S02 - Pierre CBOC 36C26324R0005_11302023.pdf

PAGE 1 OF 1. REQUISITION NO.

2. CONTRACT NO. 3. AWARD/EFFECTIVE DATE 4. ORDER NO. 5. SOLICITATION NUMBER 6. SOLICITATION ISSUE DATE

a. NAME b. TELEPHONE NO. (No Collect Calls) 8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY CODE 10. THIS ACQUISITION IS UNRESTRICTED OR SET ASIDE: % FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ IFB RFP

15. DELIVER TO CODE 16. ADMINISTERED BY CODE

17a. CONTRACTOR/OFFEROR CODE FACILITY CODE 18a. PAYMENT WILL BE MADE BY CODE

TELEPHONE NO. DUNS: DUNS+4:

PHONE: FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER

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

SEE ADDENDUM

19. 20. 21. 22. 23. 24.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

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

25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AWARD AMOUNT (For Govt. Use Only)

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA ARE ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________ 29. AWARD OF CONTRACT: REF. ___________________________________ OFFER COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DATED ________________________________. YOUR OFFER ON SOLICITATION DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY (BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION (REV. 2/2012)

PREVIOUS EDITION IS NOT USABLE Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

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

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 174

36C26324R0005 11/30/2023

Shanna Comparato, Contract Specialist

402-995-3692 1/26/2024

15:00 CST 10

36C263

Department of Veterans Affairs Network 23 Contracting Office

316 Robert Street N. STE. 506 St. Paul, MN 55101

X

621498

$25.5 Million

X

N/A

X

36C618

Department of Veterans Affairs VA Black Hills Health Care System 113 Comanche Road h Fort Meade MN 57741

Network 23 Contracting Office

316 Robert Street N. STE. 506 St. Paul, MN 55101

Financial Services Center PO Box 149971 Austin, TX 78714-9971

See CONTINUATION Page

Community Based Outpatient Clinic (CBOC) services to be located Within the city limits of Pierre, South Dakota to provide Primary Care Health Services.

See B.2 for Schedule of Services, on Page 7

See B.3 for Performance Work Statement, Pages 10 - 100

See CONTINUATION Page

Paid separately via individual issued Task Orders

X X

X -One-

Travis Johnson Contracting Officer

Table of Contents

SECTION A

A.1 SF 1449 SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

SECTION B - CONTINUATION OF SF 1449 BLOCK 18A

B.1 Contract Administration Data

B.2 Schedule of Services

B.3 Performance Work Statement (PWS)

1. General

1.1. Services Required:

1.3. Authority:

1.4. Policy and Regulations:

1.5. Definitions / Acronyms:

2. Staffing and Qualifications

2.1. Minimum Patient Aligned Care Team (Pact) Staffing Requirements:

2.2. Physician Director:

2.3. Primary Care Teamlet Staffing:

2.4. Discipline Specific Pact Team Members:

2.5. Specialty Care Staffing:

2.6. Ancillary Support Services Staffing:

2.7. Telehealth Services Clinical Staff:

2.8. License and Accreditation:

2.9. Credentialing and Privileging:

2.10. CME/CEU:

2.11. Training (ACLS / BLS / VA Mandatory):

2.12. Access to Patient Information:

2.13. Rules of Behavior for Automated Information Systems:

2.14. Standard Infection Control Measures (PPD, Immunizations, etc.):

2.15. National Provider Identification (NPI):

2.16. Prescription Drug Monitoring Program:

2.17. Conflict of Interest:

2.18. Annual Office of Inspector General (OIG) Statement:

2.19. Non-Personal Services:

2.20. Contract Personnel:

2.21. Inherently Governmental Functions Prohibited

2.22. Torts:

2.23. Ryan Haight Act:

2.24 Individual Provider Requests to Opt Out of Care:

3. Hours and Holidays

3.1. Hours:

3.2. Federal Holidays:

4. Contractor Responsibilities:

4.1. General:

4.2. Registration and Financial Assessments:

4.3. Episodic Care for Unassigned/Unenrolled Patients:

4.4. Patient Handbook:

4.5. Standards of Practice:

4.6. Health Equity

4.7. Patient Care:

4.8. Administrative:

4.9. Grievance System Requirements:

4.10. Space Requirements:

4.11. Environment of Care (EOC):

4.12. Equipment, Office Supplies and Technical Support:

4.13. Performance Standards, Quality Assurance and Quality Improvement:

4.14. Performance Standards and Surveillance:

4.14. Required Registration with Contractor Performance Assessment Reporting System (CPARS) .. 90

5. Government Responsibilities:

5.1. Oversight of Service/Performance Monitoring:

6. Special Contract Requirements

6.1. Contract Start-up Requirements:

6.2. Billing Codes:

B.4 Records Management Obligations (NARA Language)

SECTION C – CONTRACT CLAUSES

C.1 FAR 52.212-4 Contract Terms and Conditions-Commercial Products and Commercial Services (December 2022) C.2 FAR 52.204-9 Personal Identity Verification of Contractor Personnel (January 2011) C.3 FAR 52.204-21 Basic Safeguarding of Covered Contractor Information Systems (November 2021) C.4 FAR 52.216-18 Ordering (August 2020) C.5 FAR 52.216-19 Order Limitations (October 1995) C.6 FAR 52.216-22 Indefinite Quantity (October 1995) C.7 FAR 52.217-8 Option to Extend Services (November 1999) C.8 Addenda to 52.217-8 Evaluation of Option to Extend under FAR 52.217-8 C.9 FAR 52.217-9 Option to Extend the Term of the Contract (March 2000) C.10 FAR 52.222-30 Construction Wage Rate Requirements-Price Adjustment (None or Separately Specified Method) (August 2018) C.11 FAR 52.228-5 Insurance Work on a Government Installation (January 1997) C.11 Supplemental Insurance Requirements C.12 VAAR 852.201-70 Contracting Officer’s Representative (December 2022) C.13 VAAR 852.203-70 Commercial Advertising (May 2018) C.14 VAAR 852.204-71 Information and Information Systems Security (February 2023) C.14 VAAR 852.211-76 Liquidated Damages – Reimbursement for Data Breach Costs (February 2023) C.15 VAAR 852.215-70 Service-Disabled Veteran-Owned and Veteran-Owned Small Business Evaluation Factors (January 2023) C.16 VAAR 852.215-71 Evaluation Factor Commitments (October 2019) C.17 VAAR 852.219-70 VA Small Business Subcontracting Plan Minimum Requirements (November 2022) C.18 VAAR 852.232-72 Electronic Submission of Payment Requests (November 2018) C.19 VAAR 852.237-70 Indemnification and Medical Liability Insurance (October 2019) C.20 VAAR 852.237-72 Crime Control Act – Reporting of Child Abuse (October 2019) C.21 VAAR 852.237-74 Nondiscrimination in Service Delivery (October 2019) C.22 VAAR 852.237-75 Key Personnel (October 2019)

