AMD RE HYPERTENSION DIABETIS WITH ADHS.PDF

ARIZONA DEPARTMENT OF
HEALTH SERVICES
INTERGOVERNMENTAL AGREEMENT(IGA) 150 n. 18TH Ave. Suite 280
AMENDMENT Phoenix, Arizona 85007
(602) 542-1040
(602) 542-1741 Fax
Agreement No: ADHS16-113997 Amendment No. 2 Procurement Officer:
Russell Coplen
HYPERTENSION AND DIABETES SYSTEM OF CARE
Effective upon signature, it is mutually agreed that the Agreement referenced above is amended as follows:
1. Pursuant to Terms and Conditions, Provision 6. Contract Changes, Section 6.1 Amendments, Purchase Orders and
Change Orders, the Agreement Scope of Services is revised and replaced with the Scope of Services of this
Amendment Two (2).
2. Pursuant to Terms and Conditions, Provision 6. Contract Changes, Section 6.1 Amendments, Purchase Orders and
Change Orders, the Price Sheet is revised and replaced with the Price Sheet of this Amendment Two (2).
Continued on next page.
CONTRACTOR SIGNATURE
Maricopa County by and through its,
Maricopa County Dept. of Health
Contractor Name Contractor Authorized Signature
Clint L. Hickman
4041 N. Central Ave.
Address Printed Name
Phoenix AZ 85012 Chairman, Maricopa County Board of Supervisors
City State Title
Zip
CONTRACTOR ATTORNEY SIGNATURE This Intergovernmental Agreement Amendment shall be
Pursuant to A.R.S. § 11-952, the undersigned public effective the date indicated. The Public Agency is hereby
agency attorney has determined that this cautioned not to commence any billable work or provide
Intergovernmental Agreement is in proper form and is any material, service or construction under this IGA until
within the powers and authority granted under the laws of the IGA has been executed by an authorized ADHS
the State of Arizona. signatory.
State of Arizona
Signed this _________ day of _________________ 2016
Signature Date
Printed Name Procurement Officer
Attorney General Contract No. P0012014000078, which
is an Agreement between public agencies, has been
reviewed pursuant to A.R.S. § 11-952 by the undersigned
Assistant Attorney General, who has determined that it is
in proper form and is within the powers and authority
granted under the laws of the State of Arizona.
Signature
Date
Assistant Attorney General
Printed Name:
ATTEST:
___________________________________________ Page 1 of 10
Clerk of the Board Date

CONTRACT NUMBER INTERGOVERNMENTAL AGREEMENT
ADHS16-113997 SCOPE OF SERVICES
1. BACKGROUND:
1.1. The Arizona Department of Health Services (ADHS) Bureau of Tobacco and Chronic Disease (BTCD) is part
of the Centers for Disease Control and Prevention (CDC) state-based chronic disease prevention program.
The program’s intent is to change health care systems to improve prevention and management of heart
disease, stroke, diabetes and their risk factors. The program encourages the adoption of established clinical-
community-linkage models to improve the quality of care and outcomes for patients with these conditions
and their risk factors.
1.2. Cardiovascular disease is the leading cause of death both nationally and in Arizona. The main components
of cardiovascular disease are coronary heart disease, congestive heart failure, and stroke. In Arizona, heart
disease and stroke claim the lives of more than 13,000 people each year. One of the primary risk factors for
developing heart disease or stroke is hypertension. Nationally one (1) in three (3) Americans has
hypertension and in Arizona, more than twenty-four percent (24%) of the adult population has hypertension.
This is well above the Healthy People 2010 goal of sixteen percent (16%) or less of the adult population
diagnosed with hypertension. In the 2011, 9.8% of U.S. adults said that they have been diagnosed with
diabetes. Similarly, 9.5% of adults in Arizona said that they had been diagnosed with diabetes, and 7.8% of
adults with pre-diabetes.[1] However, American Indians have the highest mortality rate from diabetes (79.3
per 100,000), 3.9 times higher than the diabetes mortality rate for all Arizona residents (20.1 per 100,000).[2]
1.3. BTCD recognizes the value and effectiveness Community Health Workers (CHW’s) in the healthcare setting,
and has chosen the CHW model as its program delivery strategy in community health center interventions in
the past.
“CHWs are known by a variety of names, including community health worker, community health advisor,
outreach worker, community health representative (CHR), promotora/promotores de salud (health
promoter/promoters), patient navigator, navigator promotoras (navegadores para pacientes), peer
counselor, lay health advisor, peer health advisor, and peer leader ”.
1.4. The success of these past programs have demonstrated that this method provides a level of personalized
patient care which the traditional medical model does not often provide on a consistent level, particularly
within priority population groups. This current program will utilize a CHW model to achieve its objectives by
leveraging the benefits of this approach:
“CHWs are frontline public health workers who are trusted members of and/or have an unusually close
understanding of the community served. This trusting relationship enables CHWs to serve as a liaison,
link, or intermediary between health/social services and the community to facilitate access to services
and improve the quality and cultural competence of service delivery. CHWs also build individual and
community capacity by increasing health knowledge and self-sufficiency through a range of activities
such as outreach, community education, informal counseling, social support, and advocacy.”
1.5. ADHS has been awarded funding from the CDC to implement a project to address identification and control
of high blood pressure and diabetes in Arizona by implementing a continuum of care partnership in the
community.
2. SCOPE OF WORK
The Contractor shall:
2.1. Implement a hypertension and diabetes system of care program. During the implementation of this program,
the Contractor shall partner with a community health center(s) to bring CHWs into the healthcare team; and
provide feedback to primary care physicians on the compliance of their patients. Through this program, a
patient that is at risk of, or has been diagnosed with hypertension or diabetes (and pre-diabetes) will be
enrolled into an educational hypertension/diabetes treatment and monitoring program utilizing a community
health worker system to ensure solid communication and follow-up between the patient and the rest of the
Page 2 of 10

