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O n e i d a C om p r e h e n s i ve H e a l t h D i v i s i o n

Memorandum of agreement with health partners Oneida Tribe of Indians of Wisconsin. O n e i d a C om p r e h e n s i ve H e a l t h D i v i s i o n

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O n e i d a C om p r e h e n s i ve H e a l t h D i v i s i o n

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  1. Memorandum of agreement with health partners • Oneida Tribe of Indians of Wisconsin OneidaComprehensiveHealthDivision OneidaCommunityHealthCenterBehavioralHealthServicesAnnaJohnNursingHomeEmployeeHealthNursing POBox365 Oneida, WI54155 MEMORANDUMOFAGREEMENT BETWEENTHE ONEIDACOMMUNITYHEALTHCENTERDIABETESTEAM ANDTHE ONEIDACOMMUNITYHEALTHCENTERHEALTHPROMOTION/DISEASEPREVENTIONDEPARTMENT ANDTHE ONEIDAFAMILYFITNESSCENTER 1. Preamble 1.1.ThisMemorandumofAgreement (MOA)isenteredintobytheOneida CommunityHealthCenter(OCHC)DiabetesTeam(DT),Health Promotion/DiseasePrevention(HPDP),andtheOneidaFamily FitnessCenter (OFF). 2. Purpose 2.1.ThepurposeofthisMOAisprovidetheframeworkwithinwhichtheOCHCDT, OCHCHPDP,andOFFwillworkcollaborativelytoprovidestructuredexercise programsforpatients referredbyanOCHCphysicianorotherOCHDmedical professionalneedingassistancewithpreventionand/orcontrolofmedically diagnosedconditions.Thesecollaborativeprogramsarecurrentlyreferredto as: TRIADProgram(TakingResponsibilityInAddressingDiabetes), TwatakalitatsProgram,andDPP orDiabetesPreventionProgram). TheyarejointeffortsbetweentheOCHCDT,OCHCHPDP,andOFF.Theseprograms arefundedbytheSpecialDiabetesProgramforIndians(SDPI)Grant,Health Promotion/DiseasePreventionCooperativeAgreement (HPDP),andDiabetesPreventionProgram(DPP)andaresubjecttofollowallgrantpoliciesaswellas applicabletribal,organizational,anddepartmentpolicies. Themailingaddresstoall locationsis:P.O.Box365, Oneida,WI 54155

  2. 3. • Definitions • TRIAD: TakingResponsibilityInAddressingDiabetes • HPDP:HealthPromotion/DiseasePreventionGrantforTwatakalitatsProgram • DPP:DiabetesPreventionProgram • C2F:CommittoFitProgram • OCHD:OneidaComprehensiveHealthDivision • DT:DiabetesTeam • Graduates:Patients/Clientswhosuccessfullycompletethe12or16week programsincludingpreandpostassessments. 4. ScopeandNatureofServices 4.1.DesignatedOCHCDT,HPDP,andOFFpersonnelwillworktogethertoprovide servicesto: 4.1.1. 4.1.2. Followuponhealthscreeningsandreadinessassessments. Implementwellnesscoachingtoenhancephysicalactivitygoal achievement,retention,providemedicalrecorddocumentation,and provideadvocacyforeachpatient. Provideweekly,biweeklyormonthlyeducationrelatedtoahealthylifestyle. Designandimplementindividualizedfitnessplanstoinclude cardiovascularandstrengthtraining. Maintainrecordsas requiredbyOCHC,OFF,andapplicable grants/cooperativeagreements. DevelopprogramsinresponsetotheIHSStandardsofDiabetes Care,AmericanDiabetesAssociation,andAmericanCollegeof SportsMedicineasapplicable. 4.1.3. 4.1.4. 4.1.5. 4.1.6. 5. Implementation ProcessandResponsibilities 5.1.TheOCHC throughtheDTagrees toassurethefollowing: 5.1.1. Patientsneedingorrequestingassistancewithlifestylemodifications topreventorcontrolmedicalconditionswillbereferredbytheirhealth careproviderorOCHDstafftoawellnessprogram. ThehealthcareproviderorOCHDstaffwillcompleteandsubmitthe MedicalClearance/Referral FormandHIPPAAuthorizationformtoa designatedbasketintheDToffice. TheDT entersthepatientintoTRIADdatabaseandanHPDPReferral (electronic)database,verifyingallformshavebeencompleted. TheDT andhealthcareprovidercompletesthemedicalscreeningto verifythepatientissafetoexercisewithanacceptableA1Clevel. 5.1.2. 5.1.3. 5.1.4. 5.1.4.1. If thepatientisnotsafetoexercise,theDTwillfollowup every3monthswiththepatient. TheDTwillassistthepatientbyschedulingappointmentsas neededwiththeappropriatehealthcareprovider. Oncethepatientisdeemedsafetoexercisebytheirhealth careprovider,theDT refersthepatienttoHPDP. 5.1.4.2. 5.1.4.3.

