36C24525Q0087_2.docx

36C24525Q0087

GENERAL INFORMATION

SET-ASIDE

VAMC (688)

50 Irving Street NW Washington DC 20422

POINT OF CONTACT*

Contract Specialist Charles Willis charles.willis@va.gov

PLACE OF PERFORMANCE

VA Medical Center

50 Irving St, NW

Washington, DC

ADDITIONAL INFORMATION

AGENCY’S URL

URL DESCRIPTION

AGENCY CONTACT’S EMAIL ADDRESS

EMAIL DESCRIPTION

DESCRIPTION

Department of Veterans Affairs, VA Medical Center, Washington, DC is issuing Combined Synopsis/Solicitation. The contractor shall provide provide outreach, housing placement, case management, and supportive services as defined herein in the Washington DC VA Medical Center (DC VAMC) catchment area to HUD-VASH eligible Veterans and their families. VA Washington DC’s catchment area is Montgomery, Prince George’s, Calvert, Prince William, Fairfax, Arlington, Loudoun Counties and Southern Maryland.

This is a “request for quotations (RFQ). The associated NAICS code for procurement is 621420 with a size standard of $19 million.

As a result of the solicitation, the Government intends to award Firm Fixed Price – Base Year Plus 4 Option Years.

Prospective quoters must be registered in sam.gov. All SDVOSB/VOSB must be registered and current in U.S. Small Business Administration (SBA VetCert) at Veteran Small Business Certification (sba.gov) and beta.Sam.gov, https://beta.sam.gov to be eligible for award. Contractors that submit quotation for SDVOSB/VOSB set asides that are not listed in VIP will be deemed non-responsive.

All quotes shall be submitted via email by March 21, 2025 at 3pm, EST. All interested contractors shall submit quotation via email to Contracting Officer, Charles.willis@va.gov. Prospective contractors are responsible for downloading attachments, and any issued amendments from https://beta.sam.gov. Late proposals will be processed in accordance with FAR 52.212-1(f), “Late submission, modifications, revisions, and withdrawals of offers.”

Combined Synopsis/Solicitation Notice Combined Synopsis/Solicitation Notice

Combined Synopsis/Solicitation Notice

PAGE 1 OF

1. REQUISITION NO.

2. CONTRACT NO.

3. AWARD/EFFECTIVE DATE

4. ORDER NO.

5. SOLICITATION NUMBER

6. SOLICITATION ISSUE DATE

a. NAME

b. TELEPHONE NO. (No Collect Calls)

8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY

CODE

10. THIS ACQUISITION IS

UNRESTRICTED OR

SET ASIDE:

% FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ

IFB

RFP

15. DELIVER TO

CODE

16. ADMINISTERED BY

CODE

17a. CONTRACTOR/OFFEROR

CODE

FACILITY CODE

18a. PAYMENT WILL BE MADE BY

CODE

TELEPHONE NO.

UEI:

EFT:

PHONE:

FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19.

20.

21.

22.

23.

24.

ITEM NO.

SCHEDULE OF SUPPLIES/SERVICES

QUANTITY

UNIT

UNIT PRICE

AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA

26. TOTAL AWARD AMOUNT (For Govt. Use Only) 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________

29. AWARD OF CONTRACT: REF. ___________________________________ OFFER

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

DATED ________________________________. YOUR OFFER ON SOLICITATION

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED

SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER) 30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION

(REV. NOV 2021)

PREVIOUS EDITION IS NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

36C24525Q0087 02- -2025 CHARLES WILLIS; charles.willis@va.gov 410-691-1328 -202 3pm

EST

36C245 Department of Veterans Affairs

VAMC (512)

RPO EAST / NCO 5

849 International Drive Linthicum MD 21090 X 621420 $19 Million N/A X C688 Department of Veterans Affairs

VAMC(

688) 50 Irving Street NW Washington DC 20422 36C245 Department of Veterans Affairs

VAMC (512)

RPO EAST / NCO 5

849 International Drive Linthicum MD 21090

PAYMENT WILL BE MADE BY

FSC e-Invoice Payment Invoice must be submitted electronically http://www.fsc.va.gov/einvoice.asp Invoice Setup Information 1-877-489-6135 See CONTINUATION Page Contractor shall provide HUD VASH Support Services for the VA Medical Center, Washington, DC in accordance with the statement of work Questions to this solicitation must be submitted to charles.willis@va.gov

NLT

March 7, ; 2pm EST.

Period of Performance- Base Year plus 4 option years Service Contract Labor Standards apply to this solicitation.

Contractor shall be responsible for the correct title classification of workers and compliance with all applicable wage and hour laws.

IAW with VHA Privacy Regulations; A Business Agreement (BAA) Will be required at time of award. Contractor shall be

Responsible for a BAA within 15 days post award.

*See Supplemental Instructions to Offerors for all details.

