190727 Application for Response TB Outpatient Services~1.docx

The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health 250 Washington Street, Boston, MA 02108-4619 Rev 8

APPLICATION RESPONSE FORM, INSTRUCTIONS, AND CHECKLIST

For use with the M03/MM3 RFR

General Instructions:

1. See the RFR and COMMBUYS posting for complete procurement specifications.

2. All responses are to be submitted using the online submission tools available to Vendors registered in COMMBUYS. There is no charge to register in COMMBUYS. To Register go to www.COMMBUYS.com and click on the “Register” link on the front page.

Bidders are solely responsible to monitor COMMBUYS for Bid amendments, if any. Bidders may monitor the record by frequently checking the Amendment Section on the Summary screen for the BID in COMMBUYS.

3. All Bidders are advised to allow adequate time for submission by considering potential online submission impediments like Internet traffic, Internet connection speed, file size, and file volume. DPH is not responsible for delays encountered by Bidders or their agents, or for a Bidder’s local hardware failures, such as computers or related networks, associated with bid compilation or submission. Bids submitted via COMMBUYS are time stamped by the COMMBUYS system clock which is considered the official time of record.

Formatting Instructions:

This document was prepared using Microsoft Word’s forms feature. Complete the form on your computer using Microsoft Word.

1. Save this document file to your computer.

2. Enter your responses in the text box, moving between the text boxes using the tab key on your keyboard.

3. Responses to check boxes are made by clicking once on the check box. To remove the X from a check box, click on the check box again.

4. Text responses are limited to a maximum number of characters and the limits are noted in each question. Once the maximum character limit is reached, MS Word will not allow more than this limit. Please note that a space is counted as a character, and using the enter key to begin a new line in a response is also counted as a character. It is not recommended that applicants insert graphics into the responses. Spell-check does not work in text boxes.

5. Those with visual impairments may use an electronic text reader by unlocking the Application Response Form.

RFR #______

APPLICATION RESPONSE COVER PAGE

Make this the first page of your proposal.

RFR TITLE Tuberculosis Outpatient Services

RFR # 190727

Organization Organization Name: [ ]

Address:

City: [ ] State: [ ] Zip: [ ]

Vendor Code: [ ]

CEO (Chief Executive Officer) First Name: [ ] Last Name: [ ]

FEIN: [ ]

Contact Person First Name: [ ] Last Name: [ ]

Title: [ ]

Telephone: ( ) - FAX: ( ) -

E-Mail: [ ]

Contact Person Address (if different):

City: [ ] State: [ ] Zip: [ ]

Organization Information

Is your agency pre-qualified to conduct business with the Commonwealth? |_| Yes |_| No

If so, which Massachusetts Department is your Principal Purchasing Agent (PPA): [ ]

Location of Proposed Service Program Name: [ ]

Program Address:

City: [ ] State: [ ] Zip: [ ]

RFR #190727

A note about the text boxes: Text input is limited to a maximum number of characters. MS Word will not allow more than this limit. Spaces, commas, line breaks, etc. are counted as characters. The spell-check feature does not work in a text box.

QUESTIONS FOR RESPONSE

Enter your response in the text boxes using Microsoft Word.

1. Provide an abstract of your proposal that includes:

a. Agency mission;

b. Services to be provided;

c. Staffing;

d. Geographic area to be served.

Upload the agency mission statement and organization chart showing the location of the proposed service within the agency to COMMBUYS.

Enter text here; text limit 1,875 characters (approximately 300 words)

|_| Most recent mission statement uploaded to COMMBUYS.

|X| Organization Chart uploaded to COMMBUYS.

2. Briefly describe your expertise and experience in providing tuberculosis diagnosis, treatment and care.

Enter text here; text limit 1,250 characters (approximately 200 words)

3. Complete and upload the Proposed Staffing Table with names, titles and functional roles for key staff associated with the proposed TB Outpatient Services. In addition to the clinical staff, include lead staff for administration/contract management and fiscal operations. Submit Curricula Vitae for key clinical staff.

|X| Proposed Staffing Table uploaded to COMMBUYS.

