Effective Practices in HUD-VASH ContractingAn Innovative Practice in VHA Homeless Program OperationsWhite PaperDeveloped byVHA Homeless Programs Office

INTRODUCTIONThe VHA Homeless Programs Office (HPO) identifies and disseminates innovative practices in homelessprogram operations. The Housing and Urban Development VA-Supportive Housing (HUD-VASH) ContractingCommunity of Practice (CCoP) group has been identified as a cohort of sites with strong innovative practices incontracting for HUD-VASH case management services.As one of the largest permanent supportive housing programs in the country, HUD-VASH serves over 100,000Veterans annually. Caring for these Veterans requires thousands of dedicated staff from a variety of disciplinesincluding social work, nursing, addictions counseling, vocational development, recreation therapy, psychiatry,peer support, and others. To ensure adequate staffing so that Veterans receive the case management supportthey needed, many HUD-VASH programs establish contracts with community providers. This was possible dueto the Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012 (Public Law [PL] 112154) which required VA to consider establishing contracts with non-VA community providers to help Veteransfind suitable housing and to connect Veterans with other services for which they might be eligible.Sites that established contracts reported many benefits. The VA New York Harbor Health Care System (HCS)found that contracting helped them administer new vouchers that were allocated each year, despite runningout of office space for new staff. At the Washington DC VA Medical Center (VAMC), after requiring thatcontractors be agencies that participated in their local homeless Continuum of Care (CoC), contracting lead toincreased collaboration with community partners and agencies. VA Puget Sound HCS noted that contractorsoften had more flexibility in providing staff recruitment and retention incentives, helping to reduce staff turnoverand improve continuity of care. Lastly, at the James J. Peters VAMC in Bronx, NY, contract agency staff wereoften hired and onboarded more quickly than local VA staff.Still, as of 2021, only a handful of sites established contracts. Many sites who did not contract experiencedsignificant and ongoing recruitment and retention barriers such as high costs of living and federal wages notbeing competitive with the private sector. To help mitigate these barriers, in January 2021, Congress passed anew law – the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of2020 (PL 116-315). Section 4207 of this new law now made contracting mandatory for any HUD-VASHprogram when 15 percent of their allocated housing vouchers during the preceding fiscal year were unused,and when they had one or more case manager positions that were vacant for at least nine consecutive months.This new mandate went into effect at the start of fiscal year (FY) 2022.PRACTICE OVERVIEWTo support sites who were now required to establish contracts, in June 2021, HPO launched a formal HUDVASH CCoP. This group was intended to facilitate the exchange of ideas and best practices aroundcontracting HUD-VASH case management services, identify cross cutting challenges, and help HPO

disseminate formal guidance. In synthesizing feedback shared during CCoP call discussions, several strongpractices emerged that reportedly enhanced the effectiveness of HUD-VASH contracts. These includedcontracting officer’s representatives (COR) and clinical liaisons being the same person, structuring contractteams like standard HUD-VASH teams, and strong practices related to monitoring and billing.Contracting Officer’s Representative (COR) and Clinical LiaisonsA Contracting Officer’s Representative (COR) is a formalized and critical role for all federal contracts. Asdefined by the Federal Acquisition Regulation (FAR)1, a COR is designated and authorized to perform specificadministrative and technical contract functions, such as monitoring performance of the day-to-day workperformed by the contractor and inspecting the quality of the deliverables (i.e., services). All HUD-VASHprograms that establish contracts are required to designate a COR. However, some sites went further andestablished an additional role known as a clinical liaison. Though not formalized in the FAR, clinical liaisonsserve as important subject matter experts who assist in monitoring performance and quality of services of thecontract agency. Clinical liaisons also provide necessary training to the contract agency’s staff. Since the rolesand responsibilities of these positions significantly overlapped, most of the HUD-VASH CCoP sites elected tohave one social worker simultaneously serve as both the Contracting Officer’s Representative (COR) and thecontract clinical liaison – a COR/liaison. This decision not only simplified communication between theContractor, the HUD-VASH COR/liaison, and the Contract Officer, but it also made administrative tasks thatwere shared by both the COR and contract clinical liaison roles more streamlined and efficient.Embedded TeamWhile most sites in the HUD-VASH CCoP set up their contracts in a structure that mirrored HUD-VASH casemanagement processes (i.e., unhoused Veterans were assigned to the contractor who housed and providedthem with the ongoing case management services), there was variability in how fully the contract agency staffwere embedded in the VA HUD-VASH team. “Embedding” was operationalized in a variety of ways. Forexample, having contract staff:-Included on all e-mails sent to the HUD-VASH team.Participate in VA staff meetings.Receive orientation by the VA HUD-VASH program, andGranting contract staff access to the VA share drives or SharePoint sites.VA Northern California HCS and VA Puget Sound HCS engaged in all of these practices, essentially treatingthe contract staff as though they were one team among many within their HUD-VASH program. They alsoreported increases in team cohesion, greater standardization training, and improvements in communication.1