$0.00 See CONTINUATION Page X X X

ONE

CHARLES WILLIS

Contracting Officer Page 1 of Table of Contents

A.2 SPECIAL NOTICE

This acquisition shall be awarded to the contractor who can provide proof of eligibility. The definition of eligibility has been defined by 38 USC 2041:

"(a) In General. -(1) The Secretary of Veterans Affairs shall consider entering into contracts or agreements, under sections 513 and 8153 of title 38, United States Code, with eligible entities to collaborate with the Secretary in the provision of case management services to covered veterans as part of the supported housing program carried out under section 8(o)(19) of the United States Housing Act of 1937 ( 42 U.S.C. 1437f(o)(19)) to ensure that the homeless veterans facing the most significant difficulties in obtaining suitable housing receive the assistance they require to obtain such housing.

"(c) Eligible Entities. - For purposes of this section, an eligible entity is any State or local government agency, tribal organization (as such term is defined in section 4 of the Indian Self[-]Determination and Education Assistance Act (25 U.S.C. 450b) [now 25 U.S.C. 5304]), or nonprofit organization

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

1. Contract Administration: All contract administration matters will be handled by the following individuals:

a. CONTRACTOR:

2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:

3. INVOICES: Invoices shall be submitted in arrears:

4. GOVERNMENT INVOICE ADDRESS: All Invoices from the contractor shall be submitted electronically in accordance with VAAR Clause 852.232-72 Electronic Submission of Payment Requests.

ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

B.2 PRICE/COST SCHEDULE

ITEM INFORMATION

Program Manager Contract Period: Base POP Begin: 04-01-2025 POP End: 03-31-2026 PRINCIPAL NAICS CODE: 621420 - Outpatient Mental Health and Substance Abuse Centers PRODUCT/SERVICE CODE: G004 - Social - Social Rehabilitation

Lead Case Manager

POP Begin: 04-01-2025 POP End: 03-31-2026

Certified Substance Abuse Counselor

POP Begin: 04-01-2025 POP End: 03-31-2026

Peer Support Specialist

POP Begin: 04-01-2025 POP End: 03-31-2026

12.00

MO

Housing Specialist

POP Begin: 04-01-2025 POP End: 03-31-2026

Program Manager Contract Period: Option 1 POP Begin: 04-01-2026 POP End: 03-31-2027

Lead Case Manager

POP Begin: 04-01-2026 POP End: 03-31-2027

Certified Substance Abuse Counselor

POP Begin: 04-01-2026 POP End: 03-31-2027

Peer Support Specialist

POP Begin: 04-01-2026 POP End: 03-31-2027

Housing Specialist

POP Begin: 04-01-2026 POP End: 03-31-2027

Program Manager Contract Period: Option 2 POP Begin: 04-01-2027 POP End: 03-31-2028

Lead Case Manager

POP Begin: 04-01-2027 POP End: 03-31-2028

Certified Substance Abuse Counselor

POP Begin: 04-01-2027 POP End: 03-31-2028

Peer Support Specialist

POP Begin: 04-01-2027 POP End: 03-31-2028

Housing Specialist

POP Begin: 04-01-2027 POP End: 03-31-2028

Program Manager Contract Period: Option 3 POP Begin: 04-01-2028 POP End: 03-31-2029

Lead Case Manager

POP Begin: 04-01-2028 POP End: 03-31-2029

Certified Substance Abuse Counselor

POP Begin: 04-01-2028 POP End: 03-31-2029

Peer Support Specialist

POP Begin: 04-01-2028 POP End: 03-31-2029

Housing Specialist

POP Begin: 04-01-2028 POP End: 03-31-2029

Program Manager Contract Period: Option 4 POP Begin: 04-01-2029 POP End: 03-31-2030

Lead Case Manager

POP Begin: 04-01-2029 POP End: 03-31-2030

Certified Substance Abuse Counselor

POP Begin: 04-01-2029 POP End: 03-31-2030

Peer Support Specialist

POP Begin: 04-01-2029 POP End: 03-31-2030

Housing Specialist

POP Begin: 04-01-2029 POP End: 03-31-2030

B.3 STATEMENT OF WORK

36C24525Q0087

Page 1 of Page 1 of

1. BACKGROUND.

1.1. The U.S. Department of Veterans Affairs (VA) requires a contractor to provide housing placement, case management and supportive services for Veterans who would benefit from these services due to the complexity and acuity of their needs. Services will be in support of in the U.S. Housing and Urban Development (HUD) - Veterans Affairs Supportive Housing (VASH) (HUD-VASH) program which is a collaborative partnership intended to place and maintain homeless Veterans in permanent, community-based housing using HUD Section 8 Housing Choice Vouchers that are paired with ongoing case management and supportive services. Many of these Veterans have co-morbid conditions that include serious mental illnesses, substance abuse disorders, and other serious medical conditions. The contractor shall provide outreach, housing placement, case management, and supportive services as defined herein in the Washington DC VA Medical Center (DC VAMC) catchment area to HUD-VASH eligible Veterans and their families. VA Washington DC’s catchment area is Montgomery, Prince George’s, Calvert, Prince William, Fairfax, Arlington, Loudoun Counties and Southern Maryland.

