36C26121Q0549.docx

36C26121Q0549

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.

DUNS:

DUNS+4:

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. 2/2012)

PREVIOUS EDITION IS NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

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

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

36C26121Q0549 05-06-2021 Latasha Winston 916-923-4973 05-31-2021

11:59 PM

PDT

612MCP

Department of Veterans Affairs VA Sierra Pacific Network (VISN 21) VA Northern California HealthCare System 5342 Dudley Blvd, Bldg 209 McClellan

CA

95652-2609 X X 624229 $16.5 Million N/A X ** See Preformace Work Statement **

612MCP

Department of Veterans Affairs Department of Veterans Affairs VA Northern California HealthCare System 3230 Peacekeeper Way, Bldg. 209 McClellan

CA

95652-1012

Department of Veterans Affairs FMS VA-9(101) Financial Services Center PO Box 149971 Austin

TX

78714-9971 See CONTINUATION Page The Contractor shall provide HUD-VASH Housing Placement and Case Management Services for San Francisco VA Healthcare System in Marin, Mendocino, Lake, and Sonoma Counties, CA.

All performance shall be in accordance with the Performance Work Statement contained herein.

See Schedule of Supplies/Services in Section B.2 Period of Performance: 07/01/2021 - 06/30/2026 Ordering Period One: 07/01/2021 - 06/30/2022 Ordering Period Two: 07/01/2022 - 06/30/2023 Ordering Period Three: 07/01/2023 - 06/30/2024 Ordering Period Four: 07/01/2024 - 06/30/2025 Ordering Period Five: 07/01/2025 - 06/30/2026 Point of Contact Latasha Winston (latasha.winston@va.gov) See CONTINUATION Page X X Latasha Winston Contracting Officer Table of Contents

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:

1. CONTRACTOR: TBD

1. GOVERNMENT: Contracting Officer 36C261 Latasha Winston Department of Veterans Affairs Network Contracting Office (NCO) 21 5342 Dudley Blvd., Bldg. 209 McClellan CA 95652

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:

a. Quarterly [ ]

b. Semi-Annually [ ]

c. Other [X] Monthly - in Arrears

1. GOVERNMENT INVOICE ADDRESS: Invoices will be electronically submitted to the Tungsten website at http://www.tungstennetwork.com/uk/en/ Tungsten direct vendor support number is 877-489-6135 for VA contracts. The VA-FSC pays all associated transaction fees for VA orders. During Implementation (technical set-up) Tungsten will confirm your Tax Payer ID Number with the VA-FSC. This process can take up to 5 business days to complete to ensure your invoice is automatically routed to your Certifying Official for approval and payment. In order to successfully submit an invoice to VA-FSC please review “How to Create an Invoice” within the how to guides. All invoices submitted through Tungsten to the VA-FSC should mirror your current submission of Invoice, with the following items required. Clarification of additional requirements should be confirmed with your Certifying Official (your CO or buyer). The VA-FSC requires specific information in compliance with the Prompt Pay Act and Business Requirements. For additional information, please contact:

Tungsten Support Phone: 1-877-489-6135 Website: http://www.tungsten-network.com/uk/en/ Department of Veterans Affairs Financial Service Center Phone: 1-877-353-9791 Email: vafscched@va.gov

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

AMENDMENT NO DATE

B.2 PRICE/COST SCHEDULE

The Contractor shall provide HUD-VASH Housing Placement and Case Management Services for San Francisco VA Healthcare System in Marin, Mendocino, Lake, and Sonoma Counties, CA in accordance with the specifications listed herein.

The guaranteed minimum award amount for this contract is $1,000. The maximum aggregate value of orders that can be placed under this contract is $6,500,000. The Government does not guarantee that it will place any orders under this contract in excess of the guaranteed minimum award amount.

ITEM INFORMATION

Ordering Period One: PERIOD OF PERFORMANCE: July 01, 2021 – June 30, 2022

HUD-VASH Case Management

DO NOT PRICE

(Level 5 encounter 1 Veteran x 4 visits per month) 120 Visits (30 Veterans)

(monthly total)

(Level 4 encounter 1 Veteran x 2 visits per month 50 Visits (25 Veterans)

(Level 3 encounter 1 Veteran x 1 visit per month) (26 Veterans)

(Level 2 encounter 1 veteran x 1 visit per quarter )

(18 Veterans)

(monthly total)

Ordering Period Two: PERIOD OF PERFORMANCE: July 01, 2022 – June 30, 2023

HUD-VASH Case management

DO NOT PRICE

(Level 5 encounter 1 Veteran x 4 visits per month) 120 Visits (30 Veterans)

