This is not a solicitation announcement. This is a pre-solicitation notice only. The purpose of this pre-solicitation notice is to announce that the Government has an upcoming requirement for a contractor to provide Community Project-Based Voucher (PBV) VA Supportive Housing (VASH) services. All Offerors who provide goods or services to the United States Federal Government must be registered in the System for Award Management (SAM) database found at https://www.sam.gov at the time of proposal submission and at the time of award. The contract will be issued as an Indefinite Delivery-Indefinite Quantity contract, with Fixed Unit Prices. All requirements shall be detailed in the impending solicitation to be issued on or about June 1, 2023. No questions will be answered prior to the solicitation being released. See below for DRAFT statement of work excerpt. ______________________________________________________________________ B.3 STATEMENT OF WORK BACKGROUND HUD-VASH is a national program serving Veterans and their families throughout the country. This program continues to expand and has become one of the largest VA interventions to assist homeless Veterans. It represents one of VA s most significant efforts to achieve the President s goal of ending homelessness among Veterans. To be eligible for the HUD-VASH program, a Veteran must be eligible for VA health care as determined by the local VA medical center, determined to be homeless based on McKinney-Vento Act definitions by the local VA medical center HUD-VASH program with every effort made to identify and serve the most chronically homeless and vulnerable Veterans. The target population for this contract includes chronically homeless Veterans who demonstrate the most need/vulnerability and may often have severe mental health, medical, and/or substance use disorders (SUD) issues. Veterans may not be chronically homeless and may fall into one of the priority groups: women, women Veterans with children, Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans, and/or Veterans who have physical health problems and/or Substance Use Disorders (SUD) with frequent emergency room visits, multiple treatment failures, and limited access to other social supports (reference VHA HUD-VASH Directive 1162.05. Other priority groups per HUD Guidelines include homeless person with a disability with long periods of episodic homelessness and severe service needs, homeless persons with disability with severe service needs, homeless persons with a disability coming from places not meant for human habitation, safe havens, or emergency shelters without severe service needs and/or homeless person with a disability coming from transitional housing. The Contractor shall assess each applicant on an individual basis and prioritize highest need for the program based on the Veteran s acuity per clinical judgment and resource availability. Through this contract initiative, Contractor will assist Veterans in obtaining and maintaining permanent community-based housing, while simultaneously providing case management and supportive services until the Veteran is eligible for discharge. The HUD-VASH program is reserved for homeless Veterans with serious medical, SUD, and/or mental health problems with a demonstrated need for case management services to obtain and sustain housing. VHA HUD-VASH DIRECTIVE 1162.05(1), attached below, and VHA HUD-VASH Directive definition of Chronically Homeless. HUD Notice CPD-16-11, Notice on Prioritizing Persons Experiencing Homelessness, at https://files.hudexchange.info/resources/documents/notice-cpd-16-11-prioritizing-persons-experiencing- chronic-homelessness-and-other-vulnerable-homeless-persons-in-psh.pdf. The U.S. Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System (VAGLAHS) requires the Contractor to have demonstrated experience in the U.S. Housing and Urban Development (HUD) and Veterans Affairs Supportive Housing (VASH) program to provide community project-based case management and supportive services for Veterans who would benefit from onsite intensive case management due to the complexity and acuity of their needs. Intensive case management is a team-based approach that offers a coordinated and brokered approach-delivering therapeutic services utilizing a strengths-based model of care. Project Based Vouchers (PBVs) are a component of the Public Housing Authorities (PHAs) housing support program (Refer to Definitions Section of this Statement of Work (SOW). Under the PBV program, a PHA enters into an assistance contract with the owner of the property for a specified number of units and for a specified term. The assistance is tied to a unit. An individual/family who moves from a PBV unit does not have any right to continued housing assistance unless they are eligible to receive a Housing Choice Voucher (HCV) when one becomes available. The purpose of this contract is to serve homeless Veterans with complex medical and psychiatric needs who have few resources and require long-term case management to either obtain and/or maintain permanent supportive housing. HUD-VASH follows the definition of homeless as authorized in 24 CFR 91.5, 38 U.S.C. 202(1) Reference VHA HUD-VASH Directive 1162.05 and the McKinney-Vento Homeless Assistance Act, as amended by S.896 the HEARTH Act of 2009 at (https://files.hudexchange.info/resources/documents/HomelessAssistanceActAmendedbyHEARTH.pdf). Through the HUD-VASH program, the Contractor shall place Veterans into community Project Based housing while simultaneously providing case management and supportive services; and assist the Veteran in maintaining housing in the project-based unit. The contractor shall provide these services to a maximum