Attach_4_PWS_RN_Healthcare_Integrator_26_Jun_19.pdf

Performance Work Statement

Registered Nurse: Healthcare Integrator

6th Medical Group, MacDill AFB, FL

26 Jun 19

HEALTH CARE INTEGRATOR

1.0 DESCRIPTION OF SERVICES: The contractor shall provide all management, tools, supplies, equipment, and labor necessary to operate and maintain qualifications as a Health Care Integrator (Registered Nurse) at MacDill AFB 6th Medical Group. Duty location is MacDill AFB Clinic, 3250 Zemke Ave Bldg 1078, MacDill AFB, Tampa, FL 33621 or Sabal Park Clinic, 9208 King Palm Dr, Tampa FL 33619. Duty schedule is Mon – Fri. Duty hours are 7:00 am - 4:00 pm or 7:30 am - 4:30 pm (supervisor’s discretion). This is a Performance Based Service Acquisition and the contractor is required to perform all items in the Performance Work Statement (PWS) during the specified duty hours except for up to 1 hour each duty day as a break, approved federal holidays, up to 80 hours of vacation time per year, and up to 56 hours of sick leave per year. A replacement for these breaks is not requested by the 6th Medical Group.

1.1 SCOPE OF WORK: The incumbent of this position is the Health Care Integrator (HCI) and is responsible for the planning, design, implementation and evaluation of population health and disease management programs based on the identified needs of the managed beneficiary population. The incumbent is responsible for collecting, reviewing, and interpreting population based data to identify, recommend, and implement improvements as deemed appropriate to improve patient health, improve clinical outcomes, reduce morbidity, and ensure that patients receive comprehensive, coordinated care in a cost-effective manner.

1.2 QUALIFICATIONS FOR HEALTH CARE INTEGRATOR: The contractor shall possess the following qualifications:

1.2.1 DEGREE: Baccalaureate of Science in Nursing degree or other population health-related fields from an accredited educational institution is required. Advanced degree in a health care discipline is highly desirable, a masters in community health is desirable.

National certification in a related field (e.g. community health, ambulatory nursing, or occupational health, etc.) is recommended. Strong background in inpatient and outpatient nursing specialties, ambulatory care nursing, prevention, health promotion, disease/condition management, case management, discharge planning, and clinical data analysis highly desirable.

1.2.2 EXPERIENCE: Broad-based clinical nursing background is required with at least 7 years of clinical experience. The clinical experience must include positions in acute care and outpatient settings. Experience in case management, condition management, discharge planning, utilization management, performance improvement, and personnel management is preferred. Computer skills in data management, Excel, Power Point, and Access are desirable.

1.2.3 LICENSE: For positions involving patient care, candidates must have a permanent, full, and unrestricted Registered Nursing license to practice nursing in a State, District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States.

1.2.4 OTHER: Must complete Air Force Medical Service Health Care Integration Course and the Air Force Medical Home Operations (AFMHO) Course within one year of hire at contractor's expense. Travel is required at the contractor’s expense.

1025505936C Highlight

1.3 SPECIFIC TASKS AND REQUIREMENTS FOR HEALTH CARE INTEGRATOR

1.3.1 Provide leadership to integrate resources and communication ability to cross all Squadron lines, working with assigned teams to build healthy people, communities, and a fit and ready force by utilizing population-based health principles. Incumbent will lead the MTF in population health program development that integrates all aspects of care along the health continuum. Objective is to establish links with utilization managers, case managers, discharge planners, and contractors to provide all aspects of services for patients who experience barriers to appropriate care. Incumbent develops educational programs for the staff on integrated healthcare processes and data management, and works with the Group Practice Manager (GPM) and Squadron Administrator to develop and monitor metrics and other tools to evaluate and continuously improve efficiency and effectiveness of healthcare delivery systems.

1.3.2 Consults and collaborates with providers and other health professionals to coordinate and ensure consistent health teaching, counseling, guidance, and instruction to individuals and families participating in available disease management programs. The HCI interacts with the Disease Managers and a variety of other administrative and professional staff to ensure comprehensive and appropriate coordination of care and services for the eligible beneficiary population served by at MacDill 6th Medical Group. Consults with the Chief. Health Care Integration and communicates through the SGH of the Medical Group.

1.3.3 Assists in research and development of evidence-based clinical practice guidelines (CPG) in collaboration with providers and other multidisciplinary team members to reduce variances in treatment and improve clinical outcomes in a cost-effective manner. Coordinates with the Director of Medical Services (SGH) to promote the use of evidence-based clinical practice guidelines and pathways. Advocates case management for smooth delivery and continuity of care.

