36C26226Q1477.docx

SUBJECT*

Veteran Affairs Greater Los Angeles (VAGLAHS) Tenant Based Vouchers (TBV)

GENERAL INFORMATION

SET-ASIDE

Network Contracting Office 22 4811 Airport Plaza Drive Suite 600 Long Beach CA 90815

POINT OF CONTACT*

Danielle Carroll Danielle.Carroll4@va.gov

PLACE OF PERFORMANCE

VA Greater Los Angeles Healthcare System

11301 Wilshire Blvd

Long Beach CA

COUNTRY

ADDITIONAL INFORMATION

AGENCY’S URL

URL DESCRIPTION

AGENCY CONTACT’S EMAIL ADDRESS

EMAIL DESCRIPTION

THIS REQUEST FOR INFORMATION (RFI) – SOURCES SOUGHT IS ISSUED SOLELY FOR MARKET RESEARCH AND PLANNING PURPOSES ONLY AND DOES NOT CONSTITUTE A SOLICITATION.

1. Responses to this Sources Sought must be in writing. The purpose of this Sources Sought Announcement is for market research only to make appropriate acquisition decisions and to gain knowledge of Small Business Capability, including Service-Disabled Veteran Owned Small Businesses and Veteran Owned Small Businesses (SDVOSB/VOSB) interested and capable of performing the work.

2. The NAICS for this requirement is 624229 – Other Community Housing Services

3. VA Greater Los Angeles Healthcare System (VAGLAHS) requires the services of a contractor to provide Housing and Urban Development-VA Supportive Housing (HUD-VASH) Housing Placement and Case Management services for Homeless Veterans. Contractors interested and capable of providing these services are asked to respond to this RFI by providing examples of their experience providing housing placement and case management services for people experiencing homelessness. Interested and capable vendors shall respond by providing the below information for up to five (5) recent (within 3 years) examples of your relevant experience providing housing placement and case management services for people experiencing homelessness. If you do not provide any examples or fail to provide enough information for the Government to meaningfully consider, you will not be considered a viable source:

a) The legal name of the entity with whom the Contractor held the contract.

b) The contract number.

c) A detailed description of services providing housing placement and case management services for a population of 870 Veterans or greater. Include what services you provided, how you provided those services, and staffing levels under the contract. Re-statements or summaries of the Performance Work Statement (attached) will not be considered.

d) The geographic location where the Contractor performed these services.

e) The dates during which the Contractor performed the contract.

f) The monthly service volume under the contract broken down by month for a 12-month period, reflecting the number of individuals experiencing homelessness the Contractor supported through housing placement and case management services. If there are fluctuations in the number of individuals serviced each month, include an explanation for the fluctuation.

g) Indicate if your company performed the services or if you subcontracted/teamed/partnered with another entity to perform services. If you subcontracted/teamed/partnered with another entity, describe the services you performed and the services your subcontractor/partner performed.

h) The name, phone number, and email address of a person at the entity with whom the Contractor held the contract who can verify this information.

The Government’s need for services requires immediate mobilization with a maximum of 30 days to onboard/mobilize. Due to the critical nature and importance of the services, you must be able to start immediately. Please respond to the following:

a. How many case managers do you currently employ that have the capacity to take on this work? Do NOT respond with the total number of employees in your company. We are looking to see the capacity your firm/employees have to take on this new workload.

b. If you do not currently have any employees with capacity, how would you hire and train staff to be able to perform by the contract start date? The response must be realistic and tangible (not vague).

c. Describe your hiring practices and if you offer any incentives for retention of staff.

d. How many individuals does each case manager currently service each month?

e. What is your selection criteria when hiring case managers?

4. Responses shall be submitted via email to Danielle.Carroll4@va.gov by October 22, 2026. Responses shall also include the interested Contractor’s Unique Entity Identification (from SAM) and the type of small business, if applicable, (e.g. Services Disabled Veteran Owned small business (SDVOSB), Veteran-owned small business (VOSB), 8(a), HUB-Zone, Women Owned Small Business, Small disadvantaged business, or Small Business).

5. Please see below DRAFT Statement of work (page 4) excerpt from the impending solicitation. This draft is for information only and no questions regarding this SOW will be considered.