of 1,000 Veteran patients, referred for placement in community project-based HUD-VASH units provided by a Public Housing Authority. These Veterans will be placed in these project-based housing due to complex medical/MH needs to promote accessibility of services; therefore, the contractor is expected to engage in frequent care coordination activities with VA and community providers working with the Veteran. The number of Veterans is expected to fluctuate over time. Each facility under this contract has a varying number of units as agreed upon with the Public Housing Authority, this contract will serve various sites, up to 1,000 Veteran patients. The VA and Contractor may mutually agree to assign Veterans to the facility, at the same; price per voucher currently in effect as showing in the Price schedule. Through this contract, the VA seeks to expedite the placement of eligible HUD-VASH Veterans and their families in community based, project-based, HUD-VASH housing. GENERAL CONTRACT REQUIREMENTS Contractor shall provide case management, and supportive services to Veteran beneficiaries of diverse backgrounds as specified herein. Contractor shall provide all labor, supervision, supplies, materials, and logistics required to perform these services for the duration of the contract. Contractor shall perform services remotely or at the Contractor s location, unless otherwise required by performance requirements listed in the SOW, or otherwise specified by the task orders issued under this contract. The Contractor shall submit all deliverables to the VA s Contracting Officer s Representative (VA COR) or VA COR designee, who will evaluate all deliverables submitted and certify invoices based upon acceptable deliverables. A Quality Assurance Surveillance Plan (QASP) will be used by the COR to measure performance success and/or failure. The VA COR or designee will also be the Contractor s main point of contact for Veteran-related issues in conjunction with the VA homeless team. The VA COR will provide clinical oversight but will not provide direct clinical supervision. HUD-VASH Contracting Billing Protocol. Clinical oversight refers to a working relationship between VA COR and Contractor. The VA COR monitors compliance with the contract deliverables, and quality of care that is provided by the Contractor to Veterans. In providing clinical oversight, VA CORs may also serve as consultants to the Contractor in enhancing safe and effective person-centered care in complex situations to meet the needs of Veterans in conjunction with VA regulations, requirements, and guidelines. Contractor shall have the staffing and expertise to execute the tasks and associated deliverables associated with this Statement of Work without reliance on the VA COR or designee to provide support that would reasonably be considered clinical supervision. The Contractor shall provide routine, ongoing clinical supervision to its staff performing on this contract. Contractors Primary Point of Contact. Contractor shall have a primary point of contact for the management this contract who will work directly with the VA COR or designee contract and invoicing matters. This person shall have full authority to act for the Contractor on all matters relating to the daily operation of this contract. An alternate may be designated, but the Contractor shall identify, in writing, those times when the alternate shall act as the point of contact. The Contractor shall provide the following information regarding their primary point of contact for this contract to the VA COR and update it as necessary including for short notice absences of the primary point of contract: NAME, PHONE NUMBER, FAX NUMBER AND VA EMAIL ADDRESS SPECIFIC CONTRACT REQUIREMENTS Contractor shall work with Veterans who will be housed in the project-based units. Contractor shall provide supportive services to Veterans, which may include but are not limited to: resident town halls, harm reduction/recovery groups, recreational activities, life skills groups, social skills building, community resource linkage (e.g., legal, financial), peer support groups, and/or employment support. Contractor shall provide case management in accordance with Stages of Case Management, and minimum visit requirements (SOP) and HUD-VASH Case Management SOP, both attached below. Contractor shall provide interdisciplinary teams who work collaboratively to provide patient-centered care. Team compositions may consist of addiction treatment professionals, licensed clinical social workers, licensed marital and family therapist, licensed mental health counselors, nurses, psychologists and peer support specialists. Contract clinical supervisors shall have a minimum of a Master s Degree of Social Work or Marriage and Family Therapy with the appropriate licensure of LCSW/LMFT and at least 50% of providers shall be master s level. Contractor shall provide 24/7 coverage for case management support. Contractor shall comply with HUD-VASH and GLA policy and procedures regarding documentation and evaluation standards for Veterans enrolled in HUD-VASH. Reference HUD-VASH Documentation SOP, attached below. Contractors shall attend the HUD-VASH All Staff monthly meeting. Contract staff shall visit Veterans if in an institutionalized setting (hospital, assisted living, skilled nursing facility, etc.). Contractor shall engage in treatment and discharge planning with inpatient providers. If Veterans are incarcerated, staff shall contact Veterans Justice Outreach (VJO) care coordination. Contract staff shall accompany Veterans to medical appointments, emergency visits, or other appointments as clinically indicated. Contractor shall obtain approval from the VA COR/Liaison