1.2. HUD-VASH is a national program serving Veterans and their families throughout the country. This program continues to expand and has become one of the largest VA interventions to assist homeless Veterans. It represents one of VA’s most significant efforts to achieve the President’s goal of ending homelessness among Veterans. To be eligible for the HUD-VASH program, the Veteran must be determined “homeless” based on Attachment 1: McKinney-Vento Homeless Assistance Act definitions and determined to be eligible for the HUD-VASH program under The National Defense Authorization Act for Fiscal Year 2021 (PL 116-283), which includes provisions expanding eligibility for HUD-VASH by the local VA medical center with every effort made to identify and serve the most chronically homeless and vulnerable Veterans.

1.3. The target population for this contract includes chronically homeless Veterans who demonstrate the most need/vulnerability and may often have severe mental health, medical, and/or substance use disorders (SUD) issues. Veterans may not be chronically homeless and may fall into one of the priority groups such as women, women Veterans with children, OEF/OIF/OND Veterans, and/or Veterans who have physical health problems and/or SUD, with frequent emergency room visits, multiple treatment failures, and limited access to other social supports. The Contractor shall assess each applicant on an individual basis and prioritize highest need for the program based on the Veteran’s acuity per clinical judgment and resource availability. Through this contract initiative, Contractor will place individuals into housing while simultaneously providing case management and supportive services; and assist the Veteran in maintaining housing until the Veteran is eligible for discharge. The HUD-VASH program is reserved for homeless Veterans with serious medical, SUD, and/or mental health problems with a demonstrated need for case management services to obtain and sustain housing.

2. GENERAL CONTRACT REQUIREMENTS:

2.1. Contractor shall provide outreach, housing placement, case management, and supportive services to Veteran beneficiaries of diverse backgrounds as specified herein. Contractor shall provide all labor, supervision, supplies, materials, and logistics required to perform these services for the duration of the contract. Contractor shall perform services remotely or at the Contractor’s location, unless otherwise required by performance requirements listed in the SOW.

2.2. The Contractor shall submit all deliverables to the designee, who will evaluate all deliverables submitted and certify invoices based upon acceptable deliverables. Contractor performance will be evaluated by the COR annually via. Contractor Performance Assessment Reporting System (CPARS) and manual Performance Evaluation Documents to the Contracting Officer (CO). The COR or designee will also be the Contractor’s main point of contact for Veteran-related issues in conjunction with the VA homeless team. The VA Liaison will provide clinical oversight but will not provide direct clinical supervision. The COR and VA Liaison duties may be fulfilled by a single individual.

2.3. Clinical oversight refers to a working relationship between COR and Contractor. The VA Liaison monitors compliance with the contract deliverables, and quality of care that is provided to Veterans. COR may also serve as consultants to the Contractor in conjunction with VA regulations, requirements, and guidelines.

2.4. Contractor shall have the staffing and expertise to execute the tasks and associated deliverables associated with this Statement of Work (SOW) without reliance on the COR or designee to provide support that would reasonably be considered clinical supervision. The Contractor shall provide routine, ongoing clinical supervision to its staff performing on this contract.

2.5. Contractor shall ensure access to case management services to HUD-VASH Veterans is available on an as-needed basis. Contractors shall perform all services described in this SOW for each Veteran enrolled in the program.

3. SPECIFIC CONTRACT REQUIREMENTS.

3.1. Contractor shall provide housing placement services to support Veterans in securing permanent housing in the community.

3.2. Contractor shall provide supportive services to Veterans, which includes recovery groups, recreational activities, life skills group, substance abuse groups, bringing in community resources (e.g., legal, financial), Peer support groups, increasing social and community engagement and/or employment services/opportunities.

3.3. Contractor shall provide case management in accordance with Attachment 2: VHA Directive 1162.05 HUD-VASH Program. The Contractor shall maintain staffing at a weighted caseload capacity that is a minimum 25:1 staff-to-veteran ratio.

3.4. Contractor shall provide interdisciplinary teams who work collaboratively to provide patient centered care. Team compositions may consist of addiction treatment professionals, licensed clinical social workers, licensed mental health counselors, nurses, occupational therapist, psychologists and may also include housing specialist, unlicensed Social Workers and peer support specialists. Contractor’s clinical supervisors shall have a minimum of a master’s degree of Social Work with the appropriate licensure of Licensed Independent Clinical Service Worker (LICSW) as per the qualifications outlined in the Social Work’s qualification.