C.23 VAAR 852.239-70 Security Requirements for Information Technology Resources (February 2023) C.24 VAAR 852.239-73 Information System Hosting, Operation, Maintenance, or Use (February 2023) C.25 VAAR 852.239-74 Security Controls Compliance Testing (February 2023) C.26 VAAR 852.239-76 Information and Communication Technology Accessibility (February 2023) C.27 VAAR 852.242-71 Administrative Contracting Officer (October 2020) C.28 FAR 52.252-2 Clauses Incorporated by Reference (February 1998) C.29 FAR 52.212-5 Contract Terms and Conditions Required to Implement Statues or Executive Orders – Commercial Products and Commercial Services (November 2023)

SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS

SECTION E - SOLICITATION PROVISIONS

E.1 FAR 52.212-1 Instructions to Offerors – Commercial Products and Commercial Services (September 2023) E.2 Proposal Preparation Instructions (Addendum to FAR 52.212-1) E.3 FAR 52.204-24 Representation Regarding Certain Telecommunication and Video Surveillance Equipment (November 2021) FAR 52.209-7 Information Regarding Responsibility Matters (October 2018) E.4 FAR 52.216-1 Type of Contract (Apr 1984) E.5 FAR 52.222-5 Construction Wage Rate Requirements – Secondary Site of the Work (May 2014) E.6 FAR 52.233-2 Service of Protest (September 2006) E.7 VAAR 852.209-70 Organizational Conflicts of Interest (October 2020) E.8 VAAR 852.233-70 Protest Content/ Alternative Dispute Resolution (September 2018) E.9 VAAR 852.233-71 Alternate Protest Procedure (September 2018) E.10 VAAR 852.239-71 Information System Security Plan and Accreditation (February 2023)156 E.11 VAAR 852.239-75 Information and Communication Technology Accessibility Notice (February 2023) E.12 VAAR 852.252-70 Solicitation Provisions or Clauses Incorporated by Reference (January 2008) E.13 VAAR 852.273-70 Late Offers (November 2021) E.14 852.273-74 Award Without Exchanges (November 2021) FAR 52.252-1 Solicitation Provisions Incorporated by Reference (February 1998) E.15 52.212-2 Evaluation – Commercial Products and Commercial Services (November 2021) E.16 FAR 52.212-3 Offeror Representations and Certifications – Commercial Products and Commercial Services (November 2023)

Pierre, South Dakota CBOC 36C26324R0005

SECTION B - CONTINUATION OF SF 1449 BLOCK 18A.

B.1 Contract Administration Data System for Award Management (SAM):

SAM Registration: Offeror must be registered in the System for Award Management (SAM). No contract will be entered into with an unregistered contractor. Internet access allows registration by completing an electronic on-line registration application at https://sam.gov/content/home.

Under the authority of Title 38 USC § 8153, “Health Care Resources (HCR) Sharing Authority”, the Contractor agrees to provide Health Care Resources in accordance with the terms and conditions stated herein, furnished to/and at the VA Black Hills Health Care System, the services and prices specified in the Sections B.2 (Schedule of Services) and B.3 (Performance Work Statement).

1. Contract Administration: All contract administration matters will be handled by the following individuals:

a. CONTRACTOR: (Offerors are required to designate a person and their point of contact information for prompt administration).

Name of Company:

Name of Government POC:

Title/Position of Government POC:

Email of Government POC:

Phone Number of Government POC:

Contractor Address:

City/State/Zip:

b. GOVERNMENT: Travis Johnson, Contracting Officer (90C)

Network Contracting Office (NCO) 23 2501 W. 22nd Street Sioux Falls, SD 57105 605-333-6822 Travis.Johnson2@va.gov

c. Contractor and Government points of contact can be changed by written notification to the other party.

Notification will be placed in the Contract file and shall not require a modification to the Contract.

2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor should be mailed to the following address (Contractor fill in address information below): N/A

3. ELECTRONIC INVOICE SUBMISSION: All Invoices shall be submitted electronically in accordance with VAAR Clause 852.232-72, Electronic Submission of Payment Requests. Invoicing shall be in accordance with the requirements of the Department of Veterans Affairs (VA) Financial Services Center (VA FSC). The ;attest information shall be used for invoicing and payments and may change during the Period of Performance of this acquisition. Current invoicing information is located at: https://www.fsc.va.gov/einvoice.asp.

A) Tungsten direct vendor support number is 877-489-6135 for VA contracts;

B) The VA-FSC pays all associated transaction fees for VA orders;

C) During Implementation (technical set-up) Tungsten will confirm your Taxpayer ID Number with the VA-FSC;

D) This process can take up to 5 business days to complete to ensure your invoice is automatically routed to your Certifying Official for approval and payment;

https://sam.gov/content/home https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title38-section8153&num=0&edition=prelim mailto:Travis.Johnson2@va.gov https://www.fsc.va.gov/einvoice.asp

E) To successfully submit an invoice to VA-FSC please review “How to Create an Invoice” within the “how-to” guides;

F) All invoices submitted through Tungsten to the VA-FSC should mirror the current submission of Invoice, with the following items required.;

G) Clarification of additional requirements should be confirmed with your Certifying Official the Contracting Officer or Contract Specialist.

