RFI HUD VASH Portland.docx

SOURCES SOUGHT NOTICE

This is a Sources Sought Notice (SSN) ONLY. The U.S. Government is conducting market research only to determine the availability of qualified sources capable of providing HUD VASH Case Management Services for the VA Portland Healthcare System. Potential Contractors are invited to provide a response via e-mail to Contract Specialist at james.harris13@va.gov by June 1, 2022 12:00 pm (PT). Responses will be used to determine the appropriate strategy for a potential acquisition. Please clearly identify any information your company considers sensitive or proprietary. This notice is issued solely for information and planning purposes - it does not constitute a Request for Quotation/Proposal (RFQ/RFP), or a promise to issue an RFQ/RFP in the future. This notice does not commit the U.S. Government to contract for any supply or service. Further, the U.S. Government is not seeking quotes, or proposals at this time and will not accept unsolicited quotes in response to this sources sought synopsis. The U.S. Government will not pay for any information or administrative costs incurred in response to this notice. Submittals will not be returned to the responder. Not responding to this notice does not preclude participation in any future RFQ, if any is issued.

BACKGROUND: HUD-VASH is designed to serve homeless Veterans and their families. Many of these Veterans have co-morbid conditions that include serious mental illnesses, substance abuse disorders, and other serious medical conditions. VA intends to engage a Contractor to provide housing placement services to VA referred Veterans and their families.

NAICS: 624229 - Other Community Housing Services

Interested potential Contractors please provide the following.

1) Company Name, address, point of contact, phone number, email address, and DUNS

Please indicate business size:

Small Disadvantage Business (SDB)____ 8(a)____ Historically Underutilized Business Zone (HUBZone)____ Service-Disabled Veteran-Owned Small Business (SDVOSB)____ Veteran-Owned Small Business (VOSB)_____ Economically Disadvantaged Women-Owned Small Business (EDWOSB)_____ Women-Owned Small Business concerns (WOSB)_____ Small Business_____ Large Business_____

Please state if you possess a Federal Supply Schedule (FSS)__________________.

2) Please submit a brief capability statement (maximum three pages) with enough information to demonstrate to the Veterans Affairs that your business has the required licensed clinical social worker, case managers, housing specialist to provide the case management services stated in the attached Draft Performance Work Statement.

Draft Performance Work Statement

1. Background 1.1 The Contractor shall assist the U.S. Department of Veterans Affairs (VA) with the provision of housing placement and case management services through the U.S. Department of Housing and Urban Development (HUD) – VA Supportive Housing (VASH) program. The program is a partnership between HUD and VA to place and maintain homeless Veterans in permanent, community-based housing using HUD Section 8 Housing Choice Vouchers (HCV) that are paired with ongoing VA case management services. Many of these Veterans have co-morbid conditions that include serious mental illnesses, substance use disorders, and other serious medical conditions. The Contractor shall provide housing placement services in the Portland, Oregon region to include Multnomah County, along with ongoing case management services to HUD-VASH eligible Veterans and their families.

2. 1.2 The Contractor shall meet all requirements in the Performance Work Statement (PWS) in accordance with VHA Directive 1162.05(2) “Housing and Urban Development Department of Veterans Affairs Supportive Housing Program”. The Contractor shall comply with all future updates to this Directive during the life of the contract. If changes in the Directive impacts the agency’s ability to fulfill the PWS, the agency has the option to request a modification in the contract. The most updated version of the Directive will be provided to the Contractor.

3. 1.3 The Contractor shall support Veterans in obtaining housing while simultaneously providing case management and supportive services; and assist the Veteran in maintaining housing.

4. 1.4 The Contractor shall provide all labor, supervision, supplies, and materials necessary to carry out the tasks specified in this PWS. Performance will occur at the Contractor’s location and the Greater Portland Metro area unless otherwise required by work requirements listed in the PWS, or otherwise specified by the task orders issued under this contract.

5. 1.5 The Contractor shall not commence performance under the contract until the Contracting Officer (CO) has conducted a kickoff meeting or has advised the Contractor that a kickoff meeting has been waived.

6. 1.6 The Contracting Officer’s Representative (COR) will evaluate all deliverables submitted. The COR is responsible for certifying invoices for payment only for deliverables received and deemed acceptable by the COR. The COR will measure performance success or failure using quality assurance surveillance and quarterly and annual reviews. VA Liaison(s) will be identified by the VA Portland Health Care System (VAPORHCS) HUD-VASH program. They will act as the clinical liaison for all Veteran related issues in conjunction with the COR between the Contractor and the VA homeless team. They will provide clinical oversight, but will not provide direct clinical supervision. Multiple CORs may be appointed to handle administrative, clinical, or other duties as assigned. The COR and HUD-VASH Liaison roles may be filled by a single individual.

1. General Requirements 2.1 The Contractor shall provide services to eligible Veteran/Veteran families for whom such care is specifically authorized by the referring VA Portland Health Care System (VAPORHCS). The Contractor shall perform the following tasks: 2.1.1 The Contractor shall ensure enough full-time staffing is in place with case management ratios that meet or exceed the VA staffing standard. The VA staffing standard is 35 to 1. The Contractor Case Managers must be a Licensed Clinical Social Workers, Licensed Professional Counselors, Licensed Professional Mental Health Counselors, or Psychologist, or working toward licensure under the supervision of a Licensed Mental Health Professional.

