75H70322R00005 Combined.pdf

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CODE 18a. PAYMENT WILL BE MADE BY

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OFFEROR

Sacramento CA 95814 650 Capitol Mall, Suite 7-100 John E Moss Federal Bldg California Office of the Director

CODE 16. ADMINISTERED BYCODE

X

X

X

541990

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% FOR:SET ASIDE:UNRESTRICTED OR123

RFPIFB

10. THIS ACQUISITION ISCODE

RFQ

14. METHOD OF SOLICITATION

13b. RATING

NAICS:

SMALL BUSINESS

08/26/2022 1400 PT

08/02/2022

CORDELL BAILEY

(No collect calls)

INFORMATION CALL:

FOR SOLICITATION 8. OFFER DUE DATE/LOCAL TIMEb. TELEPHONE NUMBERa. NAME

4. ORDER NUMBER3. AWARD/ 6. SOLICITATION

75H70322R00005

5. SOLICITATION NUMBER

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 1. REQUISITION NUMBER PAGE OF

1 51 OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

TELEPHONE NO.

17a. CONTRACTOR/

15. DELIVER TO

Sacramento CA 95814 650 Capitol Mall, Suite 7-100 John E Moss Federal Bldg

9. ISSUED BY

7.

2. CONTRACT NO.

EFFECTIVE DATE

$16.50

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW

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TION UNLESS BLOCK IS

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SEE SCHEDULEX

12. DISCOUNT TERMS

THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13a.

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

8(A)

California Office of the Director

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

24.

AMOUNT

23.

UNIT PRICE

22.

UNIT

21.

QUANTITY

20.

SCHEDULE OF SUPPLIES/SERVICES

19.

ITEM NO.

NOTE: This Solicitation incorporates HHSAR 326.600-2 Buy Indian Act acquisition regulations.

Native American Small Business will be given Preference for Award. All Small Business are still required to submit a Proposal for consideration if a Native American Small Busines is not successful.

The Diabetes Program Consultant (DPC) is a person with current knowledge and considerable experience that is acceptable by medical

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

HEREIN, IS ACCEPTED AS TO ITEMS:

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XX

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CORDELL M. BAILEY

. YOUR OFFER ON SOLICITATION (BLOCK 5),

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26. TOTAL AWARD AMOUNT (For Govt. Use Only)

OFFER

STANDARD FORM 1449 (REV. 2/2012)

Prescribed by GSA - FAR (48 CFR) 53.212

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25. ACCOUNTING AND APPROPRIATION DATA

29. AWARD OF CONTRACT:

REF.

Cordell.Bailey@ihs.gov

916-505-4011

California Office of the Director John E Moss Federal Bldg 650 Capitol Mall, Suite 7-100 Sacramento CA 95814

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32c. DATE 32b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:

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RECEIVED INSPECTED

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CORRECT FOR

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COMPLETE

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42d. TOTAL CONTAINERS42c. DATE REC'D (YY/MM/DD)

42b. RECEIVED AT (Location)

42a. RECEIVED BY (Print)

41c. DATE41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT

STANDARD FORM 1449 (REV. 2/2012) BACK

24.

AMOUNT

23.

UNIT PRICE

22.

UNIT

21.

QUANTITY

20.

SCHEDULE OF SUPPLIES/SERVICES

19.

ITEM NO.

standards of practice. This Consultant is to be a reliable resource to the diabetes program staff and other medical providers working in California

Tribal or urban healthcare centers.

Period of Performance: 09/26/2022 to 09/25/2023

1 Base Period

Period of Performance

September 26, 2022 to September 25, 2023

2 1st Option Period

Period of Performance

September 26, 2023 to September 25, 2024

(Option Line Item)

09/01/2023

Period of Performance: 09/26/2023 to 09/25/2024

3 2nd Option Period

Period of Performance

September 26, 2024 to September 25, 2025

(Option Line Item)

09/01/2024

Period of Performance: 09/26/2024 to 09/25/2025

32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

51 2 of

SCHEDULE

Diabetes Program Consultant (DPC)

CLIN Item Price

0001 Base Period $_____________________ Period of Performance September 26, 2022 to September 25, 2023

0002 1st Option Period $_____________________

September 26, 2023 to September 25, 2024

0003 2nd Option Period $_____________________

September 26, 2024 to September 25, 2025

Total Base and Two Option Periods $_____________________

PERFORMANCE WORK STATEMENT

DIABETES PROGRAM CONSULTANT

SECTION 1. GENERAL INFORMATION

1.1. Through the Special Diabetes Program for Indians (SDPI), the Indian Health Service/

California Area Office (IHS/CAO) is authorized to contract for a Diabetes Program Consultant.

The Diabetes Program Consultant (DPC) is a person with current knowledge and considerable experience that is acceptable by medical standards of practice. This Consultant is to be a reliable resource to the diabetes program staff and other medical providers working in California Tribal or urban healthcare centers. The Consultant must have knowledge of and experience working with federally funded Tribal and urban Indian healthcare clinics. Considerable knowledge of diabetes and prediabetes as it relates to American Indian/Alaska Native (AI/AN) populations is required. The Consultant must demonstrate knowledge and experience in diabetes education and care management, care coordination, and effective use of data. In addition, the Consultant must demonstrate proficiency in grant writing and grants management, and the ability to evaluate program capacity and effective and efficient use of program resources. The Consultant must demonstrate ability to teach these skills to others to support efforts in diabetes prevention and care, program management and resource utilization. To qualify for the position, a current health occupations license or registration (such as Registered Nurse, Physician Assistant, Physician, or Registered Dietitian) is required. Certification as a Diabetes Education and Care Specialist (CDECS), or an equivalent credential with expert knowledge and experience in diabetes care and education is required.