H) Payments will only be made for actual services rendered;

I) Payments shall be made monthly, in arrears upon receipt of a properly prepared invoice IAW FAR 52.212-4(g), FAR 52.232-33, and VAAR 852.232-72;

J) The Contractor shall be reimbursed at the capitation rate specified in Section B.2 Schedule of Services;

K) The VA-FSC requires specific information in compliance with the Prompt Pay Act and Business Requirements;

L) The Contractor shall be reimbursed upon receipt of a proper invoice. Invoices must contain the following information:

a) Total number of listed Veterans from the previous month's invoice;

b) New Veterans added to the billable roster since the previous month's invoice;

c) Veterans removed from the billable roster since the previous month's invoice;

d) Number of Veterans (if any) whose disenrollments generate a credit, the amount of the credit, and the calculation(s) used to arrive at the credit;

e) Firm’s Taxpayer ID Number (TIN);

f) Firm’s “Remit Address” information;

g) The VA Purchase Order (PO) number;

h) Firm’s contact information: (Personal Name, Email, and Phone);

i) VA point of contact information: (Personal Name, Email, and Phone);

j) The Period of Performance dates (Beginning and Ending); and

k) All discount information if applicable (Percent and Date Terms)

M) For additional information, please contact:

1) Tungsten Support:

a) Phone: 1-877-489-6135

b) Website: https://www.fsc.va.gov/einvoice.asp

2) Department of Veterans Affairs Financial Service Center

a) Phone: 1-877-353-9791

b) Email: vafscched@va.gov

4. Type of Contract:

Primary Care Services at Capitation Rates; Per Member/Per Month (PMPM). 10-Year, Fixed Price, Indefinite Delivery Indefinite Quantity Contract.

https://www.fsc.va.gov/einvoice.asp mailto:vafscched@va.gov

B.2 Schedule of Services In accordance with Title 38 USC § 8153, “Health Care Resources (HCR) Sharing Authority” and FAR Part 15; the Contractor shall provide continuous delivery of Contractor Operation Primary Care Services, including Primary Care Services inclusive of space for tele-health services in accordance with the terms, conditions, and provisions stated herein. The Contractor shall furnish services to eligible Veteran beneficiaries enrolled within the VA Black Hills Health Care System, and the prices specified within the Schedule of Services below. A contract resulting from this solicitation will be awarded of one year, with the Government having the option to extend the contract for nine

(9) additional one-year periods.

This solicitation covers the provision of Primary Care Services. The clinic is to be located within the city limits of Pierre, South Dakota. The Contractor shall establish one location to provide the required services specified under the resultant contract. Primary care must be provided at the same site as the primary clinic. Veterans to be services under the resultant contract reside primarily in Pierre, South Dakota, inclusive of Veterans residing in Fall River, Hughes, Hyde, Jones, Lyman, Meade, Potter, Stanley and Sully Counties.

Primary Care Services will be provided to patients enrolled to the clinic by the VA Black Hills Health Care System (VA BHHCS). Payment for services will be based upon orders issued against the resultant contract. The guaranteed minimum contract amount is: $500,000.00.

CBOC ORDERING PROCEDURES: VA has the sole authority to assign Veterans treated by the Contractor into the Primary Care Management Model (PCMM) software program used to track primary care clinic Veteran rosters.

Specific billable processes for issuing task orders under the resultant contract include: determining Veteran eligibility, enrollment eligibility, and at least one qualifying encounter by the Contractor’s primary care provider (PCP) within the previous 12 months.

The Contractor will be provided a list of all enrolled patients at the beginning of the contract and will be able to bill for these patients immediately. In order to remain enrolled in the clinic, patients must have a qualifying visit within 12 months of their last visit. Qualifying encounters are further defined in PWS Section 6.2.2. Please review in detail to ensure compliance for issuance of subsequent task orders and payment processing.

Any services to be furnished under this contract shall be ordered by issuance of Delivery Orders or Task Orders by the Contracting Officer or Administrative Contracting Officer. Orders may be issued by electric commerce methods.

This is a Fixed Price (FP) Indefinite Delivery, Indefinite Quantity (IDIQ) Contract under C.6 FAR 52.216-22. The Task Orders shall specify the estimated quantities of services for each Period of Performance and to be furnished under this contract and shall comply with C.4 FAR 52.216-18 and C.5 FAR 52.216.19.

Contract Minimum: $500,000.00, Contract Maximum: $17,000,000.00

*PMPM includes cost of unassigned patient visits, The Contractor shall not bill separately or propose an additional Line-Item Numbers (LIN) or bill separately for these costs. All quantities are estimated, the Government will pay for services performed as certified by the Contracting Officer’s Representative (COR).

Base Year, Period of Performance– 04/01/2024-03/31/2025

Line Item

Services Unit

Estimated Quantity

Price per

Total Estimated Cost per month

Total Estimated Cost per year

0001 Primary Care Services at capitation rates per member per month (PMPM)

Per Member Per Month

Total Estimated for Base Year $________________________ https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title38-section8153&num=0&edition=prelim https://www.acquisition.gov/far/part-15