prior to discharging Veterans from case management services and adhere to VASH Discharge SOP, attached below. Discharge planning may include linkage to alternate case management services, housing resources, and other supports as needed. Case Management visits to Veterans shall be conducted in accordance with VHA HUD-VASH Directive and HUD-VASH Stages of Case Management and Minimum Visit Requirements SOP, attached below. Contractor staff shall ensure that when Veterans have achieved housing stability, the focus of the service support changes to community integration and other goals as discussed and agreed upon with Veteran, and their contact with the Veteran does not diminish. Contractor staff shall participate in continuing education training related to Pathways Housing First model, trauma informed care, motivational interviewing (refer to definitions section of this SOW), relapse prevention, supported employment and supported education. The Contractor shall participate in all VA mandatory trainings for staff mentioned in section 1.23.1.4 and 3.20.5 of this SOW. The VA shall also extend an invitation to Contract staff to participate in new trainings as approved throughout the year; if the Contractor chooses to provide their own similar trainings for staff, the contractor shall show that these trainings are performed by a certified trainer. The Contractor shall provide full staffing as defined herein within 60 days of the contract award. The Contractor shall maintain Basic Life Support (BLS) certification for all staff working on this contract. Certification is required prior to providing direct patient care. Contractor shall remove any staff with expired certification from direct patient care until recertification is obtained. Contractor shall regularly provide VA COR/Liaisons with an updated list containing staff names and BLS expiration dates. Contractor shall encourage Veterans to actively engage in healthcare and, when clinically indicated, mental health and or addiction services. Contractor shall document changes of status for Veterans to include Veteran level of Care (LOC), employment, and housing status as indicated in the National website - Homeless Operations Management and Evaluation (HOMES). Documentation shall be entered within 3 business days of Veteran encounters. HOMES is the database used by the VHA Homeless Program Office (HPO) to gather homeless Veteran s data and statistics for analytical purposes. Contractor shall enter Veteran information (e.g., name, SSN), after obtaining a release of information into the Coordinated Entry System and Health Information Management System (HMIS) within 3 business days. Contractor shall assess Veterans to determine if criteria is met for enrollment into the HUD-VASH program. The contractor shall complete HOMES, screening/admission, and encounter documentation consistent with the HOMES reporting policy and VA medical documentation, and in compliance with HUD-VASH Documentation Standard Operating Procedure (SOP), attached below. Contractor shall document using the appropriate note template for all progress notes and ensure all encounters are entered within 3 business days or on the same day for emergent issues. Contractor staff shall document in the electronic health record (EHR) services delivered during a patient encounter using appropriate Current Procedural Terminology (CPT) coding. An encounter is a professional contact between a patient and a provider vested with responsibility for diagnosing, evaluating, and treating the patient s condition. The reason for the services provided (diagnosis) and the actual services provided to the patient by the provider must be fully and clearly documented and coded using nationally accepted coding schemes. Licensed Independent Providers e.g., Psychologist, Pharmacist, Licensed Clinical Social Worker, are to be listed as the primary provider for any trainees they supervise (e.g., Psychology Intern, Pharmacy Resident) or any other non-licensed independent provider (NLIP) under their supervision. Contractors documenting in CPRS are required to participate in productivity training conducted by VA. Contractors shall generate encounters and use CPT and Diagnostic codes when they have contact with Veterans. Contractor shall make corrections in CPRS by the due date indicated by the VA when documentation and encounter errors occur per VHA Directive 1082 Patient Care Data Capture and VHA Directive 1161 Productivity And Staffing In Clinical Encounters For Mental Health Providers, attached below. Contractors are required to attend the HUD-VASH CPT training. Contract Program Manager shall participate in a weekly administrative meeting with the VA COR/Liaison to discuss any administrative concerns and contractor performance. The Contractor shall work with Veterans on obtaining and maintaining housing and developing independent living skills. Contractor shall participate in and coordinate with the VA COR/Liaison during huddles regarding updates and changes in the Veteran s care plans to foster a collaborative relationship with the VA and Contractor in meeting the Veteran s needs. Case conferencing may be done in person or by telephonic conference calls as determined by the VA HUD-VASH Coordinator or his or her designee. All Veterans should be huddled once every quarter (no less than every 90 days) or as clinically indicated. All huddles shall be documented in a VA approved huddles Spreadsheet. Additional providers-including primary care, specialty clinics, etc., shall be added as additional signers for awareness and collaboration. The Contractor shall involve other disciplines to participate in these huddles based on providers working with the Veteran