Exhibit D Draft Statement of Work.pdf

I. Entity Name:

II. Project Description:

ThisprojectservestosupportEmergencyMedicalService(EMS)Providerswhoneedassistance with physical, emotional or psychological conditionsthatmaybedetrimentaltotheirabilityto provide emergency medical services. This is in accordance with SB 19-065 and will be done primarily through a network of clinical service providers throughout the state to educate, evaluate, treat, and refer EMS Providers requesting program services. The services will be offered to currently registered, certified or licensed Emergency Medical ServiceProvidersand their family members, in the state of Colorado.

III. Definitions:

1. CDPHE- Colorado Department of Public Health & Environment(the Department)

2. EMS- Emergency Medical Services

3. EMS Provider - an individual currently registered, certified or licensed to provide emergency medical services in the state of Colorado.

4. EMTS- Emergency Medical and Trauma Services Branch

5. Family Member - a family member is considered the participant’slegalspouseorpartner and children (by birth, marriage/union, adoption).

6. HFEMS- Health Facilities and Emergency Medical ServicesDivision

7. Participant - an EMS Provider or their family member, utilizing Path4EMS program services.

8. Participant Number - unique number assignedtoaparticipantbythePath4EMSprogram coordinator and provided to designated program services providers for reporting and invoicing purposes.

9. Path4EMS-nameoftheprogramcreatedbyColoradoSenateBill19-065toprovideforthe education, evaluation, and treatment of EMS Providerswhomaybeexperiencingphysical, emotional or psychological conditions that could be detrimental to their ability to provide emergency medical services.

10. PeerHealthAssistanceProgram–amentalhealthservicesagencyorproviderdesignated by CDPHE in accordance with CRS § 25-3.5-208.

11. Program Services - counseling sessions and support provided by a Colorado licensed counselor ormentalhealthprofessional;forEMSProvidersandtheirfamilymembers,who may be experiencing physical, emotional or psychological conditions that could be detrimental to their ability to provide emergency medical services.

12. Referral - an EMS Provider involved in an enforcement action who is advised that Path4EMS program services may prove beneficial to their overall situation.

13. Telehealth-AHIPAAcompliantvideo/telephoneserviceusedtodeliverPath4EMSservices thatincludecounselingandwellnesssessions,intake,evaluation,andcasemanagementand monitoring.

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Exhibit D

IV. Work Plan

Goal #1: To protect the health, safety and welfare of all who receive health care services in Colorado.

Objective #1: No later than the expiration of this Purchase Order (PO), the Contractor shall provide program services for Colorado EMS Providers and their family members, who need assistancewithphysical,emotionalorpsychologicalconditionsthatmaybedetrimentaltotheir ability to provide emergency medical services, or affecting other areas of their daily life.

PrimaryActivity#1:TheContractorshallprovideprogramservicestoStateofColoradoEMS Providers,andtheirfamilymembers,whenrequested,forconditionsthatmaybedetrimentalto their ability to provide emergency medical services, or affecting other areas of their daily life.

Sub-Activities #1:

1. Verify program eligibility of participants prior to providing reimbursable services.

2. Offer program services (in-person and/or virtually), to meet the needs of participants.

3. Evaluate the presenting physical, emotional and/or psychological condition.

4. Screen participants for signs of crisis and other related conditions.

5. Provide treatment for participant’s condition or refer them to an appropriate level of service, based on the evaluation and screening.

Primary Activity #2:The Contractor shall track andreport the utilization of program services.

Sub-Activities #2:

1. The Contractor shall collect the following information for each participant, on a monthly basis:

a. Participant Number – assigned by Path4EMS program coordinator

b. Dates Services Provided

c. Amounts of Services Provided (Hours/Minutes)

d. Reimbursement Rate Requested

e. Participant Status:

(1) Initial/Ongoing

(2) Resolved

(3) Referred

(4) Discontinued

(5) Not Specified

2. The Contractor may submit an approved utilization report to aid in the creation of monthly billing invoices.

3. The Contractor shall submit a signed Reimbursement Invoice Form on a monthly basis.

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Standards and Requirements

1. The content of electronic documents located on CDPHE and non-CDPHE websites and information contained on CDPHE and non-CDPHE websites may be updated periodically during the contract term. The contractor shall monitor documents and website content for updates and comply with all updates.

2. The Contractor shall send all program correspondence that does not contain PHI or PII to the Path4EMS program coordinator via email.

3. The Contractor shall only send participant-related correspondence that contains PHI or PII via encrypted email.

4. Regular business hours are defined as 8:00 a.m. to 5:00 p.m., Monday through Friday, except state holidays defined by the Colorado Secretary of State, located at the following link and incorporated here by reference:

https://www.sos.state.co.us/pubs/info_center/holidayCalendar.html

5. The Contractor may verify a participant’s eligibility for the Path4EMS program prior to obtaining a participant number by verifying an EMS provider’s current registration, certification or licensure status on the CDPHE website located at the following link and incorporated here by reference:

https://colorado.emsbridge.com/licensure/public/colorado/portal#/lookup

6. The Contractor shall contact the Path4EMS program coordinator to obtain a participant number for reporting and invoicing purposes.