Option Year I, Period of Performance – 04/01/2025-03/31/2026 Line Item

Total Estimated Cost per month

Total Estimated Cost per year

1001 Primary Care Services at capitation rates per member per month (PMPM)

Per

1,005

Total Estimated for Option Year I $________________________

Option Year II, Period of Performance – 04/01/2026-03/31/2027

Line Item

Total Estimated Cost per month

Total Estimated Cost per year

2001 Primary Care Services at capitation rates per member per month (PMPM)

Per

1,020

Total Estimated for Option Year II $________________________

Option Year III , Period of Performance – 04/01/2027-03/31/2028

Line Item

Total Estimated Cost per month

Total Estimated Cost per year

3001 Primary Care Services at capitation rates per member per month (PMPM)

Per

1,035

Total Estimated for Option Year III $________________________

Option Year IV , Period of Performance – 04/01/2027-03/31/2028

Line Item

Total Estimated Cost per month

Total Estimated Cost per year

4001 Primary Care Services at capitation rates per member per month (PMPM)

Per

1,050

Total Estimated for Option Year IV $________________________

Option Year V , Period of Performance – 04/01/2028-03/31/2029

Line Item

Total Estimated Cost per month

Total Estimated Cost per year

5001 Primary Care Services at capitation rates per member per month (PMPM)

Per

1,065

Total Estimated for Option Year V $________________________

Option Year VI , Period of Performance – 04/01/2029-03/31/2030 Line Item

Total Estimated Cost per month

Total Estimated Cost per year

6001 Primary Care Services at capitation rates per member per month (PMPM)

Per

1,080

Total Estimated for Option Year VI $________________________

Option Year VII , Period of Performance – 04/01/2030-03/31/2031

Line Item

Total Estimated Cost per month

Total Estimated Cost per year

7001 Primary Care Services at capitation rates per member per month (PMPM)

Per

1,095

Total Estimated for Option Year VII $________________________

Option Year VIII , Period of Performance – 04/01/2031-03/31/2032

Line Item

Total Estimated Cost per month

Total Estimated Cost per year

8001 Primary Care Services at capitation rates per member per month (PMPM)

Per

1,110

Total Estimated for Option Year VIII $________________________

Option Year IX , Period of Performance – 04/01/2032-03/31/2033

Line Item

Total Estimated Cost per month

Total Estimated Cost per year

9001 Primary Care Services at capitation rates per member per month (PMPM)

Per

1,125

Total Estimated for Option Year IX $________________________

TOTAL ESTIMATED FOR BASE AND ALL NINE OPTION YEARS $___________________________

B.3 Performance Work Statement (PWS)

1. General

1.1. Services Required:

The VA Black Hills Health Care System (VA BHHCS); requires the following services to be provided in a private hospital, office or clinic environment to Veterans, primarily residing in Pierre, South Dakota.

1.1.1. Primary Care CBOC: offers both medical and mental health care (physically on site and by telehealth) and may offer support services such as pharmacy, laboratory, and x-ray. Primary Care CBOCs are required to provide both primary care and mental health services. Mental Health services will be provided by VA staff via telehealth.

1.2. Place of Performance:

Within the City limits of Pierre, South Dakota.

1.3. Authority:

In accordance with Title 38 USC § 8153, “Health Care Resources (HCR) Sharing Authority”, to be furnished by the Contractor on behalf of VA Black Hills Health Care System, 113 Comanche Rd., Fort Meade, South Dakota.

1.4. Policy and Regulations:

The Contractor is required to meet VHA performance and quality criteria and standards including, but not limited to, access, customer satisfaction, prevention index, chronic disease index and clinical guidelines.

Performance and quality standards may change during the contract. New or revised quality/performance criteria or standards will be provided to the Contractor before implementation date and throughout the life of the contract through unilateral or bi-lateral modifications, as applicable. Copies of current VA Publications and VHA publications are hyperlinked. Compliance with mandated performance is required as a condition of this contract.

Contractor shall comply with all relevant VA policies and procedures, including those related to quality, access, patient safety and performance, including, but not limited to the policies listed on the Contracted Clinic Policy Document located at: https://www.patientcare.va.gov/primarycare/Resources.asp.

1.5. Definitions / Acronyms:

1.5.1. AAMA: American Association of Medical Assistants

1.5.2. ABMS: American Board of Medical Specialties

1.5.3. ABHES: Accrediting Bureau of Health Education Schools

1.5.4. ACLS: Advanced Cardiac Life Support

1.5.5. ACEN: Accreditation Commission for Education in Nursing

1.5.6. ACEND: Accreditation Council for Education in Nutrition and Dietetics

1.5.7. ACGME: Accreditation Council for Graduate Medical Education

1.5.8. ACPE: Accreditation Council for Pharmaceutical Education

1.5.9. ACO: Administrative Contracting Officer

1.5.10. ADE: Adverse Drug Event(s)

1.5.11. AED: Automatic External Defibrillator

1.5.12. AIS: Automated Information Security

1.5.13. AMT: American Medical Technologists

1.5.14. ANA: American Nurses Association

1.5.15. AND: Academy of Nutrition and Dietetics

1.5.16. APA: American Psychological Association

1.5.17. ARRT: American Registry of Radiologic Technology

https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title38-section8153&num=0&edition=prelim https://www.va.gov/health/ http://www.va.gov/vapubs/ http://www.va.gov/vhapublications/ http://www.va.gov/vhapublications/ https://www.patientcare.va.gov/primarycare/Resources.asp https://www.aama-ntl.org/ https://www.abms.org/ https://www.abhes.org/ https://cpr.heart.org/en/cpr-courses-and-kits/healthcare-professional/acls https://www.acenursing.org/ https://www.eatrightpro.org/acend https://www.acpe-accredit.org/ https://americanmedtech.org/ https://www.nursingworld.org/ana/ https://www.eatright.org/ https://www.apa.org/ https://www.arrt.org/

1.5.18. ASC: Ambulatory Surgery Center

1.5.19. ASRT: American Society of Radiological Technologists

1.5.20. Assigned: A Veteran is “assigned” to an outpatient clinic via PCMM (i.e., CBOC) where the patient receives their primary care after the patient’s eligibility is determined through registration and enrollment.

1.5.21. Asynchronous Care: Care provided outside of bookable time and includes but is not limited to the following activities: refilling prescriptions, reviewing outside records, huddles and case management, team meetings, processing view alerts, secure messaging and training.