if clinically indicated. The contractor shall monitor the huddles schedule to ensure all Veterans have been reviewed as stated in the latter, the VA COR/Liaison may request updates on progress and updated copies of the VA approved huddles spreadsheet. HUD-VASH Huddle SOP is attached for reference. Contractor shall ensure staff working on the contract complete a VA Security/background investigation prior to providing direct patient care via National Agency Check with Written Inquiries (NACI), and a Special Agreement Check (SAC) which includes electronic fingerprinting. Results of investigation must return favorable in order for staff to perform on the contract. Contractor shall include VA COR in all onboarding correspondence. VetPro is necessary for all licensed, registered or certified clinical staff members (e.g. LCSW, LMFT, RN, CASAC.) Contractor shall ensure staff who meet this criteria complete the credentialing process through the VA s VetPro system. Staff awaiting VetPro clearance may only begin work on the contract prior to receiving credentialing by performing tasks that do not involve Protected Health Information (PHI, Refer to Definitions section of this SOW). The Contractor shall make every effort to communicate with the VA regarding this contract through the Network Contracting Office (NCO) 22, via the designated primary VA COR and/or at minimum when reaching out to Contracting office, include the COR in the communication. Contractor shall complete the VA s online Information Security and Privacy Awareness Training Course, the Privacy Policy Awareness Training Course, and Mandatory Training for Transitory, Part-Time and Intermittent Clinical Staff (MTTCS) for staff members working directly with Veterans under this contract. All required trainings must be maintained on schedule as required by the VA. These trainings shall be completed annually by the due date to maintain access to the VA Network. ADMISSIONS/REFERRALS Veterans enter the HUD-VASH program by being identified as meeting HUD-VASH admission criteria (Reference VHA Directive 1162.05 HUD-VASH Program) and/or referred by the VA as eligible for the program or through community outreach conducted by the Contractor. The Contractor shall conduct screenings, including an interview with the Veteran, VA medical record system chart review, and HOMES assessment as appropriate to determine VASH eligibility based on the homeless and chronic homeless criteria and Homes Forms, attached below. The Contractor shall also conduct a basic screening for healthcare eligibility that shall include a review of the Veteran s DD214 by obtaining access to SQUARES (see definition section of SOW). Contractors shall admit Veterans to the HUD-VASH program without VA approval after completing necessary screenings, however, the Contractor shall notify the VA COR by email within 24-hours of the Veterans admission and add the Veteran to the Agency list. Note: Admission is by clinical decision of HUD-VASH Staff, or, if indicated, in more complex situation, with consultation of homeless program leadership or other appropriate service. Contractors shall maintain a list of Veterans who do not meet the eligibility criteria and provide those Veterans with a copy of HUD VASH Denial letter. Veterans must be informed that they have a right to file an appeal within 60 days from receipt of the denial letter by following the process noted in the letter. Veterans shall also be provided with alternate resources for housing. Reference Sample Resource Handout, attached below. VASH admission criteria (Reference VHA Directive 1162.05 HUD-VASH Program) through referral by the VA as eligible for the program or through community outreach conducted by the Contractor. To be eligible for the HUD-VASH program, a Veteran must be determined to be eligible by the VAGLAHS Enrollment and Eligibility based on discharge type: Honorable Discharge General Discharge Other than Honorable Discharge (in Lieu of court-martial or from a special court-martial) Bad Conduct Discharge (from a special court-martial) Uncharacterized (Entry Level Separation) Undesirable (confirm with Eligibility, must be adjudicated). If Veteran was previously screened and denied by VA, as evidence by screening note in VA Medical record, contractor shall contact VA COR/Liaison to consult prior to completing their screening and/or admission into program. Contractor shall provide simultaneous housing and case management services for Veterans under their care. Veterans are considered admitted into HUD-VASH when accepted for case management. Admission decisions shall occur within 24 hours or one business day of a completed referral interview with the appropriate documentation in HOMES. In the case of a two-Veteran household, the individual identified as head of household with the primary need for case management is the voucher holder. If both Veterans require case management, there shall be two separate entries in HOMES showing that they are case managed although one Veteran has a HUD-VASH Voucher issued. Contractor Housing Placement & Stabilization Duties: The Contractor shall perform Housing Placement & Stabilization Duties that include the following: Identify and enroll Veterans who meet criteria for program admission. To be eligible for the HUD-VASH program, a Veteran must be determined to be homeless based on national HUD-VASH Policies and Practices with every effort made to identify and serve the most chronically homeless and vulnerable Veterans. Assist the Veteran in completing and submitting PHA and other Federal, local, and state entitlement program paperwork (e.g. Social Security, food stamps, utility assistance, etc.) Advocate with landlords on