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B.3 STATEMENT OF WORK

1. BACKGROUND.

1.1. The U.S. Department of Veterans Affairs (VA) requires a contractor with demonstrated experience in the U.S. Housing and Urban Development (HUD) and Veterans Affairs Supportive Housing (VASH) (HUD-VASH) program to provide case management and supportive services for Veterans who would benefit from these services due to the complexity and acuity of their needs. 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. The contractor shall provide outreach, housing placement and case management 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: includes all of 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 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 SUD, with frequent emergency room visits, multiple treatment failures, and limited access to other social supports. The Contractor assess each applicant on an individual basis and prioritize highest need for the program based on the Veterans acuity per clinical judgment and resource availability. 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 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.

1.4. The reference for more information on the prioritization of non-chronically homeless Veterans is HUD Notice CPD-16-11, Notice on Prioritizing Persons Experiencing Chronic Homelessness and Other Vulnerable Homeless Persons in Permanent Supportive Housing, located at the following link https://www.hudexchange.info/resources/documents/notice-cpd-16-11-prioritizing-persons-experiencing-chronic-homelessness-and-other-vulnerable-homeless-persons-in-psh.pdf.

NOTE: This linked document is outside VA control and may or may not conform to Section 508 of the Rehabilitation Act.

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 Contractors 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) who will evaluate all deliverables submitted and certify invoices based upon acceptable deliverables. Contractor performance will be evaluated by the VA COR or VA Liaison using a Quality Assurance Surveillance Plan (QASP). The VA Liaison 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 oversign but will not provide direct clinical supervision.

2.3. Clinical oversight refers to a working relationship between VA Liaison and the Contractor in which the VA Liaison ensures compliance with the tasks and associated deliverables, as well as ensures quality of care is provided by the Contractor to Veterans. In providing clinical oversight, VA Liaisons may also serve as consultants to the Contractor in enhancing safe and effective person-centered care in complex situations to meet the needs of Veterans 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 or undue burden on the VA COR or VA Liaison 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 utilize 100% of the issued vouchers by resulting task orders and ensure that maximum effort be made in respects to outreach and housing placement. The VA may make Veteran/voucher referrals to the Contractor. 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 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 will be included in the task order RFP. Price shown in the Schedule of Services and Price is the maximum price that the Contractor may charge for 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 include: 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 BB HUD-VASH Case management and Attachment A Stages of Case Management and minimum visit requirements Standard Operating Procedure with staffing ratios not to exceed twenty-five Veterans per case manager (25:1 Weighted Capacity *NOTE: Housing and Employment Specialist should not be considered in this capacity).

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/or peer support specialists. Contractor’s supervisors shall be master’s level with appropriate licenses 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 per Attachment B HUD-VASH Documentation SOP. Note: All SOPS are reviewed and updated at least every three (3) years. Contractor staff shall attend the VA’s monthly HUD VASH meeting to stay informed about program changes and updates.

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, they shall reach out to Veterans Justice Outreach (VJO) for coordination and collaboration of follow-up and services. Contractors 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 VA Liaison. 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.

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 with Veteran, and their contact with the Veteran shall remain in accordance with level of care.

3.11. The Contractor shall meet the performance measures 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 the Homeless Operations Management and Evaluation System (HOMES please refer to Definition section of this SOW). Reference Attachment N - Technical Manual FY 2022 Homeless Performance Measures.

3.12. Contractor’s case management services shall follow the principles and practices of the Pathways Housing First Model (written by Sam Tsemberis). A copy of this book can be provided to the Contractor by the VA.

3.13. Contractor staff shall participate in continuing education training 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 all VA mandatory trainings for staff mentioned in this SOW. If the Contractor provides their own similar trainings for staff, the contractor shall provide documentation to the VA COR or VA Liaison demonstrating that these trainings are performed by a certified trainer.

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

3.15. The Contractor shall maintain Basic Life Support (BLS) certification for all technical and professional staff; American Heart Association certification is preferred but not required. Contractor staff shall be removed from direct patient care if their certification expires and will not return to performance under the contract until it is obtained.

3.16. Contractor shall encourage Veterans to actively engage in healthcare and, when clinically indicated, mental health and or addiction services.

3.17. Contractor shall document in Homeless Operations Management and Evaluation (HOMES) within 3 business days of Veteran encounters and change of Veteran status as indicated. Reference National policies from HOMES Main page. https://vaww.homes.va.gov/VAHomesNew.aspx

3.18. 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 Refer Definition section of this SOW.

3.19. 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 may include but 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).