2.1.2 The Contractor shall be an “eligible entity,” which is classified as any State or local government agency, tribal organization or nonprofit organization that has demonstrated experience in providing housing case management services and working collaboratively with the Department of Veterans Affairs or the Department of Housing and Urban Development.

2.1.3 The Contractor shall use a case management team approach whenever possible which may include a mix of Licensed Clinical Social Workers, Licensed Professional Counselors, Licensed Professional Mental Health Counselors, Mental Health and Substance Use Disorder Treatment Professionals, Nurses, Psychologists, Housing Specialists, and Peer Support Specialists to meet the clinical needs of Veterans served.

2.1.4 The Contractor shall comply with HUD-VASH, VA Portland Health Care System (VAPORHCS), VAPORHCS Community Reintegration Services (CRS), and HOMES policies and procedures, identified in this PWS regarding documentation and evaluation standards for Veterans receiving services under this contract.

2.1.5 While most services will be provided in the community or a Veteran’s home, the Contractor’s team shall visit Veterans if hospitalized or incarcerated and shall also accompany Veterans to clinics, ERs or other appointments as clinically indicated.

2.1.6 When Veterans have achieved housing placement and stability, the Contractor shall focus on services and support for maintaining housing, community integration and other goals as defined by the Veteran.

2.1.7 When Veterans no longer need case management, they will be graduated from case management after consultation with the VA COR/Liaison and in compliance with HUD-VASH Directive 1162.05(2), “Housing and Urban Development Department of Veterans Affairs Supportive Housing Program,” VAPORHCS CRS SOP 16 “CRS HUD-VASH Case Management Stages,” and VAPORHCS CRS “Graduation Checklist”.

2.1.8 The Contractor shall follow Housing First Principles, which are found in “HUD-VASH: Housing First Principles” when providing case management services.

2.1.9 The Contractor shall provide full staffing as outlined in this PWS in Section 3 within 60 days of contract award.

2.1.10 The Contractor shall enter Veteran information, after obtaining a release of information (ROI), into the Homeless Management Information System (HMIS), as required by the HMIS system.

2.1.11 The Contractor shall participate in and coordinate with the VA COR/Liaison during weekly case conferences regarding updates and changes in the Veteran’s care plan. Weekly case conferencing may be done in person, virtual, or by telephonic conference calls as determined by the VA COR/Liaison and Contractor.

2.1.12 The Contractor shall meet the same performance measures in the technical manual set forth for the VA by the VHA Homeless Program Office found in the “Technical Manual: FY24 Homeless Performance Measures”. This requirement shall include any subsequent updates and/or revisions to this manual. If changes in the technical manual impacts the agency’s ability to fulfill the PWS, the agency has the option to request a modification in the contract.

2.1.13 The Contractor shall participate in the gathering of consumer experience information through the Universal Stakeholder Participation Experience Questions (uSPEQ) survey or other VA identified tool. The Contractor shall disseminate and collect the survey at the indicated points of service. The results from this survey will be used as part of the VA Homeless services evaluation.

2.1.14 The Contractor shall work with the Veteran on housing placement, maintaining housing, strengthening independent living skills including independence in transportation, budgeting, accessing healthcare services, employment, and assistance obtaining appropriate VA and non-VA benefits.

2.1.15 The Contractor shall communicate with the VA regarding this contract via the VA COR/Liaison.

2.1.16 Upon contract award and as changes may occur, the Contractor shall submit a staffing plan for approval to the VA COR/Liaison that includes information about how supervision will be provided.

2.2 The Contractor shall have experience providing social services for homeless individuals.

Staffing 3.1 The Contractor shall provide staffing as outlined in Section 3 of this PWS to work directly with referred Veterans. The Contractor shall provide VA COR/Liaison with Contractor staff employee/applicant resume for preliminary review of staffing qualifications and requirements. Each staff member the Contractor provides shall complete VA security and credentialing procedures, including: 3.1.1 The Contractor shall complete the medical center’s Without Compensation (WOC) security measures

3.1.2 Security/background investigation via National Agency Check with Written Inquiries (NACI) and a Special Agreement Check (SAC), which included 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, home address, phone number, and email addresses to the COR. U.S. Citizenship or legal resident status will be verified as part of this process. COR will provide above mentioned staff information to VA Human Resources to initiate security/background checks.

3.1.3 For Contractor staff and their supervisor to perform under this contract they shall complete the credentialing process through the VA’s VetPro system. VetPro credentialing is required for all licensed, registered, or certified clinical staff members (e.g., LCSW, RN, LPC, LPMHC, etc.). Staff shall be cleared through VetPro based on their current licensure/registration status and shall not perform work at a lower level than their current licensure/registration status while awaiting VetPro clearance. COR will provide instructions to complete VetPro clearance to Contractor staff.

3.1.4 A Federal Personal Identification Card will also be issued to Contractor staff; this requires an in person visit to VA Human Resources or VA Police for verification of documents and photographs of the individual staff member.

3.1.5 All Contractor employees and subcontractor employees requiring access to VA information and VA information systems shall complete the following before being granted access to VA information and its systems: 3.1.5.1 Sign and acknowledge (either manually or electronically) understanding of and responsibilities for compliance with the Contractor Rules of Behavior, relating to access to VA information and information located in the “Contractor Rules of Behavior”.