MonitoringMonitoring of the contract agency was generally comprised of three main components: performance reviews,electronic health record (EHR) documentation reviews, and clinical meetings.Performance reviews started with the development of a quality assurance surveillance plan (QASP) thatoutlined processes to ensure that the quality of services provided were appropriate. COR/liaisons then usedthe QASP to manage and evaluate the contractor’s performance. The contractor was responsible fordeveloping their own internal processes to achieve the results outlined in the QASP and relay any changes tothe standards back to the COR for approval. QASPs were often considered “living documents” with occasionalchanges being made following approval by the Contracting Officer. All CCoP sites scheduled QASP reviewmeetings with the Contractor as needed, and some went further and scheduled reviews as regular quarterlymeetings.With regard to EHR reviews, all sites arranged for their contractors todocument progress notes in the Veterans’ official VA EHR. However,there was variability as to whether the COR/liaison or equivalent wouldbe added as a required co-signer or as an additional signer (colloquiallyknown as “tagging”)2. This difference is subtle but significant, with prosand cons for each. EHR notes that required co-signing were notconsidered finalized until they were co-signed. Additionally, EHR notesthat required co-signers automatically prompted the appropriateCOR/liaison or equivalent when notes were ready to be reviewed andsigned as a function of VA’s current Computerized Patient RecordSystem (CPRS). For sites like the Washington DC VAMC, with asignificant proportion of highly vulnerable Veterans, co-signingguaranteed that the COR/liaison had full visibility into all patient careinteractions. However, this full visibility also was a heavy administrativeburden on the COR/liaison. In contrast, EHR notes that only usedadditional signers required the contract staff to manually designate theCOR/liaison or equivalent as an additional signer to trigger the prompt.This allowed sites like VA Puget Sound HCS to lower the administrativeburden and focus primarily on the critical cases. However, there was a“As HUD-VASH strives toexpand case managementcapacity to meet the needsof all of our Veterans,we’re incrediblyappreciative of the effortsof the sites that haveshared their strongpractices and lessonslearned.Simply put, their insightswill help make thecontracting process easierfor new sites that want orneed to establishcontracts.”Meghan Deal, LICSWNational DirectorHUD-VASH Programrisk that critical cases may be inadvertently overlooked. As an added layer of accountability, whether co-2As of this writing, VHA is transitioning its EHR from VisTA Computerized Patient Record System (CPRS) to Cerner. Theoption for co-signatures is not available on the Cerner platform.