3.5. Contractor shall provide case management services as part of the Washington, DC VA Medical Center and surrounding communities. Contractor shall work traditional work hours, M-F, 7:00 a.m. to 3:30 p.m., 7:30 a.m. to 4:00 p.m., or 8:00 a.m. to 4:30 p.m. Contractor shall maintain office hours at a minimum of 12 hours per week at the Community Resource Referral Center (1500 Franklin Street NW, Washington, DC 20018). Contractor will not be required to work Federal Holidays. Federal Holidays observed are:

3.6. Contractor shall comply with HUD-VASH and local policy and standard operating procedures (SOPs) and evaluation standards for Veterans enrolled in HUD-VASH. Contractor is encouraged to attend the VA’s monthly HUD-VASH meeting to learn about program updates and VA services.

3.7. Contractor case management staff shall visit Veterans if in an institutionalized setting (hospital, assisted living, Board and Care, Community Nursing home, etc.). If Veterans are incarcerated, Contractor case management staff shall reach out to Veterans Justice Outreach (VJO) for coordination and collaboration of follow-up and services. Contractor staff shall also accompany Veterans to clinics, Emergency Rooms or other appointments as clinically indicated, while working with Veterans to foster independence and a sense of self- determination.

3.8. Contractor shall not discharge Veterans from case management services without prior approval from COR or designee. If a Veteran assigned a voucher leaves the DC VAMC catchment area and begins to reside elsewhere, the Contractor shall establish alternative case management services as appropriate prior to discharge and in collaboration with the VA Liaison.

3.9. Case Management visits to Veterans shall be conducted in accordance with Attachment 2, VHA Directive 1162.05(1) HUD-VASH Program, which is made part of this contract and is incorporated by reference herein.

3.10. Contractor shall ensure that when Veterans have achieved housing stability, the focus of the service support changes to community integration and other goals as discussed and agreed upon in Veteran’s treatment plan and their contact with the Veteran shall remain in accordance with level of care.

3.11. Contractor’s case management services shall follow the principles and practices of the Housing First Model, See Attachment 2, VHA Directive 1162.05(1) HUD-VASH Program.

3.12. The Contractor shall participate in VA mandatory trainings related to the 6500.6 clause and security requirements. Additionally, the Contractor staff must participate in required VA Healthcare training and the required VA Homeless Veteran Certification training through the Talent Management System (TMS).

3.13. The Contractor shall have 90 days to mobilize required staff to meet the terms and conditions of this contract after award.

3.14. The Contractor shall be required to complete the Basic Life Support (BLS) through TMS and maintain certification for all staff that are working on this contract; Contractor shall remove staff from direct patient care if their certification expires and shall not return those staff to performance under the contract until it is obtained.

3.15. Contractor shall encourage Veterans to actively engage in healthcare. The encouragement shall include scheduling healthcare appointments, making all appointments with providers, medication compliance, and compliance with case management.

3.16. Contractor shall document changes of status for Veterans to include, Veteran level of Care (LOC), employment, and housing status as indicated in the National website: Homeless Operations Management and Evaluation (HOMES), which can be accessed here: https://vaww.homes.va.gov/VAHomesNew.aspx. HOMES is the database used by the VHA Homeless Program Office (HPO) to gather homeless Veteran’s data and statistics for analytical purposes.

3.17. Contractor shall enter Veteran information (e.g., name, SSN), after obtaining a release of information into the Coordinated Entry System and Health Information Management System (HMIS) within 72 business hours.

3.18. Contractor shall assess Veterans to determine if the Veteran meets the criteria for admission into the HUD-VASH program. The VHA HUD VASH program shall be responsible for training the contractor and providing examples, on HUD VASH specific templates, documents, and VA medical documentation. The Contractor shall complete HOMES documentation, consistent with the HOMES Reporting Policy and VA Medical documentation which is made part of this contract and is incorporated by reference herein. HOMES documentation may include, but is not limited to, changes to admission, housing, voucher, or employment status, encounter documentation, screening/admission notes, release of information forms, housing service agreements, suicide risk assessments, advanced directive discussions, clinical reminders, treatment plans and safety plans. Contractor shall document using the appropriate template format for all clinical notes and ensure all encounters are entered within 3 business days or on the same day in cases of crisis.

3.18.1. Contractor staff shall document in the electronic health record (EHR) services delivered during a patient encounter using appropriate Current Procedural Terminology (CPT) coding. An encounter is a professional contact between a patient and a provider vested with responsibility for diagnosing, evaluating, and treating the patient’s condition. The reason for the services provided (diagnosis) and the actual services provided to the patient by the provider must be fully and clearly documented and coded using nationally accepted coding schemes. Which are consistent with VA coding schemes. VA provides training to contractors several times a year addressing productivity and coding practices. Reference - Attachment 3, VHA Directive 1161 Productivity and Staffing In Clinical Encounters For Mental Health Providers and Attachment 4, VHA Directive 1082(1) Patient Care Data Capture and Closeout.