(Level 4 encounter 1 Veteran x 2 visits per month 50 Visits (25 Veterans)

(Level 3 encounter 1 Veteran x 1 visit per month) (26 Veterans)

(Level 2 encounter 1 veteran x 1 visit per quarter )

(18 Veterans)

(monthly total)

Ordering Period Three PERIOD OF PERFORMANCE: July 01, 2023 – June 30, 2024

HUD-VASH Case Management

DO NOT PRICE

((Level 5 encounter 1 Veteran x 4 visits per month) 120 Visits (30 Veterans)

(Level 4 encounter 1 Veteran x 2 visits per month 50 Visits (25 Veterans)

(Level 3 encounter 1 Veteran x 1 visit per month) (26 Veterans)

(Level 2 encounter 1 veteran x 1 visit per quarter )

(18 Veterans)

(monthly total)

Ordering Period Four: PERIOD OF PERFORMANCE: July 01, 2024 – June 30, 2025

HUD-VASH Case Management

DO NOT PRICE

((Level 5 encounter 1 Veteran x 4 visits per month) 120 Visits (30 Veterans)

(Level 4 encounter 1 Veteran x 2 visits per month 50 Visits (25 Veterans)

(Level 3 encounter 1 Veteran x 1 visit per month) (26 Veterans)

(Level 2 encounter 1 veteran x 1 visit per quarter )

(18 Veterans)

(monthly total)

Ordering Period Five: PERIOD OF PERFORMANCE: July 01, 2025 – June 30, 2026

HUD-VASH Case Management

DO NOT PRICE

((Level 5 encounter 1 Veteran x 4 visits per month) 120 Visits (30 Veterans)

(Level 4 encounter 1 Veteran x 2 visits per month 50 Visits (25 Veterans)

(Level 3 encounter 1 Veteran x 1 visit per month) (26 Veterans)

(Level 2 encounter 1 veteran x 1 visit per quarter )

(18 Veterans)

(monthly total)

B.3 PERFORMANCE WORK STATEMENT

1. GENERAL

1.1 SERVICES REQUIRED: The Contractor shall provide HUD-VASH Housing Placement and Case Management Services for San Francisco VA Healthcare System in Marin, Mendocino, Lake, and Sonoma Counties, CA.

1.2 PERIOD OF PERFORMANCE: The period of performance (POP) shall be for one (1) year starting on the effective award date of the contract, with 4 ordering periods.

1.2.1 The Contractor shall not perform work beyond the POP unless there is written authorization by the Contracting Officer. Any work performed without prior authorization will be performed by the Contractor at no additional cost to the Government.

2. Background

2.2 The U.S. Department of Veterans Affairs (VA) is seeking a contractor to assist with the provision of housing placement and case management services through the HUD-VASH program. The program is a partnership between the U.S. Department of Housing and Urban Development (HUD) and VA Supportive Housing (VASH) to place and maintain homeless Veterans in permanent, community-based housing using HUD Section 8 Housing Choice Vouchers that are paired with ongoing VA case management services. Many of these Veterans have co-morbid conditions that include serious mental illnesses, substance abuse disorders, and other serious medical conditions. VA intends to engage a Contractor to provide housing placement services in Marin, Mendocino Lake, and Sonoma Counties along with ongoing case management services to HUD-VASH eligible Veterans and their families.

2.3 Contractors should be aware that 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, a Veteran must be:

2.3.1 Eligible for VA health care as determined by the local VA medical center

2.3.2 Determined to be homeless based on 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.

2.4 The target population for the HUD-VASH Housing Placement and Case Management contract includes chronically homeless Veterans who are the most vulnerable and may have severe mental health and/or substance abuse problems. Veterans may not be chronic 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 Substance Use Disorders (SUD), with frequent emergency room visits, multiple treatment failures, and limited access to other social supports. Through this contract initiative, Contractor(s) 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 shall be reserved for homeless Veterans with serious mental health problems who have few resources and require long-term case management to either obtain and/or maintain permanent supportive housing.

2.4.1 In addition to targeting the most vulnerable homeless Veterans, HUD-VASH utilizes a Housing First approach in working with Veterans to ensure rapid housing placement and stabilization. Housing First is an approach that centers on providing homeless individuals with “housing first” and then providing services and treatment as needed. What differentiates a Housing First approach from other strategies is that there is an immediate need and primary focus on helping individuals and families quickly access and sustain permanent housing.