1.5.22. BAA: Business Associate Agreement

1.5.23. BI-RADS: Breast Imaging-Reporting and Data System; a quality assurance tool designed to standardize mammography reporting

1.5.24. BLS: Basic Life Support

1.5.25. BOS: Bureau of Osteopathic Specialists

1.5.26. CAAHEP: Commission on Accreditation of Allied Health Education Programs

1.5.27. CACREP: Council on Accreditation of Counseling and Related Educational Programs

1.5.28. CAP: College of American Pathologists

1.5.29. CARF: Commission on Accreditation of Rehabilitation Facilities

1.5.30. CBO: VA Central Billing Office.

1.5.31. CCNE: Commission on Collegiate Nursing Education

1.5.32. CDC: Centers for Disease Control and Prevention

1.5.33. CDR: Council on Dietic Registration

1.5.34. CEU: Certified Education Unit

1.5.35. CLIA: Clinical Laboratory Improvement Amendments

1.5.36. CME: Continuing Medical Education

1.5.37. CMS: Center for Medicare and Medicaid Services

1.5.38. CO: Contracting Officer

1.5.39. COAMFTE: Commission on Accreditation for Marriage and Family Therapy Education

1.5.40. COPD: Chronic Obstructive Pulmonary Disease

1.5.41. COR: Contracting Officer’s Representative

1.5.42. COS: Chief of Staff

1.1.1. CPA: Canadian Psychological Association

1.5.43. CPA: Collaborative Practice Agreement

1.5.44. CPP: Clinical Pharmacist Practicioner

1.5.45. CPRS: Computerized Patient Record System

1.5.46. CPT: Current Procedural Terminology

1.5.47. CRNP: Certified Registered Nurse Practitioners

1.5.48. CSRE: Comprehensive Suicide Risk Evaluation

1.5.49. CSWE: The Council on Social Work Education

1.5.50. CPARS: Contractor Performance Assessment Reporting System

1.5.51. CVT: Clinical Video Telehealth

1.5.52. DICOM: Digital Image and Communication in Medicine

1.5.53. DIGMA: Drop-in Group Medical Appointment

1.5.54. DRG: Diagnostic Related Group

1.5.55. DSS: Decision Support System

1.5.56. ECC: Extended Care Center

https://www.asrt.org/ https://cpr.heart.org/en/cpr-courses-and-kits/healthcare-professional/basic-life-support-bls-training https://certification.osteopathic.org/bureau-of-osteopathic-specialists/ https://www.caahep.org/ https://www.cacrep.org/ https://www.cap.org/ https://www.carf.org/home/ https://www.aacnnursing.org/CCNE https://www.cdc.gov/ https://www.cdrnet.org/ https://www.cdc.gov/clia/index.html https://www.cms.gov/ https://www.coamfte.org/ https://cpa.ca/ https://www.ama-assn.org/amaone/cpt-current-procedural-terminology http://www.cswe.org/ file://oitminhsmsmb602.va.gov/services/CONTRACTING/Shan%20Comparato/2%20-%20WORKING%20ASSIGNMENTS/Pierre%20CBOC%20Info/Contractor%20Performance%20Assessment%20Reporting%20System

1.5.57. Enrollment: The process of establishing eligibility for VA’s “Medical Benefits Package.” Most Veterans are required to “enroll” into the VA Health Care System to be eligible for VA health care and to be assigned to an outpatient clinic like a CBOC, however some can still receive care without enrolling.

Applicants are only required to “enroll” once for VA health care unless they are determined ineligible for care at time of application or they have disenrolled.

1.5.58. EPRP: External Peer Review Program

1.5.59. FDA: Food and Drug Administration

1.5.60. FSMB: Federation of State Medical Boards

1.5.61. HCC: Health Care Center An HCC is a VA-owned, VA-leased, contract, or shared clinic operated at least 5 days per week that provides primary care, mental health care, on site specialty services, and performs ambulatory surgery and/or invasive procedures which may require moderate sedation or general anesthesia.

1.5.62. HHS: Department of Health and Human Services

1.5.63. HICPAC: Healthcare Infection Control Practices Advisory Committee - a federal advisory committee made up of 14 external infection control experts who provide advice and guidance to the CDC and the Secretary of HHS regarding the practice of health care infection control, strategies for surveillance and prevention and control of health care associated infections in United States health care facilities.

1.5.64. HT: Home Telehealth

1.5.65. ICD 10: International Classification of Diseases, 10th edition

1.5.66. iMED: software used by VA for informed consent

1.5.67. INR: International Normalized Ratio

1.5.68. ISO: Information Security Officer

1.5.69. LIP: licensed independent practitioner

1.5.70. MCCR: Medical Care Cost Recovery

1.5.71. Mental Health Services: per VHA Handbook 1160.06 (or subsequent policy release). is meant to include services for the evaluation, diagnosis, treatment, and rehabilitation of both substance use disorders and other mental disorders.

General mental health services include:

1.5.71.1. Diagnostic and treatment planning evaluations for the full range of mental health problems;

1.5.71.2. Treatment services using evidence-based pharmacotherapy, or primary evidence-based

1.5.71.3. psychotherapy for patients with mental health conditions and substance use disorders;

1.5.71.4. Patient education;

1.5.71.5. Family education when it is associated with benefits to the Veterans;

1.5.71.6. Referrals as needed to inpatient and residential care programs; and

1.5.71.7. Consultation about special emphasis problems including Post Traumatic Stress Disorder

(PTSD) and Military Sexual Trauma (MST).

