36C26223R0021_1.docx

36C26223R0021

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

36C26223R0021 04-10-2023 Danielle L. Carroll 562-766-2240 05-09-2023

10AM

PDT

36C262 ATTN: Danielle L. Carroll, CS Network Contracting Office 22 4811 Airport Plaza Drive Suite 600 Long Beach CA 90815 X 624229 $16.5 Million N/A X 36C691 Department of Veterans Affairs VA Greater Los Angeles Healthcare System 11301 Wilshire Blvd Los Angeles CA 90073 36C262 Department of Veterans Affairs Network Contracting Office 22 4811 Airport Plaza Drive Suite 600 Long Beach CA 90815

36C262 Department of Veterans Affairs Financial Services Center Submit Invoices Electronically to:

https://www.Tungsten-Network.com

1(877)489-6135 HUD-VASH Housing Placement, Case Management and Supportive Services to the Services For homeless Veterans in the VAGLAHS catchment area.

Please see subsequent pages.

See CONTINUATION Page X X X Table of Contents

D.6 ATTACHMENT AA HUD-VASH TEAM ROLES.V (SEE ATTACHED) 70

D.7 ATTACHMENT B HUD-VASH DOCUMENTATION. (SEE ATTACHED) 70

D.8 ATTACHMENT BB HUD-VASH CASE MANAGEMENT. (SEE ATTACHED) 70

D.9 ATTACHMENT C VHA DIRECTIVE 1162.05 HUD-VASH PROGRAM 02. (SEE ATTACHED) 70

D.10 ATTACHMENT CC HUD-VASH NURSING SERVICES - REFERRAL, MANAGEMENT AND DISCHARGE POLICY. (SEE ATTACHED) 70

D.11 ATTACHMENT D CASE CONFERENCE GUIDE FOR LIAISONS. (SEE ATTACHED) 70

D.12 ATTACHMENT DD PREINSPECTIONSCHECKLIST. (SEE ATTACHED) 70

D.13 ATTACHMENT E MENTAL HEALTH TREATMENT PLAN . (SEE ATTACHED) 70

D.14 ATTACHMENT EE HUD-VASH LANDLORD SOP. (SEE ATTACHED) 70

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:

b. GOVERNMENT: Department of Veterans Affairs, Network Contracting Office -22 Danielle Carroll, Contract Specialist 4811 Airport Plaza Drive Suite 600, Long Beach, CA 90815 Telephone number: 562-766-2240 Email: Danielle.carroll4@va.gov

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:

c. Other [x]: To be determined

4. GOVERNMENT INVOICE ADDRESS: Please contact Tungsten at the phone number or email address listed below to begin submitting your electronic invoices to the VA Financial Services Center for payment processing. If you have any questions about the e-invoicing program or Tungsten, please contact the FSC at the phone number or email address listed below:

· Tungsten e-Invoice Setup Information: 1-877-489-6135

· Tungsten e-Invoice email: VA.Registration@Tungsten-Network.com

· Website: www.tungsten-network.com

· FSC e-Invoice Contact Information: 1-877-353-9791

· FSC e-Invoice email: vafsccshd@va.gov

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

B.2 SCHEDULE OF SERVICES AND PRICE

The guaranteed minimum amount for this contract is $2,000.00. the maximum aggregate value of the orders that can be placed under this contract is $40,000,000.00. The Government does not guarantee that it will place any orders under this contract in excess of the guaranteed minimum amount.

The contract period of performance for this Multiple Award Indefinite Delivery Indefinite Quantity (IDIQ) contract is five (5) years from June 1, 2023 through May 31, 2028. The schedule of services and price below indicates pricing for each contract year.

Contract Year One (1): June 1, 2023 – May 31, 2024

Contract Year Two (2): June 1, 2024 – May 31, 2025

Contract Year Three (3): June 1, 2025 – May 31, 2026

Contract Year Four (4): June 1, 2026 – May 31, 2027

Contract Year Five (5): June 1, 2027 – May 31, 2028

B.3 STATEMENT OF WORK

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 VA Greater Los Angeles Healthcare System (VAGLAHS) catchment area to HUD-VASH eligible Veterans and their families. VAGLAHS’s catchment area includes Kern, Los Angeles, San Luis Obispo, Santa Barbara, and Ventura counties.

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, a Veteran must be: Eligible for VA health care as determined by the local VA medical center, 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.

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, or otherwise specified by the task orders issued under this contract.

2.2. The Contractor shall submit all deliverables to the VA’s Contracting Officer’s Representative (VA COR) or VA Contract Liaison(s) (VA Liaison) designee, who will evaluate all deliverables submitted and certify invoices based upon acceptable deliverables. Contractor performance will be evaluated by the VA COR or designee using a Quality Assurance Surveillance Plan (QASP). The VA 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.