  3. 5.1.5. TheDTwillprovideHPDPwiththeMedicalClearance/ReferralForm. TheHIPPA authorizationformwillbefiledinthepatient’smedical record. TheDTwillupdateHPDP andOFFstaffasnecessarywithany patientinformationand/orchangesthatmayoccur. Submitquarterlyreport,whichincludes:PreandPostHemoglobinA1Ctests. Providecopyofreportsummarytoallpartiesinvolvedinthis agreement. 5.1.6. 5.1.7. 5.1.8. 5.2.TheOCHC throughHPDP agrees toassurethefollowing: 5.2.1. HPDPwillreceiveallphysicianreferralsviaemailwithascanned copyoftheMedicalClearance/Referral Form.HIPPA authorization formwillbekeptinthepatient’smedicalrecord. HPDPwillassignacoachbasedonavailabilityandtomeettheneed ofthepatient. HPDP staffwillcontactthepatientandcompletethereadiness assessment. 5.2.2. 5.2.3. 5.2.3.1. Pre-contemplationstage:TheHPDP staffwillfollowupmonthlywithpatienttoeducate,support,andmotivate patientuntilhe/shemovesfrom“Pre-contemplation”to “Contemplation”or“Preparation”stage. Contemplationstage: TheHPDP staffwillworkwithpatient onabiweeklybasisusingMotivationalInterviewingandAppreciativeInquiryuntilpatientmovesfrom“Contemplation”to“Preparation”stage. Preparationstage: TheHPDP staffwillreferthepatientto theappropriateprogram: TRIAD,C2ForDPP. Action/MaintenanceStage:Atthisstagethepatientis alreadymeetingtheoutcomesoftheprograms.HPDPStaff willdocumentthisstageintheHPDPReferralDatabase. ThepatientwillnotenterTRIAD,C2F,orDPP butmaybe offeredaPersonalTrainingsessionand/ormonthlyfollowup visitsforgoalsetting. 5.2.3.2. 5.2.3.3. 5.2.3.4. 5.2.4. HPDPwill: 5.2.4.1. 5.2.4.2. 5.2.4.3. Introducepatienttoappropriateprogram. SetupWellnessVisionappointment. SendorprovideWellnessAssessmenttopatient. 5.2.5. • UponcompletionoftheWellnessvision,HPDP staffwill: • Setupweekly,biweeklyormonthlyfollowupcoaching appointmentsforgoalsettingandtrackingfitnessprogress.ForTRIAD,seeattached“HPDPWeeklyProgramming.” • Providereferraltoappropriateprogramwhichincludesa copyofMedicalClearance/Referral Form,WellnessVision andWellnessAssessment results.

  4. 5.2.6. Uponcompletionofanyprogram: 5.2.6.1. 5.2.6.2. 5.2.6.3. CompletepostWellnessAssessment. AssistpatientinschedulingpostFitnessAssessment. Assessinitialprogramgoalsandsetnewgoalsfor3,6or9months. Offerand/orschedulemonthlyfollowupcoachingvisits,at patient’sdiscretion. ForTRIAD,providepatientaconfidentialspacetocomplete TRIADevaluationformandsealinanenvelope.HPDP staff willforwardtoDiabetesProgramSupervisor. ForTRIAD,provideNikeshoevoucherandwalkpatientto OFFtoorderappropriateshoesize. 5.2.6.4. 5.2.6.5. 5.2.6.6. Monthlycoachingvisitswillcontinuefor6-9monthsatwhichtime anotherWellnessAssessmentwillbecompleted. UsingProchaska’sStagesofChangeModel,determinewhether patientshouldcontinuemonthly,quarterly,orsemi-annualfollowup coachingvisits. SubmitmonthlyreportforTRIADtoDiabetesProgramSupervisor, whichincludes: 5.2.7. 5.2.8. 5.2.8.1. 5.2.8.2. 5.2.8.3. 5.2.8.4. 5.2.8.5. #ofactiveparticipants #ofcoachingsessions #ofselfreportedphysicalactivityminutes #check-instoOFFWeightloss 5.2.9. SubmitquarterlyreporttoDiabetesProgramSupervisor,whichincludes: 5.2.9.1.Total#ofparticipants 5.2.9.2.Total#ofcoachingsessions 5.2.9.3.Averageselfreportedphysicalactivityminutes 5.2.9.4.Total#ofcheck-instoOFF 5.2.9.5.Totalweightloss ActivelyparticipateinSDPI/DPPGrant Teammeetings. ProvidecopyofreportsummaryforDPP toallpartiesinvolvedinthis agreement. 5.2.10. 5.2.11. 5.3.TheOFFagreestoassurethefollowing: 5.3.1. OFFwillreceivereferralsfromHP/DPviaMedicalClearance/Referral Form. ThepatientwillpresenttheMedicalClearance/ReferralFormtoOFFFrontDeskwhowillassistpatientwithmembershipapplicationand routepatienttoFitnessServiceDesktobeginappropriateprogram. 5.3.2.1.TRIAD: 5.3.2.