3.1.5.2 Successfully complete the VA Cyber Security Awareness and Rules of Behavior training and annually thereafter.

3.1.5.3 Successfully complete the appropriate VA Privacy Training and annually thereafter; and

3.1.5.4 Successfully complete any additional trainings as required for VA personnel with equivalent information system access.

3.1.5.5 The Contractor shall provide the VA COR/Liaison a copy of the training certificates and certification of signing the Contractor Rules of Behavior for each applicable employee within two (2) weeks of the initiation of the contract and annually thereafter, as required.

3.1.5.6 Failure to complete the mandatory annual trainings within the timeframe required is grounds for suspension or termination of all physical or electronic access privileges and removal from work on the contract until the trainings and documents are completed.

3.1.6 The Contractor’s team shall participate in VA and/or community-based continuing education related training including Housing First, trauma informed care, motivational interviewing, relapse prevention, supported employment, and supported education.

3.1.7 Contractor personnel shall maintain an active license with the licensing boards in their respective profession accordingly.

3.1.8 Basic Life Support (BLS) certification is required for all technical and professional staff.

3.2 The Contractor shall provide the following in performing the tasks required under this contract: 3.2.1 A Mental Health provider as the Case Management Team Clinical Supervisor and a multi-disciplinary team sufficient to meet the clinical needs for Veterans served and make home visits consistent with the Veteran’s Mental Health Treatment Plan.

3.2.2 The Contractor shall provide staffing at a level to ensure that all services listed in the contract are met for each Veteran receiving service under this contract. The Contractor shall have staff who are trained to provided services as identified. The Contractor shall ensure that sufficient staff remain available to provide services for the term of this contract. The VA staffing standard is 35 to 1. Contractor proposals should meet or exceed this standard.

3.2.3 The Contractor shall ensure there is coverage for staff when they are out on planned or unplanned leave and shall notify the VA COR/Liaison of this plan.

3.2.4 The Case Management Team Clinical Supervisor and Case Managers shall be Contractor’s full-time employees and assigned full-time to this contract.

3.3 The Contractor shall comply with the following staffing requirements: 3.3.1 The Clinical Supervisor shall hold an independent clinical practitioner license and the license shall be active, current, and unrestricted.

3.3.2 The Case Management Team Clinical Supervisor shall provide supervision of case management personnel for the purposes of clinical oversight, documentation, and crisis management. Supervision shall be available any time clinic personnel are providing services including clinical services provided after designated hours of the clinic. The Clinical Supervisor shall be available for team conferences as requested by the local VAPORHCS HUD-VASH program. In addition, they shall ensure appropriate supervision of any non-clinical/non-licensed Contractor staff providing related supportive services to Veterans to ensure quality of care.

3.3.3 Case Managers shall have a minimum of a Master’s degree from an accredited institution in mental health or behavioral health and are licensed to practice independently in the State of Oregon. If not yet independently licensed, case managers must be actively working towards the highest independent level of licensure and will provide evidence of registration of an associate or probationary license with the Oregon Board of Licensed Social Workers or similar board within 60 days of hire and/or upon request.

3.3.4 The Contractor shall also consider utilizing non-case management staff who provide direct services such as Housing Specialists, Certified Substance Use Treatment Counselors, Employment Specialists, Registered Nurses, Licensed Vocational Nurses, Licensed Practical Nurses, and/or Peer Support Specialists. These staff shall provide support to the case management team but do not impact the 35:1 case management ratio.

3.4 The Contractor shall have competency folders for their staff, which will be kept under the control of the Contractor, for VA COR/Liaison review. Documents in this folder must be current, valid, compliant with VAPORHCS MCM 14A-05, Competency Assessment of Staff, and include, at minimum, the following: 3.4.1 TB and Immunization Records

3.4.2 Copy of Current Professional License (if applicable)

3.4.3 Copy of Current BLS

3.4.4 Copy of Valid Driver’s License

3.4.5 Copy of evidence of completion of all required trainings

3.4.6 Copy of signed VA Rules of Behavior

3.4.7 The Contractor shall provide the Government with all the information necessary to ensure that Government records are maintained correctly and in compliance with The Joint Commission (TJC), OSHA and the Center for Disease Control health records requirements, for each individual Contractor employee.

Documentation 4.1 The Contractor shall complete and update Homeless Operations Management and Evaluation (HOMES) documentation and be consistent with the “HOMES Reporting Policy”. All required information is included using designated HOMES forms. Veteran updates are made in HOMES within forty-eight (48) hours of occurrence. The Contractor shall meet local, regional, and national reporting requirements.