1.2.

The contract involves close coordination with the IHS/CAO, IHS Division of Grants Management (DGM) and the Division of Diabetes Treatment and Prevention (DDTP), and has responsibility for monitoring the programmatic aspects of diabetes care and education among California Tribal and urban Indian healthcare centers. In coordination with the IHS/CAO and DDTP, the Contractor exercises responsibility for evaluation of the healthcare centers diabetes program capacity in sustaining compliance with the terms and conditions of the SDPI grant requirements.

The IHS provides SDPI grant funds to approximately thirty-five (35) California Tribal and urban Indian healthcare centers. The CAO and its Contractors will provide individualized assistance to Tribal and urban Indian healthcare programs for SDPI grant-related activity.

The Contractor will evaluate capacity of grantees and provide technical support and feedback that can assist in strengthening submission of their SDPI application. To continue to be eligible to receive SDPI grant funds, healthcare centers must:

1.2.1 Successfully apply annually via the Federal GrantSolutions System to IHS for their Continuation SDPI Community Directed grant or Grants.gov if the process becomes competitive

1.2.2 Create and maintain a current diabetes registry of their patients with a Diabetes diagnosis

1.2.3 Perform and submit an IHS Annual Diabetes Care and Outcomes Audit to continue their eligibility for the SDPI grant

1.2.4 Concentrate grant effort on one of the IHS Diabetes Best Practices

1.2.5 Follow the IHS Diabetes Standards of Care

1.2.6 Participate in, and receive continuous training and technical assistance provided by IHS/DDTP to optimize diabetes care, to include California Area Native American Diabetes Organization (CAN-DO) web-based conference and telephone calls that provide support and education on current diabetes topics and standards; engage in sharing with other AI/AN healthcare program

1.2.7 Provide Annual Progress Report (APR) via GrantSolutions, including Narrative and Federal Financial Statement - SF 425 and comply with all grant regulations. Encourage submission of mid-year report, though optional

1.2.8 Manage grant funds within IHS grant guidelines and comply with the IHS Diabetes Best Practice requirements.

1.3 Period of Performance: One year from time of award.

SECTION 2. DEFINITIONS

2.1 The language in this section is suggested for use only as appropriate and necessary.

ADC Area Diabetes Consultant AI/AN American Indian/Alaska Native CAC Clinical Applications Coordinator CAN-DO California Area Native American Diabetes Organization CAO California Area Office CAO-ADC California Area Office Area Diabetes Consultant CDCES Certified Diabetes Care & Education Specialist CQI Continuous Quality Improvement CRS Clinical Reporting System DDTP Division of Diabetes Treatment and Prevention DGM Division of Grants Management DM Diabetes Mellitus DP Diabetes Prevention Initiative GPRA Government Performance and Results Act HbA1c Hemoglobin A1c HH Healthy Heart Initiative IHS Indian Health Service IPC Improving Patient Care IT Information Technology

ORC Objective Review Committee PA Physician Assistant PCMH Patient Centered Medical Home QI Quality Improvement Q-Man Query Utility Manager RPMS Resource and Patient Management System SDPI Special Diabetes Program for Indians TA Technical Assistance TLDC Tribal Leaders Diabetes Committee Web Audit Diabetes Audit submitted via the internet to IHS

2.2 Area

A defined geographical region for Indian Health Service administrative purposes. There are 12 Areas in the IHS System, with California Area one of the 12 Areas.

2.3 Annual IHS Diabetes Care and Outcomes Audit

Data entered during the calendar year for diabetes care.

2.4 Best Practices

Indian Health Services approach to Quality Diabetes Care

2.5 Contracting Officer (CO)

A government employee authorized and warranted to issue contracts, and to make subsequent modification(s). The CO has full authority to make determinations on all changes and disputes regarding the contract.

2.6 Contractor

The individual awarded a legal binding contract to provide supplies and/or services.

2.7 Diabetes Registry

A registry of patients served by the program and maintained through RPMS or other software.

2.8 Defective Service

A service output that does not meet the standard of performance requirement specified in the contract for that service.

2.9 Inspector

A government employee authorized to provide verbal and written performance direction to the Contractor that the Contractor must follow without exception.

2.10 Performance Requirement

The point that divides acceptable and unacceptable performance of a task according to the PRS and the Inspection of Services Clause.

2.11 Performance Requirements Summary

A listing of the service outputs under the contract that are to be evaluated by the project officer on a regular basis, the surveillance methods to be used for these outputs, and the performance requirements of the listed outputs.

2.12 Pre-Diabetes

The metabolic condition that exists prior to diabetes

2.13 Project Officer

A government representative appointed by the IHS/CAO to assist in the management of the contract. The project officer will work cooperatively under the direction of the contracting officer.

2.14 Quality Assurance

A planned and systematic pattern of all government actions necessary to provide confidence that adequate technical requirements are established; products and services conform to established technical requirements; and satisfactory performance is achieved. Quality assurance refers to actions by the government assurance functions for a contracted service.

2.15 Quality Control

Those actions taken by a contractor to control the production of outputs to ensure that they conform to the contract requirements.

2.16 Standards of Care

IHS evidence-based standards of Quality Diabetes Care

SECTION 3. GOVERNMENT FURNISHED INFORMATION AND PROPERTY

The government may provide property, at the Government’s discretion. The contractor is required to comply with FAR 52.245-1 Government Property rules and regulations.