3.19.1. 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, such as International Classification of Disease, Clinical Modification (ICD-CM) codes, current edition, CPT codes and Healthcare Common Procedural Coding System (HCPCS). Licensed Independent Providers e.g., Psychologist, Pharmacist, Licensed Clinical Social Worker, are to be listed as the primary provider for any trainees they supervise (e.g., Psychology Intern, Pharmacy Resident) or any other non-licensed independent provider (NLIP) under their supervision. VA provided training presentations addressing productivity calculation and coding practices are mandatory for contractors. References: Attachment J - VHA DIRECTIVE 1082 and Attachment K - VHA Directive 1161.

3.20. The Contractor’s Program Manager shall engage in a 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.

3.21. The Contractor shall work with the Veteran on obtaining and maintaining housing, developing independent living skills to include but no limited to budgeting, employment and/or assistance obtaining VA benefits.

3.22. Prior to performing on the contract, Contractor’s staff shall complete a 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 shall provide staff member’s date of birth, social security number, hair color, eye color, address, phone number, and email addresses. U.S Citizenship or legal resident status will be verified as part of this process.

3.23 Prior to performing on the contract, Contractor’s staff shall 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. VetPro is necessary for all licensed, registered or certified clinical staff members (e.g. LCSW, RN, CASAC.) and unlicensed case managers. Staff awaiting VetPro clearance may only begin work on the contract prior to onboarding by performing tasks that do not involve Protected Health Information (PHI, Refer to Definitions section of this SOW).

3.24 Contractor’s staff performing on this contract 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. The Privacy Awareness Training requirement may be fulfilled under additional privacy awareness training options. In order to complete online VA Privacy and Information Security Training, Contractor staff shall set up a VA Employee Education System account. This shall 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). All required trainings must be maintained on schedule as required by the VA.

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 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 completing necessary screenings. The Contractor shall notify the VA COR/Contract Liaison(s) by VA email within 24-hours of the Veterans admission and add the Veteran to the agency list. Note: Admission is by clinical decision of HUD-VASH Staff, or, if indicated, in more complex situations, with consultation of homeless program leadership or other appropriate service. Contractors shall maintain a list of Veterans who do not meet the eligibility criteria and provide those Veterans with a copy of Attachment N-HUD VASH Denial letter. 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. An example of resource handout (attachment X) is attached.

4.5. If Veteran was previously screened and denied by VA, as evidenced by screening note in VA Medical record, contractor shall contact VA COR or VA Liaison to consult prior to completing their screening and/or admission into program.

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

4.7. Veterans are considered admitted into HUD-VASH when they are accepted for case management services by the Contractor. Admission decisions shall occur within 24 hours or one business day of a completed referral interview with the appropriate documentation in HOMES.

4.8. In the case of a two-Veteran household, the Contractor shall enter into HOMES, the individual identified as head of household and the voucher holder and the Contractor shall provide case management in accordance to the level of care for that individual. The other Veteran, if also in need of case management, shall also be assisted as appropriate or provided with supportive services and/or referrals to 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 eligible for the HUD-VASH program, a Veteran must be:

4.9.1.1.1. Determined to be eligible by the VA Greater Los Angeles Healthcare System (VAGLAHS) Enrollment and Eligibility Office based on military discharge type:

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 (in Lieu of court-martial or from a 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.)

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). 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). When a Veteran is in Prep-for Discharge, Contractor shall engage with Landlord at least quarterly to ensure sustainability of housing.

4.9.4. Contractor shall assist 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 Attachment C VHA Directive 1162.05 HUD-VASH Program and Attachment A HUD-VASH Stages of Case management and minimum visit requirements SOP. Veterans in these units have been identified as psychiatrically and medically complex and it is the expectation of the VA that the Contractor shall conduct visits according to the Veterans level of care or more as clinically indicated. When clinically indicated, visits should be conducted by a 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 HCV to live in the community of their choice, within certain limits. 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 (Reference Attachment BB HUD-VASH Case Management).

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 rental housing as quickly as possible and ensure the housing is permanent;

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;

5.2.2. Veteran agrees to participation in Case manager in order to pursue and maintain housing. Non-compliance with case management may result in loss of housing and/or voucher.

5.2.3 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 staff shall address the documented needs of Veterans and make home visits consistent with the needs of the Veterans and in accordance with Attachment A HUD-VASH Stages of Case management and minimum visit requirements SOP and Attachment E Mental Health Treatment.

5.2.5 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 garnish all required equipment to staff in order to complete any/all tasks as stated in this SOW. Staff shall ensure meetings are respectful of Veterans privacy at all times.