3.19. The Contractor’s Supervisor shall engage in weekly administrative meeting with the COR and/or VA Liaison, which may include other VA Staff, to discuss any administrative concerns and Contractor performance. A minimum of 30 minutes shall be allotted for this call and/or online conference.

3.20. The Contractor shall work with the Veteran on obtaining and maintaining housing, developing independent living skills to include, budgeting, employment, and assistance obtaining VA benefits.

3.21. The Contractor shall maintain referral networks for purposes of assisting veterans in demonstrating eligibility for assistance and additional services under entitlement and assistance programs available for Veterans, and to otherwise aid Veterans in obtaining such assistance and services.

3.22. Contractor shall ensure staff working on the contract complete a VA Security/background investigation via National Agency Check with Written Inquiries (NACI), and a Special Agreement Check (SAC) which includes electronic fingerprinting for staff working with Veterans during the onboarding process. Contractor shall be in compliance with VA Handbook 6500.6 Appendix C clause.

3.23. Contractor shall ensure appropriate staff complete the credentialing process through the VA’s VetPro system in alignment with the VetPro policies and operating procedures Attachment 5: Reference VHA Handbook 1100.19 Credentialing and Privileging https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2910 which is made part of this contract and is incorporated by reference herein. Staff awaiting VetPro clearance may only begin work on the contract prior to receiving credentialing by performing tasks that do not involve Protected Health Information (PHI, Refer to Definitions section of this SOW).

3.25. Contractor shall submit an annual report to the VA, including a description of, for the year covered by the report the following:

3.25.1. The services and assistance provided as part of the contract.

3.25.2. The process by which Veterans were referred to the entity for such services and assistance.

3.25.3. The specific goals jointly set by the entity and the VA for the provision of such services and assistance and whether the entity achieved such goals; and

3.25.4. The average length of time taken by a covered veteran who received such services and assistance to successfully obtain suitable housing and the average retention rate of such a veteran in such housing; and

3.25.5. to meet such other requirements as the VA considers appropriate for purposes of providing assistance to Veterans in obtaining suitable housing.

4. ADMISSION/REFERRALS.

4.1. Veterans enter the HUD-VASH program by being identified as meeting HUD- VASH admission criteria Reference (Attachment 2 VHA Directive 1162.05(1) HUD-VASH Program), through referral by the VA as eligible for the program, or through community outreach conducted by the Contractor.

4.2. The Contractor shall conduct screenings, including an interview with the Veteran, VA medical record system chart review, and HOMES assessment as appropriate to determine HUD-VASH eligibility based on the homeless and chronic homeless criteria.

4.3. The Contractor shall also conduct a basic screening for healthcare eligibility that shall include a review of the Veteran’s DD214 by obtaining access to SQUARES (see definition section of SOW).

4.4. Contractors shall admit Veterans to the HUD-VASH program (VA approval not required) after Contractor completes necessary screenings and receives a VA eligibility office determination of Veteran discharge status indicating Veterans are eligible for the HUD-VASH program. The Contractor shall notify the COR or designee(s) by VA email within 24-hours of the Veterans admission and add the Veteran to the agency list. Note: Admission is the clinical decision of HUD-VASH Staff, or, if indicated, in more complex situations, with consultation from HUD-VASH COR, VA Liaison or designee. Veterans not approved for HUD-VASH Program shall also be provided with alternate resources for housing.

4.6. Contractor shall provide simultaneous housing placement and case management services for Veterans under their care.

4.7. Veterans are considered admitted into HUD-VASH when they have met all the appropriate screening criteria for HUD-VASH case management and HUD guidelines. The appropriate documentation indicating HUD-VASH participation must be entered in to HOMES.

4.8. In the case of a two-Veteran household, the Contractor shall enter HOMES, the individual identified as head of household and the voucher holder. Contractor shall provide case management services in accordance with the level of care for that individual. The additional Veteran, if also in need of case management services, shall be assisted appropriately with supportive services and/or referrals to community case management resources as needed.

4.9. Contractor Housing Placement & Stabilization Duties. The Contractor shall perform housing placement & Stabilization Duties that include the following:

4.9.1. Identify and enroll Veterans who meet criteria for program admission:

4.9.1.1. To be admitted to the HUD-VASH program, a Veteran must be:

4.9.1.1.1. Determined to be eligible for the HUD-VASH program under The National Defense Authorization Act for Fiscal Year 2021 (PL 116-283), which includes provisions expanding eligibility for HUD-VASH.

4.9.1.1.2. Determined to be homeless based on Attachment 1: McKinney-Vento Act definitions by the local VA medical center HUD-VASH program with every effort made to identify and serve the most chronically homeless and vulnerable Veterans.