4.2 The Contractor shall comply with national and local policies regarding the VA Electronic Health Record (EHR) documentation, per VHA Directive 1907.1 “Health Information Management and Health Records”, as well as VAPORHCS MCM 11-55 “Health Information Management and Documentation”, and VHAPORHCS CRS “Attachment D, HUD-VASH Workflow Guide”. The EHR documentation shall consist of changes to admission, eligibility documentation, psychosocial assessments, Treatment Plans, updates to housing, receipt of voucher, voucher status, employment status, encounter documentation, screening/admission notes, release of information forms, housing service agreements, suicide risk assessments, safety plans, Advance Directives, clinical reminders, discharge notes, resources provided and progress notes. The Contractor shall document encounters using “Data, Assessment, Plan (DAP)” or “Subjective, Objective, Assessment, Plan (SOAP) note templates and consistent with “CRS Basic Charting Guidelines” that are provided by VA COR/Liaison. All encounters shall be entered into the EHR within forty-eight (48) hours of providing service. In addition to documenting contact with the Veteran, the Contractor shall also document in the EHR evidence of the Contractor’s collateral contacts with individuals and agencies engaged to support the Veteran’s housing and recovery needs. 4.2.1 The Contractor shall use local HUD-VASH program note templates, assessments, etc., when documenting any contacts or pertinent information regarding Veterans receiving services under this contract. Any changes the Contractor makes to the forms shall be in collaboration with VA COR/Liaison. The VA COR/Liaison will give final approval on forms used prior to implementation.

4.3 The Contractor shall document all case management encounters in CPRS and meet or exceed the number of contacts based on Veteran’s acuity level assignment during quarterly case conference meetings (also reference 8.7 in this PWS). All documentation is due in the Veteran’s EHR within forty-eight (48) hours of the encounter.

4.4 The initial Treatment Plan is created within 30 days from the HUD-VASH admission date. The initial treatment plan focuses specifically on finding housing/housing needs and is created with the Veteran. A copy of the plan shall be offered to the Veteran. Treatment Plan updates are as follows: 4.4.1 When Biopsychosocial assessment is completed.

4.4.2 As clinically appropriate, such as indicated by changes in housing status, acuity, Veteran identified needs and preferences of care.

4.4.3 Annually.

4.4.4 When exited from case management.

4.4.5 Updates to the Treatment Plan are added in the EHR as an addendum to the Initial Treatment Plan.

4.5 The Contractor shall complete a Biopsychosocial assessment within 60 days of the Veteran signing their lease.

4.6 The Contractor shall complete Clinical Reminders when due, including Tobacco, Depression PHQ-2, PHQ-9, Suicide Risk Screen C-SSRS, Alcohol Audit C, Homelessness/Food Insecurity Screening, Advance Directive, Sexual Orientation Reminder, Toxic Exposure Screening, Offer Overdose Education and Naloxone and any subsequent screenings completed by VAPORHCS CRS HUD-VASH program. Clinical Reminders are completed using designated note titles and templates in EHR and according to VAPORHCS policy.

4.7 The Contractor shall fulfill additional documentation and/or data reporting as required by VAPORHCS based on changing or subsequent local, VISN, or national HUD-VASH requirements. If changes in the Directive impacts the Contractor’s ability to fulfill the PWS, the Contractor has the option to request a modification to the contract.

4.8 The Contractor shall document all encounters with Veterans in EHR within 48 hours of the encounter. If there is an immediate concern regarding the Veteran, the note shall be entered immediately for other providers to have access to the note and any concerns which might impact service delivery. Documentation and encounters shall be entered accurately.

4.9 An approved, assigned Clinical Supervisor must sign off on all notes if the staff member providing direct services to the Veteran is not independently licensed.

Referrals and Admissions 5.1 VA COR/Liaison shall assign admitted and eligible HUD-VASH Veterans to the Contractor’s case load. VA COR/Liaison will inform the Contractor that a Veteran has been admitted to the HUD-VASH program and to proceed with case management services, the completion of the application, voucher scheduling, housing placement and housing maintenance support. The Contractor shall not provide case management services to Veterans unless assigned by VA COR/Liaison.

5.2 The Contractor shall refer homeless Veterans seeking eligibility assessment to the CRRC for screening and referrals to the HUD-VASH program, if eligible.

Referrals and admissions to the HUD-VASH program shall be conducted solely by the VA Community Resource and Referral Center (CRRC).

Contractor Case Management Team Duties 6.1 The Contractor shall ensure that sufficient staff are available to provide services to meet the needs of the Veterans and the VHA performance standards set forth for the VA by the VHA Homeless Program Office located in the “Technical Manual: FY24 Homeless Performance Measures” (and all subsequent updates), as well as the ability to make home and community visits consistent with the level of care at which each Veteran is being treated. The VA will ensure the Contractor has the most current technical manual. In addition, the Contractor shall provide sufficient staff to ensure the following: 6.1.1 Ensure consistency of team services to enhance staff ability to engage and form relationships with Veterans and provide consistent and highly skilled interventions in keeping with the principles of Housing First.

The Contractor shall have procedures in place to ensure Veterans have access to case management services Monday – Friday during normal tours of duty and access to 24/7 crisis management and referral services.

6.1.2 Review the Treatment Plan with the Veteran quarterly and document the review and any changes to the plan in the VA medical record.

6.2 The Contractor shall perform the following Case Management duties: 6.2.1 Engage the Veteran in the HUD-VASH process and perform assessment, counseling, and case management of identified Veterans, provide psychosocial assessments to identify treatment needs which affect Veteran’s adjustment to their environment and establish treatment goals with the primary purpose of obtaining and maintaining housing.