SECTION 4. CONTRACTOR FURNISHED PROPERTY

The contractor shall provide all equipment, material, and supplies necessary to provide Diabetes Management services described herein.

SECTION 5. SPECIFIC REQUIREMENTS

5.1. This Performance Work Statement (PWS) is to provide virtual technical assistance

(TA) to each California Tribal and urban Indian healthcare program during the period of performance. On-site visits will be provided to the programs requiring increased assistance as determined by the Contractor and CAO-ADC (an estimated 10 site visits during the period of performance). Virtual site visits will be provided to the programs requiring increased assistance for whom the Contractor cannot visit on-site, with approval by the CAO-ADC. Complete one program assessment for each assigned Tribal and urban Indian healthcare SDPI program, as required during the period of performance. Contractor works collaboratively with the SDPI grantees and the IHS and is responsible for the full range of programmatic technical assistance and grants management duties for the California Area region. The goal of the IHS/CAO is to prevent diabetes, improve diabetes outcomes and coordination of services, and promote effective and efficient use of resources.

5.2. The contractor will provide services to a list of California healthcare programs that may include the following:

Urban Programs:

5.2.1 American Indian Health and Services Corp. (Santa Barbara)

5.2.2 Bakersfield American Indian Health Project (Bakersfield)

5.2.3 Fresno American Indian Health Project (Fresno)

5.2.4 Native American Health Center (Oakland)

5.2.5 San Diego American Indian Health Center (San Diego)

5.2.6 United American Indian Involvement, Inc. (Los Angeles)

5.2.7 Indian Health Center of Santa Clara Valley (San Jose)

5.2.8 Sacramento Native American Health Center (Sacramento)

Tribal Programs:

5.2.9 Central Valley Indian Health Center

5.2.10 Chapa-De Indian Health Program, Inc.

5.2.11 Colusa Indian Community Council

5.2.12 Consolidated Tribal Health Project, Inc.

5.2.13 Feather River Tribal Health, Inc.

5.2.14 Greenville Rancheria

5.2.15 Hopland Band of Pomo Indians

5.2.16 Hoopa Valley Tribe (K’ima:w)

5.2.17 Indian Health Council, Inc.

5.2.18 Karuk Tribe of California

5.2.19 Lake County Tribal Health Consortium

5.2.20 M.A.C.T. Health Board

5.2.21 Northern Valley Indian Health

5.2.22 Pit River Health Services, Inc. (CRIHB)

5.2.23 Quartz Valley Indian Reservation, ANAV (CRIHB)

5.2.24 Redding Rancheria

5.2.25 Riverside-San Bernardino County Indian Health Inc.

5.2.26 Rolling Hills Clinic (Corning)

5.2.27 Round Valley Indian Health Center

5.2.28 Santa Ynez Tribal Health

5.2.29 Shingle Springs Tribal Health

5.2.30 Sonoma County Indian Health Project, Inc. (CRIHB)

5.2.31 Southern Indian Health, Inc.

5.2.32 Strong Family Health Center (Modoc Indian Health)

5.2.33 Susanville Indian Rancheria Health Center (Lassen Indian Health Center)

5.2.34 Table Mountain Rancheria

5.2.35 Toiyabe Indian Health Project

5.2.36 Tule River Indian Health Center, Inc.

5.2.37 Tuolumne Me-Wuk Indian Health Center

5.2.38 United Indian Health Services, Inc. (CRIHB)

5.2.39 Warner Mountain (CRIHB)

5.2.40 Wilton Rancheria

5.3. The Contractor will coordinate virtual and on-site visits following a successful grant application and grant award. These visits will be coordinated with the Tribal and Urban Indian Health clinic staff, specifically, the Diabetes Coordinator, Grant Writer (if applicable), GPRA Coordinator (if applicable), Medical Director and/or Executive Director. A site visit report will be submitted to the ADC following the virtual/on-site visit.

5.4. The Contractor will be responsible for providing technical assistance and support through virtual (web-based conferences, phone calls) and on-site visits to the above listed sites. This includes:

5.4.1. SDPI grants management

5.4.2. Diabetes case/care management

5.4.3. Diabetes program management

5.4.4. Healthcare systems improvement and Quality Improvement

5.4.5. Program evaluation using the Diabetes Audit and GPRA measures reports

5.4.6. RPMS training and technical assistance (DMS, CM, iCare)

5.5. The IHS Division of Grants Management (DGM) provides management and administration of IHS grants. The Contractor must be able to coordinate with the IHS DGM regarding SDPI grantee issues, as well as provide TA to the Tribal or urban Indian healthcare center’s Diabetes Coordinator, grants manager and/or designee in the following task related to management of the SDPI grant:

5.5.1. Provides TA to grantees once the applicant is a successful grantee

5.5.2. Monitors all aspects of grant requirements and maintains close coordination with T/U programs to ensure that all required actions are executed by grantees in a timely manner

5.5.3. Provides technical assistance to program staff and grantees in the interpretation and application of grant regulations, policies and procedures

5.5.4. Reviews all appropriate data and information to determine the adequacy and acceptability of applicants that have had no prior experience with federal grants.

5.5.5. Appraises the grantee of these requirements during the life of the grant and in the proper use of public funds.

5.5.6. In coordination with the ADC, DDTP and DGM, exercises responsibility for assuring compliance with terms of grants, working with grantees to resolve problems of grant obligations and determining corrective action

5.5.7. Assist ADC with monitoring of all progress, financial status, closeout, and other reports required by the terms and conditions of the grant and exercises responsibility for ensuring that such reports are properly processed.