CONTRACT NUMBER INTERGOVERNMENTAL AGREEMENT
ADHS16-113997 SCOPE OF SERVICES
healthcare team. Additional referral requirements will be followed as they apply to the specific patient’s
needs, resources, and availability. Examples of these programs are: Diabetes Self-Management Education
Programs, Chronic Disease Self-Management Programs, clinic, hospital or community-based support
networks, etc.
3. OBJECTIVES
By June 30, 2017, the Contractor shall develop or improve a system of care to include:
3.1. Development of a CHW program with clinician oversight; within a community health clinic setting whose
patient and potential-patient census includes a majority of patients from the following high-risk populations
groups:
3.1.1. African American Women;
3.1.2. Hispanic males;
3.1.3. Asian/Pacific Islanders; and
3.1.4. American Indians.
3.2. Development of a multidisciplinary CHW team at each clinic consisting of a minimum of one (1)
participant from:
3.2.1. Clinic administration;
3.2.2. Medical professional;
3.2.3. Designated program lead; and
3.2.4. Community health worker.
3.3. Identification of medical and behavioral health patients at risk of already diagnosed with hypertension or
diabetes during patient appointment intake via the clinics electronic health record (EHR) system;
3.4. Enrollment of identified patients into an educational program provided by CHW(s);
3.5. Referral of patients in other avenues of treatment/support as they are discovered through the intake
process (such as diabetes education, tobacco cessation, etc.);
3.6. Tracking of referral actions for follow up and to increase participation;
3.7. Assessment of the patient’s self-efficacy to manage their chronic conditions (Hypertension/Diabetes);
3.8. Outreach to clinic’s geographical coverage area for hypertension and diabetes new-patient identification
and medical home assignment (creating a community-clinic linkage);
3.9. Follow up with the patient by the CHW to increase the successful self-management of
hypertension/diabetes and decreased miss appointment rates;
3.10. Feedback to the primary care provider by the CHW regarding the patient’s self-management of their blood
pressure and diabetes;
3.11. Reassessment of enrolled patients at the appropriate time to measure the HTN/DIAB self-efficacy and
program/ medication adherence;
Page 3 of 10