6.2.2 Actively involving the Veteran and their family or significant others in coordination with the team members, based on the psychosocial assessments; develop Treatment Plans with the Veteran using his/her/their language whenever possible, ensuring he/she/they have a copy of the plan including goals for clinical treatment and graduation/discharge from case management. The Contractor shall complete the initial Treatment Plan within thirty (30) days of Veteran’s admission into the HUD-VASH program.

6.2.3 The Contractor shall integrate the Treatment Plan with relevant VA health and mental health services. The Contractor shall refer Veterans as needed to VA medical Facilities, VA Regional Offices, and community-based agencies for a variety of services that may include health care, entitlements, vocational assistance, education, recreation, and any other needed assistance.

6.2.4 The Contractor shall utilize counseling strategies to include crisis intervention, case management and Motivational Interviewing with Veterans, including both short- and long-term services, working toward the long-term goal of housing stability and graduation/discharge from HUD-VASH.

6.2.5 The Contractor shall screen each Veteran for suicidal and homicidal risk as per VAPORHCS MCM 11-04 “Suicides, Attempts and Suicidal Behavior”. The Contractor’s screening and assessment of the Veteran shall be documented in progress notes, suicide risk assessments, and safety plans in the VA Electronic Health Record (EHR). If the Veteran is a danger to themselves or others, the Contractor shall take immediate steps to provide appropriate intervention and notify VA COR/Liaison immediately. C-SSRS/CSRE are completed within seventy-two (72) hours of initial meeting with Veteran, preferably at first meeting. All documentation is due in EHR within forty-eight (48) hours of encounter or same day for high-risk situations.

6.2.6 The Contractor shall coordinate and execute crisis management and mandated reporting consistent with VHA Directive 1199 “Reporting Cases of Abuse and Neglect,” local laws, policies, and mandated reporting per licensing board. Identification Assessment and Management of Veterans at Risk – Mandatory Reporting of Suspected Abuse of Children Elders and Dependent Adults – by the Contractor and shall be reported to the VA COR/Liaison and other VA staff, including the local Suicide Prevention Coordinator if related to Veteran suicidality.

6.2.7 The Contractor shall facilitate the Veteran’s involvement in therapeutic and work restoration programs, as well as supporting team-based interventions such as Assertive Community Treatment (ACT), Critical Time Intervention (CTI), Harm Reduction, Housing First and Intensive Case Management (ICM) as outlined in VHA Directive 1162.05(2) “Housing and Urban Development Department of Veterans Affairs Supportive Housing Program” across the Veteran’s individual treatment team and advocating on behalf of the Veteran.

6.2.8 The Contractor shall provide and coordinate direct mental health and substance abuse counseling per the requirements of the PWS and assist in securing available VA services using tele-mental health services when appropriate. The Contractor shall also facilitate the Veteran’s involvement in therapeutic and work restoration programs, such as Vocational Rehabilitation Services (VRS), as appropriate.

6.2.9 The Contractor shall assist Veteran with accessing appropriate healthcare programs and establishing primary care services.

6.2.10 The Contractor shall utilize VA and community resources to connect Veteran to services once a need has been identified. Contractor will connect the Veteran to the appropriate resource within 30 days of the identification of the need. The Contractor shall document all resources and referrals provided to Veteran in EHR within 48 hours of encounter.

6.2.11 The Contractor shall complete all necessary VA Release of Information (ROI) forms per VA Policy and prior to contact with person or entity listed on ROI. The Contractor shall update ROI forms annually or more frequently if indicated by VA Policy or ROI expiration date. VA ROI forms must be documented and uploaded into EHR for VA and Contractor to be able to communicate with PHA, Landlords, Emergency contacts, additional household members and other ROIs needed to assist in Veteran’s care. If Veteran declines completing ROI, this must be documented in EHR. Contractor will follow process to upload ROI for scanning into Veteran’s EHR. All documentation shall be submitted in EHR within forty-eight (48) hours of encounter.

6.2.12 The Contractor shall enter consults into the EHR within forty-eight (48) hours of the encounter. The Contractor is responsible for following up on consult and coordinating with Veteran and other providers until consult completion.

6.2.13 The Contractor shall pursue case management discharge for Veterans, when clinically appropriate. The VA may assign additional Veterans to the Contractor for case management services to replace those Veterans who have been discharged from the program. Assignment of additional Veterans for case management services is not guaranteed and will be dependent upon the demand for such services and the VA’s needs at that time. Veterans needing to return to case management within 6 months of discharge will return to the Contractor for case management, unless clinically indicated otherwise.

6.3 The Contractor shall submit a monthly tracking sheet derived from the HOMES OR7 Report and delivered in that format approved by the VA COR/Liaison that provides status updates for Veterans receiving services under this contract regarding change in level of care, milestones met, employment/benefits, potential discharges, case management interventions, and other fields as approved by the VA COR/Liaison.