Specialty mental health services include:

1.5.71.8. Consultation and treatment services for the full range of mental health conditions;

1.5.71.9. Evidence-based psychotherapy;

1.5.71.10. Mental Health Intensive Case Management (MHICM);

1.5.71.11. Psychosocial Rehabilitation Services, including: PRRCs, family psychoeducation,

1.5.71.12. Family education, skills training, peer support, and Compensated Work Therapy (CWT) and supported employment;

1.5.71.13. PTSD teams or specialists;

1.5.71.14. MST special clinics;

1.5.71.15. Homeless programs; and

1.5.71.16. Specialty substance abuse treatment services.

1.5.72. MQSA: Mammography Quality Standards Act

https://www.fda.gov/ https://www.fsmb.org/ https://www.hhs.gov/ file://oitminhsmsmb602.va.gov/services/CONTRACTING/Shan%20Comparato/2%20-%20WORKING%20ASSIGNMENTS/Pierre%20CBOC%20Info/Healthcare%20Infection%20Control%20Practices%20Advisory%20Committee https://www.cdc.gov/ https://www.hhs.gov/ https://www.cdc.gov/nchs/icd/icd10.htm https://www.datahub.va.gov/dataset/Medical-Care-Cost-Recovery-National-Database-MCCR-/gbx4-ntxr https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2937 https://www.fda.gov/radiation-emitting-products/mammography-quality-standards-act-and-program

1.5.73. MSN: Master of Science in Nursing

1.5.74. NLN: National League for Nursing

1.5.75. OPM: Office of Personnel Management

1.5.76. OTC: Over the Counter

1.5.77. PA: Physician Assistant

1.5.78. PACS: Picture Archiving and Communications System

1.5.79. PACT: Patient Aligned Care Team VA has implemented a PCMH model at all VA Primary Care sites which is referred to as PACT. This initiative supports VHA’s Universal Health Care Services Plan to redesign VHA healthcare delivery through increasing access, coordination, communication, and continuity of care. PACT provides accessible, coordinated, comprehensive, patient-centered care, in team-based environment including the active involvement of other clinical and non-clinical staff. PACT allows patients to have a more active role in their health care and is associated with increased quality improvement, patient satisfaction, and a decrease in hospital costs due to fewer hospital visits and readmissions.

1.5.80. Parent Facility: VAMC responsible for performance monitoring and payment for contracted Outpatient Site of Care services.

1.5.81. PBM: Pharmacy Benefits Management

1.5.82. PCMH: Patient-Centered Medical Home

1.5.83. PCMM: Patient Centered Management Module - a software program used to track Primary Care

Clinic Veteran rosters.

1.5.84. PCP: Primary Care Provider

1.5.85. PCSAS: Psychological Clinical Science Accreditation System

1.5.86. Phar.D.: Doctor of Pharmacy

1.5.87. POC: Point of Care Testing

1.5.88. Primary Care Visit: an episode of care furnished in a clinic or virtually that provides integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Primary care includes, but is not limited to, diagnosis and management of acute and chronic biopsychosocial conditions, health promotion, disease prevention, overall care management, and patient and caregiver education. The VHA site classification defines primary care as those encounters that occur within the primary care class of encounters.

1.5.89. PCMHI: Primary Care-Mental Health Integration

1.5.90. PSAC: Personnel Security Adjudication Center

1.5.91. PWS: Performance Work Statement

1.5.92. QAPI: Quality Assessment and Performance Improvement

1.5.93. QASP: Quality Assurance Surveillance Plan

1.5.94. RME: Reusable Medical Equipment

1.5.95. RRTP: Residential Rehabilitation Treatment Program

1.5.96. SOP (Clinical): Scope of Practice

1.5.97. SFT: Store and Forward Telehealth

1.5.98. SMA: Shared Medical Appointments

1.5.99. SPD: Sterile Processing Division

1.5.100. SPE: Senior Procurement Executive

1.5.101. SPS: Sterile Processing Service

1.5.102. Support Staff (PACT): PACT Staff assisting providers in the actual delivery of care to patients. It consists of RNCMs, clinical associates, and administrative associates.

1.5.103. Synchronous Care: Bookable, real-time care provided in person or virtually (VA Video Connect, CVT, telephone) with a Veteran and involves clinical decision-making in a two-way conversation.

https://www.nln.org/ https://www.opm.gov/ https://www.va.gov/health/ https://www.va.gov/health/ https://www.pcsas.org/ https://www.va.gov/securityinvestigationscenter/

1.5.104. TJC: The Joint Commission

1.5.105. TMS Talent Management System

1.5.106. TIU: Text Integration Utility

1.5.107. TCT: Telehealth Clinical Technicians

1.5.108. VA: Veterans Affairs

1.5.109. VA BHHCS: VA Black Hills Health Care System

1.5.110. VA EHR: VA Electronic Health Record

1.5.111. VAMC: Veterans Affairs Medical Center

1.5.112. VetPro: VetPro is a federal web-based credentialing program for healthcare providers.

1.5.113. VHA: Veterans Health Administration

1.5.114. VVC: VA Video Connect

1.5.115. WHEN: Weekend- Holiday- Every Night

2. Staffing and Qualifications

2.1. Minimum Patient Aligned Care Team (Pact) Staffing Requirements:

PACTs comprise the patients, the patients’ personal support persons, teamlets (Primary Care Providers (PCPs), Registered Nurse Care Managers (RNCMs), Clinical Associates, Administrative Associates), and discipline specific team members (Clinical Pharmacy Specialists (CPSs), Licensed Clinical Social Workers (LCSWs), Registered Dietician/Nutritionists, and Primary Care-Mental Health Integration (PCMHI) staff).

2.1.1. The Contractor shall provide PACT staffing in numbers and qualifications capable of fulfilling the standards outlined in the resultant contract.

2.1.2. The Contractor shall provide a sufficient number of primary care providers so that each primary care provider has a caseload ratio to meet VA standards. Current standards are 1200 active patients per full time physician and 900 active patients per full time midlevel provider.

2.1.3. Actual panel sizes can be determined by the VA in accordance with VHA Directive 1406, “Patient Centered Management Module (PCMM) for Primary Care” (or subsequent policy release).