CONTRACT NUMBER INTERGOVERNMENTAL AGREEMENT
ADHS16-113997 SCOPE OF SERVICES
3.12. ADHS, in compliance with the CDC, utilizes only evidence-based interventions to achieve systems change
and impact the burden of heart disease and stroke in Arizona. Reports/documents like these are highly
encouraged to be reviewed and integrated where applicable:
3.12.1. Addressing Chronic Disease through Community Health Workers, A Policy and Systems Approach
(http://www.cdc.gov/dhdsp/docs/chw_brief.pdf),
3.12.2. Community Health Workers/Promotores de Salud: Critical Connections in Communities
http://www.cdc.gov/diabetes/projects/comm.htm,,
3.12.3. Community Health Workers Evidence Based Models Toolbox
http://www.hrsa.gov/ruralhealth/pdf/chwtoolkit.pdf.
3.12.4. Cardiovascular Disease Prevention and Control: Interventions Engaging Community Health
Workers http://www.thecommunityguide.org/cvd/CHW.html
3.13. In order to support the contractors training efforts for this program, the Arizona BTCD has contracted with
the University of Arizona Mel and Enid Zuckerman College of Public Health Prevention Research Center to
assist in providing a training program for the CHW(s) to be utilized in the clinical setting. The training
program developed will be a population and clinic specific overview which will include, but not be limited to:
the roles and responsibilities of CHW’s , core competencies, hypertension and its association to heart
disease and stroke, diabetes, warning signs of heart disease and stroke, risk factor management and
treatment/medication adherence. (This cost is NOT incurred by the grantee for this project);
3.14. The contractor should utilize the Joint National Committee’s Seventh (JNC-7) Report as the guidelines for
the prevention, detection and treatment of hypertension. The JNC-7 report details the guidelines for
determining if a patient is considered hypertensive, pre-hypertensive, diabetic and pre-diabetic or not;
(http://www.nhlbi.nih.gov/guidelines/hypertension/);
3.15. In the JNC-7 guideline revision, the category of pre-hypertensive was added to show that early detection
and aggressive treatment of hypertension can avoid serious chronic disease complications in the future of
that patient. These guidelines will be used by the providers to identify and diagnose those who have
hypertension or pre-hypertension and refer them into the education program;
3.16. Additionally, the American Diabetes Association-supported Clinical Guidelines for Diabetes treatment and
management should be utilized as well. http://www.ndei.org/treatmentguidelines.aspx; and
3.17. Membership and participation of the CHW Supervisor and CHW(s) in the statewide CHW Workforce
Coalition and the Arizona Community Health Outreach Workers (AzCHOW) professional association.
4. TASKS:
The Contractor shall:
4.1 Identify a community health clinic(s) with a priority population that is at an increased risk of mortality from
heart disease and stroke, and conduct baseline survey of its existing services relating to the scope of this
project who are NOT currently utilizing CHW’s for the purposes described in this document, but have the
capacity to introduce this CHW system of care for diabetes and hypertension;
4.2 Identify CHW(s) internally or to be employed, who will attend training offered by the University of
Arizona and be assigned the HTN and DIAB program duties;
4.3 Identify both internal and external partners who will be involved in this project;
Page 4 of 10

CONTRACT NUMBER INTERGOVERNMENTAL AGREEMENT
ADHS16-113997 SCOPE OF SERVICES
4.4 Identify a multidisciplinary CHW team at each clinic consisting of a minimum: One (1) participant from
clinic administration, medical professional, designated lead CHW;
4.5 Ensure the development of identification and tracking methods for patients who have been diagnosed
with, or are at risk of developing hypertension and diabetes;
4.6 Implement an evaluation program with the ADHS Evaluation staff, which shall measure at a minimum
the following:
4.6.1 Patient self-efficacy in the area of treatment adherence for hypertension1 after enrollment in the
HTN system of care,
4.6.2 Integration of CHW’s into the clinic(s) medical and behavioral health treatment system, and
4.6.3 Biometric measures (Blood Pressure, A1C - aggregate and de-identified) of participating patients.
4.8 Ensure the development of a referral system between the primary care providers in both medical care
and behavioral health care to move the patient into the CHW/HTN/DIAB educational/navigation
program;
4.9 Deliver the educational program to the patient(s) who have been referred to the program;
4.10 Partner with the ADHS and the University of Arizona to ensure that the activities are being done are
successful, delineate a clear scope of work for the CHW, and to ensure program fidelity to the CHW
training;
4.11 Ensure the primary care providers (medical and behavioral health) attend an initial training on the JNC-
7 (or more recent) guidelines to prevent, diagnose, and treat hypertension;
4.12 Ensure that the community health workers/promotoras attend in-service trainings on additional material
relating to improving their role as CHW/HTN patient navigators;
4.13 Develop and implement policies that integrate the community health workers into the healthcare team;
and
4.14 Leverage program, policy activities or reports/surveys, etc. with other initiatives/opportunities only with
the approval of the ADHS Chronic Disease Office.
5. DELIVERABLES AND DELIVERY SCHEDULE:
The Contractor shall provide documentation of activities and products related to this contract in scheduled reports
that include:
5.1. Enrollment of at a minimum two hundred and fifty (250) unique participants during contract duration, ration
of hypertension and diabetes patients no to exceed 60/40 (ex: 60% diabetes patients, 40% hypertension
patients or vice versa).
5.2. Document baseline and target measures as program moves forward (6.1-6.3 above at a minimum)
5.2.1. Document barriers encountered;
5.2.2. Document suggestions for improvement: and quarterly; and
Page 5 of 10