6.4 The Contractor shall follow VHA Directive 1162.05(2) “Housing and Urban Development Department of Veterans Affairs Supportive Housing Program”, CRS Prevention and Management of Disruptive Patient Behavior and Workplace Violence and Mandatory reporting of Injuries from Death Weapons and Assaultive Abusive conduct and notify VA of any negative incident occurring with the Veteran within twenty-four (24) hours of being informed or made aware of the incident. The Contractor shall complete a written incident report in the format indicated by the VA within twenty-four (24) hours of notification. The Contractor shall provide documentation, as required by the VA COR/Liaison describing the incident, analysis of cause and effect, and corrective action take. Local incident report protocols shall be followed, and documentation completed depending on type of incident. Reportable incidents include: 6.4.1 Death

6.4.2 Fire

6.4.3 Drug/police raid

6.4.4 Suicide/suicide attempt

6.4.5 911 call to police, fire, paramedics, or other

6.4.6 Severe medical illness/emergency

6.4.7 Severe psychiatric illness emergency

6.4.8 Sexual assault

6.4.9 Act of violence by Veteran against others

6.4.10 Abusive behavior by staff against Veteran

6.4.11 Accident that resulted in emergency medical treatment

6.4.12 Medication problems or adverse drug reactions that resulted in an emergency medical intervention.

6.5 The Contractor shall provide monthly written status reports, a Summary Spreadsheet, to the VA COR/Liaison by the 5th of each month to ensure quality assurance of case management services per the PWS requirements. The Summary Spreadsheet shall include, at minimum, patient data, (names, last four digits of SSN or other identification number), type of services performed, with date service(s) performed, Veteran’s acuity level, name and contact information of the Case Manager assigned to each Veteran through secure means that protects the Veterans’ confidentiality. Updated and accurate information will be included in the Summary Spreadsheet.

6.6 The Contractor shall meet with VA COR/Liaison weekly for quality assurance, case consultation and caseload status updates.

6.7 The Contractor case managers shall attend HUD-VASH weekly meetings, unless otherwise discussed with the COR.

Contractor Housing Placement and Stabilization Duties 7.1 The Contractor shall perform Housing Placement and Stabilization duties that include: 7.1.1 The Contractor shall assist Veteran in completing Public Housing Authority (PHA) voucher application, appointments, and steps to obtain a HUD-VASH voucher. The Contractor shall assist the Veteran in submitting completed HUD-VASH voucher application to PHA for processing and voucher issuance.

7.1.2 The Contractor shall assist Veterans to obtain the needed documentation required by the PHA to include, but not limited to, birth certificates, driver’s license or government issued photo ID, income verification, and any additional information required by the PHA and/or potential landlord. If these documents cannot be obtained, efforts made to obtain them must be clearly documented. All documentation is due in the Veteran’s EHR within 48 hours of the encounter.

7.1.3 The Contractor shall accompany Veteran to any PHA appointments including voucher issuance, annual certifications, briefings, and interim appointments, as clinically indicated. In cases where the Veteran is unable to access or use existing public transportation networks or other community provided transportation, the Contractor shall provide transportation in Contractor-owned or operated vehicles for Veteran to attend appointments at the VA, at the Public Housing Authority, benefits agencies, with landlords, relating to housing searches, or relating to medical care. The Contractor shall assist Veteran in completing and submitting PHA documentation and other Federal, local, and state entitlement program paperwork (e.g. Social Security, SNAP benefits, utility assistance, etc.).

7.1.4 The Contractor shall provide hands on assistance to support Veteran in finding suitable housing within the appropriate catchment area of the PHA for which they have applied. Assistance to include but not limited to, transporting Veteran around neighborhoods to locate vacant apartments; helping Veteran conduct online housing searches if locally available; advocacy with potential landlords; assisting Veteran in obtaining necessary items to establish a household (i.e. move in costs, not limited to accessing outside funding for deposits, utility deposits and furnishings as well as budgeting for this). Assistance provided as clinically indicated by assessment of level of need, acuity level, stage of case management, independence, and Veteran autonomy. The Contractor shall also assist Veteran in applying for housing support resources including deposit, furniture, utilities, and arrears assistance when appropriate. All documentation is due in the Veteran’s EHR within 48 hours of the encounter.

7.1.5 The Contractor shall 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. Advocate with landlords on behalf of the Veteran to maintain a lease. The Contractor shall ensure that the Veteran has completed the VA release of information so communication between the landlord, Contractor, and VA COR/Liaison and HUD-VASH program can occur as needed.

7.1.6 The Contractor shall work collaboratively with the Veteran to obtain housing within 90 days of receipt of voucher.

7.1.7 The Contractor shall verify whether the Veteran is paying rent and utility bills in a timely manner and provide budgeting/money management assistance as needed.

7.1.8 The Contractor shall evaluate and assist the Veteran with budgeting education to promote the ability to manage expenses including those related to housing while also assisting the Veteran with locating both community and Government resources (i.e., Social Security benefits, disability compensation, local food banks, clothing, and furniture donations) as needed.

7.1.9 The Contractor shall assist the Veteran as clinically indicated in making calls to utility providers to ask questions and resolve issues (including restoring, turning on, turning off or transferring utilities).

7.1.10 The Contractor shall assist Veteran as clinically indicated in increasing income by applying for all eligible benefits, both VA and non-VA, including Veteran’s Benefits Administration (VBA) benefits, Social Security Administration (SSA) benefits, and pursuing employment opportunities.

7.1.11 The Contractor shall assist Veteran as clinically indicated in establishing medical care through VA Health Care or community provider.