2.1.4. The staffing standard for support staff shall be in ratios to Primary Care Providers of at least three (3) full time equivalent (FTE) support staff (1 FTE RNCM, 1 FTE Clinical Associate, 1 FTE Administrative Associate) for each FTE Primary Care Provider.

2.1.5. The Clinical Pharmacy Specialist (CPS) shall be provided the same support staffing given to other providers on the team when they are working in the capacity of a mid-level provider.

2.1.6. The Contractor shall provide personnel in numbers and qualifications capable of fulfilling the standards outlined in the resultant contract.

2.1.7. The Contractor must establish and implement contingency plans for ensuring patients receive continuity of and access to appropriate primary care during periods of inadequate resources, extended staff absences, staff turnover, understaffing, and nature-related events (e.g., extreme weather conditions, natural disasters).

2.1.8. If the number of patients reaches 90% of maximum panel size assigned by the facility the Contractor shall communicate to the VA the Contractor’s future staffing plan to ensure staffing ratio standards remain in accordance with PCMM staffing standards.

2.1.9. Total Estimated Patients enrolled/assigned to site: 949.

2.2. Physician Director:

FTE Ratio Performance Standard: 0.05 FTE per PACT Responsible Party: Shall be provided by Contractor.

2.2.1. Qualifications: Contractor’s Physicians (including subcontractors) providing physician director services under the resultant contract shall demonstrate evidence of education, training, and experience in Internal Medicine or Family Practice. Contactor’s Physicians performing under this contract shall be https://www.jointcommission.org/ https://www.va.gov/vdl/documents/Clinical/CPRS-Text_Integration_Utility_(TIU)/tiutm.pdf https://www.va.gov/ https://fcp.vetpro.org/Admin/Login/Index https://www.va.gov/health/ https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5430 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5430 board certified (or board eligible) by the ABMS in Internal Medicine and/or Family Practice or the BOS in Internal Medicine and/or Family Practice.

2.2.2. If proposed staff do not meet VA credentialing requirements, the Contractor shall propose substitute acceptable personnel within five (5) calendar days.

2.2.3. The physician Director may also be credentialed and privileged to function as a PCP. (If so, authorization for prescriptive authority is required).

2.2.4. Physicians shall be licensed in the state in which the Outpatient Site of Care (i.e. CBOC) is located;

otherwise qualifications as per VA Handbook 5005, Appendix G2(or subsequent policy release). .

2.2.5. Position Responsibilities: Serves as medical director to oversee and be responsible for the provision of covered services to enrolled and unassigned patients presenting for care at the site.

2.3. Primary Care Teamlet Staffing:

All primary care teamlet staffing shall be provided by Contractor.

2.3.1. Teamlet Member 1- Primary Care Provider (PCP): FTE Ratio Performance Standard: Current standards are 1200 active patients per full time physician and 900 active patients per full time midlevel provider. Contractor shall propose quantity of FTE to meet Standard FTE ratio to panel size. Contractor to propose mix of PCP from the options below. Contractor is required to provide at least 1 FTE physician.

2.3.1.1. Option 1: Physician (MD): Qualifications:

A) Physicians shall demonstrate evidence of education, training, and experience in Internal Medicine or Family Practice.

B) Physicians performing under this contract shall be board certified (or board eligible) by the ABMS in Internal Medicine and/or Family Practice or the BOS in Internal Medicine and/or Family Practice.

C) Authorization for prescriptive authority is required.

D) If proposed staff do not meet VA credentialing requirements, the Contractor shall propose substitute acceptable personnel within five (5) calendar days.

E) Physicians shall be licensed in the state in which the Outpatient Site of Care (i.e. CBOC) is located; otherwise qualifications as per VA Handbook 5005(or subsequent policy release).

F) Position Responsibilities: Responsible for-

1) The provision of covered services to enrolled and unassigned patients presenting for care;

2) Providing health care commensurate to the PCP’s licensure and clinical privileges or scope of practice;

3) Ensuring the patient’s care plan contains medical recommendations for clinically indicated care;

4) Offering clinically indicated health care services to patients assigned to the PACT, and providing or arranging for care to which patients consent;

5) Providing leadership to the team including shared delegation of appropriate care and care processes to appropriate team members, reviewing available clinical and performance data with the team; and

6) Focusing on continuous improvement of critical team processes, ensuring the patient has same-day access for face-to-face, and virtual care visits during regular clinic hours, and collaborating with PACT staff to develop personal health plans that incorporate care management and care coordination appropriate to the patient’s needs.

2.3.1.2. Option 2- Certified Registered Nurse Practitioner (CRNP): Qualifications:

A) ARNP’s (including subcontractors) must have an MSN from a NLN accredited nursing program and have ANA Certification as a Nurse Practitioner in either Adult Health or Family Practice.

B) Authorization for prescriptive authority is required.

C) Three years of clinical nursing experience is required.

D) A minimum of one (1) year clinical experience as a CRNP is required (three (3) years preferred).

https://www.abms.org/ https://certification.osteopathic.org/bureau-of-osteopathic-specialists/ https://www.va.gov/vapubs/viewPublication.asp?Pub_ID=1358&FType=2 https://www.abms.org/ https://certification.osteopathic.org/bureau-of-osteopathic-specialists/ https://www.va.gov/vapubs/viewPublication.asp?Pub_ID=1358&FType=2 https://www.nln.org/ https://www.nursingworld.org/ana/

E) Experience in outpatient care in a Family Medicine or Internal Medicine environment is preferred.

F) ARNPs shall have current, full, active, and unrestricted license and registration as a graduate professional nurse in the state in which the Outpatient Site of Care (i.e. CBOC) is located;

otherwise qualifications as per VA Handbook 5005, Appendix G6 (or subsequent policy release).