2.3. Clinical oversight refers to a working relationship between VA COR and Contractor. The VA Liaison monitors compliance with the contract deliverables, and quality of care that is provided to Veterans. VA 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 without reliance on the VA 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 use 100% of the vouchers issued. The VA may make additional Veteran/voucher referrals to the Contractor HUD-VASH program. Contractors shall perform all services described in this SOW for each Veteran enrolled in the program.

2.6. Task Order Ordering Procedures. Task orders shall be issued against this IDIQ contract and shall be competed amongst all IDIQ contract holders by issuing competitive requests for proposals (RFP) to the IDIQ contract holders. Evaluation criteria used to determine the task order awardees and the number of Veteran vouchers issued for each task order will be included in the task order RFP. Price shown in the Schedule of Services and Price for the base IDIQ contract (Section B.2 of this contract) is the maximum price that the Contractor may charge for each line item listed in the Schedule for services provided during the dates shown in the Schedule. The Contractor may propose to provide the Schedule services at less than the Schedule price, but the Contractor shall not propose prices that exceed the Schedule price applicable to the dates that apply to the task order period of performance.

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 resident town hall, recovery groups, recreational activities, life skills group, substance abuse groups, bringing in community resources (e.g., legal, financial), Peer support groups, religious/church services and/or employment services/opportunities.

3.3. Contractor shall provide case management in accordance with Attachment A, Stages of Case Management, and minimum visit requirements (SOP) and Attachment BB, HUD-VASH Case Management SOP. Contractor shall maintain staffing at a weighted caseload capacity that doesn’t exceed 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 marital and family therapist/licensed mental health counselors, nurses, psychologists and may also include housing specialist and peer support specialists. Contractor’s clinical supervisors shall have a minimum of a Master’s Degree of Social Work or Marriage and Family Counseling with the appropriate licensure of LCSW/LMFT as per the qualifications outlined in section 5 of this Statement of Work (SOW).

3.5. Contractor shall provide case management services 24 hours per day, 365 days per year.

3.6. Contractor shall comply with HUD-VASH and GLA policy and standard operating procedures (SOPS) and evaluation standards for Veterans enrolled in HUD-VASH reference Attachment B, HUD-VASH Documentation SOP, which is made part of this contract and is incorporated by reference herein. 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 VA COR or designee. If a Veteran assigned a voucher leaves the VAGLAHS 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 C, VHA HUD-VASH Directive and Attachment A, HUD-VASH Stages of Case Management and Minimum Visit Requirements SOP, 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 Pathways Housing First Model (written by Sam Tsemberis).

3.12. Contractor staff is encouraged to participate in any continuing education training that is related to Pathways Housing First model, trauma informed care, motivational interviewing (refer to definitions section of this SOW), relapse prevention, supported employment, supported education and all suicide prevention and related documentation training provided by the VA. The Contractor shall participate in VA mandatory trainings if serving on this contract. If the Contractor provides their own similar trainings for staff, the contractor shall provide documentation to the VA COR or designee demonstrating that these trainings are performed by a certified trainer.

3.13. The Contractor shall have 60 days to mobilize required staff to meet the terms and conditions of this contract after award.

3.14. The Contractor shall maintain Basic Life Support (BLS) 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 and, when clinically indicated, mental health and or addiction services.

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 days.

3.18. Contractor shall assess Veterans to determine if the Veteran meets the criteria for admission into the HUD-VASH program. The Contractor shall complete HOMES documentation, consistent with the HOMES Reporting Policy and VA Medical documentation, consistent with Attachment B- HUD-VASH Documentation Standard Operating Procedure (SOP), 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, in accordance with Attachment B- HUD-VASH Documentation Standard Operating Procedure (SOP).

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 J, VHA Directive 182 Patient Care Data Capture and Attachment K, VHA Directive 1161 Productivity And Staffing In Clinical Encounters For Mental Health Providers.

3.19. The Contractor’s Program Manager shall engage in weekly administrative meeting with the VA 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.

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. 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.

3.22. Contractor shall ensure staff that possess a degree in Social Work or Marriage and Family counseling, complete the credentialing process through the VA’s VetPro system in alignment with the VetPro policies and operating procedures 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).

3.23. Contractor shall complete the VA’s online Information Security and Privacy Awareness Training Course, the Privacy Policy Awareness Training Course, and Mandatory Training for Transitory, Part-Time and Intermittent Clinical Staff (MTTCS) for case managers and their supervisors working directly with Veterans under this contract.

4. ADMISSION/REFERRALS.

4.1. Veterans enter the HUD-VASH program by being identified as meeting HUD- VASH admission criteria (Reference Attachment C VHA Directive 1162.05 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 (Reference Attachment M HOMES Forms) 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 without VA approval 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 VA 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 Contract Coordinator, HUD-VASH Coordinator or designee. Contractors shall maintain a list of Veterans who do not meet the eligibility criteria and provide those Veterans with a copy of HUD-VASH Denial letter reference attachment N, which is made part of this contract and is incorporated by reference herein. Veterans must be informed that they have a right to file an appeal within 60 days from receipt of the denial letter by following the process noted in the letter. Veterans shall also be provided with alternate resources for housing. Reference Attachment X to the contract.