signing or additional signing, VA Puget Sound HCS had the COR/liaison or equivalent add an addendum toeach note which clearly, and in writing, acknowledged the review of the chart. As there was no clearconsensus among CCoP sites as to which process was ultimately “better”, sites are encouraged to considerthe pros and cons in the context of the local needs of their Veterans served.Regarding clinical review meetings, some sites held weekly meetings with the contract clinical supervisorsupplemented with quarterly “in depth” case conferencing meetings with the contract agency clinical supervisoron specific Veterans. For all sites, clinical supervision of contract agency staff was required to be provided bythe contract agency. VA Greater Los Angeles HCS also encouraged the contract agency’s supervisor to invitecontract case managers to these meetings to receive direct consultation on relevant cases. They reported thatthis greatly improved communication with the contractor and improved care for the Veteran. Additionally, VAGreater Los Angeles HCS developed a comprehensive, spreadsheet-based “white board” to track bothadministrative and clinical concerns derived from the standards set in the QASP. These “white boards” werefrequently shared with both the contract clinical supervisor and the contract director to ensure both clinical andadministrative reconciliation of all Veterans.BillingAmong the CCoP sites, four general price scheduling frameworksemerged across two domains: minimum required visits and acuitylevel of Veterans served. Figure 1 shows the differentframeworks. Price frameworks that included minimum visitrequirements only paid the contractor when the minimum numberof clinical encounters, commiserate with the Veteran’s casemanagement level, were documented with an appropriate 522Clinic Stop Code. In contrast, price frameworks that did not haveCCoP Price Schedule FrameworksMinimum VisitsNo Minimum VisitsRequired /Required /Flat Acuity RateFlat Acuity RateMinimum VisitsNo Minimum VisitsRequired /Required /Higher Rate forHigher Rate forHigher AcuityHigher Acuityminimum visit requirements paid the contractor regardless of thenumber of clinical encounters. With regards to acuity, priceFigure 1: Price Schedule Frameworksframeworks either paid a flat rate regardless of acuity or a higher rate for higher acuity Veterans, based oncase management level. Different sites chose one of these four frameworks based on their unique local needs.VA Greater Los Angeles HCS, for example, used the Minimum Visits Required / Flat Acuity Rate frameworkwhere they paid the contractor only for Veterans who received the minimum number of required clinicalencounters based on the Veterans’ case management stage. Many CCoP sites in the northeast used theMinimum Visits Required / Higher Rate for Higher Acuity framework, paying the contractor based only whenVeterans received the required number of visits, but at a higher rate with Veterans in more intense casemanagement stages. VA Puget Sound HCS utilized a No Minimum Visits Required / Flat Acuity Rateframework that, because of their strong relationship with the contractor, they believe lead to exceptionaloutcomes. Interestingly, VA Puget Sound noted that, when a strong and effective collaboration exists, the No

Minimum Visits Required / Flat Acuity Rate framework may encourage staff to go above and beyond forVeterans with major service challenges in ways they did not believe would happen with either of the variableframeworks. VA Northern California HCS had a unique version of the No Minimum Visits Required / Flat AcuityRate framework as their contract was established across their health system’s Social Work Service. Their priceschedule also paid the contactor a set rate per hour based on whether that staff member is licensed orunlicensed.Some programs within Veterans Integrated Service Network (VISN) 2 covering New York and New Jerseyestablished two additional terms to address missed visits or client no shows. First, the contractor may receive aprorated monthly payment for any missed case management visits (i.e., if a weekly visit was missed, thecontractor would not be paid for that visit but the other visits that month will be paid on a prorated basis).Second, VA Northport HCS included a “due diligence standard” that outlined the contractor’s responsibilitieswhen they were unable to reach a Veteran for a scheduled visit. If the due diligence standard wasappropriately followed after a no-show to a scheduled visit, the contractor could be paid for that missed visit.CONCLUSIONWith more HUD-VASH sites anticipated to establish contracts, the HUD-VASH CCoP will continue to serve asa venue for guidance and support as well as for surfacing strong and innovative practices. This will be inconjunction with efforts by the HPO and the VA National Contracting Office to streamline and increaseefficiencies in contracting processes as well as to develop and disseminate guidance on initiating contracts.We would like to thank the dedicated staff at VA Greater Los Angeles HCS; the VA Hudson Valley HCS; theJames J. Peters VAMC in Bronx, NY; the VA New Jersey HCS; the VA New York Harbor HCS; the VANorthern California HCS; the VA Northport HCS; the VA Puget Sound HCS; the VA San Diego HCS; the SanFrancisco VA HCS; and the Washington DC VAMC for sharing their practice with us. For more information,please contact Meghan Deal, LICSW, ACSW, National Director for the HUD-VASH at [email protected].

White Paper . INTRODUCTION The VHA Homeless Programs Office (HPO) identifies and disseminates innovative practices in homeless . - Granting contract staff access to the VA share drives or SharePoint sites. VA Northern California HCS and VA Puget Sound HCS engaged in all of these practices, essentially treating