SOW_for__DM_Program_shoes_2016_-_Wewoka_3-3-16.pdf

Statement of Work

Diabetes Program Shoes, Inserts, and Compression Stockings

March 3, 2016

1. Statement of Work

The statement of work describes the requirement for the provision of diabetic foot evaluations and custom shoes and/or inserts, and compression stockings for the

Wewoka Indian Health Center, Wewoka, OK.

a. Provide diabetic foot evaluations and custom shoe and/or inserts for patients referred for these services.

b. Provide an onsite evaluation and fitting for diabetes program participants to insure proper fit and function.

c. Deliver the shoes to check with each participant for proper fit and function.

d. Services shall be fully coordinated and integrated with the direct patient care program with respect to services provided and professional relationships.

e. Accountability requires that all services be under professional direction, therefore, the Contractor will be fully responsible for any subcontracts (if applicable), professionally, administratively, and financially.

2. Professional Qualifications

Contractor shall be a Certified Pedorthist and have experience working with patients with complicated disease processes and complications of diabetes.

3. Government Furnished Information, Property and Services

Written referrals for service shall be provided to the contractor by fax and clinic space shall be provided twice per month for fitting and delivery of shoes, inserts and compression stockings. The Government shall contact all patients regarding the shoes appointment times.

4. Contractor Furnished Information, Property and Service

The Contractor shall provide patient evaluations, fittings, shoes and/or inserts, and adjustments or modifications as needed. Compression stockings shall be measured for each individual patient and fitted according to prescription strength compression.

5. Work Schedule

The contactor shall come (2) scheduled times per month for 8 hours each to the clinic to evaluate the participants feet and to check for fitting and shoe delivery.

This shall be during regular clinic hours.

6. Specific Requirements

Diabetic Foot evaluations (measuring of feet, testing for protective sensation, palpating and checking for range of motion and foot deformities and gait evaluation)

Extra Depth Diabetic Approved footwear A5500

Heat Molded Footwear A5501

Heat Molded Diabetic Inserts A5512

Custom Fabricated Diabetic Inserts A5513

Custom Fabricated Toe Fillers L5000

Onsite (in-person) fitting and dispensing of footwear and inserts, checking for proper fit and function

Adjustments and modifications of shoes and/or inserts if necessary

Compression stockings 15-20mmHg Knee high and Thigh high, 20-30mmHg

Knee high and Thigh high if ordered by provider.

After wearing the shoes at home or at the gym (without wearing outside), the contactor shall replace if the shoe does not fit well or is causing pain within 15 days. The contactor shall replace with a more appropriate fitting shoe.

7. Rates of Payment

Payments on Diabetic shoes and inserts shall not exceed Medicare Rates for the services provided. Payments on the compression stocking shall not exceed reasonable retail cost for knee high and thigh high stockings.

Knee high 15-20mmHg Thigh high 15-20mmHg

Knee high 20-30mmHg Thigh high 20-30mmHg

If the contractor’s price changes as a result of notification from the Center for

Medicare/Medicaid Services (CMS) or cost to charge ratio, they must provide a letter from CMS to Wewoka Indian Health Center within 30 days of receipt along with a corrected price list in order to be paid at the new rate.

8. Reporting Requirements

a. The contractor shall provide services for patients referred within 30 days of receipt of the written referral.

b. The contractor shall provide special reports requested by the Contracting

Officer during the contract on technical or administrative aspects of the contract performance. Request for such reports shall be provided in writing to the

Contractor stipulating information required, time frames for responses and instructions on submission.

c. The contractor shall provide a Monthly Report of Services, a narrative report with comparison of actual services provided according to requirements established and the quantity of shoes, inserts, and compression stockings provided as well as the number of problems encountered and circumstances, if any, adversely affecting the delivery of services and recommendations.

9. Performance Period

One year