5.5.8. Provide training, or referral to appropriate resources, for SDPI application submission process via GrantSolutions or Grants.gov

5.5.9. Provide the ADC with a site visit report following each visit within 30 days

5.6. The Contractor will provide virtual (web-based conferences and telephone calls), and on-site technical assistance and address current issues with SDPI grant activity for the CAO as follows:

5.6.1. Provide 10 site visits during the contract period

5.6.2. Provide assistance to the grantees with their selected SDPI Best Practice and

Target Group, and use of the SDPI Outcomes System (SOS) to enter, check, and download their Required Key Measure (RKM) data, as needed

5.6.3. Assist grantees by reviewing applications (during continuation years) and tracking and monitoring selected Best Practice, RKM and Target group data

5.6.4. Maintain an aggregate table of all grantee’s RKM reports and provide assistance to grantees in retrieving their RKM from SOS, if requested

5.6.5. Keep the grantees informed of required reporting due dates: SDPI Application, mid-year and Annual Progress Report (APR), Annual DM Audit Report and Required Key Measures (RKM) Reports

5.6.6. Keep grantees informed of required trainings through IHS/DDTP and the trainings offered by CAO

5.7. The Contractor will assist California Tribal health care programs in promoting positive health outcomes for their population of patients with diabetes. Tasks include the following:

5.7.1 Assess and evaluate the existing diabetes program, clinic capacity, diabetes care and education, care/case management system, and over-all quality improvement process measures

5.7.2 Provide technical assistance and support to the Diabetes Program Coordinators to improve patient care and outcomes.

5.7.3 Promote and teach concepts of Diabetes Case/Care Management and patient-centered care planning

5.7.4 Promote patient-centered care using individual and population management tools, e.g., iCare

5.7.5 Provide new DM coordinators with resources, e.g., website links to DDTP for IHS DM Standards of Care, Best Practices, DM educational materials, etc. Review DDTP website with new Coordinators during on-site visits

5.7.6 Utilize checklist to ensure all areas of program assessment, technical assistance and training are addressed during virtual/on-site visits.

5.7.7 Provide site visit report, that includes assessment and evaluation, to ADC and T/U programs within 30 days of virtual/on-site visit

5.8. The Contractor will assist all Tribal/Urban healthcare programs with the Annual IHS

Diabetes Care and Outcomes Audit process and submission via the IHS Web Audit -for the 2023 audit year (calendar year January thru December)

5.8.1 Provide instruction and TA to T/U Diabetes Program staff on generating the

DM Audit using the IHS Diabetes Care and Outcomes Audit instructions

5.8.2 Provide TA and training on creating an export file and uploading into Web

Audit

5.8.3 Identify potential errors in DM Web Audit and work with programs to correct errors

5.8.4 Assist program staff in use of DM Audit data for the SDPI application and quality improvement work

5.9. The IHS Resource and Patient Management System (RPMS) is utilized solely by IHS as its patient data base system. Most California T/U programs do not use RPMS. For T/U programs using RPMS, the Contractor must be able to provide technical assistance to the Diabetes Program Coordinator and/or designee in the following tasks using RPMS:

5.9.1 Demonstrate proficient use of the Diabetes Management System (DMS)

Software package to maintain DM Registers

5.9.2 Generate all reports in the DMS package

5.9.3 Generate the IHS Annual Diabetes Care & Outcomes Audit as well as create an export file and upload the file to the IHS Web Audit

5.9.4 Create new registers using Case Management (CM) for RKM

5.9.5 Train on use of DMS, CMS and basic use of iCare to build panels of

DM/pre-DM patients

5.9.6 The Contractor is NOT expected to have expert knowledge of other

Electronic Health Record systems, besides RPMS

5.10. The Contractor shall provide the following technical assistance and support:

5.10.1 Assist the ADC with the delivery of services

5.10.2 Develop appropriate materials and program announcements

5.10.3 Participate in grant application review panel meetings and on Objective

Review Committee(s) during a competitive grant application process

5.10.4 Participate in seminars, web-based trainings, workshops, conferences, meeting, etc.

5.10.5 Collaborate via phone or email with ADC and other CAO contractors and staff

5.10.6 Report appropriate data and information by T/U’s programs to DDTP, DGM, GS

5.10.7 Collect and aggregate data and information for monthly, quarterly and other required reports to ADC/CAO

5.10.8 Provide the ADC with a monthly report of work provided virtually and on-site, including hours spent on each program, meeting or training.

5.10.9 Assist the ADC in developing an assessment tool to access and evaluate the capacity of DM program capacity and a checklist for topics covered during site visits.

5.11. Support the California Area Office’s vision and goals through work with T/U programs and by attending the following meetings or trainings and participate in multi-disciplinary team meetings and trainings:

5.11.1 Participate in the CAO targeted activity goals and participate in multi-disciplinary team meetings and trainings as requested

5.11.2 Attend other meetings and trainings, via web-conference and telephone calls as requested

5.11.3 Participate in planning and execution of quarterly CAN-DO webinars and assist in the development of web-based trainings to provide support and education on current diabetes topics and standards; facilitate sharing between Tribal programs

5.11.4 Attend two, one-day meetings at the IHS CAO. All travel costs shall be included in the contract total price, location to be Sacramento, California

5.11.5 Participate in California Medical Best Practices & Diabetes Day, three-four-day training conference. All travel costs shall be included in the contract total price, location based on prior years to be Sacramento California.

5.11.6 Attend one, TLDC/ADC two-day meeting, at request of the ADC. All travel costs shall be included in the contract total price, locations TBD

5.11.7 Attend Bi-annual IHS Diabetes in Indian Country, three-four-day conference. All travel costs shall be included in the contract total price

5.12. The contractor shall meet the following qualifications:

5.12.1 The contractor shall hold a current health occupations license or registration (such as Registered Nurse, Physician Assistant, Registered Dietitian).