4.9.2. Contractor shall assist Veteran in completing and submitting Public Housing Authority (PHA) and other Federal, local, and state entitlement program paperwork (e.g., Social Security, food stamps, utility assistance, etc.) to the appropriate agency.

4.9.3. Contractor shall advocate with landlords on behalf of the Veteran to maintain a lease and advise any potential landlords that the Contractor shall be providing assistance and case management services to the Veteran in order to help the Veteran remain successfully housed. Contractor shall assist Veterans with all inspections required for move-in. Contractor shall ensure that the Veteran has completed the VA release of permitted information so communication between the landlord, Contractor, and VA can occur as needed. Contractor shall engage with Landlord at least once a month, or more if clinically indicated. When a Veteran is in preparation for discharge, Contractor shall engage with Landlord at least quarterly to ensure sustainability of housing.

4.9.4. Contractor shall assist Veteran with developing a budget and assist the Veteran in securing necessary funding for recurrent monthly expenses.

4.9.5. Contractor shall assist the Veteran in making calls to utility providers to ask questions and resolve issues (including turning off or transferring utilities), ensure the Veteran is paying rent and utility bills in a timely manner and provide budgeting/money management assistance as needed.

4.9.6. Contractor shall assist Veteran in applying for all eligible benefits, both VA and non-VA, including but not limited to; Veteran’s Benefits Administration (VBA), Employment Development Department (EDD), Social Security Administration (SSA).

4.9.7. Contractor shall assist Veterans in applying for Medicaid and accessing community-based services when ineligible for VA Healthcare.

4.9.8. Contractor shall conduct home visits of HUD-VASH units to ensure that Veterans reside in healthy residences in accordance with Attachment 2: VHA Directive 1162.05(1) HUD-VASH Program. The Contractor shall conduct home visits according to the Veterans level of care, or more often as clinically indicated. When clinically indicated, visits should be conducted by Contractor clinical staff.

4.10. Contractor understands that the Veteran is entitled to Portability of his/her voucher. Portability provides Veterans the opportunity to transfer their housing choice voucher (HCV) to live in the community of their choice if there is an opening. In addition to local VA guidelines, Federal Register Notice of May 6, 2008, addresses portability in HUD-VASH. The Notice can be found at: https://www.federalregister.gov/documents/2014/06/18/2014-14167/section-8-housing-choice-vouchers-revised-implementation-of-the-hud-va-supportive-housing-program. NOTE: This linked document is outside VA control and may or may not conform to Section 508 of the Rehabilitation Act.

5. CASE MANAGEMENT DUTIES:

5.1. The Contractor shall have procedures in place to ensure Veterans have access to clinical case management services, which shall include crisis management and referrals.

5.2. The Contractor shall ensure consistency of case management services to enhance staff ability to engage and form relationships with Veterans and provide consistent and highly skilled interventions in keeping with the Housing First (HF) model as described below:

5.2.1. Housing First is an approach that centers on providing homeless individuals with housing quickly, and then providing services and treatment as needed. The primary focus of the Housing First approach is to identify an immediate need for housing and helping individuals and families quickly access and sustain permanent housing. Housing First programs share four (4) critical elements:

5.2.1.1. Focus on helping individuals and family’s access and sustain permanent housing as quickly as possible.

5.2.1.2. A variety of services delivered primarily following a housing placement to promote housing stability and individual well-being.

5.2.1.3. Time-limited or long-term services depending upon the individual need.

5.2.1.4. Veteran agreement to participation in Case Management Services of pursuing and maintaining housing.

5.2.2. Contractor staff shall support family (Refer to the Definitions section of this SOW) members who reside with the Veteran by assisting them in connecting to supportive social services programs/resources as needed.

5.2.3. Contractor staff shall address the documented needs of Veterans and make home visits consistent with the needs of the Veterans.

5.2.4. Contractor shall apply Harm Reduction interventions when working with Veterans in accordance with Attachment 2, VHA Directive 1162.05(1) HUD-VASH Program.

5.3. Contractor shall conduct meetings and normal business operations with Veterans, as needed. The contractor shall also furnish all required equipment, materials, and supplies to complete all tasks as stated in this SOW. Contractor staff shall ensure meetings are always respectful of Veterans privacy.

5.5. Contractor shall ensure that sufficient staff are available to provide services to meet the needs of the Veterans as well as to make home visits consistent with the level of care at which each Veteran is being treated. Contractor shall perform the following work:

5.5.1. Create a Individual Service Plan (ISP) within two weeks of program admission. This plan will be documented in the VA medical record by the Case Manager completing the initial admission to HUD-VASH program.

5.5.2. Review and update the ISP with the Veteran every six months or when there is a significant change in Veteran’s functioning level, or circumstances that call for a change in his/her treatment. Document the review and any changes to the ISP in the VA medical record.

5.5.3. Comply with additional documentation and/or data reporting as required by VA based on local, regional, or national HUD-VASH requirements.