4. Complete and upload the Program Staff Demographics Table to COMMBUYS. Describe the client [patient] populations served by your agency and/or clinical program/service (e.g., TB outpatient service, infectious disease outpatient service, or pulmonary outpatient services). Describe the demographics of your staff, and discuss strategies for delivering culturally competent and linguistically appropriate services to the population served. For assistance in developing strategies to provide culturally and linguistically appropriate standards of care, please see the Cultural and Linguistic Appropriate Services Standards and Guidelines attachment available at the COMMBUYS Bid Attachment Section.

Enter text here; text limit 2,500 characters (approximately 400 words)

|_| Program Staff Demographics Table uploaded to COMMBUYS.

5. Outline the proposed tuberculosis outpatient services, including:

a. The processes to:

i. Receive and prioritize referrals

ii. Schedule appointments

iii. Register insured and uninsured individuals in need of TB outpatient services

iv. Assure that access to services is not denied or delayed for uninsured individuals.

b. The service model, detailing where and how medical services, laboratory and radiology will be delivered (on-site or through referral networks) to provide tuberculosis diagnosis, care and treatment. Consider the diagnostic spectrum, and include details for individuals who are symptomatic and potentially infectious.

c. Communications with referring providers, including mechanisms by which communications will occur.

d. The plan to support engagement and retention of patients treated in tuberculosis services.

e. Your capacity for TB outpatient services, described in number of new and continuing patient appointments per week or month.

Enter text here; text limit 5,000 characters (approximately 800 words)

6. Provide information about your electronic health record/electronic medical record (EHR/EMR) system, including the following:

a. Name and version of the EHR/EMR system:

Is this an enterprise version (i.e., centrally hosted and used by multiple sites)?

|_| Yes |_| No

Is a change in the EMR vendor planned within the next 1-3 years?

|_| Yes |_| No

b. Does the EHR/EMR enable your facility to share individual patient records with other facilities?

|_| Yes |_| No

If yes, provide the names of the facilities or system:

If yes, enter text here; text limit 625 characters (approximately 100 words)

b. Does your agency plan to modify your EHR/EMR (e.g., to add clinical prompts to improve linkage with services) |_| Yes |_| No

c. Does your facility have the capacity to extract structured data fields from the EMR in a format that could be securely transmitted to MDPH?

|_|Yes |_| No

d. How likely is it that your facility would participate in the MDPH ESP initiative for public health data reporting?

|_| Already participating |_| Implementation in progress |_| More information required / Would discuss with MDPH |_| Other strategy for data transfer in place/proposed [specify in text box]:

If "Other", enter text here; text limit 625 characters (approximately 100 words)

7. Identify the outpatient pharmacy from which patients being treated for tuberculosis will receive their tuberculosis medications.

|_| Facility [applicant] out-patient pharmacy |_| Other pharmacy [specify in text box]:

If "Other", enter text here; text limit 625 characters (approximately 100 words)

8. Complete and attach the Levels of Cooperative Activities Table (located in the COMMBUYS Bid Attachment Section) to identify medical, clinical, and other resources that the agency will coordinate access to for individuals served, via referral, linkage, and collaboration.

|_| Levels of Cooperative Activities Table uploaded to COMMBUYS.

9. Name a coalition that that you plan to participate in and describe how this participation will enhance the work of the proposed program. Participation in a coalition is a requirement of DPH funding. To find coalitions in your area visit http://www.hriainstitute.org/coalitions.

Enter text here; text limit 2,500 characters

10. Upload the agency’s most recently submitted Supplier Diversity Plan Form for POS (“SDP Plan Form for POS”) to signify to the Procurement Management Team that a form has been submitted. Bidders that do not currently hold POS contracts with Commonwealth Departments, Bidders that are exempt from filing a UFR or Bidders who have not yet submitted a SDP Plan Form for POS with their most recent UFR are required to complete the Form (located in the COMMBUYS Bid Attachment Section) and include it with their proposal.

|_| Copy of SDP plan form is uploaded to COMMBUYS (original was submitted with UFR) or |_| Original SDP plan form is uploaded to COMMBUYS.

11. If the proposal being submitted contains subcontracts, name the proposed subcontractors. Describe how the subcontracts will function, including descriptions of responsible parties and structures for operation and accountability. All subcontracts are subject to DPH approval. If you are proposing to use subcontractors, complete the Direct Care Proposed Subcontractor Identification List, found in the COMMBUYS Bid Attachment Section. (text input limit 2,500 characters, approximately 400 words):

Enter text here; text limit 2,500 characters

|_| Proposed Subcontractor Identification List uploaded to COMMBUYS (if applicable).

