IHS Special Diabetes Program for Indians

This solicitation is a sole source requirement to be issued under FAR 6.302-1 Only one responsible source and no other supplies or services will satisfy agency requirements, 41 U.S.C. 3304(a)(1). The associated North American Industry Classification System code (NAICS) 621111 Offices of Physicians the small business size standard is $9.m. B.2.Title Shinnecock SDPI and Diabetes Prevention & Control Programs B.3 BACKGROUND The Shinnecock Service Unit has been awarded a grant from the IHS Special Diabetes Program for Indians for FY23 and FY24. As a - PRC-Only program, we do not provide clinical services. However, our proposal was successful in obtaining an award because the grant's Scope of Work focused on our partnership via a contract with Vital Care Services, Inc.(VCS - UEI# KQBWXFCJNF76). VCS is our Contractor for the Telehealth Vital Sign Monitoring Program. This program grew out of our COVID-19 Response Program within which we provided the means for patients to monitor their vital signs from their homes while sheltering-in-place. Each patient is provided a telehealth monitoring kit that includes a cellular tablet with pre-paired and pre-configured Bluetooth low energy devices. These devices include a wireless pulse oximeter, cordless blood pressure monitor, wireless body weight scale, and wireless ear thermometer. Additionally, patients are able to enter their blood glucose readings and answer health questions Pertaining to their care plan. We expanded and supplemented this program with additional Community Health Outreach and now have 90 kits deployed in the Shinnecock community. The VCS data monitoring service provides frontline non-clinical monitoring for our patients. This includes screening for high-risk readings and non-compliance. For high-risk readings, technicians in VCS's call center request second readings from our patients, as well as verify medication compliance. For non-compliant patients, a reminder phone call is made to ensure compliance. Essential information such as recent patient hospitalizations and discharges is recorded and reported to clinical staff. In the early afternoon, clinical staff receive a concise report of alerts that require immediate clinical follow up. This service is offered 365 days a year. For our SDPI program, Shinnecock selected Blood Pressure data monitoring as our Required Key Measure. Since this data is already being collected by VCS, we collaborated with them to develop the SDPI Scope of Work, which was then selected for an award. Through this contract action, we plan to implement our SDPI program and implement a program beyond the current scope of SDPI to include Diabetes Prevention and Control. B.4. OBJECTIVE The objective of this project is two-fold. Part A will implement the SDPI Program at the Shinnecock Indian Nation. The objective of this part is to meet the terms and conditions of the Scope of Work for the SDPI award. This objective will be accomplished by having VCS modify its program and approach under our current contract to collect and process the Required Key Measure data needed for SDPI. Under Part B of the project, we will implement a program of Diabetes Prevention & Control (DPC). The DPC Program will enhance and supplement the SDPI Program and plan for future expansion under SDPI. The program will add a Diabetes Coordinator to the Community Health and Wellness Education component of the Telehealth Monitoring Program. The outreach and education objectives will function through partnership with existing wellness programs being conducted by the Shinnecock Indian Nation. The Nation's programs will be enhanced and supported to include DPC objectives. Patients for the SDPI initiative will be identified through this outreach and education effort. Description/Specifications SCOPE OF WORK Part A - Shinnecock SDPI A Diabetes Coordinator / Nurse Case Manager will serve as the primary team member responsible for coordinating the programmatic and reporting components of the SDPI program to IHS. The incumbent will manage a full range of clinical as well as administrative functions including but not limited to: Attend SDPI required training including grants management and clinical training. Track/update pre-diabetic/diabetic patient information. Participate in the IHS Diabetes Care and Outcomes Audit. Serve as a principle liaison with Vital Care Telehealth Services (VCS) the Service Unit's Contractor for the Home Vital Sign Monitoring Program. Ensure timely reporting and flow of data transmission between VCS and SDPI. Collaborate with the Shinnecock Health Clinic to promote the Diabetes Program and provide diabetes education and health promotion to the community. Report on the SDPI Grant program compliance to Shinnecock Service Unit, IHS DGM, USET and other partners. Part B - Diabetes Prevention & Control The overall goal of this proposal is to provide care programs to the community following national SDPI guidelines and best practices. 1) Diabetes Prevention: It is estimated that many community members do not know that they have a pre-diabetes condition and are at higher risk to develop Type 2 diabetes, therefore, the goals of the diabetes prevention program are Provide health and wellness checks to all community residents during planned community events and identify individuals that are at risk of pre-diabetes and diabetes. Since pre-diabetes condition is reversible, the goal of diabetes prevention program is to help community residents reverse their pre-diabetes condition via educational and intervention programs as specified by the national SDPI. Provide weekly health monitoring at various community settings including senior center, Walking Club, Yoga, Gardening Club and Kick box programs, etc. Provide diabetes educational information and prepare a participants list ready for CDC approved 16 weeks diabetes prevention program to be launched in year 2 (2025) Diabetes Control: It has been well established that patients with Type 2 diabetes condition can prevent diabetes complications by controlling their blood sugar levels. Six monthly A1C testing will be conducted to monitor their average blood sugar levels. Additionally, blood pressure and weight reading will be collected during the weekly community monitoring program. Diabetes education program include education on healthy diet and daily exercise programs. A copy of participants monitoring data will be provided to share with their physician. C. 2. CONTRACT REQUIREMENTS/ AND PERSONNEL QUALIFICATIONS The Contractor shall provide a position for Program Management. The requirements and qualifications for the Program Manager position shall include: Recruitment, hiring, training, and management of Diabetes Coordinator. Ability to stay organized and handle multiple tasks. Positive and encouraging personality and strong team player. Identifying key metrics and reporting on weekly and monthly deliverables. Coordination of program with SDPI, telehealth program, participants, and the clinic. Travel to and from sites and/or conference/training sessions. This position requires approximately 20 hours per week. The Contractor shall provide a position for the Diabetes Coordinator / Nurse Case Manager. The requirements and qualifications for this position shall include: Expertise in diabetes and its management and prevention. Ability to work well with the community population. Comfortable communicating to members in the community and reporting to IHS Proficient in data input and analysis. Regular coordination with area statistician to obtain and report on required metrics. Coordination with other IHS and USET partners for the SDPI program. Obtain and disperse SDPI prevention and control program incentives. Ability to respond to work related emails/phone calls in a timely fashion. Travel to and from sites and/or conference/training sessions. This position requires approximately 30 hours per week. All personnel associated with this contract will fulfill the requirements as outlined in the Scope of Work and Notice of Grant Award of the IHS SDPI Program. In addition, the requirements of the Diabetes Program of the USET Tribal Health Program Support office as Technical Assistance provider for IHS.