Specialized training and education as a Certified Diabetes Education and Care Specialist (CDES), or equivalency, is required. Contractor must have experience in diabetes care and education, knowledge of federally funded Tribal and urban Indian healthcare clinics and considerable proficiency in providing diabetes care management and evaluation of the diabetes programs.

5.12.2 Demonstrate expert level knowledge of working with Diabetes programs

5.12.3 Knowledge of principles, practices and procedures regarding consultation and healthcare delivery to AI/AN populations

5.12.4 Knowledge of grants management processes and procedures

5.12.5 Thorough knowledge of current evidence-based practices, and treatment modalities to prevent, manage and treat Type 2 diabetes and its complications in AI/AN patients.

5.12.6 Knowledge of social, cultural and economic factors of individuals, families, Tribal communities and organizations as they apply to public health care in diabetes

5.12.7 Thorough knowledge of community resources in clinical and public health diabetes activities in relation to health care delivery in American Indian and Alaskan Native communities

5.12.8 Ability to keep T/U professional and para-professional staff informed regarding current diabetes standards of care and evidence-based practices, available teaching materials, conferences, and webinars to enhance their knowledge and skills related to diabetes and related chronic conditions

5.12.9 Knowledge of principles of consultation and skill in collaborative approaches working with multiple geopolitical groups and organizations

5.12.10 Ability to function as part of a multi-functional team that includes but is not limited to CAO professional staff, ADC, and other IHS departmental professionals on various projects and the ability to develop creative ideas and approaches and integrate these into programmatic developments

5.12.11 Ability to lead workgroups, committees and other task-oriented groups with minimal guidance

5.12.12 The contractor shall satisfactorily demonstrate knowledge of computer skills, including Microsoft Outlook and Office; ability to utilize online webinar tools (e.g., Adobe Connect, Zoom) preferred.

5.12.13 The contractor shall satisfactorily demonstrate advanced working knowledge of RPMS the IHS Resource and Patient Management System software.

5.13. The contractor shall have advanced working knowledge of:

5.13.1 The IHS Diabetes Standards of Care

5.13.2 The IHS Diabetes Best Practices

5.13.3 GrantSolutions System and Grants.Gov

5.13.4 Microsoft Power Point, Word, and Excel

5.14. Preference shall be given to contractors demonstrating a working knowledge of

RPMS to be able to utilize the Diabetes Management System and iCare that are sub-programs of the IHS software.

SECTION 6. APPLICABLE PUBLICATIONS

6.1 AADE Guidelines for the Practice of Diabetes Self-Management Education and

Training (DSME/T):

http://www.diabeteseducator.org/DiabetesEducation/position/Practice_Guidelines.ht ml

6.2 AADE7 System Self-Care:

http://www.diabeteseducator.org/ProfessionalResources/AADE7/A7S.html

6.3 IHS Diabetes Best Practices:

http://www.ihs.gov/MedicalPrograms/Diabetes/index.cfm?module=toolsBestPractice s

6.4 IHS Balancing Your Life and Diabetes:

http://www.ihs.gov/MedicalPrograms/Diabetes/RESOURCES/Catalog/index.cfm?mo http://www.diabeteseducator.org/DiabetesEducation/position/Practice_Guidelines.html http://www.diabeteseducator.org/DiabetesEducation/position/Practice_Guidelines.html http://www.diabeteseducator.org/ProfessionalResources/AADE7/A7S.html http://www.ihs.gov/MedicalPrograms/Diabetes/index.cfm?module=toolsBestPractices http://www.ihs.gov/MedicalPrograms/Diabetes/index.cfm?module=toolsBestPractices http://www.ihs.gov/MedicalPrograms/Diabetes/RESOURCES/Catalog/index.cfm?module=productList&productNameApprox=Balancing%20Your%20Life%20and%20Diabetes dul e=productList&productNameApprox=Balancing%20Your%20Life%20and%20Diabe tes

6.5 Standards of Care and Clinical Practice Recommendations: Type 2 Diabetes/

Diagnosis of Type 2 Diabetes and Prediabetes:

https://www.ihs.gov/diabetes/clinician-resources/soc/diagnosis-dm1/

SECTION 7. ATTACHMENT/TECHNICAL EXHIBIT LISTING

7.1 Performance Requirements Summary

7.2 Reports, Data and Other Deliverables

http://www.ihs.gov/MedicalPrograms/Diabetes/RESOURCES/Catalog/index.cfm?module=productList&productNameApprox=Balancing%20Your%20Life%20and%20Diabetes http://www.ihs.gov/MedicalPrograms/Diabetes/RESOURCES/Catalog/index.cfm?module=productList&productNameApprox=Balancing%20Your%20Life%20and%20Diabetes http://www.ihs.gov/MedicalPrograms/Diabetes/RESOURCES/Catalog/index.cfm?module=productList&productNameApprox=Balancing%20Your%20Life%20and%20Diabetes http://www.ihs.gov/MedicalPrograms/Diabetes/RESOURCES/Catalog/index.cfm?module=productList&productNameApprox=Balancing%20Your%20Life%20and%20Diabetes https://www.ihs.gov/diabetes/clinician-resources/soc/diagnosis-dm1/

Technical Exhibit #1 Performance Requirements Summary

Performance-based Task Indicator Standard Quality Assurance

The Contractor shall conduct site visits and provide virtual technical assistance to all California Tribal and urban Indian healthcare grantees on diabetes case management and program management per section 5.6 of PWS.