12. Describe how your agency will meet the expectations of the Policy Statement on Community Health Workers (CHW) (found in the COMMBUYS Bid Attachment Section). Include a general statement of how CHWs are incorporated into the service system that you are proposing. Describe your overall outreach plan according to the elements of an outreach plan as outlined in the Policy Statement on Community Health. Describe your internal agency plan for training, supervising, and supporting CHWs according to the elements of an agency plan as outlined in the Community Health Worker attachment (text input limit 1,250 characters, approximately 200 words):

Enter text here; text limit 1,250 characters

Assurances and Attestations

The Assurances and Attestations should be initialed by a representative of the applicant agency. Print this page. The Executive Director/CEO should sign to indicate agreement with universal assurances. Upload to CommBuys and mail original signature with other documents

The agency will adhere to all requirements mandated by MDPH, including updates and/or additions to fiscal procedures, reporting, and programming implemented during the lifetime of this procurement.

The agency will implement policies and protocols to maximize service payment from third-party reimbursements.

The agency will assess participants’ insurance status, coordinate access to insurance enrollment, and support maintenance in insurance coverage.

The agency will cooperate with the MDPH Culturally and Linguistically Appropriate Services (CLAS) initiative and submit a CLAS self-assessment form annually to demonstrate current and planned efforts to provide culturally competent services for individuals served.

Initial Date

The agency will submit timely, complete, and accurate patient data to MDPH, as specified in the RFR and consistent with requirements throughout the lifetime of this procurement.

Initial Date

The agency will maintain fiscal and patient records that document provision of contracted services. The agency will permit MDPH, and/or agents officially working on MDPH’s behalf, access to those records when necessary for contract monitoring and/or quality management activities.

Initial Date

The agency will participate in contract monitoring and quality management activities including, but not limited to, scheduled and unscheduled fiscal and programmatic site visits; clinical and/or non-clinical client chart reviews; program data review; mandatory trainings, technical assistance sessions, and or other capacity-building initiatives; mandatory vendor meetings, webinars, and telephone calls; and quality improvement projects.

Initial Date

The agency will collaborate with MDPH to implement electronic billing processes through which the facility will report all delivered services paid by a third party using 837 HIPAA Health Claims & Equivalent Encounter Information. The agency will adhere to EOHHS and MDPH fiscal policies and protocols including, but not limited to, accurate and timely submission of invoices, amendments, line item adjustments, and additional requirements established by the Virtual Gateway and EIM/ESM system. The agency acknowledges that the accounts payable period to pay encumbrances for the fiscal year ending on June 30 runs from July 1 through August 31. Claims for services provided during the state fiscal year (July 1- June 30) must be received no later than August 15, or may not be paid.

The agency will collaborate with MDPH on activities supporting linkage to care and retention in care.

Initial Date

The agency will assure capacity for tuberculosis diagnosis, care and management as outlined in the RFR and agree to follow national and MDPH standards for these services.

The agency will agree to coordinate the delivery of tuberculosis diagnostic and treatment services that are in accordance with national standards as established by the Centers for Disease Control and Prevention (CDC), the American Thoracic Society (ATS) and the Infectious Disease Society of America (IDSA) [see https://www.cdc.gov/tb/publications/guidelines/pdf/clin-infect-dis.-2016-nahid-cid_ciw376.pdf]. MDPH guidelines are published on-line at www.mass.gov/dph/cdc/tb. Note that services to be arranged may include home infusion therapy.

The agency will agree to communicate and collaborate with state and local public health for management of patients in Priority 1 and Priority 2 populations.

The agency will agree to collaborate with primary care providers for latent TB infection by providing initial evaluation and treatment recommendations for those primary care providers who will manage latent TB infection treatment in primary care.

The agency will agree to work with designated pharmacy(ies) for TB patients, from which medications will be provided with no out of pocket expenses through the TB Drug Assistance Program (or the MDPH 340B supply until TB Drug Assistance Program onboarding).

The agency will agree to adhere to surveillance and reporting requirements through implementation of electronic data transfer in collaboration with MDPH to facilitate disease reporting, patient monitoring, program evaluation, and quality improvement.