behalf of the Veteran to maintain a lease and 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. Contractor shall assist Veterans with all inspections required for move-in reference Pre-inspection checklist, attached below. Contractor shall ensure that the Veteran has completed the VA release of permitted information so communication between the landlord, Contractor, and VA can occur as needed. Assist with developing a budget and assist the Veteran in securing necessary funding for recurrent monthly expenses. Assist the Veteran in making calls to utility providers to ask questions and resolve issues (including turning off or transferring utilities), ensure the Veteran is paying rent and utility bills in a timely manner and provide budgeting/money management assistance as needed. Assist Veteran in applying for all eligible benefits, both VA and non-VA, including but not limited to; Veteran s Benefits Administration (VBA), Employment Development Department (EDD), Social Security Administration (SSA). Perform site visits of HUD-VASH apartments to ensure that Veterans reside in healthy residences in accordance with VHA Directive 1162.05 HUD-VASH Program and HUD-VASH Stages of Case management and minimum visit requirements SOP. Veterans in these units have been identified as psychiatrically and medically complex and it is the expectation of the VA that the Contractor shall visit Veterans monthly with the Lead case manager making at least quarterly face to face contact with the Veteran. The Veteran is entitled to Portability of his/her voucher. Portability provides Veterans the opportunity to transfer their HCV to live in the community of their choice, within certain limits. In addition to local VA guidelines, Federal Register Notice of May 6, 2008 addresses portability in HUD-VASH. The Notice can be found at: Federal Register: Section 8 Housing Choice Vouchers: Revised Implementation of the HUD-VA Supportive Housing Program Technical Correction. NOTE: This linked document is outside VA control and may or may not conform to Section 508 of the Rehabilitation Act. CASE MANAGEMENT DUTIES The Contractor shall have procedures in place to ensure Veterans have access to clinical case management services twenty-four (24) hours per day, 365 days per year, which shall include crisis management and referrals (Reference HUD-VASH Case Management). The Contractor shall ensure consistency of case management services to enhance staff ability to engage and form relationships with Veterans and provide consistent and highly skilled interventions in keeping with the Housing First (HF) model as described below. Housing First is an approach that centers on providing homeless individuals with housing quickly, and then providing services and treatment as needed. The primary focus of the Housing First approach is to identify an immediate need for housing and helping individuals and families quickly access and sustain permanent housing. Housing First programs share four (4) critical elements Focus on helping individuals and family s access and sustain rental housing as quickly as possible and ensure the housing is permanent; A variety of services delivered primarily following a housing placement to promote housing stability and individual well-being. Time-limited or long-term services depending upon the individual need; Veteran agreement to participation in case management Services to support housing maintenance. Non-compliance with Case management services may result in a loss of housing and/or voucher; Contractor staff shall support Veteran s family members who reside with the Veteran by assisting them in connecting to supportive services /resources as needed. (Refer to the Definitions section of this SOW). Contractor staff shall address the documented needs of Veterans and make visits in accordance with HUD-VASH Stages of Case management and minimum visit requirements SOP and Mental Health Treatment, which are made part of this contract and incorporated by reference herein. Contractor shall apply Harm Reduction interventions when working with Veterans. The Contractor shall have space available at the project-based site for the staff to conduct group meetings with the Veterans under contract care. This space must provide Veterans with privacy. Contractor shall submit a monthly tracking sheet (commonly referred to as White Board) with requested fields as approved by the VA COR or designee. Contractor shall ensure sufficient staff are available to provide services to meet the needs of the Veterans and conduct visits consistent with the level of care at which each Veteran is being treated. Contractor shall perform the following work: Create a Mental Health Treatment Plan (MHTP) Mental Health Treatment Plan and Mental Health Treatment Plan Goals, which are made part of this contract and are incorporated by reference herein. For MHTP entry time frames reference HUD-VASH Documentation SOP, both attached below. Review and update the MHTP with the Veteran every six months or when there is a significant change in Veteran s functioning level, or circumstances that call for a change in treatment. Comply with additional documentation and/or data reporting for the Housing First demonstration as required by VAGLAHS based on local, regional, or national HUD-VASH requirements. Engage in the HUD-VASH screening process to assess Veterans considered high risk due to medical, mental, and/or addiction history; identify service and treatment needs which may affect housing stability and recovery/community reintegration. Reference Sample Psychosocial Assessment, attached below. Utilize case management strategies working toward long term independent housing and community