2.5 Through this contract, the VA seeks to expedite the placement of HUD-VASH Veterans and their families in affordable, permanent housing and assist them in maintaining housing thereafter. This housing must meet the criteria for inclusion in HUD‘s Section 8 Housing Choice Voucher program. Contractors are expected to provide housing as part of this contract, but they are expected to have appropriate staff and resources in place to assist Veterans in finding acceptable community-based housing in a timely manner that meets Section 8 criteria. Housing inspections are conducted by the local Public Housing Authority or its agent. Some HUD-VASH housing units may be available through pre-approved project-based vouchers as agreed to by the local Public Housing Authority and the VA medical center.

2.6 The purpose of this contract is to enter into an Indefinite Delivery, Indefinite Quantity (IDIQ) firm fixed-price contract with a community partner (Contractor) who will provide housing placement, case management, and supportive services to Veteran beneficiaries as specified herein. All services shall be provided in accordance with the terms, conditions and provisions of this contract for a period of one year from the date of award, with the Government’s option to exercise four (4) one (1) year ordering periods. The Contractor shall provide all labor, supervision, supplies (including vehicles), and materials necessary to carry out the task specified in this Performance Work Statement (PWS). Performance will occur at the Contractor’s location and the San Francisco VA Healthcare System (SFVAHCS) unless otherwise required by work requirements listed in the PWS, or otherwise specified by the task orders issued under this contract. All services are to be performed within the Veteran Integrated System Network (VISN) 21 geographic areas.

2.7 VISN 21 geographic areas included in this contract and subsequent contract include the following VA Medical Center catchment areas: Marin, Mendocino, Lake and Sonoma Counties. The Contractor shall not commence performance on the resulting tasks order in the awarded contract until the Contracting Officer (CO) has conducted a kick off meeting or has advised the contractor that a kick off meeting has been waived.

2.8 The Contracting Officer’s Representative (COR) will evaluate all deliverables submitted. The COR is responsible for certifying invoices for payment only for deliverables received and deemed acceptable by the COR. A Quality Assurance Surveillance Plan (QASP) will be used by the COR to measure performance success and/or failure. VA Liaisons will be identified by the SFVAHCS HUD-VASH program. They will act as the clinical liaison for all Veteran related issues in conjunction with the COR between the Contractor and the VA homeless team. They will provide clinical oversight but will not provide direct clinical supervision.

2.9 Veteran/voucher referrals will be made to the Contractor at the discretion of the VA Medical Center. Contractors will work with the amount of cases per year based on the needs of the VA Medical Center.

3. General Requirements

3.2 Contractor shall provide case management and housing placement services to eligible beneficiaries per year for whom such care is specifically authorized by the referring VA. Contractor shall perform the following task:

3.2.1 The Contractor will need to ensure sufficient full-time staffing is in place with ratios at a minimum of 35:1.

3.2.2 Team staff composition must include case managers with credentials of Masters Level Social Worker (MSW), Licensed Clinical Social Workers (LCSW), Masters Level Marriage and Family Therapists (MFT) or Licensed Marriage and Family Therapists (LMFT). Team staff composition may be a combination of MFT, LMFT, MSW, and LCSW. The contractor Supervisor must be a Licensed Clinical Social Worker (LCSW) or Licensed marriage and Family Therapist. Unlicensed MSW and MFT staff shall register with an accredited state licensing board and be working to obtain official license in accord with state board regulations.

3.2.3 Contractor shall provide 24/7 coverage point of contact in case of emergency

3.2.4 Contractor shall comply with HUD-VASH and SFVAHCS policy and procedures for Veterans receiving services under this contract.

3.2.5 While most services will be provided in the home, the team will visit Veterans if hospitalized or incarcerated. They will also accompany Veterans to ER’s and, as needed, to clinics or other appointments

3.2.6 When Veterans have achieved housing stability, the focus of the service support changes to support community integration and other goals, it does not diminish

3.2.7 Case Management services shall follow the principles and practices of the Housing First Model

3.2.8 Team shall participate in continuing education related training including the Housing First Model, trauma informed care, motivational interviewing, relapse prevention, supported employment, and supported education.

3.2.9 The Contractor shall be able to provide full staffing as outlined in task and deliverables within 60 days of contract award either through existing staff or new hires.