Submission of Site Visit and monthly reports

Site visit report will be delivered within 30 days following the visit Detailed monthly report submitted 5 days after end of month Quarterly report summarizing activity

100% Inspection of the monthly & quarterly reports 100% Inspection of site visit reports Random monitoring of site visits by the

ADC

Provide training and technical assistance to SDPI grantees on grant application process and submission and use of SOS for tracking and monitoring RKM per section

5.5 of PWS.

SDPI Grant application submitted by due date RKM Baseline and Final Reports

SDPI Grant application instructions and checklist Site Visit Report submitted within 30 days of site visit

100% inspection of Site Visit Report 100% inspection of Application review document 100% inspection of Assessment report

Provide technical assistance and support for DM Case Management, Diabetes Program Management, Healthcare Improvement, Quality Improvement, and use of DM Care and Outcomes Audit and GPRA measures and Required Key Measure of Best Practice reports as Quality Assessment benchmarks per section 5.7 of PWS.

Delivery of Site Visit and Monthly Reports Delivery of Assessment Tool

Site Visit Report submitted within 30 days Detailed monthly report submitted within 5 days after end of month

100% Inspection of the monthly reports 100% Inspection of site visit reports 100% Inspection of Assessment Tool Random monitoring of site visits by the

ADC

Provide technical assistance virtually, in person, and by phone to sites on RPMS/DMS or other systems per section 5.9 of

PWS.

Delivery of site visit report and monthly report

Site visit report will be delivered within 30 days following the visit and/or end of month’s work

100% Inspection of the Contractor's monthly reports 100% Inspection of Assessment Tool

Provide technical assistance and support for the Annual Diabetes Care and Outcomes Audit via Web Audit per section 5.8 of PWS.

Submission of Annual Diabetes Web Audit for approximately 35

T/U SDPI

programs

Annual Diabetes Audit accurately compiled and successfully submitted by the deadline established (TBD) Annually based on the National due date

100% Inspection of the Annual Diabetes Audit 100% Inspection of the Assessment Tool

Utilize Assessment Tool to assess and evaluate SDPI program capacity per section

5.10 of PWS.

Assessment of grantee capacity and effectiveness for sustaining SDPI grant activity

Assessment tool will be submitted with site visit reports within 30 days of the site visit to the ADC

100% Inspection of the Assessment Tool results for each site visit

Technical Exhibit #2 Reports, Data, and Other Deliverables

Written Report, which includes a brief 1-2-page summary of a site visit or other task, based on an individual task item.

Site Visit Report, which will include the following:

A. Health program name/location/date B. Staff names and titles participating in site visit C. Purpose of Visit D. Organizational Overview E. Diabetes Program description and staffing list F. Diabetes Education

This section must state:

1. How group and/or individual education occurs on site

2. The Name of the Diabetes Education Curriculum utilized

3. Key activities included in the programs approach to education

4. Diabetes prevention/education efforts in their community

G. Diabetes Case Management This section must state:

1. How patients identified with diabetes and/or pre-diabetes is managed in the program

2. Description of the use of the program’s diabetes audit data for quality improvement

3. Description of the Case Manager’s team meetings

4. Outreach efforts and coordination with medical staff and other departments within the organization.

H. Patient-Centered Medical Home status I. Clinical Care Data Review

This section must state:

1. Status of the Government Performance and Results Act (GPRA)Dashboard for previous year (October 1-September 30)

2. Summary of discussion of the results with appropriate staff

3. Diabetes Outcomes Audit results (Audit year January 1 – December 31)

4. Summary of discussion of the results with appropriate staff

J. Tracking/Monitoring/Reporting

1. Status of RPMS Register:

- Total number on Diabetes Registry

- Active (AI/AN & primary care at clinic)

- Transient (primary medical care elsewhere)

- Inactive (not seen in past 2 years)

- Lost to Follow-up (status unknown)

- Non IHS (non AI/AN)

- Un-reviewed (require review & status designation)

- Deceased

2. Status of Pre-Diabetes Registry (if applicable)

3. Reports ran at time of visit

4. Description on use of non-RPMS software system to manage DM/Pre-DM patients K. Status of the Health Programs SDPI grant/ Best Practice goals and objectives.

This section must state:

1. The Best Practice(s) selected for SDPI grant application

2. Progress made with RKM for Best Practice

3. Data used for programs self-evaluation of progress of goals, objectives and activities

4. Identify data improvement benchmarks/goals.

L. Summary of the visit M. Recommendations to the program

This section must state:

1. SDPI Best Practice and RKM monitoring

2. Use of data to measure goals and objectives of Diabetes program

3. Case management

4. Individual patient-centered care and population health management

5. Diabetes Self-Management Education (DSME)

6. Diabetes team development and teamwork resources

Appendix___: Business Associate Agreement

I. Authority:

Pursuant to 45 C.F.R. § 164.502(e), the Indian Health Service (IHS), as a covered entity, is required to enter into an agreement with a “business associate,” as defined by 45 C.F.R. § 160.103, under which the business associate must agree to appropriately safeguard Protected Health Information (PHI) that it will use and disclose when performing functions, activities or services pursuant to its contract with the IHS. By signing Contract No. ________ (Contract), _______________ agrees that it is a Business Associate and will comply with the terms below, in addition to other applicable Contract terms and conditions, and applicable law, relating to the safekeeping, use, and disclosure of PHI. This Appendix comprises the Business Associate Agreement (Agreement).