7.1.12 The Contractor shall provide life skills education and assistance to Veteran in accordance with VHA Directive 1162.05(2), found in “Housing and Urban Development Department of Veterans Affairs Supportive Housing Program” and VAPORHCS CRS SOP 16 HUD-VASH Case Management Stages.

Case Management Visits 8.1 The Contractor shall conduct Case Management visits with Veterans based on the clinically appropriate stage of case management in accordance with VHA Directive 1162.05(2) “Housing and Urban Development Department of Veterans Affairs Supportive Housing Program” and VAPORHCS CRS SOP 16 HUD-VASH Case Management Stages and any subsequent updates. Case management visits provided in accordance with Veteran’s individualized Treatment Plan.

8.2 The Contractor shall visit each Veteran face-to-face at the intervals required by the VHA Directive 1162.05(2) “Housing and Urban Development Department of Veterans Affairs Supportive Housing Program” and VAPORHCS CRS SOP 16 HUD-VASH Case Management Stages. Face-to-face visits shall be conducted in accordance with VAPORHCS CRS SOP 16 HUD-VASH Case Management Stages. Visits which are not required to take place in the Veteran’s home may occur in the community, at the Contractor agency, or a place mutually agreed upon by the Veteran and Case Manager. Phone contacts, while an acceptable way to communicate with the Veteran, are generally not considered visits in meeting the minimum visit requirements under this contract.

8.3 Under some circumstances, as determined by the VA COR/Liaison, the Contractor may provide telehealth services, including virtual video visits (preferred) and telephone calls, in place of face-to-face visits. Under such circumstances, telehealth visits would be considered visits in meeting the minimum visit requirements. All staff using VA Video Connect (VVC) must complete the required training in the VA Talent Management System (TMS) prior to engaging Veterans in VVC. Training on use of VVC will be provided by the VA.

8.4 In the event the Contractor is unable to locate the Veteran for the required number of visits, the Contractor shall document all attempts to contact the Veteran including face-to-face attempts, VVC, phone calls and/or letters sent to the Veteran. This should include dates and times in the VA Electronic Health Record as verification of services rendered and to show due diligence has been exercised. Contractor challenges in completing case management visits with Veterans shall be discussed by the Contractor with VA COR/Liaison during weekly case conference meetings. 8.4.1 Case Management Due Diligence. The Contractor shall adhere to the following requirements outlining acceptable efforts in completing case management services for monthly invoicing purposes, specifically for Veterans who cannot be located or contacted. Homeless and formerly homeless Veterans may be difficult to reach, fail to keep appointments, and/or abscond from services at unexpected times. The Contractor shall proceed with a sense of urgency and accountability in following up with Veterans who cannot be located or contacted to assure their safety and well-being. This is referred to as “due diligence”.

8.4.2 Clinical Due Diligence. The Contractor shall notify the VA COR/Liaison any time an urgent or emergent concern arises about a Veteran’s well-being or if the Contractor requires the VA COR/Liaison’s immediate consultation. Contractor staff shall use clinical judgement and collaborate with the VA COR/Liaison in determining appropriate next steps in these emergent situations.

8.5 The Contractor shall perform home visits to HUD-VASH apartments to verify whether Veterans reside in healthy residences. The Contractor shall provide appropriate support and education to Veterans who are not maintaining a hygienic residence.

8.6 The Contractor shall adhere to transition between HUD-VASH Stages of Case Management and discharge criteria consistent with VAPORHCS CRS SOP 16 HUD-VASH Case Management Stages, Graduation/Discharge checklist and consultation with VA COR/Liaison.

8.7 On a minimum of a quarterly basis, based on the documented needs of the Veteran, a joint clinical case conference between the VA COR/Liaison and Contractor, VAPORHCS CRS SOP 16 HUD-VASH Case Management Stages, and VHA Directive 1162.05(2) “Housing and Urban Development Department of Veterans Affairs Supportive Housing Program”, the VA COR/Liaison shall designate the Case Management Stage and corresponding minimum visit requirement for each Veteran the Contractor services under this contract. No reduction in the visit schedule shall occur without concurrence from the VA COR/Liaison. However, if a Veteran presents with an urgent need for increased contact, the Contractor shall act to provide services based on the presenting needs prior to review with the VA COR/Liaison.

8.8 The Contractor shall re-assess any Veteran who does not meet the goals and objectives outlined in his/her/their Treatment Plan to determine any barriers to housing stability. The Contractor shall work with the Veteran to eliminate any barriers, which may involve engagement issues, continued active use of substances, serious mental illness (SMI), or a history of violence. The Contractor shall continue efforts to engage the Veteran unless there is a risk to the safety of the Contractor. The Contractor shall consult with VA COR/Liaison when Veterans present a safety risk to the Contractor and follow Prevention and Management of Disruptive Behavior (PMDB) and Disruptive Behavior Board (DBB) regarding disruptive behavior reporting and compliance with behavioral flags in the VA EHR. 8.8.1 Where required, the Contractor shall use Motivational Interviewing Techniques to assist the Veteran in redefining goals and making needed changes to the Treatment Plan. Under the guidance of the VA COR/Liaison, the Contractor shall consult with facility CRS Leadership, police service, or other VA program staff such as SUD programs, VA Disruptive Behavior Committee (DBC), or other homeless programs for assistance in determining alternative clinical treatment approaches.