5.5.4. Engage in the HUD-VASH screening process to perform interviewing, counseling, and case management services with Veterans while identifying those Veterans that are considered high risk due to medical, mental, and/or addiction history; provide psychosocial assessments, to identify service and treatment needs which affect Veteran’s housing stability, recovery/community reintegration.

5.5.5. Utilize case management strategies to include crisis intervention and both short and long-term services working toward long range independent housing and community reintegration. Contractor shall provide services as needed based on Veterans’ needs, acuity level and preferences for care. Contractor shall reassess Veterans’ needs on a regular basis, no less than quarterly and in accordance with local policy for changes in their needs, acuity level and preferences for care. Contractor shall screen each Veteran for suicidal and homicidal risk with each contact. This screening shall be documented in Veterans VA medical record by progress notes, suicide risk assessments, and safety plans.

5.5.6. If the Veteran is a danger to him/herself or others, the Contractor shall take immediate steps to provide appropriate intervention.

5.5.7. Crisis management shall be coordinated and executed by the contractor and shall be reported to the COR or VA Liaison and other VA staff as directed.

5.5.8. Contractor shall adhere to the reporting requirements located in the U.S. Department of Housing and Urban Development Public and Indian Housing Notice PIH 2011-53(HA), issued 09/20/2011 and available at https://www.hud.gov/sites/documents/pih2011-53.pdf, which is made part of this contract and is incorporated by reference herein, including any subsequent changes, updates, or revisions to the PIH Notice.

5.5.9. Contractor shall facilitate the Veteran’s involvement in supportive employment and other restoration programs when clinically indicated.

5.5.10. Formulate case management treatment goals and plans with Veteran, that address identified needs, stressors, problems that are attainable. Actively involve the Veteran and their family or significant others in coordination with the team members, based on the psychosocial assessments, to develop a treatment plan with the Veteran using his/her language, ensuring he/she has a copy of the plan including goals for clinical treatment and discharge from case management.

5.6. Contractors shall provide direct mental health and substance abuse counseling within the scope of practice of these disciplines and assist in securing available VA services including the use of tele-mental health services.

5.7. Contractor shall integrate housing stabilization planning with relevant VA health and mental health services. The Contractor’s housing stabilization plan shall provide a case management and supportive services framework for the Veteran’s sustainability in HUD-VASH and identify the Veteran’s goals with steps to achieve those goals.

5.8. The Contractor shall visit each Veteran face-to-face at the intervals required by Attachment 2, VHA Directive 1162.05(1) HUD-VASH Program. Additionally, the Contractor shall adhere to the following:

5.9.1. The Contractor shall notify the COR or designee of any change in Level of Care (LOC) within 1 business day via VA email and by adding them as a cosigner to the note in the VA medical record system. Should the COR or designee have concerns regarding the change of LOC, the Contractor shall engage in a discussion with the COR or designee regarding this change. This discussion may lead to the change of LOC not being approved if the COR has concerns for Veteran’s safety/well-being. The Liaison shall document this both in email to the Contractor and in the Veterans electronic medical record.

5.9.2. Case management services visits, while not required to take place in the Veterans home, are encouraged to be done in the home at least on a quarterly basis to assess conditions of the home for acuity levels of maintenance, and preparation for discharge. Veterans in the intensive stage of case management shall have at least one home visit a month, visits can also take place in the community, at the Contractor agency, or a place mutually agreed upon by the Veteran and the contractor if the Veteran is unhoused.

5.9.3. Phone contacts, while an acceptable way to communicate with the Veteran, are not considered visits in meeting the minimum visit requirements for any acuity level. All staff using VA Video Connection, (VVC) must complete the required training in the VA Talent Management System (TMS) prior to engaging Veterans in VVC. Training on use of VVC will be provided by the VA. In the event the Contractor is unable to locate the Veteran (at home or in the community), for the required number of visits, the Contractor shall document all attempts to contact Veteran, be it face-to-face, VVC attempts, phone calls, or letters sent to the Veteran. This should include dates and times in the VA medical record system as verification of services rendered and to show that due diligence has been exercised.

5.10. Case Management Due Diligence. Contractor shall adhere to the following requirements pertaining to what constitutes acceptable efforts in completing case management services for monthly invoicing purposes, specifically for Veterans who cannot be located or contacted. Homeless and formerly homeless Veterans may be difficult to reach, fail to keep appointments, and/or abscond from services at unexpected times. Contractor shall proceed with a sense of urgency and accountability in following up with Veterans who cannot be located or contacted to assure their safety and well-being. This is referred to as “due diligence.”

5.10.1. Clinical Due Diligence: Contractor shall notify the COR or VA Liaison at any time an urgent or emergent concern arises about a Veteran’s health and safety or if the Contractor requires the VA Liaison’s immediate consultation with the Contractor pertaining to the health or safety of a Veteran. Contractor staff shall use clinical judgement and collaborate with the COR or VA Liaison in determining appropriate next steps in these emergent situations.