reintegration. Contractor shall reassess Veteran acuity in accordance with local policy for changes in their needs, stage of case management and preferences for care. Contractor shall assess each Veteran for suicidal and homicidal risk with each contact. This assessment shall be documented in the VA medical record using appropriate note titles. If the Veteran is a danger to themselves or others, the Contractor shall take immediate steps to provide appropriate intervention per CERS Procedure for Medical and Psychiatric Emergency Response in the Community and CERS Management and Escalation of Health Status Concerns, both attached below. Crisis management shall be coordinated and executed by the contractor and shall be reported to the VA COR/Liaison and other VA staff in accordance with CERS Management and Escalation of Health Status Concerns and CERS Incident-Death Reporting Manual, attached below. Contractor shall adhere to the reporting requirements located in the U.S. Department of Housing and Urban Development Public and Indian Housing Notice PIH 2011-53(HA), issued 09/20/2011 and available at https://www.hud.gov/sites/documents/pih2011-53.pdf, which is made part of this contract and is incorporated by reference herein, including any subsequent changes, updates, or revisions to the PIH Notice. Contractor shall facilitate the Veteran s involvement in supportive employment and other restoration programs when clinically indicated. Contractor shall assess and promote engagement with appropriate healthcare, especially mental health and addiction care when clinically indicated. Reference the attached CERS Primary Care Engagement SOP. Formulate treatment goals and plans with Veteran that address identified needs, stressors, and areas of concern. Actively involve the Veteran and other relevant parties, based on psychosocial assessments, to develop a treatment plan with the Veteran using their language, ensuring they have a copy of the plan including discharge from case management.4.2.19. Actively involve the Veteran and their family or significant others in coordination with the team members, based on the psychosocial assessments, to develop a treatment plan with the Veteran using his/her language whenever possible, ensuring he/she has a copy of the plan including goals for clinical treatment and discharge from case management. Contractors shall provide direct mental health and substance abuse counseling within their scope of practice and assist in securing VA services. Contractor shall integrate housing stabilization planning with relevant VA health and mental health services. The Contractor s housing stabilization plan shall provide a framework for the Veteran s sustainability in HUD-VASH and identify the Veteran s goals with steps to achieve those goals. Contractor shall have procedures in place to ensure clients have 24/7 access to clinical staff who can provide case management services which shall include crisis management and referral. A staff member shall be identified for on-call (via telephone) services after hours and on weekends as needed. Contractor shall visit each Veteran face-to-face at the intervals required by HUD-VASH Directive and Stages of Case Management and Minimum Visit Requirements, which are made part of this contract and are incorporated by reference herein. Additionally, the Contractor shall adhere to the following: The Contractor shall notify the VA COR or designee of any change in Level of Care (LOC) within 1 business day via VA email and by adding them as a cosigner to the note in the VA medical record system. Should the VA COR or designee have concerns regarding the change of LOC, the Contractor shall engage in a discussion with the VA COR or designee regarding this change. This discussion may lead to the change of LOC not being approved if the VA COR has concerns for Veteran s safety/well-being. The Liaison shall document this both in email to the Contractor and in the Veterans electronic medical record. Case management visits, while not required to take place in the Veterans home, are encouraged to be done in the home at least on a quarterly basis to assess conditions of the home for acuity levels of maintenance, and preparation for discharge. Veterans in the intensive stage of case management shall have at least one home visit a month, visits can also take place at a location mutually agreed upon by the Veteran and the contractor. Phone contacts, while an acceptable way to communicate with the Veteran, are not considered visits in meeting the minimum visit requirements for any acuity level. All staff using VA Video Connection, (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. In the event the Contractor is unable to locate the Veteran (at home or in the community), for the required number of visits, the Contractor shall document all attempts to contact Veteran including face-to-face, VVC attempts, phone calls, or letters sent to the Veteran. This should include dates and times in the VA medical record system as verification of services rendered and to show due diligence has been exercised. Case Management Due Diligence. 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. 