7. Counseling Services shall include sessions by a Colorado licensed mental health counselor or professional; for issues including emotional stress, depression, substance use, PTSD, personal issues, marital and family issues, death and grief, or work Environment.

8. For Path4EMS services, a family member is considered the EMS Provider’s legal spouse or partner and children (by birth, marriage/union, adoption).

9. The Contractor shall respond to any inquiry made by CDPHE staff no later than two (2) business days from the date of receipt of the inquiry.

10. CDPHE will respond to any inquiry made by the Contractor no later than two (2) business days from the date of receipt of the inquiry.

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Exhibit D https://www.sos.state.co.us/pubs/info_center/holidayCalendar.html https://colorado.emsbridge.com/licensure/public/colorado/portal#/lookup

11. The Contractor shall maintain participant medical records in compliance with State and Federal laws.

12. The Contractor shall dispose of participant medical records in accordance with HIPAA requirements found at the following link and incorporated here by reference:

https://www.hhs.gov/hipaa/for-professionals/faq/disposal-of-protected-healthinformation/ index.html

13. The Contractor shall accommodate individuals with visual or other impairments consistent with the ADA found at the following link and incorporated here as reference:

https://www.ada.gov/2010_regs.htm

14. The Contractor shall utilize the Federal Communications Commission Telecommunications Relay Services (TRS) 711 number for all persons with a hearing or speech disability to communicate telephonically with the Contractor.

15. The Contractor shall comply with all applicable laws regarding public accommodation.

16. The Contractor shall be compliant with Title III of the ADA found at the following link and incorporated here by reference:https://www.ada.gov/ada_title_III.htm

17. The Contractor shall make necessary adjustments to in-person contact and physical exposure, to comply with any applicable public health orders.

Expected Results of Activity(s)

1. The Path4EMS program will ensure that EMS providers who are experiencing physical, emotional or psychological conditions that could be detrimental to their ability to provide emergency medical services, have access to treatment and support options.

Measurement of Expected Results

1. A quarterly review of monthly utilization data will be used to gauge overall participation across various demographics and to analyze trends.

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Exhibit D https://www.hhs.gov/hipaa/for-professionals/faq/disposal-of-protected-healthinformation/ https://www.hhs.gov/hipaa/for-professionals/faq/disposal-of-protected-healthinformation/ https://www.ada.gov/2010_regs.htm https://www.ada.gov/ada_title_III.htm

Deliverables

Description Completion Date

1. The Contractor shall contact the Path4EMSprogram coordinator to verify participant eligibility and/or obtain a participant number for reports and invoicing.

Prior to submitting the initial invoice for reimbursable services.

2. The Contractor shall submit an approved utilization report to the Path4EMS program Coordinator if invoicing assistance is needed.

No later than 5 days after the end of each month.

3. The Contractor shall submit a signed Reimbursement Invoice Form to the Path4EMS program coordinator via email, using a template or format provided by the Department.

No later than 2 weeks (14 days) after the end of each month.

V. Budget TheContractorwillbereimbursedonamonthlybasisforservicesprovidedinaccordancewith this Purchase Order and Statement of Work.

Effective Dates Rate shall not exceed

Annual amount per participant shall not exceed

Annual amount for all services shall not exceed

[INSERT

DATES HERE] $125.00 per hour $1,875.00 $[INSERT HERE]

VI. Monitoring CDPHE’s monitoringofthepurchaseorderforcompliancewithperformancerequirementswill be conducted throughout the purchase order period by the Path4EMS program coordinator.

MethodsusedwillincludeareviewofdocumentationdeterminedbyCDPHEtobereflectiveof performance to include monthly utilization data and other fiscal and programmatic documentationasapplicable.TheContractor’sperformancewillbeevaluatedatsetintervalsand communicated to the contractor.

VII. Resolution of Non-Compliance TheContractorwillbenotifiedinwritingwithin15calendardaysofdiscoveryofacompliance issue.Within15calendardaysofdiscovery,theContractorandtheStatewillcollaborate,when appropriate, to determine the action(s) necessary torectifythecomplianceissueanddetermine when the action(s) must be completed. The action(s) and timeline for completion will be documented in writing and agreed to by both parties. If extenuating circumstances arise that requires an extension to the timeline, the Contractor must email a request to the Path4EMS program coordinator and receive approval for a new due date. The State will oversee the completion/implementation of the action(s) to ensure timelines are met and the issue(s) is resolved. If the Contractor demonstrates inaction or disregard for the agreed uponcompliance resolutionplan,theStatemayexerciseitsrightsundertheTermsandConditionsofthisPurchase Order.

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