3.2.10 Contractor personnel shall maintain an active standing with the licensing boards in their respective profession in accordance with the below requirements:

3.2.10.1 Basic Life Support (BLS) is required for all professional staff;

3.2.10.2 American Heart Association certification is preferred but not required.

3.2.11 Contractor shall assist Veterans with obtaining and maintaining housing authorized by HUD and the Public Housing Authority in the area assigned.

3.2.12 Contractor shall work with Veterans and their families with a wide range of backgrounds and bio psychosocial challenges and vulnerabilities including severe mental illness, chronic and current substance abuse, and serious medical problems.

3.2.13 Contractor will receive cases from HUD-VASH program and will confirm that the Veteran meets the criteria for admission into the HUD-VASH program, which includes ability to live independently. The Contractor must complete Homeless Operations Management and Evaluation (HOMES) documentation, consistent with the HOMES Reporting Policy, including but not limited to changes to admission, housing, voucher, or employment status, and Computerized Patient Records System (CPRS) encounter documentation including but not limited to a screening/admission note, treatment plan, release of information forms, housing service agreement, suicide risk assessment, Advanced Directive Discussions, and safety plan. Contractor shall document using the SOAP format for all clinical notes and ensure all CPRS encounters are entered after the service provided but no later than 72 hours of service in accordance with SFVAHCS HUD-VASH Documentation Policy.

3.2.14 Contractor must meet SFVAHCS encounter and productivity standards.

3.2.15 Contractor shall document Veteran encounters and change of Veteran status in the HOMES system within 72-hours of occurrence.

3.2.16 Contractor shall enter Veteran information, after obtaining a release of information, into the Coordinated Entry System that has been selected per county.

3.2.17 Contractor shall accompany Veterans to medical appointments, meetings, and other appointments as deemed necessary based on the clinical assessment. Contractor shall simultaneously work with Veterans to foster independence and a sense of self-determination.

3.2.18 Contractor shall participate in and coordinate with the VA COR/Liaison during weekly case conferences regarding updates and changes in the Veteran’s care plans to foster a collaborative relationship with the VA and Contractor in meeting the Veteran’s needs. Case conferencing may be done in person or by telephonic conference calls as determined by the VA COR.

3.2.19 The Contractor shall meet the same performance measures set forth for the VA by the VHA Homeless Program Office located in the technical manual “Performance Measures and Metrics”, this requirement shall include any subsequent updates and/or revisions, to include standards set forth in the VA Supportive Housing Target and Business Rules, including the responsibility to update the Employment Tracker in HOMES, our most recently added performance measure.

3.2.20 The Contractor shall work with the Veteran on obtaining housing, maintaining housing, independent living skills, budgeting, and employment and/or assistance obtaining VA benefits.

3.2.21 The Contractor shall make all communications with the VA regarding this contract through the Network Contracting Office (NCO) 21, via the VA COR.

3.2.22 The Contractor shall demonstrate successful completion of the following tasks, validated by VA inspection, prior to receiving case management referrals and invoicing for payment:

3.2.23 Attend a post-award kick-off meeting within seven days of contract award

3.3 Contractor shall provide Identification of staff to work directly with referred Veterans as outlined in the Performance Work Statement and their achievement of VA security and credentialing procedures including:

3.3.1.1 Security/background investigation via National Agency Check with Written Inquiries (NACI) and a Special Agreement Check (SAC) which includes electronic fingerprinting for case managers and their supervisor working with Veterans. In order to complete this background check, the Contractor must provide staff member’s date of birth, social security number, hair color, eye color, home address, phone number, and email addresses. U.S Citizenship or legal resident status will be verified as part of this process.

3.3.1.2 In order for case managers and their supervisor to perform under this contract, they must complete the credentialing process through the VA’s VetPro system. VetPro is necessary for all licensed, registered or certified clinical staff members (e.g. LCSW, RN, CASAC.) Information will be provided by SFVAHCS for staff to begin this process online. A Federal Personal Identification Card will also be issued; this requires an in person visit to the SFVAHCS Human Resources Department for verification of documents and photographs of the individual staff member.

3.3.1.3 Completion of the VA’s online Rules of Behavior Training in the VA’s Talent Management System (TMS) is required for case managers and their supervisor working directly with Veterans under this contract. Contractor staff must self-register for a TMS account. This can be done online. This requirement is in addition to any other training that may be required of the Contractor(s) and any sub-contractor(s).

4. Contractor Outreach/Case Management Duties

4.2 The Contractor shall have procedures in place to ensure Veterans have access to case management services Monday – Friday 8am – 4:30pm, which shall include crisis management and referrals. 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.