5.10.2. Contractor shall ensure clinical due diligence consists of multiple steps to reach a Veteran to ensure the Veteran’s well-being. Contractor shall follow up with appropriate case management services. Contractor in-person visits should be scheduled with the Veteran when possible. Unscheduled visits to Veteran may occur but will not be considered as non-compliance with case management on the part of the Veteran. Scheduled visits are defined as the Veteran having been contacted in advance and agreed to the appointment date, time, and location. When a Veteran is absent from a scheduled visit or meeting without notice, the Contractor shall take the following steps to contact the Veteran and/or determine the Veteran’s whereabouts:

5.10.2.1. When encountering a missed initial scheduled meeting such as the Veteran does not answer the door or is not present at the meeting location at the scheduled time, the Contractor shall attempt to contact the Veteran by phone while on the premises. (NOTE: This would not be considered a separate attempt to contact the Veteran because it is part of the scheduled appointment. This attempt to meet in person and contact the Veteran by phone shall be documented in one note in the medical record.) If the Veteran does not have a phone, the Contractor shall consult with the COR or designee(s) for alternatives based on the Veteran’s unique circumstances.

5.10.2.2. If the Contractor reaches the Veteran by phone and the Veteran is safe and well, the Contractor shall emphasize the importance of a face-to-face meeting within 24 hours of the initial scheduled event with the Veteran and the visit/meeting shall be rescheduled by the Contractor to occur as quickly as possible and shall be documented in the same note in the medical record. If the Contractor is unable to reach the Veteran by phone, the COR or designee shall be notified. The Contractor shall engage in due diligence in consultation with the Contractor’s clinical case manager supervisor to locate the Veteran by doing the following:

5.10.2.2.2. Contact all VA assigned medical providers (or non-VA medical providers if known)

5.10.2.2.3. Contact the Veteran's listed emergency contacts

5.10.2.2.4. Contact the Veteran's landlord or other persons for whom there is a completed Release of Information

5.10.2.2.5. Check local shelter system roster (if assigned to a shelter, contact the shelter staff)

5.10.2.2.6. Utilize hospital registry, prisons, and inmate lookup websites

5.10.2.2.7. Contact the local police precinct closest to the Veteran’s home to request a welfare check (police make visit to Veteran's apartment)

5.10.2.2.8. Make an unannounced visit to Veteran's home (if the missed meeting was scheduled for an alternate location)

5.10.2.2.9. Contact the city morgue.

5.11. The Contractor shall clearly document all steps taken to locate the Veteran in the clinical record. If the Veteran is located or contacted during any of steps, Contractor shall develop and implement and appropriate plan and follow-up based on Veteran’s disposition (i.e., home visit rescheduled; visit to other location such as hospital or shelter; etc.). This plan shall be reviewed by the case manager’s supervisor and documented in the VA medical record including any supervisory recommendations and timeframes for next steps.

5.11.1. If the Veteran has not been located or contacted upon completion of these steps, the Contractor shall ensure that the case has been discussed with the COR or designee and the agreed upon plan for next steps has been documented in a progress note and entered into VA medical record system on the same day as the activity occurred.

5.11.2. 2nd Attempt. If a Veteran has not been located or contacted after the steps listed in section 5.11.2.2 above have been completed, a second attempt to meet with the Veteran shall be made within 24 hours of the initial scheduled meeting. At minimum, a second attempt shall include a phone call to the Veteran. If the Veteran does not have a phone, the Contractor shall consult with the COR or designee for alternatives based on the Veteran’s unique circumstances. If the Contractor reaches the Veteran by phone, the Contractor shall emphasize the importance of a face-to-face meeting within 24 hours of the initial scheduled event with the Veteran. The Contractor shall document this as a separate administrative note. An in-person home visit is then required to be conducted by the Contractor as a phone contact is not an acceptable substitution. In the case of concerns about a Veteran’s safety, an unannounced home visit shall be attempted by the Contractor as soon as possible. In either case, the Contractor’s case manager shall consult with their supervisor and notify the COR or designee. The Contractor shall consult the COR or designee for planning purposes based on the Veteran’s unique circumstances.

5.11.1.7. If the Veteran is located or contacted during any of these steps, the Contractor shall determine an appropriate plan and follow-up based on the Veteran’s disposition (i.e., home visit rescheduled; visit to other location such as hospital or shelter; etc.). This plan shall be reviewed with the case manager’s supervisor and documented in the VA medical record including any supervisory recommendations and timeframes for next steps.

5.11.1.8. If the Veteran has not been located or contacted upon completion of these steps, the Contractor shall ensure that the case has been discussed with the COR or Liaison, and the agreed-upon plan for next steps has been documented in a…