5.4. Contractor shall also have the ability to place Contractor staff at VA facilities to provide access to Veterans as clinically appropriate.

5.5. Contractor shall submit a monthly tracking sheet (commonly referred to as White Board) approved by the VA COR or VA Liaison that includes Veterans full name, Social Security Number, HOMES ID, Lead Case manager, Team, Admission Date, Voucher Issuance Date, Move-In Date, Acuity level, PHA, PHA Voucher Number, Full Address, Income, Suicide Risk Assessment Date, ROI Date, Treatment plan date, Advance Directive Date, Phone numbers and any additional comment and/or other fields as approved by the VA COR or VA Liaison.

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

5.6.1. Create a Mental Health treatment plan (MHTP) Attachment E-Mental Health Treatment Plan and Attachment W Mental Health Treatment Plan Goals within two weeks of program admission. (This plan will be documented in the VA medical record). For MHTP entry time frames-reference Attachment B- HUD-VASH Documentation SOP

5.6.2. Review and update the Treatment Plan with the Veteran every six months or when there is a significant change in Veteran’s functioning level or circumstances that calls for a change in his/her treatment and document the review and any changes to the plan in the VA medical record. The Contractors Lead Case Manager or Supervisor shall act as the Mental Health Treatment Coordinator if the Veteran does not have a VA mental health provider. If the Lead Case manager is not licensed, all notes must be cosigned by a licensed provider.

5.6.3. Comply with additional documentation and/or data reporting for the Housing First demonstration as required by VAGLAHS based on changing or subsequent local, regional, or national HUD- VASH requirements.

5.6.4. Engage the Veteran in the HUD-VASH screening process and perform interviewing, counseling, and case management of identified Veterans who are at risk; providing psychosocial assessments (see sample attachment Y) to identify service and treatment needs which affect Veteran’s housing stability, recovery/community reintegration.

5.6.5. 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. Veterans needs to be reassessed 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.

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.

5.6.7. 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.

5.6.8. 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 to Attachment F CERS Management and Escalation of Health Status Concerns and Attachment G CERS Incident-Death Reporting Manual.

5.6.9. 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; https://www.hud.gov/sites/documents/pih2011-53.pdf including any subsequent changes, updates, or revisions to the PIH Notice.

5.6.10. Facilitate the Veteran’s involvement in supportive employment and other restoration programs, intervening and advocating on behalf of the Veteran.

5.6.11. Assess and promote engagement with appropriate healthcare, especially mental health and addiction care when clinically indicated. Reference Attachment H CERS Primary Care Engagement SOP

5.6.12. Formulate case-management treatment goals and plans with Veteran, that address identified needs, stressors and problems. 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 whenever possible, ensuring he/she has a copy of the plan including goals for clinical treatment and discharge from case management.

5.7. 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.

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

5.9. 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.

5.10. The Contractor shall visit each Veteran face-to-face at the intervals required by Attachment C HUD-VASH Directive and Attachment A Stages of Case Management and Minimum Visit Requirements. Additionally, the Contractor shall adhere to the following:

5.10.1. The Contractor shall notify the VA COR or VA Liaison 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 VA Liaison have concerns regarding the change of LOC, the Contractor shall engage in a discussion with the VA COR or VA Liaison regarding this change. This discussion may lead to the change of LOC not being approved, if the Liaison has concerns for Veterans safety/well-being. The Liaison shall document this both in email to the Contractor and in the Veterans electronic medical record.

5.10.2. 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 and at least once a month, if the Veteran is in the intensive stage of case management. Visits can also take place in the community, at the Contractor agency, or a place mutually agreed upon by the Veteran and VASH Team member.

5.10.3. 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 VVC must complete 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 for the required number of visits, the Contractor shall document face-to-face attempts, VVC attempts, phone calls, and letters sent to the Veteran including dates and times in the VA medical record system as verification of services rendered and to show that due diligence has been exercised. Note: phone calls and letters do not qualify as attempts.

cannot be located or contacted. Contractor understands that homeless and formerly homeless Veterans may be difficult to reach, fail to keep appointments, and/or abscond from services at unexpected times. VA places high emphasis on incorporating a sense of urgency and accountability in following up with Veterans to assure their safety and well-being. This is referred to as “due diligence.”