4.3 The Contractor shall have adequate and appropriate space available at the Contractor location for the VA staff to conduct group meetings with the Veterans under contract care. Contractor shall also submit a monthly tracking sheet derived from the HOMES OR7 and delivered in that format approved by the COR that provides status updates for Veterans receiving services under this contract regarding change in level of care, milestones met, employment/benefits, potential discharges, case management interventions, and other fields as approved by the COR. A list of all home visits to also be provided monthly to the VA Liaison.

4.4 Contractor shall ensure that sufficient staff are available to provide services to meet the documented needs of the Veterans and the VHA performance standards as referenced above, as well as the ability to make home visits consistent with the level of care each Veteran is being treated at in addition to the following:

4.4.1 Ensure consistency of Assertive Community Treatment (ACT) team services to enhance staff’s ability to engage and form relationships with Veterans and provide consistent and highly skilled interventions in keeping with the HF-ACT model.

4.4.2 Comply with documentation and data reporting as required by SFVACHS based on changing or subsequent local, VISN, or national HUD-VASH requirements and policies.

4.5 Contractor shall perform the following Case Management duties:

4.5.1 Engage the Veteran in the HUD-VASH process and perform interviewing, counseling, and case management of identified Veterans who are at risk; providing psychosocial assessments to identify treatment needs which affect Veteran’s adjustment to their environment, and establish treatment goals

4.5.2 Contractor will conduct high-risk screening, psychosocial assessment and treatment planning, actively involving the Veteran and their family or significant others, in coordination with the treatment team members. Psychosocial assessments will include goals for clinical treatment. Contractor coordinates and documents clinical case management and psychosocial services and documents the overall effectiveness of the case management services provided.

4.5.3 Specifically, Contractor will complete the following:

4.5.3.1 Psychosocial Assessment: The contractor case manager is responsible for utilizing the “Social Work Psychosocial Assessment Note” template in CPRS. This assessment will be completed before the Veteran receives the HUD-VASH voucher from the local Public Housing Authority. The psychosocial assessment is updated when there are significant changes in the Veteran’s status or condition, but at a minimum of once every year.

4.5.3.2 Social Work Treatment Plan: The contractor case manager is responsible for utilizing the “HUD-VASH SW Treatment Plan Note” template and progress note title in CPRS. The SW Treatment Plan will be completed at the same time the initial Psychosocial Assessment is completed. In addition, the case manager will use a collaborative approach in completing the plan with the Veteran. The Treatment Plan should be updated annually or when there are significant changes in the Veteran’s status or condition. For example, when Veteran goes from homeless to permanent housing, this is considered “significant change” and a review and update in Treatment Plan is required. Care should be taken to develop measurable goals, which are revisited during regular meetings between the case manager and the Veteran.

4.5.3.3 Contractor shall review the Treatment Plan at least every ninety (90 days) in a clinical meeting with VA Liaison and document changes in treatment plans in consultation with the Veteran and the VA liaison.

4.5.4 Utilize counseling strategies to include crisis intervention and case management including both short- and long-term services working toward long range HUD-VASH program discharge, otherwise known as “graduation.”

4.5.5 Screen each Veteran for suicidal and homicidal risk with each contact. This screening shall be documented in progress notes, suicide risk assessments, and safety plans. Contractor shall document the aforementioned in the VA medical record. If the Veteran is a danger to him/herself or others, the Contractor shall take immediate steps to provide appropriate intervention. Crisis management shall be coordinated and executed by the contractor and shall be reported to the VA COR and other VA staff in accordance with Section 8 – Contractor 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; this requirement shall include any subsequent changes, updates, or revisions to the PIH Notice.

4.5.6 Contractor will notify SFVA of any negative incident occurring with Veteran within one (1) working hour of being aware of the incident. Contractor will complete a written incident report within eight (8) working hours of notification, which may include VA Report of Contact documentation. Incidents include but are not limited to: death, fire, drug / police raid, suicide / suicide attempt, 911 call (police / fire dept. / paramedics / other), severe medical illness / emergency, severe psychiatric illness / emergency, sexual assault, act of violence by Veteran against other(s), abusive behavior by Veteran against staff, act of violence by other(s) against Veteran, abusive behavior by staff against veteran, accident, medication problems or adverse drug reactions, or other untoward events.

4.5.7 The VA Liaison may act as the Mental Health Treatment Coordinator.

4.5.8 Facilitate the Veteran’s involvement in therapeutic and work restoration programs, intervening and advocating on behalf of the Veteran.