II. Definitions:

The following terms shall have the same meaning as those terms in 45 C.F.R. Part 160 and Part 164, which are the federal regulations implementing the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended: Breach, Designated Record Set, Disclosure, Health Care Operations, Individual, Minimum Necessary, Notice of Privacy Practices, PHI, Required by Law, Secretary, Security Incident, Subcontractor, Unsecured PHI, and Use.

A. Business Associate. “Business Associate” shall generally have the same meaning as the term “business associate” at 45 C.F.R. § 160.103, and in reference to the party to this Agreement shall mean ____________.

B. Covered Entity. “Covered Entity” shall generally have the same meaning as the term “covered entity” at 45 C.F.R. § 160.103, and in reference to the party to this Agreement, shall mean the IHS.

C. HIPAA Rules. “HIPAA Rules” shall mean the Privacy, Security, Breach Notification, and Enforcement Rules at 45 C.F.R. Part 160 and Part 164.

D. Master Patient Index (MPI). The “Master Patient Index” or “MPI” is composed of a unique list of patients and a current list of medical centers where each patient has been seen. This enables the sharing of patient data between operationally and regionally diverse systems. Each record (or index entry) on the MPI contains a small amount of patient data used to identify individual entries.

The mission of the MPI is to uniquely identify a patient and to “link” that patient’s data throughout the IHS facilities using the Integration Control Number (ICN). The MPI is the authoritative source of a patient’s ICN, the enterprise-wide identifier for IHS facilities and the key to accessing a patient’s record. The accuracy of patient information and patient identification directly affects clinical, administrative, billing, and interdepartmental processes.

III. Obligations and Activities of Business Associate:

A. Compliance: Business Associate agrees not use or disclose PHI other than as authorized by the Agreement or as required by law. Business Associate acknowledges that it is directly liable under the HIPAA Rules and subject to civil and, in some cases, criminal penalties for making uses and disclosures of PHI that are not authorized by the Agreement or required by law. Business Associate agrees that it will require all of its agents, employees, subsidiaries, and affiliates, to whom Business Associate provides PHI, or who create or receive PHI on behalf of Business Associate for Covered Entity, to comply with the HIPAA Rules and to enter into written agreements with Business Associate that provide the same restrictions, terms, and conditions as set forth in the Agreement.

B. Subcontractors: In accordance with 45 C.F.R. §§ 164.502(e)(1)(ii) and 164.308(b)(2), which govern relations with subcontractors, Business Associate agrees to ensure that any subcontractors that create, receive, maintain, or transmit PHI on behalf of Business Associate agree to the same restrictions, terms, and conditions that apply to Business Associate with respect to such PHI.

C. Safeguarding PHI: Business Associate shall develop and use appropriate procedural, physical, and electronic safeguards to protect against the use or disclosure of PHI in a manner not authorized by this Agreement or required by law. Business Associate will limit any use, disclosure, or request for use or disclosure of PHI to the minimum amount necessary to accomplish the intended purpose of the use, disclosure, or request.

D. Safeguarding Electronic PHI: Business Associate agrees to use appropriate safeguards, as set forth in Subpart C of 45 C.F.R. Part 164 with respect to electronic PHI, to prevent use or disclosure of electronic PHI other than as authorized by this Agreement or required by law.

E. Reporting Use or Disclosures Not Authorized By this Agreement or Required by Law: Business Associate agrees to report to Covered Entity any use or disclosure of PHI not authorized by this Agreement or required by law within thirty (30) days of discovering the use or disclosure, or any security incident of which it becomes aware. In addition, Business Associate shall mitigate, to the extent practicable, any harmful effect that is known to Business Associate of the use, disclosure, or security incident.

F. Reporting of Breach: In accordance with the policy of the Department of Health and Human Services, Business Associate will report, within one hour of discovery, all suspected or confirmed breaches to Covered Entity.

G. Notification of Breach of Unsecured PHI: In addition to the above, Business Associate shall notify Covered Entity of a breach, as set forth in 45 C.F.R. § 164.410, of the security of any unsecured PHI that Business Associate received from, or created or received on behalf of, Covered Entity within thirty (30) calendar days after the discovery of the breach by Business Associate, its employees, officers, and/or other agents, unless notification is specifically excepted by 45 C.F.R. § 164.412.

1. Requirements of Notice. Such notice shall include, to the extent possible, the identification of each individual whose unsecured PHI has been, or is reasonably believed by Business Associate to have been, accessed, acquired, or disclosed during such breach; a brief description of the circumstances of the breach of security, including the date of the breach and the date of Business Associate’s discovery of the breach; and the type of unsecured PHI involved in the breach. Business Associate agrees to provide any other available information that Covered Entity is required to include in notification to the individual under 45 §164.404(c). In the event notification is delayed, evidence demonstrating the necessity of the delay shall accompany the notification.

H. Individual Access to PHI: Business Associate shall maintain a designated record set for each individual for whom it maintains PHI. In accordance with an individual’s right to access his or her PHI, Business Associate shall make available all PHI in the individual’s designated record set to the individual to whom that information pertains, or, upon the request of the individual, to that individual’s authorized representative, as necessary to satisfy Covered Entity’s obligations under 45 C.F.R. § 164.524. Availability to access PHI shall be made within five (5) calendar days of receipt of a valid request.

I. Accounting of Disclosures: Business Associate shall maintain records of PHI received from, or created or received on behalf of, Covered Entity and shall document subsequent uses and disclosures of such information by Business Associate. Business Associate shall, within five (5) calendar days after receiving a request from Covered Entity, provide to Covered Entity such information as Covered Entity may require to fulfill its obligations to account for disclosures of PHI pursuant to 45 C.F.R. § 164.528.