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. Clinical Due Diligence: Contractor shall notify the VA COR or VA Liaison any time an urgent or emergent concern arises about a Veteran s well-being or if the Contractor requires the VA 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. ENDING CASE MANAGEMENT SERVICES Community integration and achieving the highest level of independent housing are two primary goals of the HUD-VASH program. Contract case management team members and the Veteran shall meet to determine if the Veteran has achieved this milestone and to develop an aftercare plan ongoing receipt of needed services. The Contractor shall re-assess any Veterans who do not meet the goals and objectives outlined in their treatment plan to determine any barriers to housing stability and service engagement. The Contract case manager shall work with the Veteran to eliminate any barriers and assist with connection to needed services/resources. The case manager is expected to continue efforts to engage the Veteran unless there is a risk to the safety of staff. The Contractor shall consult with the VA COR and collaborate with VA facility Mental Health leadership, police service, SUD programs, Mental Health Intensive Case Management (MHICM), or other programs for assistance in determining alternative clinical treatment approaches. If Veterans are at risk of eviction or voucher revocation, the Contractor shall immediately notify the VA COR or designee. Veterans shall be scheduled for discussion in weekly huddle/case conferences for intervention planning. Contract case managers shall comply with VA HUD-VASH Documentation SOP and discharge procedures found in HUD-VASH Discharge SOP. In some instances, discharge from the HUD-VASH Program may be required if the Veteran refuses, despite all efforts to engage in case management. In these instances, the Contractor shall follow the procedures found in the HUD-VASH Discharge SOP. After 30 days of non-engagement by the Veteran, the Contractor shall initiate a huddle with the VA COR or designee to determine recommended action plan. Contractor case managers shall document in the EHR within 3 business days, and in the HOMES system, when a Veteran exits the program without prior notice or case conferencing. The VA COR should be notified immediately if this situation occurs. Voucher Porting: The Contractor shall provide assistance for the following voucher porting requests: Porting within the Greater Los Angeles VA Medical Center catchment area, meaning the Veteran can live within the jurisdiction of another PHA within the referring VAMC catchment area if the contractor can still provide case management services. Porting outside of the Greater Los Angeles VA Medical Center (VAMC) catchment area, either within or outside of the state of California. If a Veteran chooses to relocate to another VAMC, the Contractor shall schedule a meeting with the VAMC in the requested relocation area. The Contractor shall then determine if that new VAMC has HUD-VASH case management and voucher availability for port requests. HUD-VASH staff at the receiving VAMC must agree that they can and will provide case management services to the Veteran. The Contractor shall verify that the receiving VAMC can provide these services. The Contractor shall continue to provide case management services until transfer is complete. The Contractor shall comply with HUD-VASH Case Transfer SOP, attached below. Once the transfer of a Veteran to another HUD-VASH program has been completed, the Contractor shall complete a discharge note in the VA medical record system indicating that the Veteran is no longer part of the VAGLAHS HUD-VASH program. The Contractor shall comply with VHA HUD-VASH Directive 1162.05,and https://www.govinfo.gov/content/pkg/FR-2012-03-23/pdf/2012-7081.pdf, which is made part of this contract and is incorporated by reference herein. STAFFING QUALIFICATIONS AND REQUIREMENTS Contractor staff with licensee/certification and performing work under this contract shall maintain an active standing with the licensing boards in their respective profession in accordance with the below qualification requirements. Basic Life Support (BLS) is required for all technical and professional staff in order to provide direct care; American Heart Association certification is preferred but not required. Contractor staff shall not provide direct patient care without BLS certification. Contractor staff shall not provide direct patient care in the absence of this requirement and shall be pulled from direct patient care should the contractor staff allow this requirement to expire. Contractor shall provide verification that Contractor staff have met this requirement to the VA COR or designee. The Contractor is responsible for the following staffing requirements as described below: Program manager: This is a mandatory position and a part-time position. The program manager shall be a Licensed Clinical Social Worker (LCSW), Licensed Clinical Psychologist, Licensed Marriage Family Therapist (LMFT) or Licensed Mental Health Counselor. The Program Manager shall be assigned to the HUD- VASH contract for the staff assigned to work with Veterans and for all Supervisors for purposes of this contract. The program manager s schedule shall permit 24-hour access to Contractor s management personnel for the purposes of clinical oversight, documentation and crisis management. The licensed independent clinical practitioner must be available for huddles and case conferences as requested by the local VA medical center HUD-VASH program. The program manager shall participate in weekly administrative meetings with the VA COR to discuss contract performance and trends. The program manager shall participate in weekly administrative meetings with the VA COR to discuss contract performance and trends. The program manager shall act as the point of contact for VA correspondence and is responsible for disseminating information to Contractor staff. The program manager shall have an active, current, unrestricted license and a minimum of a master s degree or doctorate from an accredited institution in Social Work, Counseling, Marriage and Family Therapy, or Psychology. Clinical Supervisors /Team