4.5.9 Contractors shall provide and/or coordinate direct mental health and substance abuse counseling within their scope of practice and assist in securing available VA services using tele-mental health services when appropriate. The Contractor shall also facilitate the Veteran’s involvement in therapeutic and work restoration programs, such as Transitional Work Experience (TWE), as appropriate.

4.5.10 Contractor shall integrate Housing stabilization planning with relevant VA health and mental health services. Contractor shall refer and provide transportation to VA Medical Facilities, VA Regional Offices, and community-based agencies for a variety of services that may include health care, entitlements, vocational assistance, education, recreation, and any other needed assistance.

4.5.11 Contractor shall have procedures in place to ensure clients have 24/7 access to live person-to-person case management services which shall include crisis management and referral.

4.5.12 The Contractor will be paid a flat rate per Veteran per encounter per month based on services rendered in accordance with the requirements established in this PWS. The Contractor is encouraged to pursue case management discharge for Veterans. The VA may assign additional Veterans to the Contractor for case management services to replace those Veterans who have been discharged from the program. Assignment of additional Veterans for case management services is not guaranteed and will be dependent upon the demand for such services and the VA’s needs at that time.

4.5.13 The Contractor shall create and retain records that provide evidence of contacts with individuals and agencies engaged to support the Veteran’s housing and recovery needs. Members of the HF-ACT team must only work within the scope of their trained field of practice.

4.5.14 Clinical Documentations that must be completed by a MSW, LCSW, MFT, or LMFT:

4.5.14.1 Suicide Risk Assessment Prevention Plans (SRAPP)

4.5.14.2 Clinical reminders

4.5.14.3 Psychosocial Assessment and Treatment Plan

4.5.14.4 Case Management Stage determination

4.5.15 The Contractor shall create records in CPRS that provide evidence of contacts with individuals and agencies engaged to support Veteran’s housing and recovery needs.

5. Case Management Visits

5.2 Case management and home visits to Veterans shall be conducted in accordance with the HUD-VASH Directive and the SFVAHCS HUD-VASH Case Management Policy. The Contractor shall provide at the end of each month a list of all Veterans assigned to each level of care for review and verification of services rendered according to the needs of the Veteran.

5.3 The Contractor shall visit each Veteran face-to-face at the intervals required by the HUD-VASH Directive and the SFVAHCS HUD-VASH Case Management Policy. Visits are to take place in the Veteran’s home. Until the Veteran is housed or as clinically indicated once housed, visits may occur in the community, at the Contractor agency, or a place mutually agreed upon by the Veteran and Case Manager. 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. In the event the Contractor is unable to locate the Veteran for the required number of visits, the Contractor will document face-to-face attempts, phone calls, and letters sent to the Veteran including dates and times in CPRS as verification of services rendered.

5.3.1 There are five basic levels of case management: Intensive, Stabilization, Maintenance, Preparation for Discharge and Graduation/Discharge.

a) Acuity Level 5 – Intensive. The HUD-VASH Case Management team works with the Veteran to obtain clinical stability. At a minimum, weekly home visits are required, but even more frequent interactions may be needed.

b) Acuity Level 4 – Stabilization. At this stage, Veterans are more adept at managing their housing responsibilities and their physical, mental health, and substance use disorders are more stable as the Veteran works on addressing those issues that are most likely to lead to housing instability. At least twice a month home visits are required, with additional interactions as needed.

c) Acuity Level 3 - Maintenance. Case management services ensure that needed treatment, support, and mentoring assistance continue after placement in housing. Home visits need to occur at least every month, once the Veteran demonstrates stability, independence, and improved coping skill use and recovery. Other interactions, such as phone calls, may be indicated.

d) Acuity Level 2 - Preparation for Discharge. Veterans who have functioned at a very independent level for at least one year and sustained a low acuity level may be considered for this phase to practice and plan for discharge from HUD-VASH. Case management can be provided in the home, community, or at the medical center. During this phase, contacts are to occur at least quarterly and the focus of case management would address steps towards graduation from case management, and/or discharge

e) Acuity Level 1 - Graduation/Discharge. Graduation is for Veterans who no longer need the case management services in HUD-VASH, and thus, the Veteran is not required to participate in case management. A Veteran is discharged from HUD-VASH when he/she is no longer participating in case management. If the Veteran is retaining the HUD-VASH voucher for financial purposes only, he or she is considered in graduation status.