CONTRACT NUMBER INTERGOVERNMENTAL AGREEMENT
ADHS16-113997 SCOPE OF SERVICES
5.2.3. Participate in quarterly meetings with other ADHS contractors implementing a Hypertension System
of Care model.
5.3. Provide ADHS with copies of the hypertension/diabetes services baseline, interim, final evaluation surveys;
interim report and final report.
5.4. Performance Measurements: Submit to ADHS performance measurements for calendar year
02/01/2016 – 01/31/2017 by 02/03/2017. Listed below are the required 1305
performance measures for this project:
5.4.1. Proportion of health care systems with policies or systems to encourage a multi-disciplinary team
approach to blood pressure control;
5.4.2. Proportion of health care systems with policies or systems to encourage a multi-disciplinary team
approach to A1C control;
5.4.3. Proportion of patients that are in health care systems that have policies or systems to encourage a
multi-disciplinary approach to blood pressure control;
5.4.4. Proportion of patients that are in health care systems that have policies or systems to encourage a
multi-disciplinary approach to A1C control;
5.4.5. Proportion of patients with high blood pressure that have a self-management plan (may include
medication adherence, self-monitoring of blood pressure levels, increased consumption of nutritious
food and beverages, increased physical activity, maintaining medical appointments);
5.4.6. Proportion of adults with known high blood pressure who have achieved blood pressure control;
5.4.7. Decreased proportion of persons with diabetes with A1C>9%; and
5.4.8. Proportion of adults in the state aware that they have high blood pressure.
5.5. Annual action plan thirty (30) days after award that includes goals, objectives, activities, timeliness of
completion, defined deliverables, and a narrative of how project activities fit within the identified strategies
selected (Attachment A);
5.6. Hypertension/Diabetes Services Summary, Due by the end of each program month, format TBD.
5.7. Monthly Reports – due beginning thirty (30) days from award. Report format and others details and
requirements will be provided; at a minimum shall include summary of progress, accomplishments, barriers,
technical assistance needs. Report format to be provided.
5.8. Final Report – due 30 days after final contract month. Report format and requirements will be provided; at a
minimum shall include items such as executive summary, description of project, outcomes, evaluation,
future goals. Report format to be provided.
5.9. Data Agreement: Agree to share de-identification data with ADHS for the purpose of identifying, analyzing,
and reporting 1305 performance measurements to CDC. All other usage of the data will be discussed and
approved by both organizations.
5.10. Contractor Expenditure Report (CER), due thirty (30) days following the month of service.
5.11. Performance Measurements: Submit to ADHS performance measurements for calendar year
02/01/2016 – 01/31/2017 by 02/03/2017. Listed below are the required 1305 performance measures for this
project.
Page 6 of 10

CONTRACT NUMBER INTERGOVERNMENTAL AGREEMENT
ADHS16-113997 SCOPE OF SERVICES
6. NOTICES, CORRESPONDENCE, REPORTS AND INVOICES:
6.1. Notices, Correspondence, Reports and Invoices/CERs from the contractor to ADHS shall be sent to:
Arizona Department of Health Services
Bureau of Tobacco and Chronic Disease
ATTN: Yanitza Soto, CHW Program Manager
Street Address: 150 North 18th Avenue, Suite 310
City, State, and Zip Code: Phoenix, Arizona 85007
Telephone: (602) 542-8261
Facsimile: (602) 542-1890
Email: yanitza.soto@azdhs.gov
6.2. CER’s, Invoices, or Finance Inquiries from Contractor to ADHS should be submitted to:
Arizona Department of Health Services
Bureau of Health Systems Development
ATTN: Teresa Manygoats, Office Chief
Street Address: 150 North 18th Avenue, Suite 300
City, State, and Zip Code: Phoenix, Arizona 85007
Telephone: (602) 542-2849
Facsimile: (602) 542-2011
Email: Teresa.Manygoats@azdhs.gov
6.3. Notices, Correspondence, Reports and Payments from the ADHS to the Contractor shall be sent to:
Organization: Maricopa County Department of Public Health
Attention: Estella Sanchez, Senior Grants Accountant
4041 N Central Avenue #1400
Phoenix, Arizona 85012
Telephone: (602) 372-8443
Email: EstellaSanchez@mail.maricopa.gov
6.4. Payments from ADHS to the Contractor shall be sent to the “Remit To” Address listed on the Contractor’s
ProcureAZ vendor profile.
Page 7 of 10