8.9 In the event the Veteran is at risk of eviction, the Contractor shall schedule a case conference with the Case Manager, Veteran and others deemed necessary to try to prevent eviction from happening. The Case Manager shall always initiate appropriate consultation with the VA COR/Liaison on adverse events to determine the next course of action.

Transportation 9.1 The Contractor shall work with Veteran to foster independence in transportation and a sense of self-determination.

9.2 The Contractor shall connect Veteran with existing public transportation networks or other community provided transportation to include bus passes, transit cards, subsidized transportation services, and insurance funded transportation services. In cases where the Veteran is unable to access or use existing public transportation networks or other community provided transportation, the Contractor shall provide transportation in Contractor-owned or operated vehicles for Veteran to attend appointments at the VA, at the Public Housing Authority, benefits agencies, with landlords, relating to housing searches, or relating to medical care.

9.3 The Contractor shall accompany Veteran to medical appointments, meetings, and other appointments as deemed necessary based on the assessment completed by a member of the case management team.

Voucher Reconciliation with the PHA 10.1 At least quarterly, the Contractor shall reconcile data with the VA COR/Liaison to determine the status of all HUD-VASH vouchers, to include any vouchers that are being used by Veterans who have graduated from the program.

Contractor Discharge Requirements 11.1.1 The Contractor shall not discharge Veterans from case management services without prior approval from VA COR/Liaison.

11.1.2 When Veterans have accomplished their goals, no longer need case management services, and have reintegrated into the community, Veterans will be graduated from the case management portion of the HUD-VASH program and retain the HUD-VASH voucher if they remain otherwise eligible as deemed by the Public Housing Authority (PHA). If a Veteran graduates from case management and retains the HUD-VASH voucher, the Contractor will transfer the Veteran’s case back to the VA. The Contractor will document this process in the VA EHR.

11.1.3 When a Veteran transfers to another HUD-VASH site, the Contractor shall collaborate with the receiving site and Veteran to develop a transition plan. The

11.1 Veterans may be discharged from the HUD-VASH program for a variety of reasons and need discharge plans developed in collaboration with the Veteran to transition the Veteran’s services back to the VA whenever possible. The Contractor shall document in the VA medical record a discharge plan, a minimum of one (1) month prior to a Veteran’s discharge date. The discharge plan shall be shared with the Veteran and shall include all the required elements as defined in VHA Directive 1162.05(2), “Housing and Urban Development Department of Veterans Affairs Supportive Housing Program” and VAPORHCS CRS SOP 16 HUD-VASH Case Management Stages and Graduation/Discharge checklist. The Contractor shall notify the VA COR/Liaison, PHA and others deemed necessary in writing (via email) utilizing the appropriate Discharge Letter template. The Contractor shall complete the Discharge note template in EHR within forty-eight (48) hours of the discharge encounter with the Veteran.

Contractor shall document this coordination in the EHR and notify the VA COR/Liaison.

11.1.4 When a Veteran voluntarily leaves the HUD-VASH program, such as if the Veteran chooses non-VASH housing or is unhappy with the program, the Contractor shall collaborate with the Veteran on a discharge plan. Whenever possible, prior to the Veteran’s discharge, the Contractor shall initiate a case conference meeting with the Contractor staff, Veteran and others deemed necessary. The Case Manager shall always initiate appropriate consultation with the VA COR/Liaison.

11.1.5 When a Veteran is discharged involuntarily, the Contractor shall attempt to develop a discharge plan with the Veteran prior to discharge and initiate a case conference meeting with the Contractor staff, Veteran and others deemed necessary. The Case Manager shall always initiate appropriate consultation with the VA COR/Liaison.

11.1.6 When a Veteran is no longer financially eligible for HUD-VASH, the Contractor shall document a discharge plan transitioning services back to the VA in the EHR and offer a copy of the discharge plan to the Veteran.

11.1.7 When a Veteran is being discharged because the Veteran cannot be located, a discharge plan cannot be developed with input from the Veteran. The Contractor shall note this in the EHR and staff with the VA COR/Liaison.

11.1.8 When a Veteran is too ill to continue participating in the program, the Contractor shall discharge the Veteran upon transition to the appropriate level of care. The Contractor shall ensure a warm hand-off to the new care team, which the Contractor shall document in the EHR.

11.1.9 In cases where the Veteran is or will be incarcerated, the Contractor shall consult with the VA COR/Liaison and work with the PHA, landlord and Veteran to discharge from the program upon PHA termination of the voucher.

11.1.10 Upon the death of a Veteran, the Contractor shall discharge that Veteran from the HUD-VASH program. The Contractor shall notify the VA COR/Liaison immediately and document in the EHR. The Contractor shall work with the PHA, VA COR/Liaison, landlord and any household members to ensure necessary steps for discharge are met and provide referrals as needed.

11.1.11 The Contractor shall work with Veteran, landlord and PHA to minimize the number of negative discharges from the VASH program. Utilizing the Treatment Plan, VA services and community resources to address any barriers that the Veteran encounters while maintaining housing. The Contractor shall monitor their discharge rate and patterns to ensure the negative discharge rate falls below the performance threshold.

11.2 If a Veteran leaves the program without prior notice or case consulting, the Contractor shall notify the VA COR/Liaison immediately.

11.3 When a Veteran is…