4.2 Addendum – EMERGENCY RESPONSE PROTOCOL – Approval of Non-Face-To-Face Case Management Encounters

As means of contractor performance compliance at times when local and/or national emergency response guidance advises against face-to-face contacts (i.e., pandemic), The San Francisco VA Health Care System (SFVAHCS) HUD-VASH Case Management Policy may be temporarily modified to allow telephone calls, telehealth, MyHealtheVet, or other approved virtual applications as an allowable and billable case management contact with Veteran in lieu of a face-to-face encounters. Under circumstances where local and/or national emergency response guidance advises against face-to-face contacts, the contractor shall abide by SFVAHCS HUD-VASH Case Management Policy directives when the following are met:

1. National HUD-VASH Program Office provides directives to the field approving alternatives to face-to-face case management encounters

1. SFVAHCS HUD-VASH Program Director implements the directive (s)

1. Concurrence is provided by the Contracting Officer for final approval.

Under such circumstance the following take effect:

1. When local and/or national emergency response guidance advises against face-to-face contacts, the SFVAHCS HUD-VASH Program, in accord with National HUD-VASH Program Office may strongly encourages contractor staff to encounter Veterans via telephone calls, telehealth, MyHealtheVet, or other approved virtual applications. While most Veterans admitted to HUD-VASH would benefit from in-person support with housing searches and PHA application completion, HUD-VASH contractor staff may still be able to assist with these activities via telephone, telehealth, or other virtual support. Some examples of this type of support include practicing answering landlord questions, supporting independent completion of the housing packet and assisting with requesting needed materials, and directing to Veterans to available housing units. Additionally, HUD-VASH staff may be able to use mobile technology options to support a Veteran when they are visiting rental properties.

1. SFVAHCS HUD-VASH Program will independently assess the ability of the contractor to continue HUD-VASH admissions, factoring staffing capacity, facility priorities, PHA operations, and local and/or national emergency management guidance. When possible, contracted HUD-VASH case managers are encouraged to continue HUD-VASH admissions utilizing telephone, telehealth, and virtual means to conduct assessments and clinical services.

1. SFVAHCS HUD-VASH Program, in accord with National HUD-VASH Program Office strongly encourages HUD-VASH teams to work with local PHAs to develop and support flexible means of conducting briefings and issuing vouchers where possible. Some creative options employed by PHAs include:

2. Conducting individual or group briefings with Veterans via telephone;

2. Creating an audio or video recording (utilizing YouTube, Adobe Connect, or similar) which Veterans can access on personal, public, or VA devices;

2. Waiving requirements for photo identification and Social Security Number verification at time of voucher application when offices that issue those documents are closed;

2. Allowing Housing Quality Standards (HQS) inspectors to inspect vacant units and/or allowing landlords to self-certify new units meet standards without HQS visiting the units.

1. During a national emergency, SFVAHCS HUD-VASH Program, in accord with National HUD-VASH Program Office may advise contractor staff to make a good-faith effort to contact all Veterans in the HUD-VASH program on a regular basis according to level of acuity, including those that have graduated case management but retain a housing voucher, to assess their status, educate them on emergency response facts, and ensure client are safe, have adequate food supply, and medications. In emergency situations, Veterans may need assistance managing stress, anxiety, or loneliness or addressing other psychosocial concerns or case management needs during this uncertain times.

1. Billing for Telephone Encounters and Invoice and Payment When emergency response guidance advises against face-to-face contacts, the SFVAHCS HUD-VASH Program shall determine the start and end dates of the HUD-VASH Case Management Policy temporary modification to allow telephone calls, telehealth, MyHealtheVet, or other approved virtual applications. If the Contractor can demonstrate and document a successful case management telephone encounter according to standards of a face-to-face encounter, the Contractor shall receive payment for services rendered. Acceptance of services per Veteran for billing purposes will be based on the documentation criteria outlined in SFVAHCS HUD-VASH Documentation Policy, which will serve as proof of VASH enrollment and services rendered. Documentiaon of a billable telephone encounter shall include a record or log submitted to VA for approval of each attempt to contact the Veteran client, including all unsuccessful attempts and all successful attempts.

Invoices submitted for payment shall be reviewed for accuracy, verified against patient records to determine services rendered meet the standards defined in this PWS, time records and attendance logs and shall be subject to approval by the VA prior to remittance of payment. Any discrepancies found shall be brought to the attention of the Contractor for resolution. A corrected copy of the invoice must be submitted by the Contractor, as instructed by the VA within three (3) working days of invoices being returned.