CONTRACT NUMBER INTERGOVERNMENTAL AGREEMENT
ADHS16-113997 SCOPE OF SERVICES
ATTACHMENT “A”
The Annual Action Plan will identify the activity, lead personnel, key partners, time frame, and performance measures.
The Evaluation Design will incorporate performance measures for each strategy, including but not limited to those listed
below, which will be collected and reported at the county level. Assistance in methodology design and planning will be
provided by ADHS as needed. Methodology will be approved by ADHS prior to the report of performance measures.
Name of Organization/County:
Name of Project:
1. Please provide a narrative that explains the organization’s history/background in implementing this strategy/initiative.
2. Please provide a narrative of the implementation of the proposed activities related to the strategy. Please include any
timelines and deliverables that the organization/county will have.
Annual Action Plan
 Enhanced: Domain 3, Strategy 2- Increase use of team-based care in health systems
 Intervention-Increase engagement of non-physician team members (i.e., nurses, pharmacists, and patient
navigators (CHWs, promotores de salud, etc.) in hypertension (HTN) and diabetes management in health care
systems
Goal(s) of the Project:
Objective(s) of the Project:
Activity Lead Personnel Key Partners Time Performance Measures
frame
3.2.01: Proportion of health care
systems with policies or systems
to encourage a multi-disciplinary
team approach to blood pressure
control
3.2.02: Proportion of health care
systems with policies or systems
to encourage a multi-disciplinary
team approach to A1C control
3.2.03: Proportion of patients that
are in health care systems that
have policies or systems to
encourage a multi-disciplinary
approach to blood pressure
control
3.2.04: Proportion of patients that
are in health care systems that
Page 8 of 10

CONTRACT NUMBER INTERGOVERNMENTAL AGREEMENT
ADHS16-113997 SCOPE OF SERVICES
have policies or systems to
encourage a multi-disciplinary
approach to A1C control
3.2.09: Proportion of patients
with high blood pressure that
have a self-management plan
(may include medication
adherence, self-monitoring of
blood pressure levels, increased
consumption of nutritious food
and beverages, increased
physical activity, maintaining
medical appointments)
3.2.10: Proportion of adults with
known high blood pressure who
have achieved blood pressure
control
3.2.11: Decreased proportion of
persons with diabetes with
A1C>9%
B.5.01: Proportion of adults in
the state aware that they have
high blood pressure
3. Please describe how activities link to the defined performance measures:
Page 9 of 10

CONTRACT NUMBER INTERGOVERNMENTAL AGREEMENT
ADHS16-113997 SCOPE OF SERVICES
PRICE SHEET
July 1, 2016 to June 30, 2017
ITEMIZED SERVICE BUDGET (ISB) RESTRICTIONS:
Cost Reimbursement Line Items Total Amount
1. Personnel Services/ERE $8,696
2. Professional & Outside Services $90,000
3. Travel Expenses $0
4. Other Operating Expense $0
5. Capital Outlay Expense $0
6. Other (Indirect Costs) $1,304
Total Contract Amount (not to exceed) $100,000
1.1. The Contractor is authorized to transfer up to a maximum of ten percent (10%) of the total Contract amount
among the categorical line items. Transfers of funds are only allowed among funded line items as detailed in
the original ISB. Transfers exceeding ten percent (10%) of the Contracted amount, or to a non-funded line
item, shall require a Contract Amendment.
1.2. Indirect Costs shall not exceed fifteen (15%) of the combined total of Personnel Services and Employee
Related Expenses as listed on the ISB. For more detailed information regarding indirect costs, refer to the
ADHS Accounting and Auditing Procedures Manual for Contractors of ADHS Funded Programs. This manual
is incorporated into this Contract by reference herein.
Page 10 of 10