  5. Personaltrainingwilloccurweeklyfor12weeks,in½hoursessions.Seeattached“WeeklyTrainer Responsibilities.” • Personaltrainingwillincludebriefpatient education,andcardiovascularandstrength training. • Additionalpersonaltrainingwillbeofferedto • “graduates”asdeemednecessaryandagreed uponbyDT,HP,andOFF. • DesignatedFitnessSpecialistswillcompletepre andpostfitnessassessmentstoincludethe • following:BMI,Height,Weight,Waist:Hip,BloodPressure,RestingHeartRate,appropriateAerobic • Fitnesstest, Strengthtest,andappropriate Flexibilitytest. • Atcompletionofpersonaltraining,FitnessSpecialistwillinformclientaboutfinalincentiveof • NikeNativeshoetobedistributedbyHPDP coach.GiveclientformwithHPDPspecialistname • andphonenumberforpatienttocontactthemand setupfinalappointment. • SubmitpostFitnessAssessment resultstoHPDP Coachuponcompletionoftheprogram. • Submitmonthly reporttoDiabetesProgramSupervisor,whichincludesthefollowingfor • patientsWITHOUTCOACHING: 5.3.2.1.6.1#ofactiveparticipants • 5.3.2.1.6.2#selfreportedphysicalactivityminutes 5.3.2.1.6.3#checkinstoOFF • 5.3.2.1.6.4Weightloss • SubmitquarterlyreportstoDiabetesProgramSupervisor,whichincludes: • Total#ofparticipants • AveragechangeinBMI • AveragechangeinWaisttoHipRatio 5.3.2.1.8.4.AveragechangeinAerobicFitness 5.3.2.1.8.5.AveragechangeinStrength 5.3.2.1.8.6.AveragechangeinFlexibility 5.3.2.2. • C2F: • IndividualsessionsfollowingC2FProgram protocolfor12weeks. • Submitpostfitnessassessment resultstoHPDP • Coachuponcompletionoftheprogram. 5.3.2.3. DPP:

  6. 5.3.2.3.1. • FitnessSpecialistwillcompletepreandpost fitnessassessmentsforDPPParticipantsthatare OFFMembers,toinclude:BMI,Height,Weight, Waist:Hip,BloodPressure,RestingHeartRate, appropriateAerobicFitnesstest,Strengthtestand appropriateFlexibilitytest. • SubmitpostFitnessAssessmentresultstoHP • Specialist/DPPCoordinatoruponcompletionof theprogram. • ProvideavailabilityofspaceforAfter-Core activitiesinvolvingphysicalactivity. • ProvideavailabilityofOFFEducationRoomto teachDPPCurriculum. • SubmitquarterlyreportstoHPSpecialist/DPP Coordinator,whichincludes: • AveragechangeinBMI • AveragechangeinWaisttoHipRatio 5.3.2.3.5.3.AveragechangeinAerobicFitness 5.3.2.3.5.4.AveragechangeinStrength 5.3.2.3.5.5.AveragechangeinFlexibility 5.3.2.3.2. 5.3.2.3.3. 5.3.2.3.4. 5.3.2.3.5. 5.4. • Incentives: • TRIAD: • TheDTwillpurchaseandprovideHPDP and/orOFFwithpatient incentives: • Incentiveswillbeawardedtopatientswhomeetminimum • requirementsasdefinedbytheTRIADcommittee. • IncentiveswillbepurchasedfromtheSDPIgrant. • SDPIGrantpolicyallowsforincentivesthatdonotexceed$30. • IncentiveswillbestoredandinventoriedatOCHCandhanded outbyHP/DP and/orOFF. • TypesofincentivesaredeterminedbyOCHCDT,HP/DP,and • OFF. • Seeattached“TRIADIncentiveStructure.” 5.1.1. TRIADandDPP fitnessparticipation(Note:HPDP fitness participationincentivewillbegin9/1/11): 5.1.1.1.Patientsverifyingfacilityusageofatleast2timesperweek eachquarterwillreceiveanOneidaRetailCardinthe amountof$25.00. 5.3.2.3.1. HPDPCoachwillprovidepatientincentive uponverification.