Supervisors: This is a mandatory position. The Contractor shall have full-time clinical supervisors assigned to this contract. The clinical supervisors shall be Licensed Clinical Social Worker (LCSW), Licensed Clinical Psychologist, Licensed Marriage and Family Therapist (LMFT) or Licensed Mental Health Counselor. The clinical supervisors shall be available for 24-hour supervision of case management personnel for the purposes of clinical oversight, documentation, and crisis management. The clinical supervisors shall participate in team huddles and case conferences as requested by the local VA medical center HUD-VASH program. In addition, the clinical supervisors shall ensure appropriate supervision of any non-clinical/non-licensed Contractor staff providing services to Veterans to ensure quality of care and clinical supervision. The Contractor shall ensure that all unlicensed staff have an assigned clinical supervisor. The clinical supervisors shall have active, current, unrestricted licenses. Clinical Supervisors shall have a minimum of a master s degree or doctorate from an accredited institution in Social Work, Counseling, Marriage and Family Therapy, or Psychology. Clinical supervisors shall have direct oversight over unlicensed staff and staff gathering hours towards Clinical Licensure who are providing care. The clinical supervisors shall adhere to the supervision guidance provided by the state in which the license is being pursued and shall co-sign all documentation in accordance with the state licensing requirements of the applicable state. The Clinical Supervisor shall co-sign all documentation of unlicensed staff. The Contractor shall comply with HUD-VASH Documentation SOP. Lead case managers: This is a mandatory position. The Contractor shall have full-time lead case managers assigned to this contract. The lead case managers shall have a minimum of a bachelor s degree (master s degree preferred) from an accredited institution in the social sciences or family therapy and at least 2 years demonstrated case management experience with high needs/ high intensity of services populations. There is a strong preference by VA for master s level case managers. A master s degree shall be from an accredited institution in sociology, psychology, social work, mental health counseling, or family therapy. Master s level Case Manager s shall have at least 1 year of demonstrated case management experience with high needs/high intensity of service populations. Additionally, lead case managers shall: Collaboratively review their teams primary care assignment reports, medical/mental health needs of intensive-stage Veteran s needs, and any recent hospitalization reports. Provide care evaluation during huddle review, team member request, primary care provider correspondence, or by team referrals. Provide care within their scope of practice and as outlined in HUD-VASH Team Roles SOP, attached below. Be responsible for reviewing inpatient reports, primary care assignment reports, and ensuring team members are addressing needs noted in the hospital discharge summary. Promote, monitor and document Veteran s VHA or non-VHA medical and mental health primary care team to engage and follow Veterans. Utilize the Primary Care Engagement SOP, attached below, for HUD-VASH Veterans for general guidance regarding visit frequency. Vary care provision between weekly, monthly or quarterly depending on the severity of medical/mental health issues and the stage of the Veteran s case management. Shall make care decisions in consultation with Veterans primary care team, HUD- VASH team members and specify care coordination with VA and/or community providers. Peer Support Specialist (PSS):  The Contractor shall have PSS serving on this contract to provide general service support to Veterans.  PSS shall have completed the VA designated Peer Specialist approved certification course. PSS may have a history of mental health, substance misuse, health concerns, justice involvement and/or homelessness and be certified to help others with these concerns, identify and achieve specific life and recovery goals. Visits conducted by the PSS count towards the minimum visit requirement, though at least one visit per month shall be conducted by the Lead Case Manager when the Veteran is in the intensive stage of case management. The Contractor shall comply with VA Peer Specialist Approved Certification Process October 1-2019, attached below, and HUD- VASH Stage of Case management and minimum visit requirements SOP.  Contractor shall maintain a ratio of Veterans per lead case managers of at least 25:1 caseload in accordance with HUD-VASH Stages of Case Management and minimum visit requirements SOP, which is made part of this contract and is incorporated by reference herein. Peer support specialists, nursing Staff, substance abuse counselors, count towards the weighted caseload. Contractor shall ensure there is coverage for staff when they are out on planned or unplanned leave and shall notify the VA COR or designee of this plan. Contractor shall provide staffing at a level to ensure that all services listed in the contract are met for every Veteran served. The Contractor shall have staff who are trained to provide services as identified. Contractor shall ensure that sufficient staff remains available to provide services for the term of this contract. The Contractor will have access to VA subject matter experts for case consultation for any Veteran covered under this contract. Contractors are encouraged to utilize this service at least monthly thru case consultation, team huddles, and/or case conferencing, or more frequently if needed.

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