G) Position Responsibilities: Responsible for-

1) The provision of covered services to enrolled and unassigned patients presenting for care;

2) Providing health care commensurate to the PCP’s licensure and clinical privileges or scope of practice;

3) Ensuring the patient’s care plan contains medical recommendations for clinically indicated care;

4) Offering clinically indicated health care services to patients assigned to the PACT; and

5) Providing or arranging for care to which patients consent, providing leadership to the team including-

a) Shared delegation of appropriate care and care processes to appropriate team members;

b) Reviewing available clinical and performance data with the team;

c) Focusing on continuous improvement of critical team processes;

d) Ensuring the patient has same-day access for face-to-face and virtual care visits during regular clinic hours; and

e) Collaborating with PACT staff to develop personal health plans that incorporate care management and care coordination appropriate to the patient’s needs.

2.3.1.3. Option 3- Physician Assistant (PA): Qualifications:

A) PA’s (including subcontractors) must meet be a graduate of a training program which is accredited by the Accreditation Review Commission on Education of PA (ARC-PA) or one of its’ predecessor organizations. Additionally, PA’s must have:

1) A Master’s degree in any discipline or a Bachelor’s degree in any discipline with one year of experience as a PA; or

2) PA’s must have successfully passed the PA National Certifying Exam (PANCE).

B) The duration of approved academic training and health care experience must total at least five (5) years.

C) Authorization for prescriptive authority is required.

D) PA shall have current, full, active, and unrestricted license and registration in the state in which the Outpatient Site of Care (i.e. CBOC) is located; otherwise qualifications as per VA Handbook 5005, Appendix G8 (or subsequent policy release). .

E) Position Responsibilities: Responsible for-

1) The provision of covered services to enrolled and unassigned patients presenting for care;

2) Providing health care commensurate to the PCP’s licensure and clinical privileges or scope of practice;

3) Ensuring the patient’s care plan contains medical recommendations for clinically indicated care;

4) Offering clinically indicated health care services to patients assigned to the PACT, and

5) Providing or arranging for care to which patients consent, providing leadership to the team including;

a) Shared delegation of appropriate care and care processes to appropriate team members;

b) Reviewing available clinical and performance data with the team;

c) Focusing on continuous improvement of critical team processes;

d) Ensuring the patient has same-day access for face-to-face and virtual care visits during regular clinic hours; and

e) Collaborating with PACT staff to develop personal health plans that incorporate care management and care coordination appropriate to the patient’s needs.

https://www.va.gov/vapubs/viewPublication.asp?Pub_ID=1358&FType=2

2.3.1.4. Teamlet Member 2- Registered Nurse (RN) Care Manager: FTE Ratio Performance Standard:

Current standard is 1.0 FTE RNCM per 1.0 FTE PCP. Qualifications: Graduate of a school of professional nursing accredited by one of the following accrediting bodies at the time the program was completed by the applicant:

A) The Accreditation Commission for Education in Nursing (ACEN); or B) The Commission on Collegiate Nursing Education (CCNE).

2.3.1.5. Current, full, active, and unrestricted registration as a graduate professional nurse in the state in which the Outpatient Site of Care (i.e. CBOC) is located; otherwise qualifications as per VA Handbook 5005, Appendix G6 (or subsequent policy release).

2.3.1.6. Position Responsibilities: Responsible for-

A) The provision of covered services to enrolled and unassigned patients presenting for care at the site;

B) Providing all aspects of professional nursing services consistent with licensure, certification, nursing professional standards of practice as well as the clinician’s Functional Statement with elements of practice;

C) Enhancing patient safety and quality of care by collaborating with PACT staff to develop, oversee, and manage care management plans and care coordination for patients assigned to PACTs;

D) Participating in modes of communication and care delivery including, but not limited to, secure messaging, virtual care, view alerts management, shared medical appointments, face to face visits, etc., as part of care management;

E) Identifying patient needs for involvement of discipline-specific team members and discussing nursing recommendations with the PCP;

F) Engaging relevant PACT staff to support nursing care, according to locally established informal and formal communication processes;

G) Including entering consultation requests to discipline-specific PACT members, if required for formal communications;

H) Assuming full accountability for the appropriateness of assignments made by the RNCM to clinical associates or administrative associates related to care management, care coordination, nursing services, and outcomes of care;

I) Entering orders in the VA EHR for tests per approved standardized RN care management protocols or PCP orders;

J) Ensuring the RNCM has same-day access for face-to-face and virtual care visits;

K) Using nursing expertise, evidence-based guidelines, standardized nursing protocols, and professionally accepted practice standards to:

1) Promote patient engagement, self-care and wellness; and

2) Provide care to patients and determine care management requirements for individual patients or cohorts of patients.

L) Collaborating for the improvement of patient care outcomes in the Patient Aligned Care Team;

M) Promoting systems to improve access and continuity of care, uses advanced clinical knowledge and critical thinking skills to mentor staff in planning, implementing and evaluating interventions that improve patient outcomes;

N) Designs and provides age and population specific health promotion and risk reduction strategies;

O) Translates evidence-based research into practice to ensure that patients benefit from the latest innovations in nursing science;

P) Manages patients in transition between levels of care;

Q) Serves as an expert resource to implement and teach skills, including motivational interviewing to promote patient self-management toward patient-driven holistic care plan for life.

2.3.2. Teamlet Member 3- Clinical Associate: FTE Ratio Performance Standard: Current standard is 1.0 FTE clinical associate per 1.0 FTE PCP. Contractor to propose the mix of Clinical Associates from the options below.

2.3.2.1. Option 1- Licensed Practical Nurse (LPN): Qualifications:

https://www.acenursing.org/ https://www.aacnnursing.org/CCNE

A) Current, full, active, and unrestricted license in the state in which the Outpatient Site of Care (i.e.

CBOC) is located; otherwise qualifications as per VA Handbook 5005, Appendix G13 (or subsequent policy release). .

2.3.2.2. Option 2- Licensed Vocational Nurse (LVN): Qualifications:

A) Current, full, active, and unrestricted license in the state in which the Outpatient Site of Care (i.e.

CBOC) is located; otherwise…