1.3.4 Reviews and evaluates population based outcome measures. Identifies individual and populations of patients at risk for chronic, complex and co-morbid conditions and provides actionable data from various sources such as the Military Health System Population Health Portal (MHSPHP) data for use by the care coordination team (CM, OM, UM nurses and FHC).Reviews and uses the Population Health Improvement Plan and HEDIS measures as an identification source and identifies initiatives to support improved outcomes. Provides Population Health data summary reports to clinic Primary Care Managers (PCM) for the purpose of identifying their assigned population who may be at higher risk for adverse health outcomes.

1.3.5 HCI has administrative responsibility and authority to serve as the focal point for population health, clinical preventive services, and disease/condition management activities and interventions. Provides special studies, consultations, and reports as requested by squadron, flight, and element leaders. Assists in developing, implementing, and delivering demand/disease/condition management training and program direction to clinic professional and non-professional staff. Develops presentation methods, materials, training aids and applies professional educational expertise and technology to programs tailored to meet the requirements of the serviced population.

1.3.6 Compiles and maintains statistical data and generates reports for Primary Care Management (PCM) Teams, Medical Group Executive Management, Flight, HQ ACC/SG and HQ AFMONSGOP as appropriate. Prepares routine periodic reports for higher headquarters as required. Develops interdisciplinary program management through effective communication and collaboration with Squadrons, Medical Group, and Wing level organizations. Attends medical staff meetings and uses appropriate forums to establish and maintain effective working relationships with providers. Conducts ongoing research, interviews, and fact-gathering inquiries to yield accurate metric reports.

1.3.7 Utilizes and integrates the six critical success factors for effective population health management as follows:

1.3.7.1 Describe the demographic needs and health status of the population:

Assesses the health care needs of a defined population using standardized assessment tools.

Provide a population profile to the clinical teams, Executive Staff, Population Health Function (PHF). Collaborates with public health officer on surveillance measures as decision support for future initiatives.

1.3.7.2 Forecast and manage demand and capacity:

Coordinates with the GPM to operationally analyze demand-forecasting information and presents data to PHF to develop a game plan. Participates in Military Treatment Facility (MTF) level decision-making on whether to use the direct care system or the network to meet required demand, e.g., GPM or TRICARE Flight can assist. Identifies to appropriate action officer, gaps between forecasted need and medical treatment facility capability.

1.3.7.3 Proactively delivers preventive services to the enrolled population:

Identifies needs and coordinates provision for staff training for timeliness of secondary/tertiary prevention needs. Ensures assigned teams know secondary/tertiary preventive services.

Operationally analyzes provider specific population profile to assigned teams. Collates clinical preventive measures (metrics) for discussion during PHF, e.g., immunizations.

1.3.7.4 Monitors medical and disease conditions:

Identifies the high-risk population that would benefit from disease management to the Director of Medical Services (SGH) to promote the use of evidence-based clinical practice guidelines and pathways. Identifies patients with case management needs to appropriate source.

1.3.7.5 Continually evaluates improvement in the population's health status and the delivery system's effectiveness/efficiency:

Uses clinical outcome information to develop and improve condition management programs, e.g.; diabetes, asthma, low back pain, hypertension. Uses data, when possible, to produce provider and MTF level measures designed to evaluate the effectiveness of condition management programs based upon outcome measures. Uses analysis to support the identification and prioritization of clinical areas/provider teams requiring improvement to identify best practices.

1.3.7.6 Energize a total community approach to population health:

Advises and collaborates with base level Integrated Delivery System (IDS), Health and Wellness Center, and other agencies whose purpose is to develop and implement a plan to respond to community needs. Collects resource list and utilizes community agencies as appropriate.

Coordinates services within MTF and the community to reduce ineffective consumption of health care and increase usage of health promoting services.

1.3.7.7 SERVICES SUMMARY

Performance Objective PWS Para

Performance Threshold

Ability to effectively communicate and collaborate with a diverse group of people and the purpose of informing the healthcare team of plans/actions.

PWS

1.3.1 1.3.2 1.3.3 1.3.6

<2 validated complaints per month regarding problems with oral or written communication

Consults and collaborates with providers and other health professionals to coordinate and ensure consistent health teaching, counseling, guidance, and instruction to individuals and families participating in available disease management programs.

PWS

1.3.2.

100% of health teaching material provided by disease management programs to providers and other health professionals is standardized and consistent.

Provides accurately prepared special studies, consultations, and reports as requested by squadron, flight, and element leaders in a timely manner.

PWS

1.3.5

100% of studies, consultations and reports requested by squadron flight and element leaders are accurately prepared within time suspense provided by Chief Health Care lntegration.

Develops presentation methods, materials, training aids, and applies professional educational expertise and technology to provide demand/disease/condition management training and program direction to clinic professional and non-professional staff programs tailored to meet the requirements of the serviced population.

PWS

1.3.5

100% of training programs and presentations use applied clinical expertise and are tailored to meet the requirements of the serviced population.

Utilizes and integrates the six critical success factors for effective population health management.

PWS

1.3.7

100% of population management decision making can be validated using all or some of the six critical success factors.