5.11.2. Contractor shall ensure their clinical due diligence consists of multiple steps to reach a Veteran to ensure the Veteran’s well-being and the Contractor shall follow up with appropriate case management and services. Contractor in-person visits should be scheduled with the Veteran when possible. Unscheduled visits may occur and 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 following steps shall be taken to contact the Veteran and/or determine the Veteran’s whereabouts:

5.11.2.1. 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 VA COR or VA Liaison(s) for alternatives based on the Veteran’s unique circumstances.

5.11.2.2. If the Contractor reaches the Veteran by phone and the Veteran is safe and well, the importance of a face-to-face meeting within 24 hours of the initial scheduled event shall be emphasized 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 VA Liaison 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:

5.11.2.2.3. Contact the Veteran's listed emergency contacts

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

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

5.11.2.2.9. Contact the city morgue

5.12. The Contractor shall clearly document all steps taken to locate the Veteran in the clinical record. If the Veteran is located and/or contacted during any of these steps, an appropriate plan and follow up shall be determined 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 by the case managers supervisor and documented in the VA medical record including any supervisory recommendations and timeframes for next steps.

5.12.1. If the Veteran has not been located and/or contacted upon completion of these steps, the Contractor shall ensure that the case has been discussed with the VA COR or VA Liaison 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.

5.12.1.6. 2nd Attempt. If a Veteran has not been located and/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 VA Liaison for alternatives based on the Veteran’s unique circumstances. If the Contractor reaches the Veteran by phone, the importance of a face-to-face meeting within 24 hours of the initial scheduled event shall be emphasized by the Contractor 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 VA Liaison. The VA COR or VA Liaison shall be consulted at any time for planning purposes based on the Veteran’s unique circumstances.

5.12.1.7. If the Veteran is located and/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.

5.12.1.8. If the Veteran has not been located and/or contacted upon completion of these steps, the Contractor shall ensure that the case has been discussed with the VA COR or Liaison, 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. Also, the Contractor shall include other providers working with the Veteran as signers on notes for awareness if the Veteran cannot be located/contacted and there are safety concerns.

5.12.1.9. Third attempt. If the Veteran still has not been contacted or located after the steps above have been completed, the Contractor shall attempt a third time, which shall be an unannounced home visit. This attempt should occur within 24 hours of the second attempt to reach the Veteran. If there is no response, Contractor shall notify the VA COR or VA Liaison and consult with them regarding an appropriate plan based on the Veteran’s unique clinical circumstances. In addition, a certified letter should be mailed to the Veteran. The letter should include:

5.12.1.9.1. All telephone numbers used in prior attempts to reach the Veteran

5.12.1.9.2. Dates of those attempts

5.12.1.9.3. Case manager’s and supervisor’s contact information with

5.12.1.9.4. Specific request that the Veteran call to schedule an appointment.

5.12.1.9.5. This should be documented as a separate administrative note in VA medical record system to include the tracking number of the certified mail.

5.13. The Contractor shall document evidence of contacts with individuals and agencies engaged to support the Veteran’s housing and recovery needs in the VA medical record (by use of Attachment Z Dept of VA medical record system). Specific documentation and implementation of services completed in the VA medical record system and HOMES charting record shall be completed, with an approved, assigned licensed independent clinical provider signing off on all notes if the staff member providing direct services to the Veteran is not independently licensed.

5.14. Clinical Documentations that shall be completed by a master’s in social work intern under appropriate supervision or MSW or a person with equivalent or higher education are:

5.14.1. Comprehensive Suicide Risk Evaluation (CSRE) and Columbia-Suicide Severity Rating Scale (C-SSRS) to include when necessary, Safety Plan.

5.14.2. Clinical reminders

5.14.3. Mental Health Treatment Assessment and Treatment Plan

5.14.4. Stage of Case management template

5.15. The Contractor may supplement their case management staff with Masters level interns registered with the Contractor upon completion of documentation in accordance with the intern’s learning plan and oversight by contractor clinical supervisor. All interns shall have their clinical supervisor as their additional signer on notes. No task that falls within the intern’s scope of practice under the jurisdiction of the state licensing board may be completed by the Contractors bachelor’s level personnel.

5.16. Bachelor’s level Case Managers may be maintained by the Contractor as an integral part of the interdisciplinary case management team (Refer to the Definitions section of this SOW). Bachelor’s level Case Manager’s tasks shall remain within scope of a Bachelor Level Social Worker and with direct supervision of a licensed independent clinical provider per Attachment J CERS Documentation Oversight of Direct Service Personnel SOP. The supervision may also include shared visits depending upon the complexity. All other disciplines who are members of the Interdisciplinary case management team shall only work within the scope of their trained field of practice.