDPI grant

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

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

1.2.4 Concentrate grant effort on at least one of the IHS Diabetes Best Practices

1.2.5 Follow the IHS Diabetes Standards of Care

1.2.6 Participate in, and receive continuous training and technical assistance provided by IHS/DDTP to optimize diabetes care, to include California Area Native American Diabetes Organization (CAN-DO) conference calls that provide support and education on current diabetes topics and standards; facilitate sharing between tribal programs.

1.2.7. Provide mid-year and annual reports via GrantSolutions, including Narrative and Create and maintain a current diabetes registry of their patients with a Diabetes diagnosis Federal Financial Statement - SF 425 and comply with all grant regulations

1.2.8 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.

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 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 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. There are 12 Areas in the IHS System, with California Area one of the 12 Areas.

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 or other software.

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 39 California Indian Health clinic sites during the period of performance (37 SDPI funded sites currently and 2 non-funded sites with diabetes programs). On-site visits will be provided to the programs requiring increased assistance as determined by the Contractor and CAO-ADC. Provide one on-site visit to at least 11 of the Tribal or urban Indian healthcare centers diabetes programs as required during the period of performance, and broader in scope as outlined in section 5.3. The goal of the IHS/CAO is to improve diabetes outcomes, prevent diabetes, and improve efficiency, coordination of services and increasing resource utilization. This may include 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 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. (CRIHB)

5.2.23 Quartz Valley Indian Reservation, ANAV (CRIHB)

5.2.24 Redding Rancheria

5.2.25 Riverside-San Bernardino County Indian Health Inc.

5.2.26 Rolling Hills Clinic (Corning)

5.2.27 Round Valley Indian Health Center

5.2.28 Santa Ynez Tribal Health

5.2.29 Shingle Springs Tribal Health

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

5.2.31 Southern Indian Health, Inc.

5.2.32 Strong Family Health Center (Modoc Indian Health)

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

5.2.34 Table Mountain Rancheria

5.2.35 Toiyabe Indian Health Project

5.2.36 Tule River Indian Health Center, Inc.

5.2.37 Tuolumne Me-Wuk Indian Health Center

5.2.38 United Indian Health Services, Inc. (CRIHB)

5.2.39 Warner Mountain (CRIHB)

5.2.40 Wilton Rancheria

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. The contractor will coordinate site visits following a successful continuation grant application, when the Tribal and urban Indian programs continues to be a grantee. Site visits will be coordinated with the Tribal and Urban Indian Health clinic staff; specifically, the Diabetes Coordinator, Grant Writer (if applicable), GPRA Coordinator (if applicable), Medical Director 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.

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

5.4.1 This includes Diabetes Case Management

5.4.2 Diabetes program management

5.4.3 Healthcare systems improvement and Quality Improvement

5.4.4 Program evaluation using the Diabetes Audit and GPRA reports as Quality Assurance benchmarks

5.4.5 Provide an assessment tool to evaluate effectiveness of TA

5.5 The IHS Resource and Patient Management System (RPMS) is utilized solely by IHS as its patient data base system. The Contractor must be able to provide TA to the Tribal or urban Indian healthcare center’s diabetes program coordinator and/or designee in the following tasks using the RPMS User Guide:

5.5.1 Reports using the Clinical Reporting System (CRS)

5.5.2 Navigate the Diabetes Management System (DMS) Package

5.5.3 Create all reports in the DMS package

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

5.5.5 Ability to correct errors in data entry

5.5.6 Provide an assessment tool to evaluate effectiveness of TA

5.5.7 The Contractor is NOT expected 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:

5.6.1 Diabetes case management, quality improvement, and program management

5.6.2 RPMS – DMS data entry and report generation

5.6.3 Diabetes audit

5.7 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 at least 11 out of 39 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, IHS Diabetes Care and Outcomes Audit and GPRA results with a focus on the above Targeted Diabetes Audit Measures, and over-all quality improvement process measures when applicable.

5.7.2 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.

5.7.3 Provide oversight of the Web Audit submission of the Annual Diabetes Care and Outcomes Audit by all Tribal/Urban healthcare centers for the 2019 audit year (calendar year January thru December).

5.7.4 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.

5.7.5 The Contractor will assist in planning, coordinating, and attending the Annual Diabetes Day and Best Practices Medical Conference in Sacramento May 2019.

5.7.6 The Contractor will attend the annual IHS National Diabetes Conference September 2017.

5.8 Assist the Diabetes Program Coordinators in promoting positive health outcomes for their population of patients with diabetes. Sourcing IHS Diabetes Standards of Care, Diabetes Case Management and performing evaluation by using the cumulative California Area Diabetes Audit data. Coordination with the CAO, ADC and Diabetes SDPI Grant 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. Assist the CAO with the following 6 targeted activities, set as goals for the entire region:

5.8.1 Update individual program Diabetes Audit multi-year tables

5.8.2 Continue CAN-DO conference calls at least quarterly

5.8.3 Diabetes contractors to continue on-site technical assistance

5.8.4 Annual Diabetes Day for California programs in May

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

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

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 or the role as “Time Keeper” to keep the meeting on time.

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 web-conference.

5.9.1.3 At least four hours per month collaborating via phone or email with

CAO,

ADC and Diabetes SDPI Grant Consultant

5.9.1.4 Participate in the CAO targeted activity goals

5.9.1.5 Attend the Annual National IHS Diabetes Conference. All travel costs shall be included in the contract total price

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 The contractor shall provide a minimum of two hours collaborative work per month with the Grants Consultant and ADC

5.10 The contractor shall meet the following qualifications:

5.10.1 The contractor shall be a licensed Registered Nurse, Registered Dietitian, Physician Assistant, or Physician, and maintain the distinction of being a Certified Diabetes Educator (CDE)

5.10.2 The contractor shall satisfactorily demonstrate expert level knowledge of working with Diabetes programs.

5.10.3 The contractor shall satisfactorily demonstrate knowledge of working with

AI/AN

programs.

5.10.4 The contractor shall satisfactorily demonstrate knowledge of the IHS Quality

Improvement initiative: Improving Patient Care (IPC).

5.10.5 The contractor shall satisfactorily demonstrate advanced working knowledge of

RPMS the IHS Resource and Patient Management System software.

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

5.10.6 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”

5.11 The contractor shall demonstrate working knowledge of RPMS to be able to utilize the

Diabetes Management System, iCare, and/or CRS that are sub-programs of the IHS software.

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

5.12 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.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

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?modu l e=productList&productNameApprox=Balancing%20Your%20Life%20and%20Diabete s

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

SECTION 7 ATTACHMENT/TECHNICAL EXHIBIT LISTING

7.1 Performance Requirements Summary

7.2 Reports, Data and Other Deliverables

7.3 Directory of Health Programs

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/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