4.5. If Veteran was previously screened and denied admission to the HUD-VASH program by VA, as evidenced by screening note in VA Medical record, Contractor shall contact VA COR or designee to consult prior to completing another screening and/or current admission into program.

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 sign acceptance form for case management services provided by the Contractor. The appropriate documentation indicating case management acceptance needs to be entered in 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 by the VA to be eligible by the VA Greater Los Angeles Healthcare System (VAGLAHS) Enrollment and Eligibility Office based on having one of the following military discharge types:

4.9.1.1.1.1. Honorable Discharge

4.9.1.1.1.2. General Discharge

4.9.1.1.1.3. Other than Honorable Discharge (no court-martial or special court-martial)

4.9.1.1.1.4. Bad Conduct Discharge (from a special court-

martial)

4.9.1.1.1.5. Uncharacterized (Entry Level Separation)

4.9.1.1.1.6. Undesirable (confirm with Eligibility, must be

adjudicated)

4.9.1.1.2. 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.

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 (Reference Attachment DD Pre-inspection Checklist, which is made part of this contract and is incorporated by reference herein). 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, and document these engagements in the VASH Landlord note in the VA medical record system (Refer to Attachment EE HUD-VASH Landlord SOP, which is made part of this contract and is incorporated by reference herein). 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 Medi-Cal and accessing community-based services when ineligible for VA Healthcare.

4.9.8. Contractor shall conduct site visits of HUD-VASH apartments to ensure that Veterans reside in healthy residences in accordance with VHA Directive 1162.05 HUD-VASH Program, Attachment C and HUD-VASH Stages of Case management and minimum visit requirements SOP, Attachment A all of which are made part of this contract and incorporated by reference herein. Veterans in these units have been identified as psychiatrically and medically complex. The Contractor shall conduct 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 twenty-four (24) hours per day, 365 days per year, which shall include crisis management and referrals (See Reference Attachment BB HUD-VASH Case Management, which is made part of this contract and is incorporated by reference herein).

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. Non-compliance with Case management services may result in a loss of housing and/or voucher.

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.

5.2.4. Contractor shall apply Harm Reduction interventions when working with Veterans.

5.3. Contractor shall provide office space for their staff to conduct their business and conduct meetings with Veterans as needed and furnish all required equipment to staff to complete all tasks as stated in this SOW. Contractor staff shall ensure meetings are always respectful of Veterans privacy.

5.4. Contractor shall submit a monthly tracking sheet (commonly referred to as White Board) approved by the VA COR. Directive Date, Phone numbers and any additional comments or other fields as approved by the VA COR or designee.

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 Mental Health treatment plan (MHTP) Attachment E Mental Health Treatment Plan and Attachment W Mental Health Treatment Plan Goals, which are made part of this contract and are incorporated by reference herein, 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. For MHTP entry time frames reference Attachment B, HUD made -VASH Documentation SOP, which is part of this contract and is incorporated by reference herein.

5.5.2. Review and update the MHTP 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 MHTP in the VA medical record.

5.5.3. Comply with additional documentation and/or data reporting for the Housing First demonstration as required by VAGLAHS 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. Reference: Attachment Y Sample Psychosocial Assessment.

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 per Attachment O CERS Procedure for Medical and Psychiatric Emergency Response in the Community and Attachment F CERS Management and Escalation of Health Status Concerns, which are made part of this contract and are incorporated by reference herein.

5.5.7. Crisis management shall be coordinated and executed by the contractor and shall be reported to the VA COR or VA Liaison and other VA staff in accordance with Attachment F CERS Management and Escalation of Health Status Concerns and Attachment G CERS Incident-Death Reporting Manual, which are made part of this contract and are incorporated by reference herein.

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. Assess and promote engagement with appropriate healthcare, especially mental health and addiction care when clinically indicated. Reference Attachment H CERS Primary Care Engagement SOP, which is made part of this contract and is incorporated by reference herein.

5.5.11. 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. Contractor shall have procedures in place to ensure clients have 24/7 access to clinical staff who can provide case management services which shall include crisis management and referral. A staff member shall be identified for on-call (by phone) after hours and weekend phone calls as needed.

5.9. The Contractor shall visit each Veteran face-to-face at the intervals required by HUD-VASH Directive Attachment C and Stages of Case Management and Minimum Visit Requirements, Attachment A, which are made part of this contract and are incorporated by reference herein. Additionally, the Contractor shall adhere to the following:

5.9.1. The Contractor shall notify the VA 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 VA COR or designee have concerns regarding the change of LOC, the Contractor shall engage in a discussion with the VA COR or designee regarding this change. This discussion may lead to the change of LOC not being approved if the VA 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.”

5.10.2. 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:

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 VA 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:

5.10.2.2.3. 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 VA 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 VA 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 VA COR or designee. The Contractor shall consult the VA 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…