Invoices shall include all charges for care provided and payment made shall constitute payment in full for services rendered. Contractor shall not bill any additional charges to the patient, the patient’s family, or the patients’ insurance unless otherwise authorized by the VA. The following criteria will be used by the facility VA COR to adjust monthly invoices when the requirements identified in this PWS have not been fully met by the contractor for each Veteran billed. All other scenarios outside of the ones outlined in paragraph 38 will be reviewed and approved by the VA Liaison and/or COR.

5.4 In addition to documenting contact with the Veteran, the contractor shall also document in CPRS evidence of collateral contacts with individuals and agencies engaged to support the Veteran’s housing and recovery needs.

5.5 The designated Case Management Stage and corresponding minimum visit requirement determination shall require the concurrence of VA, based on the documented needs of the Veteran and a joint clinical case conference between the VA Liaison and Contractor, which will occur on a minimum of a quarterly basis as required by the HUD-VASH Directive and SFVAHCS policy. No changes in the visit schedule shall occur without concurrence from the VA Liaison. However, if a Veteran presents with an urgent need for increased contact, the Contractor will provide services based on the presenting needs prior to review with the VA Liaison.

6. COST/PRICE

6.2 The Contractor shall be paid per Face-to Face encounter with the Veteran based on the Veteran’s acuity level during that month. (A client’s acuity level may change month to month). The acuity level determines the required frequency of encounters:

6.2.1 Level 5 is encountered weekly (4x/month)

6.2.2 Level 4 is encountered bi-weekly (2x/month)

6.2.3 Level 3 is encountered monthly (1x/month)

6.2.4 Level 2 is encountered quarterly (1x/90 days)

5.2 The Contractor shall invoice for all billable monthly encounters (not to exceed maximum frequency/number of encounters) at each CLIN unit rate (acuity level) for the number of encounters at that acuity level during the month. The unit rates for each CLINs (acuity 2-5) combine for a monthly invoice total.

Encounters per month

month)

TOTAL EST. PRICE

(1 year)

Case Management Acuity Level 5 – Intensive in accordance with the Performance Work Statement

(Level 5 encounter 1x/week / 4 per month)

b. $_______ per month for 80 encounters per month

(monthly total “b.” x 12)

Case Management Acuity Level 4 – Intensive in accordance with the Performance Work Statement

(Level 4 encounter 2x/month)

b. $_______ per month for 44 encounters per month

Case Management Acuity Level 3 – Intensive in accordance with the Performance Work Statement

(Level 3 encounter 1x/month)

b. $_______ per month for 70 encounters per month

Case Management Acuity Level 2 – Intensive in accordance with the Performance Work Statement

(Level 2 encounter 1x/quarter )

b. $_______ per month for 9 encounters per month

(monthly total “b.” x 12)

Total:

7. Housing First

7.2 Housing First is an approach that centers on providing homeless individuals with housing quickly, and then providing services and treatment as needed. What differentiates a Housing First approach from other strategies is an immediate need and primary focus on helping individuals and families quickly access and sustain permanent housing. Housing First programs share four critical elements:

7.2.1 Focus on helping individuals and families access and sustain rental housing as quickly as possible and the housing is permanent;

7.2.2 A variety of services are delivered primarily following a housing placement to promote housing stability and individual well-being;

7.2.3 Services are time-limited or long-term depending upon the individual need;

7.2.4 Housing is not contingent on compliance with services. Participants must comply with a standard lease agreement and are provided with the services and supports necessary to help them to obtain and maintain housing and reintegrate into the community.

7.3 In addition to meeting all the task and deliverables for HUD-VASH case management contained herein, the Contractor shall also provide the following:

7.3.1 A Licensed Clinical Social Workers or Licensed Marriage and Family Therapists as the HF-ACT Team Supervisor

7.3.2 The HF-ACT Team Supervisor and Case Managers must be full time employees and full time to this HUD-VASH contract.

8. Contractor Housing Placement & Stabilization Duties

8.2 The Contractor shall perform Housing Placement & Stabilization Duties that include:

8.2.1 Develop with the Veteran and VA Liaison a Treatment Plan before the HUD-VASH voucher is administered to the Veteran.

8.2.2 Consult with the VA Liaison and Veteran regarding any changes in the Treatment Plan and receive VA approval prior to any discharge from the program.

8.2.3 Accompany Veteran to any Public Housing Authority appointments including annual certifications, briefings, and interim appointments. Contractor shall assist Veteran in completing and submitting PHA and other Federal, local and state entitlement program paperwork (e.g. Social Security, food stamps, utility assistance, etc.)

8.2.4 Advocate with…