Executive Director/CEO Signature for Universal Assurances Date

APPLICATION RESPONSE SUBMISSION PAGE

Organization

CERTIFICATION OF ASSURANCE OF COMPLIANCE:

ADA/ 504 and NON-DISCRIMINATION BASED ON DISABILITY

All MDPH- funded projects must certify that the Applicant Organization will comply with all state and federal requirements regarding equal employment opportunity, nondiscrimination and civil rights for persons with disabilities. The Applicant must complete a Certification of Assurance of Compliance-ADA/504/Non-Discrimination based on Disability. By signing, the Applicant formally notifies MDPH that the Applicant is in compliance and shall maintain compliance with all applicable requirements.

· I , certify, that the Applicant is in compliance and shall maintain compliance with all applicable federal and state laws protecting the rights of persons with disabilities, including but not limited to the Americans with Disabilities Act (“ADA”), 42 12131-12134; Section 504 (“504”) of the Rehabilitation Act of 1973, 29U.S.C. §§ U.S.C. § 794; Article CXIV of the Massachusetts Constitution; and Chapter 6, §§ 185-87; Chapter 93, § 103; Chapter 151B; and Chapter 272, §§ 92, 98, and 98A of the Massachusetts General Laws.

· I understand that federal and state laws prohibit discrimination in public accommodations and employment based solely on disability. I recognize that to make goods, services, facilities, privileges, advantages, or accommodations readily accessible to and usable by persons with disabilities, the Applicant, under the ADA, must:

· remove architectural and communication barriers in existing facilities, when readily achievable and, if not readily achievable, must use alternative methods;

· purchase accessible equipment or modify equipment;

· modify polices and practices; and

· furnish appropriate auxiliary aids and services where necessary to ensure effective communication.

I recognize that Section 504 of the Rehabilitation Act requires recipients of federal funds (either directly or through contracting with a governmental entity receiving federal funds) to make their programs, services, and activities, when viewed in their entirety, accessible to qualified and/or eligible people with disabilities. I understand that reasonable accommodation is required in both program services and employment, except where to do so would cause an undue hardship or burden. I also understand that the Massachusetts Constitution Article CXIV provides that no otherwise qualified individual shall, solely by reason of disability, be excluded from the participation in, denied the benefits of, or be subject to discrimination under any program or activity within the Commonwealth.

· I agree the Applicant shall cooperate in any compliance review and to provide reasonable access to the premises of all places of business and employment and to records, files, information, and employees therein for reviewing compliance with Section 504, the ADA, the Massachusetts Constitution, other applicable state and federal laws, and this Contractual Agreement.

· I agree that any violation of the specific provisions and terms of this Assurance and/or Corrective Action Plan and/or Special Contract Conditions required herein or Section 504 or the ADA, shall be deemed a breach of a material provision of the Contract between the Department and the Contractor. Such a breach shall be grounds for cancellation, termination, or suspension, in whole or in part, of this Contract by the Department.

I affirm that I will comply with the requirements of this Request for Response and with the terms of this proposal.

Authorized Signatory:

First Name: [ ] Last Name: [ ]

Title: [ ]

By clicking the check box, the submitter attests that s/he is an agent of the Bidder with authority to sign on the Bidder’s behalf and is agreeing all affirmations listed above.

CHECKLIST OF ATTACHMENTS TO THE APPLICATION RESPONSE FORM

All documents listed below must be submitted via COMMBUYS in order for you response to be considered complete. Files must be uploaded and follow the naming convention indicated in the chart.

Assign when creating documents

Scanned documents will be accepted. All scanned documents must be scanned in such a way that they can be read on a computer monitor and printed on 81/2” x 11” paper, unless otherwise specified. Attachments must be uploaded individually and cannot be combined in a zipped file.

Addendums or uploads not specifically requested in this document, the RFR or on the COMMBUYS Bid Solicitation will not be reviewed.

APPLICATION INSTRUCTIONS

1. Save, read and review the completed Application Response Form. Check entries in the text boxes to assure that the input limits did not shorten your response. Proof read text; spell-check does not work in the text boxes.

2. Upload in COMMBUYS the Application Response Form with the attachments according to the application Checklist.

3. Confirm that “No Charge” is checked or a dollar amount entered in the Unit Cost field on the Item screen in COMMBUYS. The “No Charge” selection will not be construed by the Purchaser to mean an offer to provide service or products at no charge.

4. Submit your electronic quote in COMMBUYS. (Vendors must be registered in COMMBUYS to submit quotes) image1.png