J. Amendment of PHI: Business Associate shall, within five (5) calendar days of a request by Covered Entity, make PHI available to Covered Entity for Covered Entity to fulfill its obligations under 45 C.F.R. § 164.526 to amend PHI and shall, as directed by Covered Entity, within five (5) calendar days of receipt of such direction, incorporate any amendments into PHI held by Business Associate. In addition, Business Associate shall ensure incorporation of any such amendments into PHI held by its agents or subcontractors within ten (10) days of such direction, and shall notify Covered Entity within five (5) calendar days of when those agents or subcontractors have completed the incorporation of the amendments. Business Associate shall forward to Covered Entity all requests to amend PHI that it receives directly from individuals within five (5) calendar days of its receipt of a request.

K. Carrying out Covered Entity’s Obligations: To the extent Business Associate is to carry out one or more of Covered Entity’s obligation(s) under Subpart E of 45 C.F.R. Part 164, Business Associate agrees to comply with the requirements of Subpart E that apply to Covered Entity in the performance of such obligation(s).

L. Disclosures for Verifying Compliance: Upon request, Business Associate shall permit access by the Secretary and Covered Entity during normal business hours to its facilities, books, records, accounts, and any other sources of information, including PHI and any agreements that it has with subcontractors, vendors, and/or other agents relating to the use and disclosure of PHI received from Covered Entity, or created or received by Business Associate on behalf of Covered Entity, for purposes of determining both Business Associate’s and Covered Entity’s compliance with the HIPAA Rules.

IV. Permitted Uses and Disclosures by Business Associate:

A. Business Associate shall not use or disclose PHI except to perform functions, activities, or services on behalf of Covered Entity as provided for in the Contract, this Agreement, the HIPAA Rules, or other applicable law.

B. Business Associate agrees that it may use or disclose PHI on behalf of Covered Entity only:

1. Upon obtaining the authorization of the individual to whom the PHI pertains;

2. For the purposes of treatment, payment or health care operations unless Covered Entity has agreed to a restriction pursuant to 45 C.F.R. § 164.520(b)(iv)(A) or 45 C.F.R. § 164.522; or

3. Without an authorization or consent, if in accordance with 45 C.F.R. § 164.510, 45 C.F.R. § 164.512, 45 C.F.R. § 164.514(e), 45 C.F.R. § 164.514(f), or 45 C.F.R. § 164.514(g).

C. Business Associate shall use and disclose PHI in compliance with each applicable requirement of 45 C.F.R. § 164.504(e), which section is fully incorporated herein.

D. Business Associate agrees to make uses, disclosures, and requests for PHI consistent with Covered Entity’s minimum necessary policies and procedures.

E. It is anticipated that Business Associate will have access to the MPI.

F. Business Associate may not use or disclose PHI in a manner that would violate Subpart E of 45 C.F.R. Part 164 if done by Covered Entity, except for the specific uses and disclosures set forth below.

1. Business Associate may disclose PHI for the proper management and administration of Business Associate or to carry out the legal responsibilities of Business Associate, provided the disclosures are required by law, or Business Associate obtains reasonable assurances from the person to whom the information is disclosed that the information will remain confidential and used or further disclosed only as required by law or for the purposes for which it was disclosed to the person, and the person notifies Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached.

V. Obligations of Covered Entity:

A. Covered Entity shall provide Business Associate with its Notice of Privacy Practices and any changes to the Notice.

B. Covered Entity shall notify Business Associate of any limitation(s) in Covered Entity’s Notice of Privacy Practices under 45 C.F.R. § 164.520, to the extent that such limitation may affect Business Associate’s use or disclosure of PHI.

C. Covered Entity shall notify Business Associate of any change in, or revocation of, the permission by an individual to use or disclose his or her PHI to the extent that such changes may affect Business Associate’s use or disclosure of PHI.

D. Covered Entity shall notify Business Associate of any restriction on the use or disclosure of PHI that Covered Entity has agreed to or is required to abide by under 45 C.F.R. § 164.522, to the extent that such restriction may affect Business Associate’s use or disclosure of PHI.

E. Covered Entity shall not request Business Associate to use or disclose PHI in any manner that would not be permissible under Subpart E of 45 C.F.R. Part 164 if done by Covered Entity, except as provided in Part IV, Subpart F, Section 1.

VI. Termination:

A. Term: The Term of this Agreement shall be effective as of the date Business Associate signs the underlying Contract and shall terminate when the Contract ends or on the date covered entity terminates for cause as authorized in paragraph

(b) of this Section, whichever is sooner.

B. Termination for Cause: Business Associate authorizes termination of this Agreement by Covered Entity, if Covered Entity determines Business Associate has violated a material term of the Agreement and Business Associate has not ended the violation within the time specified by Covered Entity.

C. Obligations of Business Associate Upon Termination: Upon termination of this Agreement for any reason, Business Associate, with respect to PHI received from Covered Entity, or created, maintained, or received by Business Associate on behalf of Covered Entity, shall:

1. Retain only that PHI which is necessary for Business Associate to continue its proper management and administration or to carry out its legal responsibilities;

2. Return to Covered Entity, or, if agreed to by Covered Entity, destroy, the remaining PHI that Business Associate does not need to continue its proper management and administration or to carry out its legal responsibilities;

3. Continue to use appropriate safeguards, in compliance with Subpart C of 45 C.F.R. Part 164, with respect to electronic PHI to prevent use or disclosure of electronic PHI, other than as provided for in this Part, for as long as Business Associate retains the PHI;

4. Not use or disclose PHI retained by Business Associate other than for the purposes for which such PHI was retained and subject to the same…