  7. 6. • Fiscalagreements • ForTRIAD: • FitnessSpecialistswillmaintainacombined40hoursforindividualized personaltrainingandTRIADadministrativeduties. • Atthecloseofeachmonth,OneidaFamilyFitness representativewill • emailtotalhoursforpersonaltrainingandTRIADadministrativedutiesto DiabetesProgramSupervisor. • DiabetesProgramSupervisorwillforwardtoAccountingrepresentativeto completejournalentrytransferforthereportedhours. • Atthecloseofeachmonth,AccountingwillreimburseOFFamaximumof 40hoursperweektoincludetheexactpersonnel,fringe,andindirect • coststhroughSpecialDiabetesProgramforIndiansGrant. • AnITPOwillbemadeintheamountof$1750for501-hourpersonal trainingsessionsat$35.00/sessiontobeusedforTRIADgraduates. • ForDPP: • FitnessSpecialistswillmaintainacombined20hoursforJustMoveIt– Oneidaeventplanning/facilitating,quarterlygroupexerciseinstruction(as needed),pre/postfitnessassessments,collection/reportdataasrequired byDPPGrant,andanyothergrantresponsibilitiesrelatedtophysical activityasdesignatedbyDPPProgramDirector(HPDPSupervisor). • HPDPSupervisor,throughDPPCooperativeAgreement,willworkwith • Accountingtoreimburseamaximumof20hoursperweektoinclude, personnel,fringeandindirectcosts. • Atthecloseofeachmonth,HPDPSupervisorwillrequesttotalhoursof participatinginDPP forthemonthviaemail. • HPDPSupervisorwillsendemail requesttoAccountingtocomplete journalentrytransferforthereportedhours. • MembershipcostswillnotincurtoHPDP orDT.OFFagreestothefollowingmembershippricesthatwillbepaidbyanypatient referredintothedesignated • programs,ifandonlyif,thepatientdoesnotqualifyforscholarshipeligibility. Thispriceincludeswaivingtheinitiationfee. 6.3.1. 6.3.2. 6.3.3. 6.3.4. Youthmembership(under18yearsofage)-$25.00/year Adultmembership(18yearsofageandover)-$75.00/year Eldermembership(over55yearsofage)-$25.00/year Familymembership(includes2adults)-$150.00/year 7. • Disclaimers,Terms,and Termination ofAgreement • ContinuationoftheTRIADandDPP programiscontingentuponSDPI/DPP Grantfunding. • TheeffectivedateoftheMOAisOctober7, 2011andremainsineffect annuallyuntilamendedorterminatedbyeitherparty. • ThepartiesagreethatthisMOAmaybeterminatedatanytimeuponthirty(30) calendardaysnoticebyeitherparty.Thisnoticemustbeinwriting,and • addressedanddeliveredtotheotherparty’ssignatoryorsignatoriestothisMOA.

  8. 7.4.EachpartyagreesthatthisMOA doesnotabsolvethemof responsibilitiesand obligationsthathavebeenormaybeestablishedinConstitutions,By-Laws, andPoliciesofeachorganization. 8. Amendments 8.1AmendmentstothisMOAshallbebymutualconsentandshallbecomea partofthisMOA byaddendum.Allamendmentsshallbesignedbythe signatoriesofthisMOA. OnBehalfoftheOneidaTribeofIndiansofWisconsin: BysigningbelowIagreetoalltermsofthiscontract. RyanWaterstreet OneidaFamilyFitnessDirector Date ScottMurray Fitness,Adventure&RecreationAreaManager Date RavinderVir,M.D. ComprehensiveHealthDivisionMedicalDirector OneidaCommunityHealthCenter Date DebraJDanforth,RN,BSN ComprehensiveHealthDivisionOperationsDirector OneidaCommunityHealthCenter Date

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